Benefits Consulting Northwest. LifeWise Passport Silver PCP 3000 Package HVA

Transcription

1 Benefits Consulting Northwest LifeWise Passport Silver PCP 3000 Package HVA

2 HOW TO CONTACT US Please call or write Our Customer Service staff for help with the following: Questions about the benefits of Your Plan; Questions about Your Claims; Questions or complaints about care or Services You receive; and Change of address or other personal information. Customer Service Mailing Address Bend P O Box 7709 Bend, OR Portland 2020 SW Fourth Avenue, Suite 1000 Portland, OR Local and toll-free phone numbers: TDD number for the hearing impaired (503) TDD number for the hearing impaired You'll find answers to most of Your questions about Your Plan in this benefit booklet. You can also explore Our Web site at anytime You want to: Learn more about how to use Your Plan; Locate a health care provider near You; Gain knowledge about diseases, illnesses, medications, treatment, nutrition, fitness and many other health topics. You can also call Our Customer Service staff at the numbers listed above. We are happy to answer Your questions and appreciate any comments You want to share. Group Name: Benefits Consulting Northwest Effective Date: December 1, 2015 Group Number: Plan: LifeWise Passport Silver PCP 3000 Package HVA Certificate Form Number: LWO SG LWO SG Rev LifeWise Passport Silver PCP 3000 Package HVA

3 INTRODUCTION This Benefit Booklet is for Members enrolled in this Plan. This Benefit Booklet describes the benefits and other terms of this Plan. It replaces any other Benefit Booklet You may have received. We know that healthcare Plans can be hard to understand and use. We hope this Benefit Booklet helps You understand how to get the most from Your benefits. The benefits and provisions described in this Plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with us. This benefit booklet is a part of the contract on file at the employer s office. This plan will comply with state and federal laws. If clarifications are made by regulators, this plan will comply even if they are not stated or are in conflict with a statement made in this benefit booklet. Translation Services If you need an interpreter to help with oral translation services, please call us. The Customer Service Area will be able to guide you through the service. HOW TO USE THIS BENEFIT BOOKLET Every section in this Benefit Booklet has important information. You may find that the sections below are especially useful. How to Contact Us Our website, phone numbers, mailing addresses and other contact information are inside the front cover Summary of Your Costs Lists your costs for covered services Important Plan Information Describes Deductibles, Copayments, Coinsurance, Out-of-Pocket Maximums and Allowed Amounts How Providers Affect Your Costs How using an in-network provider affects Your benefits Prior Authorization and Emergency Admission Notifications Describes Our Prior Authorization and Emergency Admission Notifications provision Utilization Review Describes Our Utilization Review provision Case Management Describes Our Case Management provision Disease Management Describes Our Disease Management provision Continuity of Care Describes how to continue care at the in-network level of benefits when a provider is no longer in the network Covered Services A detailed description of what is covered Employee Wellness Describes a program to help improve wellness Exclusions Describes Services that are not covered Other Coverage Describes how benefits are paid when You have other coverage or what You must do when a third party is responsible for an injury or Illness Sending us a Claim Instructions on how to send in a Claim Grievance and Appeals What to do if You want to share ideas, ask questions, file a complaint, or submit an appeal Eligibility and Enrollment Describes who can be covered Termination of Coverage Describes when coverage ends Continuation of Coverage Describes how You can continue coverage after Your group Plan ends Other Plan Information Lists general information about how this Plan is administered and required state and federal notices Definitions Meanings of words and terms used LWO SG Rev LifeWise Passport Silver PCP 3000 Package HVA

4 TABLE OF CONTENTS SUMMARY OF YOUR COSTS...1 IMPORTANT PLAN INFORMATION...7 Calendar Year Deductible...7 Out-of-Pocket Maximum...7 Allowed Amount...7 HOW PROVIDERS AFFECT YOUR COSTS...8 PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION...9 UTILIZATION REVIEW...11 Case Management...12 Disease Management...12 Continuity of Care...12 COVERED SERVICES...13 Common Medical Services...13 Other Covered Services...26 Employee Wellness...29 EXCLUSIONS...29 OTHER COVERAGE...32 Coordinating Benefits with Other Plans...32 Third Party Liability (Subrogation)...35 SENDING US A CLAIM...36 GRIEVANCE AND APPEALS...37 ELIGIBILITY AND ENROLLMENT...40 Effective Date of Coverage...42 TERMINATION OF COVERAGE...44 CONTINUATION OF COVERAGE...45 OTHER PLAN INFORMATION...46 DEFINITIONS...49 LWO SG Rev LifeWise Passport Silver PCP 3000 Package HVA

5 SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following: The allowed amount. This is the most this plan allows for a covered service. The copays. This is an amount You pay at the time You get Services. The deductibles. Your costs are after the deductible is met. Sometimes the deductibles are waived. These are shown below. In-network Providers Individual deductible: Family deductible: Out-of-network Providers Individual deductible: There is no family deductible for out-of network providers. $3,000 per Member $6,000 per Family $6,000 per Member The out-of-pocket maximum. This is the most you pay each year for services from in-network providers. Individual out-of-pocket maximum: Family out-of-pocket maximum: $6,350 per Member $12,700 per Family There is no out-of-pocket maximum for Services You get from out-of-network providers. Prior authorization. Some services must be authorized by Us in writing before You get them. See the Prior Authorization and Emergency Admission Notification section for details. The conditions, time limits and maximum limits described in this contract. Some services have special rules. See Covered Services for these details. COVERED SERVICES COMMON MEDICAL SERVICES IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) OUT-OF-NETWORK PROVIDERS Office and Clinic Visit Your designated Primary Care Provider $15 copay 50% Office visit with Your OB/GYN (even if not Your selected PCP) Specialist visits and other Primary Care Provider visits/additional visits Facility charges You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. $15 copay 50% $45 copay 50% 20% 50% LWO SG SYC 1 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

6 COVERED SERVICES COMMON MEDICAL SERVICES Preventive Care Limited to how often You can get them based on Your age and if You are male or female. IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) Routine exams, well baby care and immunizations $0, deductible waived Not covered Women s pelvic exams, pap smear, clinical breast exams and mammograms Pregnant women s services, diabetic supplies, electric breast pumps and supplies $0, deductible waived 50% $0, deductible waived 50% Men s prostate screening, including PSA $0, deductible waived 50% Colon cancer screening, outpatient lab and radiology for preventive screening and tests Flu shots, flu mist, immunizations for shingles, pneumonia and Pertussis at a pharmacy Contraceptive management, elective sterilization, tubal ligation and vasectomy Nicotine dependency programs and health education for conditions other than diabetes $0, deductible waived 50% OUT-OF-NETWORK PROVIDERS $0, deductible waived 0%, deductible waived $0, deductible waived 50% $0, deductible waived Not covered Fall prevention age 65 and older $0, deductible waived Not covered Diabetes health education $0, deductible waived Not covered Nutritional therapy $0, deductible waived 50% Pediatric Care Vision care, limited to members up to age 19 Routine exams limited to one per Year $45 copay $45 copay Frames, limited to one pair every two Years 0%, deductible waived 0%, deductible waived Lenses (standard and non-correction) limited to one pair every two Years Contact lenses in lieu of glasses, limited to one pair every two Years Hearing Aids and hardware, limited to Members under the age of 18 or dependents age 18 up to age 26. Limited to one hearing aid per impaired ear every three years. Dental Care, limited to Members up to age 19, except as stated under Covered Services. See Covered Services for limitations. 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived Class I Services 0%, deductible waived 30% Class II Services 30% 40% Class III Services 50% 50% Diagnostic X-ray, Lab and Imaging Lab tests, screenings and imaging 20%, deductible waived 50% MRI, MRA, CT and PET Scans 20% 50% LWO SG SYC 2 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

7 COVERED SERVICES COMMON MEDICAL SERVICES Prescription Drugs Retail Pharmacy Limited up to a 30-day supply. Preventive drugs, limited to prescribed drugs required by health care reform, and insulin during pregnancy Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) $0, deductible waived Not covered $0, deductible waived Not covered Formulary generic drugs $15 copay Not covered Formulary preferred brand name drugs $50 copay Not covered Formulary non-preferred brand name drugs 50%, deductible waived Not covered Prescriptions Mail Order Pharmacy Limited up to a 90-day supply. Preventive drugs, limited to prescribed drugs required by health care reform and insulin during pregnancy Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices $0, deductible waived Not covered $0, deductible waived Not covered Formulary generic drugs $45 copay Not covered Formulary preferred brand name drugs $150 copay Not covered Formulary non-preferred brand name drugs 50%, deductible waived Not covered Prescriptions Specialty Pharmacy Limited up to a 30-day supply for formulary, generic and brand name drugs. Outpatient Surgery Services Hospitals, ambulatory surgery center, doctor s office and the professional services Emergency Room Includes emergency room and hospital urgent care facilities. The copay is waived if You are admitted as an inpatient through the emergency room. Emergency room Physician 20% Emergency Ambulance Services Emergency air and ground ambulance services Urgent Care Centers, affiliated with Your PCP Includes facility and professional services You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. 20% Not covered 20% 50% $250 copay 20% $15 copay 50% OUT-OF-NETWORK PROVIDERS LWO SG SYC 3 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

8 COVERED SERVICES COMMON MEDICAL SERVICES Urgent Care Centers, non-affiliated with Your PCP Includes facility and professional services You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. Urgent Care Centers, facility based You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) $45 copay 50% See Emergency Room 50% Hospital Services 20% 50% Mental Health, Behavioral Health and Substance Abuse Office visits See Office and Clinic Visits Outpatient facility services 20%, deductible waived 50% Inpatient hospital, partial hospital, residential facilities Maternity and Newborn Care Prenatal, postnatal care, delivery and inpatient care. 50% 20% 50% 20% 50% Home Health Care 20% 50% Hospice Care Respite care is limited to 5 consecutive days up to a lifetime maximum of 30 days. Rehabilitation Therapy Limited to a combined 30 outpatient visits and a combined 30 inpatient days per Year. An additional 30 visits will be allowed for stroke, spinal cord/head injury; and pediatric neurodevelopmental conditions for children under age 18 with pervasive developmental disorders. 20% 50% Outpatient office services 20% 50% Inpatient facility services 20% 50% Outpatient facility services 20% 50% Habilitation Therapy Limited to physical therapy, occupational therapy and speech therapy up to a combined 30 outpatient visits and a combined 30 inpatient days per Year. An additional 30 visits per condition may be allowed for stroke, spinal cord/head injury, and pediatric neurodevelopmental conditions for children under age 18 with pervasive developmental disorders. Outpatient office services 20% 50% Inpatient facility services 20% 50% OUT-OF-NETWORK PROVIDERS LWO SG SYC 4 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

9 COVERED SERVICES COMMON MEDICAL SERVICES IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) Outpatient facility services 20% 50% Cardiac Rehabilitation Limited to 36 sessions per Year. Skilled Nursing Facility Limited to 60 days per Year. Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Foot orthotics for conditions other than diabetes are limited to 1 pair or 2 units per Year. 20% 50% 20% 50% 20% 50% OUT-OF-NETWORK PROVIDERS COVERED SERVICES OTHER COVERED SERVICES (Alphabetical Order) Allergy Testing and Treatment Alternative Care Acupuncture, Chiropractic and Naturopathy Services, combined limit of $1,500 visits per Year. IN-NETWORK PROVIDERS Covered based on the type of Services You get YOUR COSTS (of the allowed amount) 50% OUT-OF-NETWORK PROVIDERS $15 copay 50%, deductible waived Biofeedback 20% 50% Chemotherapy and Radiation Therapy Chemotherapy includes infusion, injectable drugs, and prescribed oral chemotherapy drugs. Clinical Trials Community Wellness and Safety Programs Limited to $250 per year. Craniofacial Anomalies Dental Accidents Outpatient Visits Dental Anesthesia - Outpatient Limited to the following: Members under age 7 with a disability Members with a medical condition and it is not safe to do the treatment outside a Hospital or ambulatory surgical center. Dialysis Services Dialysis Services for End-Stage Renal Disease (ESRD) 20% 50% Covered based on the type of Services You get 50% 0%, deductible waived Not covered Covered based on the type of Services You get Covered based on the type of Services You get Covered based on the type of Services You get 50% 50% 50% 20% 50% LWO SG SYC 5 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

10 COVERED SERVICES OTHER COVERED SERVICES (Alphabetical Order) Foot Care Routine care that is Medically Necessary for treatment of diabetes IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) 20% 50% Infusion Therapy (Outpatient) 20% 50% Mastectomy and Breast Reconstruction Routine Hearing Care Covered based on the type of Services You get Exams, limited to one every 2 years for all Members $45 copay $45 copay Testing, limited to one every 2 years for all Members Hearing aids and hardware, limited to $1,000 every 3 Years for Employees age 19 and older and Dependents age 26 and older Routine Vision Care Limited to Members age 19 and older 50% OUT-OF-NETWORK PROVIDERS 0%, deductible waived 0%, deductible waived 20%, deductible waived 20%, deductible waived Exams, limited to one exam per Year $45 copay $45 copay Frames and lenses, contact lenses, limited to $150 per Year 0%, deductible waived 0%, deductible waived Sleep Studies - Outpatient 20% 50% Telemedicine Services Office visits See Office and Clinic Visits Facility costs 20% 50% Therapeutic Injections 20% 50% Transplants Donor covered services 20% Not covered Office Visits Inpatient facility, outpatient care and related services Two round trip tickets, plus two weeks of accommodations for travel and lodging expenses per transplant 50% See Office and Clinic Not covered Visits 20% Not covered 0% 0% LWO SG SYC 6 LifeWise Passport Silver PCP 3000 Package HVA Benefits Consulting Northwest/

11 IMPORTANT PLAN INFORMATION This Plan is a Preferred Provider Plan (PPO). Your Plan provides You the flexibility to receive Covered Services from providers without referrals however, You will receive a lower cost share when You designate a Primary Care Provider (PCP). Please see How Providers Affect Your Costs for more information. You have access to one of the many providers included in Our network of providers for Covered Services included in Your Plan. You also have access to facilities, emergency rooms, surgical centers, equipment vendors or pharmacies providing Covered Services throughout the United States and wherever You may travel. This section includes important information about this Plan, such as Your deductibles, out-of-pocket maximum and the allowed amount. CALENDAR YEAR DEDUCTIBLE A deductible is what You pay for Covered Services for each Year before this Plan provides benefits. Individual Deductible This Plan includes an individual deductible when You see in-network providers and a separate individual deductible when You see out-of-network providers. After You pay this amount, this Plan will begin paying for Your Covered Services. See the Summary of Your Costs for Your individual deductible amount. Family Deductible This Plan limits the total deductible that must be met by all family Members on this Plan. Any amount that We count toward a Member s individual deductible also counts toward the family deductible. When the family deductible is met, all individual deductibles are also met. This is true even if some Members did not meet their individual deductible. There is no family deductible for out-of-network providers. The individual and family deductibles, if any, are subject to the following: Deductibles accrue during a Year, January 1 through December 31 There is no carry over provision. Amounts credited to Your deductible during the current Year will not count toward the next Year s deductible Amounts credited to the deductible will not be more than the allowed amount Copayments are not applied to the deductible Amounts credited toward the deductible do not accrue to benefits with a dollar maximum Amounts credited toward the deductible accrue to benefits with visit limits OUT-OF-POCKET MAXIMUM Individual Out-of-Pocket Maximum This Plan includes an individual out-of-pocket maximum for Covered Services when You use innetwork providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much You pay each Year. The deductibles, Coinsurance and Copays You pay count toward this limit. After You meet the out-of-pocket maximum, benefits for Covered Services are paid at 100% of the allowed amount for the rest of that Year. Family Out-of-Pocket Maximum This Plan includes a family out-of-pocket maximum for Covered Services when You use in-network providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much Your family pays each year. The deductibles, Coinsurance and Copays Your family pay count toward this limit. After Your family meets the out-ofpocket maximum, benefits for Covered Services are provided at 100% of the allowed amount for the rest of that Year. This Plan does not include an out-of-pocket maximum for out-of-network providers. Expenses that do not apply to the individual or family out-of-pocket maximum include: Charges above the allowed amount Services above the any benefit maximum limit or durational limit Services not covered by this Plan Covered Services or benefits that do not apply to the out-of-pocket maximum. These are shown on the Summary of Your Costs. Covered Services provided by out-of-network providers Services that are not prior authorized ALLOWED AMOUNT This Plan provides benefits based on the allowed amount for Covered Services. The allowed amount is described below. Non-Emergency Services In-Network Providers The allowed amount is the fee that LifeWise has negotiated with its in-network providers for Covered Services. Out-of-Network Providers The allowed amount is the lesser of the following: 7 LifeWise Passport Silver PCP 3000 Package HVA

12 The provider s billed charge No less than 125% of the fee schedule determined by the Centers for Medicare and Medicaid Services (CMS). LifeWise will use fee schedules from CMS in setting the allowed amount. For dialysis and related services due to End Stage Renal Disease, the allowed amount will not be less than a comparable provider that has a contracting agreement with Us and no more than 90% of billed charges. If you are entitled/eligible for Medicare due to ESRD, the allowed amount is 125% of the fee schedule determined by the Centers of Medicare and Medicaid Services (Medicare). In the event CMS does not have a fee for a given service, We will request additional information from Your provider. We will evaluate this information to determine the amount that CMS would reimburse for similar Services. The allowed amount will be the lesser of that amount of the provider s billed charges. Emergency Services Consistent with the requirements of the Affordable Care Act (federal health care reform) the allowed amount will be the greater of the following: The median amount in-network providers have agreed to accept for the same Services The amount Medicare would allow for the same Services The amount calculated by the same method the Plan uses to determine payment to Out-of-Network Providers In addition to Your deductible, Copayments and Coinsurance, You will be responsible for charges received from Out-of-Network Providers above the allowed amount. If You have questions about this information, please call us at the number listed on Your LifeWise ID card. HOW PROVIDERS AFFECT YOUR COSTS You Can Benefit By Designating A Primary Care Provider We believe wellness and overall health is enhanced by working closely with one provider. Although this Plan does not require the use or selection of a primary care provider (PCP) or a referral for specialty care, We encourage You to designate a PCP at the time You enroll in this Plan and notify Us of Your selection. Selecting a PCP gives You a partner to help You manage Your care. How Do I Pay The Lowest Copay When You use Your designated PCP You will have a lower cost share than seeing other PCPs or specialists in Our network. In-network OB/GYN is always covered at the lower cost share no matter if You have selected a PCP or not. Here is an example when You select a PCP and see that PCP for a cut that needs stitches, You will pay the lower copayment amount for the office visit and will pay Your deductible and/or coinsurance for the stitching procedure. If You do not select a PCP, Your office visit copay will be the higher copayment amount. Who May I Select As My Designated PCP A designated PCP must be an in-network provider and choices include the following providers: General practice Family practice Internal medicine Pediatrics Geriatric medicine Nurse practitioners OB/GYN Physician assistants Naturopaths How To Designate A PCP You can designate any PCP in our network who is available to accept You or Your family Members. Each enrolled family member may select a different PCP. To designate a PCP, please select one from Our provider directory at lifewiseor.com or contact Customer Service by calling the phone number listed on Your LifeWise ID card. Once You have selected a PCP, call Us and We will update Your information. What If Your PCP Is Not Available If You need to see Your PCP and Your PCP is not available, You may see a PCP with the same clinic and You will only be responsible for the lower cost share, or If Your PCP is a sole practitioner, You may see a PCP that Your provider has asked to cover in their absence. You will only be responsible for the lower copay. What If I Want To Change My PCP You have the option to change Your PCP. Change requests received by the 15 th of each month take effect on the first of the next month. Requests received after the 15 th take effect on the first of the following month. Example: If We received a request on April 10 th, Your change will take effect on May 1 st ; if we receive Your request on April 20 th, Your change will take effect on June 1 st. 8 LifeWise Passport Silver PCP 3000 Package HVA

13 In-Network Providers In-network providers are networks of Hospitals, Physicians and other providers that We contract with to provide medical Services at a negotiated fee. We have in-network providers in all categories of Services, such as laboratory and x-ray Specialists and medical specialties. You benefit in two ways when You receive Covered Services from an in-network provider. Your medical bills will be reimbursed at a higher percentage (the innetwork provider benefit level), and Our in-network providers will not charge more than the allowed amount. This means that Your portion of the charges for Covered Services will be lower. Contracted Providers Who Offer Unique Services We have contracted with some health care systems to provide unique Services that are not available from Our in-network providers. We contract with these health care systems to provide covered Medical Services at negotiated fees. These unique Services will be processed at the in-network benefit level and You will not be balance billed for any charge over the Allowed Amount. Out-of-Network Providers Out-of-Network providers are providers that do not have a contract with LifeWise. Your medical bills will be reimbursed at the lower percentage (the out-ofnetwork benefit level) and the provider may bill You for charges above the allowed amount. This means that Your out-of-pocket costs will be higher because Your benefit level is lower and You will be responsible for any charges over the allowed amount. How to Select a LifeWise In-Network Provider A list of Our in-network providers is available in Our provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help You select a provider that is right for You. We update this directory regularly but it is subject to change. We suggest that You call Us for current information and to verify that Your provider, their office location or provider group is included in the LifeWise network before You get Services. The LifeWise Provider Directory is available any time on Our website at lifewiseor.com. You may also request a copy of this directory by calling Customer Service at the number located in the front of this Benefit Booklet or on Your LifeWise ID Card. The Covered Services listed below are only available from in-network providers as shown on the Summary of Your Costs. Community Wellness Other Health Education Services Prescription Drugs Preventive Care Tobacco Use Cessation Programs Transplants Care Outside the Service Area LifeWise Members have access to a nationwide network of providers when outside the Service Area. Our Service Area is Oregon. These providers will not charge You for amounts over the allowed amount, and they will submit Claims directly to us. Out of Area Members Out of area Members are Members who live outside of Our Service Area. Out of area Members include: Eligible Employees who do not live in the Service Area A Dependent who lives outside the Service Area A Dependent who is attending school outside the Service Area You or Your Employer must notify Us when You or Your Dependent moves back into the Service Area. At that time, You or Your Dependent must designate a PCP to receive the lower cost share for office visits when seeing a PCP. You may select a PCP, however, You will always pay the lower cost share when You live out of Our Service Area. The availability of these providers may vary by location. For more information on care outside the Service Area, contact Customer Service. PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION Your coverage for some Services depends on whether the Service is approved by Us before You receive it. This process is called Prior Authorization. A planned Service is reviewed to make sure it is Medically Necessary and eligible for coverage under this Plan. We will let You know in writing if the Service is authorized. We will also let You know if the Service is not authorized and the reasons why. If You disagree with the decision, You can request an appeal. See the Grievances and Appeals section or call us. There are three situations where Prior Authorization is required: Before You receive certain medical Services or 9 LifeWise Passport Silver PCP 3000 Package HVA

14 prescription drugs Before You schedule a planned admission to certain inpatient facilities When You want to receive the higher benefit level for Services You received from an out-of-network provider How to Ask for Prior Authorization This Plan has a specific list of Services that must have Prior Authorization with any provider. Before You receive Services, We suggest that You review the list of Services requiring Prior Authorization. You can get a detailed list of medical Services requiring Prior Authorization by calling Customer Service at the number on the back of Your ID card or on Our webpage at lifewiseor.com. Services From In-Network Providers: It is Your innetwork provider s responsibility to get Prior Authorization. Your in-network provider can call Us at the number listed on Your ID card to request a Prior Authorization. Services from Out-of-Network Providers: It is Your in-network provider s responsibility to get Prior Authorization for any of the Services on the Prior Authorization list when You see an out-of-network provider. You or Your out-of-network provider can call Us at the number listed on Your ID card to request a Prior Authorization. Responding to Prior Authorizations We will respond to a request for prior authorization within 2 business days of receipt of all information necessary to make a decision. If Your situation is clinically urgent (meaning that Your life or health would be put in serious jeopardy if you did not receive treatment right away), You may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after We get all information necessary to make a decision. We will provide Our decision in writing. The prior authorization will be binding to Us when related to eligibility and obtained no more than five business days before the date of service. Our prior authorization will be valid for 30 calendar days for benefit coverage and Medical Necessity determinations. This 30-day period is subject to Your continued coverage under this Plan. If You do not receive the Services within that time, You will have to ask Us for another prior authorization. Services that must be Prior Authorized The following are types of Services that required Prior Authorization. You can see the detailed list at lifewiseor.com or You can call Customer Service. The following types of Services require Prior Authorization: Planned inpatient admission into hospitals, skilled nursing facilities and rehabilitation facilities Non-emergency ground, air, or ambulance transport Transplant and donor services Injectable medications you get in a healthcare provider s office Prosthetics and orthotics other than foot orthotics or orthopedic shoes Reconstructive surgery Home medical equipment costing $500 or more Selected surgical, medical therapeutic, and diagnostic procedures Outpatient advanced imaging, such as MRI, CT and echocardiograms Some Outpatient Services. See the detailed list at Certain Prescription Drugs. See the Pharmacy section on our website at Pediatric Orthodontia Prior Authorization Penalty For Services From In-Network Providers In-network providers will get a Prior Authorization for You. You should verify with Your provider that a Prior Authorization request has been approved in writing by Us before You receive the Services. For Services From Out-of-Network Providers It is Your responsibility to get Prior Authorization for any Services on the Prior Authorization list when You see an out-of-network provider. If You do not get Prior Authorization, the Services will not be covered. The out-of-network provider can bill You and You will have to pay the total cost for the Services. Your costs for this penalty do not count toward Your Plan deductibles and out-of-pocket maximum. Services listed below are not subject to a Prior Authorization penalty: Emergency hospital admissions. See Emergency Hospital Admission Notification described below. Prescription Drugs. See Prior Authorization for Prescription Drugs described below. Non-Emergency Services from out-of-network providers. See Non-Emergency Services From Out-of-Network Providers described below. Services that must be Prior Authorized This list includes the categories of Services that require Prior Authorization. Because medical practice standards are updated and new technologies are being developed, this list may be changed. You can get a detailed list of the Services by calling us. You 10 LifeWise Passport Silver PCP 3000 Package HVA

15 can also get this list on Our website at lifewiseor.com. You can also get a list of the Prescription Drugs that need Prior Authorization in the pharmacy section on this website. We suggest that You review the list before You get Services. You or Your provider can call us at the number listed on the inside front cover of this booklet or on Your LifeWise ID Card to request a Prior Authorization. You can also call us to ask about a specific service that Your provider is planning for you. Prior Authorization for Prescription Drugs Certain Prescription Drugs must be prior authorized before You get them at a pharmacy. You or Your provider can ask for a Prior Authorization by faxing a Prior Authorization form to us. This form is on the Pharmacy section of Our website at lifewiseor.com. Ask Your provider if a new prescription requires Prior Authorization. Your provider can check with us to see if Prior Authorization is required. You may also view a list of prescription drugs that require prior authorization through the Member portal. Once You sign in, please go to My Plan Information, then go to the Pharmacy tab and click on View drugs that require prior authorization. You will also find the form that Your physician will need to complete to send to Pharmacy Services to request prior authorization. Sometimes You may not know if a drug needs Prior Authorization, for example, You may go directly from Your provider s office to the pharmacy. If You are told at the pharmacy that the drug Your provider prescribed requires prior authorization, You or Your pharmacy should call Your provider to let them know. Your provider can fax us a Prior Authorization form for review. You can buy the Prescription Drug before it is prior authorized, but You must pay the full cost. If the drug is authorized after You bought it, You can send us a Claim for reimbursement. Reimbursement will be based on the allowed amount. See the Sending Us A Claim section for details. Non-Emergency Services From Out-of-Network Providers There may be times when You want to see an out-ofnetwork provider for non-emergency Services. In some cases out-of-network benefits may be paid at in-network cost shares if the Services are medically necessary and only available from an out-of-network provider to be considered for coverage at the innetwork cost shares. You must ask for a Prior Authorization before You see the out-of-network provider. The Prior Authorization request must include the following: A statement that the out-of-network provider has unique skills that are Medically Necessary for Your care You cannot get the same care from an in-network provider. Medical records supporting Your request. If We approve Your request, the Services will be covered at the in-network cost share. In addition to Your usual cost share, You will also pay any amounts over the allowed amount. If there are in-network providers who can give You the same care, Your Prior Authorization request will not be approved. Your costs for these Services will be at the out-of-network provider cost share. Emergency Hospital Notification The following Services are not subject to Prior Authorization, but they have separate requirements. Emergency hospital admissions, including admissions for drug or alcohol detoxification. They do not require prior authorization, but You must notify Us as soon as reasonably possible. If You are admitted to an out-of-network hospital due to an emergency condition, those Services will always be covered under Your in-network cost share. We will continue to cover those Services until You are medically stable and can safely transfer to an in-network hospital. If You chose to remain at the out-of-network hospital after You are stable to transfer, coverage will revert to the out-ofnetwork benefit. We pay services based on Our allowed amount. If the hospital is non-contracted, You may be billed for charges over the allowed amount. Childbirth admission to a hospital, or admissions for newborns who need medical care at birth. They do not require prior authorization, but you must notify us as soon as reasonably possible. Admissions to an out-of-network hospital will be covered at the out-of-network cost share unless the admission was an emergency. UTILIZATION REVIEW LifeWise has developed or adopted guidelines and medical policies that outline clinical criteria used to make Medical Necessity determinations. The criteria is reviewed annually and is updated as needed to ensure Our determinations are consistent with current medical practice standards and follows national and regional norms. Practicing community doctors are involved in the review and development of Our internal criteria. You or Your provider may request a copy of the criteria used to make a Medical Necessity decision for a particular condition or procedure. To obtain the information, please send Your request to: 11 LifeWise Passport Silver PCP 3000 Package HVA

16 LifeWise Integrated Health Management Utilization Review P.O. Box 7709 Bend, OR Fax LifeWise reserves the right to deny payment for Services that are not Medically Necessary or that are considered Experimental/Investigational. A decision by LifeWise following this review may be appealed in the manner described in the Grievance and Appeals section. When there is more than one alternative available, coverage will be provided for the least costly among medically appropriate alternatives. CASE MANAGEMENT Case Management works cooperatively with You and Your doctor to consider effective alternatives to hospitalization and other high cost care. Working together We can make more efficient use of Your Plan s benefits. Your participation in a treatment plan through case management is voluntary. DISEASE MANAGEMENT LifeWise s disease management programs are designed to improve health outcomes for Members with certain chronic diseases. These programs seek to identify individuals who may benefit from such programs, and achieve the best possible therapeutic outcomes based on an assessment of the patient needs, ongoing monitoring of care, and consultation with Your primary care provider. Participation in disease management programs is voluntary. To learn more about the availability of disease management programs, contact Customer Service at the number listed on Your LifeWise ID card. CONTINUITY OF CARE You may be able to continue to receive Covered Services from a provider for a limited period of time at the in-network benefit level after the provider ends their contract with LifeWise. To be eligible for continuity of care You must be covered under this Plan, in an active treatment plan and receiving Covered Services from an in-network provider at the time the provider ends his/her contract with LifeWise. The treatment must be Medically Necessary and You and this provider agree that it is necessary for You to maintain continuity of care. We will not provide continuity of care if Your provider: Will not accept the reimbursement rate applicable at the time the provider contract terminates Retired Died No longer holds an active license Relocates out of the Service Area Goes on sabbatical Is prevented from continuing to care for patients because of other circumstances Terminates the contractual relationship in accordance with provisions of contract relating to quality of care and exhausts his/her contractual appeal rights We will not provide continuity of care if You are no longer covered under this Plan. We will notify You no later than 10 days after Your provider s LifeWise contract ends if We reasonably know that You are under an active treatment plan. If We learn that You are under an active treatment plan after Your provider s contract termination date, We will notify You no later than the 10 th day after We become aware of this fact. To receive continuity of care, You must request continuity of care from us. You can call Us at or send Your request to: LifeWise Integrated Health Management Utilization Review P.O. Box 7709 Bend, OR Fax Duration of Continuity Of Care If You are eligible for continuity of care, You will get continuity of care until the earlier of the following: The day after You complete the active course of treatment entitling You to continuity of care The 120th day after We notified You that Your provider s contract ended, or the date Your request for continuity of care was received or approved by us, whichever is earlier If You are pregnant, and become eligible for continuity of care after commencement of the second trimester of the pregnancy, You will receive continuity of care until the later of: The 45th day after the birth As long as You continue under an active course 12 LifeWise Passport Silver PCP 3000 Package HVA

17 of treatment, but no later than the 120th day after We notified You that Your provider s contract ended, or the date Your request for continuity of care was received or approved by us, whichever is earlier When continuity of care terminates, You may continue to receive Services from this same provider, however, We will pay benefits at the out-of-network benefit level subject to the allowed amount. Please refer to the How Providers Affect Your Costs for an illustration about benefit payments. If We deny Your request for continuity of care, You may request an appeal of the denial. Please refer to the section titled Grievance and Appeals for information on how to submit a grievance review request. COVERED SERVICES This section describes the Services this Plan covers. Covered Service means Medically Necessary Services (see Definitions) and specified preventive care Services You get when You are covered for that benefit. This Plan provides benefits for Covered Services only if all of the following are true when You get the Services: The reason for the Service is to prevent, diagnose or treat a covered Illness, disease or injury The Service takes place in a Medically Necessary setting. This Plan covers Inpatient care only when You cannot get the Services in a less intensive setting. The Service is not excluded The provider is working within the scope of their license or certification This Plan may exclude or limit benefits for some Services. See the specific benefits in this section and the Exclusions section for details. Benefits for Covered Services are subject to the following: Copays Deductibles Coinsurance Benefit limits Prior Authorization. Some Services must be authorized in writing by Us before You get them. These Services are identified in this section. For more information see the Prior Authorization and Emergency Admission Notification section. Medical and payment policies. The plan has policies used to administer the terms of the plan. Medical policies are generally used to further define medical necessity or investigational status for specific procedures, drugs, biologic agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Centers for Medicare and Medicaid Services (CMS). Our policies are available to you and your provider at or by calling Customer Service. If You have any questions regarding Your benefits and how to use them, call Customer Service. Call Us at the number listed on the inside cover of this booklet or on the back of Your LifeWise ID card. COMMON MEDICAL SERVICES The Services listed in this section are covered as shown on the Summary of Your Costs. Please see the Summary of Your Costs for Your Copays, deductible, Coinsurance and benefit limits. OFFICE AND CLINIC VISITS This Plan covers professional office and home visits. The visits can be for examination, consultation and diagnosis of an Illness or injury by Your primary care provider or a specialist. Some Outpatient Services You get from a specialist must be prior authorized. See the Prior Authorization and Emergency Admission Notification section for details. Primary Care Visits For this Plan, primary care providers include general practice, family practice, internal medicine, pediatric, geriatric and obstetrical and gynecology (OB/GYN) Physicians, nurses, nurse practitioners and Physician assistants; and naturopaths. Specialist Visits For this Plan, specialist includes providers such as surgeons, anesthesiologists, psychologists, psychiatrists. You may have to pay a separate Copay or Coinsurance for other Services You get during a visit. This includes Services such as x-rays, lab work, therapeutic injections and office surgeries. PREVENTIVE CARE This Plan covers preventive care as described below. Covered Services include preventive care Services with a rating of A or B set by the United States Preventive Task Force; immunizations recommended by the Centers for Disease Control and Prevention and as required by state law; and preventive care and screening recommended by the Health Resources and Services Administration (HRSA). 13 LifeWise Passport Silver PCP 3000 Package HVA

18 These Services have limits on how often You should get them. These limits are based on Your age and if You are a male or female. Some of the Services You get as part of a routine exam may not meet these guidelines. You can get a complete list of the preventive care Services with these limits on Our website at lifewiseor.com or call Us at the number listed on the front cover for a list. You may also review the federal guidelines at uspsabrecs.htm and This list may be changed as required by law. Covered Services include: Routine exams and well-baby care. Exams for school, sports and employment are also covered. Women s pelvic exam. Pap smear and clinical breast exams. Mammograms. See Diagnostic Lab, X-ray and Imaging for mammograms needed because of a medical condition. Pregnant women s Services such as breast feeding counseling before and after delivery and maternity diagnostic screening, diabetic supplies from conception to six weeks postpartum. Electric breast pumps and supplies. Includes the purchase of a non-hospital grade breast pump or 12-month rental of a hospital grade breast pump. The cost of the rental cannot be more than the purchase price. Prostate cancer screening. Includes digital rectal exams and prostate-specific antigen (PSA) tests. Colon cancer screening. Includes exams, colonoscopy, sigmoidoscopy, double contrast barium enemas, removal of polyps in the colon and fecal occult blood tests Outpatient lab and radiology for preventive screening and tests Routine immunizations and vaccinations as recommended by Your Physician. You can also get flu shots, flu mist, and immunizations for shingles, pneumonia and Pertussis at a pharmacy or other center. Contraceptive management. Includes exams, treatment You get at Your provider s office, emergency contraceptives, supplies and devices. Tubal ligation and vasectomy are also covered. See Prescription Drugs for prescribed oral contraceptives and devices. Health education and training for covered conditions such as diabetes, high cholesterol and obesity. Includes Outpatient self-management programs, training, classes and instruction. Nutritional therapy. Includes Outpatient visits with a Physician, nurse, pharmacist or registered dietitians. The purpose of the therapy must be to manage a chronic disease or condition such as diabetes, high cholesterol and obesity. Preventive drugs required by federal law. See Prescription Drugs. Approved tobacco use cessation programs recommended by Your Physician. After You have completed the program, please provide Us with proof of payment and a completed reimbursement form. You can get a reimbursement form on Our website at lifewiseor.com. See Prescription Drugs for covered drug benefits. Fall prevention age 65 or older This benefit does not cover: Charges for Services that do not meet federal guidelines. This includes Services provided more often that the guidelines allow. Oral prescription contraceptives dispensed and billed by Your provider or a Hospital Over the counter (OTC) drugs, contraceptive foams, jellies, sponges or condoms Gym memberships or exercise classes and programs Inpatient newborn exams while the child is in the Hospital following birth. See Maternity and Newborn for those Covered Services. Facility charges. When You get preventive care at a hospital based clinic or Physician s office, You must pay Your deductible and Coinsurance for the facility charges. See Hospital for those costs. Lab and Pathology Services for colonoscopy or sigmoidoscopy. See Diagnostic Lab, X-ray and Imaging. Physical exams for basic life or disability insurance Work-related disability evaluations or medical disability evaluations PEDIATRIC CARE This Plan covers dental, hearing and vision Services for covered children. A child under age 19 is eligible for these Services as stated on the Summary of Your Costs, unless otherwise stated below. Vision Exams and Glasses This Plan covers routine eye exams and glasses and includes the following: Vision exams by an ophthalmologist or an optometrist. A vision analysis may consist of external and ophthalmoscope examination, determination of the best corrected visual acuity, 14 LifeWise Passport Silver PCP 3000 Package HVA