2011 Group Product Reference Guide (for plans effective Sept. 23, 2010 or later)

Transcription

1 A guide to group products from BlueCross BlueShield of Tennessee and its preferred vendors 2011 Group Product Reference Guide (for plans effective Sept. 23, 2010 or later)

2 Plans described in this booklet are the standard options offered to fully-insured groups with employees. Larger groups may elect non-standard benefits. Please ask your BlueCross BlueShield of Tennessee sales executive or account executive for assistance in customizing benefits for large employer groups. To become an authorized agent for BlueCross BlueShield of Tennessee, please contact the sales director in your region. Call Toll Free: East Tennessee Jeff Price ext or (423) Middle Tennessee Sheila Cook ext or (615) West Tennessee John Maki ext or (901) Lake Dyer Lauderdale Tipton Obion Crockett Haywood Gibson Weakley Carroll Henry Henderson Madison Chester Decatur Shelby Fayette Hardeman McNairy Hardin Macon Clay Stewart Montgomery Robertson Sumner Claiborne Scott Hawkins Campbell Fentress Jackson Overton Houston Union Smith Greene Dickson Davidson Wilson Putnam Morgan Anderson Jefferson Knox Humphreys DeKalb White Cumberland Cocke Williamson Roane Sevier Hickman Loudon Blount Perry Warren Maury Rhea Lewis Bedford Coffee Monroe Grundy McMinn Benton Cheatham Wayne Lawrence Giles Marshall Rutherford Lincoln Moore Trousdale Cannon Franklin Marion Van Buren Sequatchie Pickett Bledsoe Meigs Hamilton Bradley Polk Grainger Hancock Hamblen Was hington Sullivan Unicoi Carter Johnson

3 Table of Contents Table of Contents Why Choose BlueCross BlueShield of Tennessee? 2 Provider s 3 The Well+Wise Member Experience 4 Traditional PPO Plans 6 Copay PPO Plans 8 Smart Consumer Plans 10 Consumer-Directed Health Care Plans 11 Account Options for High-Deductible Health Plans 12 Prescription Drug Plans 16 Behavioral Health Riders 21 DentalBlue Plans 22 VisionBlue Plans 32 Vision Riders 35 Other Available Riders 36 Ancillary Coverage from Preferred Vendors 37 1

4 Why Choose BlueCross BlueShield of Tennessee? Brand Strength BlueCross BlueShield of Tennessee has more than 60 years of experience in delivering health care solutions as an independent, not-for-profit affiliate of the BlueCross BlueShield Association. No other insurer comes close to BlueCross BlueShield in providing quality, value and access. One in three Americans carry a BlueCross member ID card; while 90 percent of Fortune 10 companies and 76 percent of Fortune 500 companies choose BlueCross for their health care coverage. Broad Product Portfolio We offer a broad product portfolio that includes coverage for medical, dental, vision, pharmacy, behavioral health, COBRA administration, multiple funding options and only one monthly bill, so that any group can offer a comprehensive benefit package with a single member ID card. Flexibility You want flexibility and we allow you to customize plans by matching hundreds of benefit combinations with multiple provider networks and options for employer and employee contributions. Our plans can be structured for almost any size group with fully-insured or self-funded financial arrangements. Expertise in Plan Design Every group is unique and each one has certain needs for their business. Our expertise and ability to create a benefit plan that is specifically tailored to meet those needs is what further sets us apart as a health solutions company. Local Relationships, National Capabilities We are a Tennessee company with national capabilities. Our presence in communities across the state gives us the advantage of strong relationships with providers who collaborate with us to develop medical policies, quality criteria and clinical programs, including patient-centered medical homes. At the same time, we are part of the BlueCross BlueShield Association, which gives members access to national programs and networks like BlueCard PPO and Blue Distinction Centers of Excellence. Affordability Controlling costs is more important than ever for businesses. We continue to develop cost-effective products, like Smart Consumer and Consumer-Directed Health Plans to meet this demand. We also work with providers to create cost and quality transparency initiatives, develop pay for performance programs and offer deep discounts. 2

5 A Choice of Provider s Strong Provider s BlueCross has the most comprehensive network of leading providers, with full representation of all core specialties both in Tennessee and throughout the nation. We provide a unique range of physicians, hospitals and surgical facilities within our three provider networks, the largest in Tennessee. We can even provide a network analysis for your group if necessary. Groups and members can find the closest network health care providers with the Find a Doctor tool at bcbst.com. Blue P P, our flagship network, was designed to offer broad access to credentialed practitioners, hospitals and other health care providers, while offering very competitive discounts. Blue S Like P, the S provider network is based on a variety of credentialed practitioners, hospitals and other health care providers, but has a more narrow focus on access to create stronger network discounts. Blue K K helps groups deliver a lower cost health plan option by offering a limited network of credentialed practitioners, hospitals and other health care providers. Blue K was constructed with the goal of maximizing efficiency and obtaining the most cost effective network possible in major metropolitan areas. Note: K was built around medical centers in major metropolitan areas and members may be required to travel greater distances to receive in-network care BlueCard = Peace of Mind Members who live, travel or have children attending school beyond the borders of Tennessee, have peace of mind in knowing that our coverage goes with them as part of our BlueCard program. Nationwide, more than 96 percent of hospitals and 90 percent of physicians contract with BlueCross BlueShield companies more than any other insurer. Our national network is built around local market needs; which provides access to a broad, competitive network of providers across the country. Member Name CHRIS B HALL Member ID ZEB Group No Subgroup 0001 RXBIN RXGRP T138359U BLUE NETWORK: P RX04 Medical/Dental Copayments: Office Visit 25 Inpatient 500 ER: 75 RX $10/$20/$35 3

6 Well+Wise The Well+Wise Member Experience BlueCross BlueShield of Tennessee is committed to being more than just a health plan by giving members a health care experience that guides and supports personal wellness and health needs. Well+Wise provides healthy solutions for our members. It brings together wellness-related services, programs and resources, that can help members make positive steps toward better health and more informed choices about health care quality and spending. Well+Wise is part of every fully-insured plan and is available for self-funded plans as well. Valuable Preventive Care Coverage To help maintain member health, the following are included as part of every fully-insured plan: Well-woman exams Mammograms Well-child care and immunizations Prostate cancer screenings Flu immunizations Annual preventive health exams Immunizations Colorectal cancer screenings Health & Wellness Programs with Incentives Health Coaching Wellness Plans, including Walking Works, pedometers, on-site clinical health meetings Fully-funded incentives for members that engage in wellness (fully-insured groups) 4

7 Well+Wise programs and resources include: Engaging Education. Tools and information help members choose doctors based on quality, track health care costs, support good preventive care and more: Online health tools Personal health statement Preventive reminders Health resource library Educational videos Living Well. Wellness support helps members take charge of their health care, understand their health risks and take positive steps to improve health: 24/7 nurseline Lifestyle coaches Health coaches Biometric screenings Preventive health guides Personal health analysis WalkingWorks programs Caring Solutions. Programs to help members navigate the health care system as part of their disease management program, teaming with a member s physician to support informed choices, with: Chronic condition health coaching Preference-sensitive health coaching Care coordination Case management Pharmacy guidance Behavioral health programs Maternity support programs BluePerks. Exclusively for members, the BluePerks discount program features savings of up to 50 percent on health-related products and elective services typically not covered by health or dental plans like: fitness memberships, prescription discounts, massages, vision care, cosmetic surgeries and more. 5

8 Traditional PPO Plans The traditional PPO uses deductibles and coinsurance for plan benefits, with an optional office visit copay. OV Copay OV Copay ($100-$1,000 ded) ($1,500, $2,000, $2,500 and $5,000 ded) In- Out-of- Providers [2] In- Out-of- Providers [2] Annual Deductible Individual See Deductible/OOP Chart 2x In- selection See Deductible/OOP Chart 2x In- selection Family 2x individual 2x selection above 2x individual 2x selection above Annual Out-of-Pocket Maximum Amount Individual See Deductible/OOP Chart 3x In- selection See Deductible/OOP Chart 3x In- selection Family 2x individual 3x In- family OOP 2x individual 3x In- family OOP Dependent Age Limit To age 26 To age 26 Pre-Existing Waiting Period [1] 12 months 12 months 4th Quarter Deductible Carryover Provision Optional Optional Benefits for Covered Services In-network Out-of-network In-network Out-of-network Practitioner Office Services Office Visits $10, $15, $20, $25, $30 or $35 Copay or $15/$30, $15/$35, $20, $25, $30 or $35 Copay or $20/$35, $20/$40, $25/$40, $20/$35, $20/$40, $25/$40, $25/$45, $25/$50, $30/$45, $25/$45, $25/$50, $30/$45, $30/$50 Split Copays [3] $30/$50 Split Copays [3] Office Surgery [5] Routine Diagnostic Laboratory, X-ray & Injections No Additional Copay No Additional Copay Advanced Radiological Imaging [4] [6] Preventive Health Care Services Well-Child Care, under age 6 100% 100% Annual Well-Woman Exam 100% 100% Annual Mammography Screening % 100% Annual Cervical Cancer Screening 100% 100% Annual Prostate Cancer Screening % 100% Immunizations 100% 100% Well Care Services Age 6+ (includes annual exam, periodic 100% 100% colorectal cancer screening) Services Received at a Facility Inpatient Services [4] Outpatient Surgery [5] or 100% (no deductible) or 100% (no deductible) Routine Diagnostic Services 100% 100% Advanced Radiological Imaging [4][6] Other Outpatient Services [7] Emergency Care Services [8] or $250 Copay Same as In- or $250 Copay Same as In- Skilled Nursing Facility & Rehabilitation Facility Services [4] Limited to 60 days combined Medical Equipment Durable Medical Equipment Prosthetics Orthotic Appliances Therapeutic Services [9] Therapy (Limited to visits per therapy type per year) Home Health Services [10] Limited to 60 visits per year Hospice Services 100% 100% Ambulance Service Same as In- Same as In- Provider Administered Specialty Drugs Varies based on RX plan Varies based on RX plan 6

9 In- Out-of- [2] Deductible $100 $1,000 $1,500 $2,000 $2,500 Out of Pocket (OOP) Options See Deductible/OOP Chart 2x individual See Deductible/OOP Chart 2x individual 2x In- selection 2x selection above 3x In- selection 3X In- family OOP To age months Optional $250 $1,000 $1,500 $2,000 $2,500 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $4,000 $750 $1,000 $1,500 $2,000 $2,500 $3,000 $4,000 $1,000 $1,000 $1,500 $2,000 $2,500 $3,000 $4,000 $1,500 $1,500 $2,000 $2,500 $3,000 $4,000 $5,000 $6,000 $8,000 $2,000 $2,000 $2,500 $3,000 $4,000 $5,000 $6,000 $8,000 $2,500 $2,500 $3,000 $4,000 $5,000 $6,000 $8,000 $3,000 $3,000 $4,000 $5,000 $6,000 $8,000 $4,000 $4,000 $5,000 $6,000 $8,000 $5,000 $5,000 $6,000 $8,000 OOP selection must be equal to or greater than the deductible. Each plan has 70, 80 & 90 percent coinsurance options. 100% Same as In- 100% Same as In- Varies based on RX plan Coinsurance Options In- Out-of- [2] 70% 50% 80% 60% 90% 70% Notes: 1. HIPAA regulations apply. A group enrollee s pre-existing condition waiting period can be reduced by the enrollee s applicable creditable coverage. (Pre-existing condition does not apply to members under age 19.) 2. Out-of-network benefit payment based on BlueCross BlueShield of Tennessee s maximum allowable charge. The member is responsible for paying any amount exceeding the maximum allowable charge. 3. Split copays - Lower copay applies to family practice, general practice, internal medicine, OB/Gyn, pediatrics, nurse practitioner and physician assistant. 4. Services require prior authorization. Benefits will be reduced for services received from network providers outside Tennessee and all out-of-network providers when prior authorization is not obtained. 5. Surgeries include incisions, excisions, biopsies, injection treatments, fracture treatments, applications of casts and splints, sutures and invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy and endoscopy). Colorectal cancer screening covered at 100%. 6. CAT scans, PET Scans, MRIs, nuclear medicine, and other similar technologies. 7. Includes services such as chemotherapy, radiation therapy and renal dialysis. 8. Emergency Room services include all services in conjunction with ER visit, except advanced radiological imaging. Copay waived if admitted. 9. Physical, speech, manipulative, and occupational therapies are limited to 20 visits per therapy type per annual benefit period. Cardiac and pulmonary rehabilitation therapies are limited to 36 visits per therapy type per annual benefit period. 10. Requires prior authorization. 7

10 Copay PPO plans offer members predictable medical expenses through set copay amounts for covered services and no in-network deductibles. 8 Copay PPO Plans 10/100/70 10/200/60 15/400/70 In-network Out-of-network [3] In-network Out-of-network [3] In-network Out-of-network [3] Annual Deductilble Individual None $250 None $300 None $400 Family None $500 None $600 None $800 Annual Out-of-Pocket Maximum Amount Individual $1,250 [1] $2,500 $1,500 [1] $3,000 $2,000 [1] $4,000 Family $2,500 [1] $5,000 $3,000 [1] $6,000 $4,000 [1] $8,000 Dependent Age Limit To age 26 To age 26 To age 26 Pre-Existing Waiting Period [2] 12 months 12 months 12 months 4th Quarter Deductible Carryover Provision Included Included Included Benefits for Covered Services In-network Out-of-network In-network Out-of-network In-network Out-of-network Practitioner Office Services Office Visits $10 Copay $10 Copay $15 Copay Maternity Office Visits $10 Copay (1st visit only) $10 Copay (1st visit only) $15 Copay (1st visit only) 70% after Deductible 60% after Deductible Routine X-ray & Labs No Additional Copay No Additional Copay No Additional Copay 70% after Deductible Advanced Radiological Imaging [1] [4] [6] $50 Copay $50 Copay $50 Copay Preventive Health Care Services Well-Child Care $0 Copay $0 Copay $0 Copay Annual Well-Woman Exam $0 Copay $0 Copay $0 Copay Annual Mammography Screening 40+ $0 Copay $0 Copay $0 Copay Annual Cervical Cancer Screening $0 Copay $0 Copay $0 Copay Annual Prostate Cancer Screening 50+ $0 Copay 70% after Deductible $0 Copay 60% after Deductible $0 Copay 70% after Deductible Immunizations $0 Copay $0 Copay $0 Copay Well Care Services Age 6+ (includes annual exam, periodic $0 Copay $0 Copay $0 Copay colorectal cancer screening) Services Received at a Facility [1] [4] Inpatient Services $100 Copay per admission $200 Copay per admission $400 Copay per admission Outpatient Surgery [1] [5] $75 Copay $100 Copay $200 Copay 70% after Deductible 60% after Deductible Routine Diagnostic Services $0 Copay $0 Copay $0 Copay 70% after Deductible Advanced Radological Imaging [1] [4] [6] $50 Copay $50 Copay $50 Copay Other Outpatient Services [1] [7] $0 Copay $0 Copay $0 Copay Emergency Care Services [1] [8] $100 Copay $100 Copay $100 Copay $100 Copay $100 Copay $100 Copay Medical Equipment Durable Medical Equipment [1] $50 Annual Copay $50 Annual Copay $50 Annual Copay Prosthetics $50 Annual Copay 70% after Deductible $50 Annual Copay 60% after Deductible $50 Annual Copay 70% after Deductible Orthotic Appliances $50 Annual Copay $50 Annual Copay $50 Annual Copay Therapeutic Services [9] Therapy (Limited to visits per therapy type per year) $15 Copay 70% after Deductible $20 Copay 60% after Deductible $20 Copay 70% after Deductible [1] [4] Skilled Nursing Facility & Rehabilitation Facility Services Limited to 60 days combined $0 Copay 70% after Deductible $0 Copay 60% after Deductible $0 Copay 70% after Deductible Home Health Services [10] Limited to 60 visits per year $0 Copay 70% after Deductible $0 Copay 60% after Deductible $0 Copay 70% after Deductible Hospice Services $0 Copay 70% after Deductible $0 Copay 60% after Deductible $0 Copay 70% after Deductible Ambulance Services [1] $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay Provider Administered Specialty Drugs Varies based on Rx Plan 70% after Deductible Varies based on Rx Plan 60% after Deductible Varies based on Rx Plan 70% after Deductible Notes: 1. The following copays apply to the in-network out-of-pocket maximum: inpatient services, outpatient surgery, advanced radiological imaging, emergency care services, ambulance service and durable medical equipment. 2. HIPAA regulations apply. A group enrollee s pre-existing condition waiting period can be reduced by the enrollee s applicable creditable coverage. (Pre-existing condition does not apply to members under age 19.) 3. Out-of-network benefit payment based on BlueCross BlueShield of Tennessee s maximum allowable charge. The member is responsible for paying any amount exceeding the maximum allowable charge. 4. Services require prior authorization. Benefits will be reduced to 50% for services received from network providers outside Tennessee and all out-of-network providers when prior authorization is not obtained.

11 20/500/60 25/750/60 30/1000/60 35/1200/60 In-network Out-of-network [3] In-network Out-of-network [3] In-network Out-of-network [3] In-network Out-of-network [3] None $500 None $750 None $1,000 None $1,500 None $1,000 None $1,500 None $2,000 None $3,000 $2,000 [1] $5,000 $2,500 [1] $6,000 $3,000 [1] $7,500 $3,500 [1] $10,000 $4,000 [1] $10,000 $5,000 [1] $12,000 $6,000 [1] $15,000 $7,000 [1] $20,000 To age 26 To age 26 To age 26 To age months 12 months 12 months 12 months Included Included Included Included In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network $20 Copay $25 Copay $30 Copay $35 Copay $20 Copay (1st visit only) $25 Copay (1st visit only) $30 Copay (1st visit only) $35 Copay (1st visit only) 60% after Deductible 60% after Deductible 60% after Deductible No Additional Copay No Additional Copay No Additional Copay No Additional Copay $50 Copay $75 Copay $100 Copay $125 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay 60% after Deductible 60% after Deductible $0 Copay $0 Copay $0 Copay $0 Copay $500 Copay per admission $750 Copay per admission $1,000 Copay per admission $1,200 Copay per admission $250 Copay $400 Copay $500 Copay $600 Copay $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $50 Copay $75 Copay $100 Copay $125 Copay $0 Copay $0 Copay $0 Copay $0 Copay $100 Copay $100 Copay $125 Copay $125 Copay $125 Copay $125 Copay $125 Copay $125 Copay $50 Annual Copay $50 Annual Copay $50 Annual Copay $50 Annual Copay $50 Annual Copay 60% after Deductible $50 Annual Copay 60% after Deductible $50 Annual Copay 60% after Deductible $50 Annual Copay $50 Annual Copay $50 Annual Copay $50 Annual Copay $50 Annual Copay 60% after Deductible $20 Copay 60% after Deductible $25 Copay 60% after Deductible $30 Copay 60% after Deductible $35 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $0 Copay 60% after Deductible $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay $50 Copay Varies based on Rx Plan 60% after Deductible Varies based on Rx Plan 60% after Deductible Varies based on Rx Plan 60% after Deductible Varies based on Rx Plan 60% after Deductible 5. Surgeries include incisions, excisions, biopsies, injection treatments, fracture treatments, applications of casts and splints, sutures and invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy and endoscopy). Colorectal cancer screening covered at 100%. 6. CAT scans, PET Scans, MRIs, nuclear medicine, and other similar technologies. 7. Includes services such as chemotherapy, radiation therapy and renal dialysis. 8. Copayments are waived if patient is admitted to the hospital. Emergency care services include all services in conjunction with ER visit. 9. Physical, speech, manipulative, and occupational therapies are limited to 20 visits per therapy type per annual benefit period. Cardiac and pulmonary rehabilitative therapies are limited to 36 visits per therapy type per annual benefit period. 10. Requires prior authorization. 9

12 Smart Consumer Plans In-network $500/$1,500 $750/$2,250 $1,000/$3,000 $1,500/$4,500 $2,000/$6,000 $2,500/$7,500 $3,000/$9,000 $4,000/$12,000 $5,000/$15,000 Annual Deductible (Note: Out-of-network deductibles are 2x in-network deductibles) Individual $500 $750 $1,000 $1,500 $2,000 $2,500 $3,000 $4,000 $5,000 Family $1,000 $1,500 $2,000 $3,000 $4,000 $5,000 $6,000 $8,000 $10,000 Annual Out-of-Pocket Maximum Amount (Note: Out-of-network OOP amounts are 3x in-network amounts) Individual $1,500 $2,250 $3,000 $4,500 $6,000 $7,500 $9,000 $12,000 $15,000 Family $3,000 $4,500 $6,000 $9,000 $12,000 $15,000 $18,000 $24,000 $30,000 Dependent Age Limit To age 26 Pre-Existing Condition Waiting Period [1] 12 months 4th Quarter Deductible Carryover Provision Optional Benefits for Covered Services In-network Out-of-network [2] Practitioner Office Services Office Visits 70% (NOT subject to deductible) [10] Office Surgery [4] 70% after deductible 50% after deductible Routine Diagnostic Laboratory, X-ray & Injections 70% (not subject to deductible) [10] [3] [5] Advanced Radiological Imaging $200 copay per service Preventive Health Care Services Well-Child Care, under age 6 Annual Well-Woman Exam Annual Mammography Screening % 50% after deductible Annual Cervical Cancer Screening Annual Prostate Cancer Screening 50+ Immunizations, under age 6 Well Care Services Age 6+ (includes annual exam, periodic colorectal cancer screening Services Received at a Facility Inpatient Services [3] $250 copay, then 70% after deductible 50% after deductible Outpatient Surgery [4] 70% after deductible 50% after deductible Outpatient Routine Diagnostic Services 70% (NOT subject to deductible) [10] 50% after deductible Advanced Radiological Imaging [3] [5] $200 copay per service 50% after deductible Other Outpatient Services [6] 70% after deductible 50% after deductible Emergency Care Services [7] $500 copay $500 copay Emergency Care Advanced Radiological Imaging $200 copay per service $200 copay per service Skilled Nursing/Rehab Facility [3] 70% after deductible 50% after deductible (Limited to 60 days combined per year) Medical Equipment Durable Medical Equipment Prosthetics 70% after deductible 50% after deductible Orthotic Appliances Therapeutic Services [8] Therapy (Limited to visits per therapy type per year) 70% after deductible 50% after deductible Home Health Services [9] Limited to 60 visits per year 70% after deductible 50% after deductible Hospice Services 100% 50% after deductible Ambulance Service 70% after deductible 70% after deductible Provider Administered Specialty Drugs Varies based on Rx plan 50% after deductible Prescription Drugs All Standard Pharmacy options available Behavioral Health 20/25 plan or Unlimited/Parity Plan Notes: 1. HIPAA regulations apply. A group enrollee s pre-existing condition waiting period can be reduced by the enrollee s applicable creditable coverage. (Pre-existing condition does not apply to members under age 19.) 2. Out-of-network benefit payment based on BlueCross BlueShield of Tennessee s maximum allowable charge. The member is responsible for paying any amount exceeding the maximum allowable charge. 3. Services require prior authorization. Benefits will be reduced to 40% for services received from network providers outside Tennessee and all out-of-network providers when prior authorization is not obtained. 4. Surgeries include incisions, excisions, biopsies, injection treatments, fracture treatments, applications of casts and splints, sutures and invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy and endoscopy). Colorectal cancer screening covered at 100%. 5. CAT scans, PET Scans, MRIs, nuclear medicine, and other similar technologies. 6. Includes services such as chemotherapy, radiation therapy and renal dialysis. 7. Emergency care services include all services in conjunction with ER visit except Advanced Radiological Imaging. Copay waived if admitted. 8. Physical, speech, manipulative, and occupational therapies are limited to 20 visits per therapy type per annual benefit period. Cardiac and pulmonary rehabilitation therapies are limited to 36 visits per therapy type per annual benefit period. 9. Requires prior authorization. 10. Applies to out-of-pocket maximum. 10

13 Consumer-Directed Health Care (CDHC) Empowering Consumers for Smarter Spending and Better Care Consumer-Directed Health Plans help control health plan costs by giving employers choices that let them control the amount set aside for employee benefits. Employees have choices, too, and the flexibility to use their medical dollars wisely with the added support of consumer coaches and online consumer health tools that provide transparency to compare medical cost, quality and value. CDHC Financial Arrangements Three types of financial arrangements can be coupled with a High-Deductible Health Plan (HDHP) - a Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or Flexible Spending Account (FSA). Pre-tax and tax-deductible dollars contributed to these arrangements can be used for IRS-approved qualified medical expenses such as copays, deductibles, coinsurance and prescriptions. Financial Arrangement Facts HSA Groups and employees may contribute to the account. Employees own these funds and can take them from job to job. These funds roll over annually and earn interest tax-free. HRA Employers own these arrangements, and only groups can contribute. Groups determine the amounts and the reimbursable expenses. Groups determine payment order (Employee pays first, HRA pays first, etc.) Groups maintain available assets to cover potential expenses. FSA Employees contribute funds through pre-tax payroll deductions. Any PPO plan can accompany this financial arrangement Funds do not rollover annually and are not portable. Consumer Coaches To help members better understand the details of HDHPs, HSAs, HRAs and FSAs, we have a special support center of Consumer Coaches. These benefit experts can assist employees with HDHP specifics, financial plan details, IRS requirements, as well as online consumer tools and resources. Integrated HRA & FSA Solutions Integrated HRA & FSA Solutions Any health plan benefit design can be offered with an HRA or FSA. BlueCross BlueShield of Tennessee s HRA and FSA solutions provide employer- and employee-focused solutions with our integrated processes. As part of our commitment to consumerism, our HRAs and FSAs are now integrated through our claims processing system, which allows a seamless experience for groups and their employees. (Certain restrictions apply.) 11

14 Account Options for High-Deductible Health Plans HDHP Account Options Chart There are three types of financial arrangements that can be combined with a high-deductible health plan (HDHP). Pre-tax and tax-deductible dollars that are part of these arrangements can be used for qualified medical expenses such as deductibles, copays, coinsurance and prescriptions. Some can be used to pay additional expenses, such as dental expenses, vision care, long-term care insurance premiums, COBRA premiums and more. HSA account balances remain tax-free as long as they are used for health care related expenses. Funds can be used for other purposes, but may be subject to income taxes and tax penalties. Each type of financial arrangement is unique in its design, administration and use. But all are easy to set up and easy for employees to use. Account Features Account Overview Availability Health Plan Requirements Eligibility Reimbursement Method Contributions HSA Tax-exempt trust or account created to pay for qualified medical expenses of the account holder and his/her spouse/dependents. Groups with 2+ employees For 2011, a qualified HDHP with a minimum annual deductible of $1,200/$2,400. The 2011 maximum out-of-pocket limits are $5,950/$11, Someone who is enrolled in a qualified HDHP*. 2. Has no other health plans in place, other than for Workers Compensation, specific disease or illness, accidents, dental care, vision care or long-term care. 3. Is NOT enrolled in Medicare (can be eligible for Medicare). 4. Is not claimed as a dependent on someone else s tax return. Debit Card or Check Account holders and/or the Employer may contribute. For 2011, the maximum contribution is $3,050/$6,150. The catch-up contribution for those 55 or older is $1,000. Claim Substantiation Employee is required to maintain supporting tax records * Note: Self-employed, partners and those who own more than 2% stock in an S-Corporation (including their spouses and family members) are not generally considered employees and cannot receive pre-tax employer contributions to their Health Savings Accounts. Self-employed can only take an above-the-line deduction for their premium and HSA contribution. Regardless of how the S-Corporation or LLC is structured, the company cannot make pre-tax contributions to owners, shareholders, or partners. Please seek legal tax advice with any other questions. Reimburseable Expenses Account Pre-Funding by Employer Employer Funding/ Banking Requirements Carryover from Year to Year Tax Status Portability Withdrawals for Non-qualified Expenses Interest Subject to COBRA All Section 213(d) expenses not covered by any other health plan except for non-prescribed over-the-counter medications. (plus insurance premiums for COBRA, Medicare and Long-Term Care Insurance). At the discretion of the Employer At the discretion of the HSA Administrator Yes Employee contributions are tax-deductible and employer contributions are excludable from gross income and not subject to employment taxes. Employers are not subject to FICA contributions. Once the money is deposited into the account, it is owned by the account holder. Funds not used to pay for qualified medical expenses may be withdrawn but are taxed and are subject to an additional 20% tax penalty except when an individual is 65 or older, disabled or has died during the year. Interest accrues without a tax penalty. No 12

15 HRA An employer funded account used to reimburse employees for covered medical expenses. Groups with 2+ employees Typically provided along with HDHP s, but can be coupled with PPO plans that exclude 4th quarter deductible carryover. With the automatic reimbursement method, the HRA funding follows the medical deductible methodology. Embedded (per-person) medical deductibles are paired with embedded HRAs with a maximum family payout. Shared medical deductibles are paired with shared HRAs. With the debit card reimbursement method, the HRA reimburses on a shared basis regardless of the deductible type (i.e. shared or embedded) because the debit card swipes cannot differentiate between the family members. FSA A cafeteria plan created to reimburse qualified medical expenses or dependent care expenses. Groups with 2+ employees No corresponding health plan requirement. An employee whose employer offers an HRA, regardless of the number of employees and to COBRA qualified beneficiaries. Not to self-employed. HRAs are not available to partners or spouses in a partnership, shareholders, and those who own more than 2% stock in a Sub S Corporation, and members of an LLC. An employee whose employer offers an FSA option. Employers may also create a Dependent Care Account for qualifying dependents. (Non-discrimination rules apply.) Automatic Reimbursement or Debit Card Only the employer may contribute to an HRA. There are no limits to the amount. BlueCross BlueShield of Tennessee requires 100% substantiation (EOB, receipts, etc.- auto reimbursement is considered substantiation) Health plan expenses determined by Employer (i.e., deductible, coinsurance and/or copays) Not required. Employer funded via ACH Debit Available Employer contributions are excludable from an employee s gross income and are a business expense deduction for HRA payments. At the discretion of the Employer Automatic Reimbursement or Debit Card An employee, employer or both may contribute to an FSA. There are no limits to contributions, however, employers typically set the limit. The maximum annual contribution for Dependent Care Accounts is $5,000 for individuals filing taxes jointly or $2,500 for individuals filing taxes separately. BlueCross BlueShield of Tennessee requires 100% substantiation (EOB, receipts, etc.- auto reimbursement is considered substantiation) All Section 213(d) expenses not covered by any other health plan except for non-prescribed over-the-counter medications. (NO insurance premiums). Not required. Employer funded via ACH Debit No. A 2 1/2 month grace period is available at Employer discretion. This allows participants another 75 days after the end of the plan year to incur expenses to deplete their previous plan year balance. Employees are not subject to Federal, Social Security, or in most states, state taxes on contributions to an FSA. Employers are not subject to FICA or unemployment taxes on FSA contributions. Employee forfeits any unused balances. Withdrawals for non-medical expenses are not permitted. Withdrawals for non-medical expenses are not permitted. Interest does not accrue for HRA funds. Yes Interest does not accrue for FSA funds. Yes, in limited circumstances. 13

16 HSA-Qualified HDHP Plans 80% Shared Deductible [9] Shared Deductible [9] Shared or Embedded Deductible [9] Shared or Embedded Deductible [9] 1200 / 80% 1700 / 80% 2500 / 80% 3000 / 80% Providers Out-of- Providers [2 Providers Out-of- Providers [2] Providers Out-of- Providers [2] Providers Benefits for Covered Services In- Benefits Out-of-network Benefits [2] Practitioner Office Services Office Visits Routine Diagnostic Lab, X-Ray, & Injections [3] [5] Advanced Radiological Imaging Preventive Health Care Services Well-Child Care, under age 6 Annual Well-Woman Exam 80% after Deductible 100% 60% after Deductible Annual Mammography Screening 40+ Annual Prostate Cancer Screening 50+ Immunizations Wellcare Services age 6+ (Includes annual exam, periodic colorectal cancer screening 100% 100% 60% after Deductible Services Received at a Facility Inpatient Services [3] Outpatient Surgery [4] Routine Diagnostic Services-Outpatient [3] [5] Advanced Radiological Imaging-Outpatient Other Outpatient Services [6] Skilled Nursing/Rehab Facility [3] (Limited to 60 days combined per year) Emergency Care Services 80% after Deductible 80% after Deductible 60% after Deductible 80% after Deductible Medical Equipment Durable Medical Equipment Prosthetics Orthotic Appliances Therapeutic Services [7] Therapy (Limited to visits per therapy type per year) 80% after Deductible 80% after Deductible 60% after Deductible 60% after Deductible Home Health Services [8] Limited to 60 visits per year 80% after Deductible 60% after Deductible Hospice Services 80% after Deductible 60% after Deductible Ambulance Service 80% after Deductible 80% after Deductible Behavioral Health 80% after Deductible 60% after Deductible Limited to 20 Inpatient Days, 25 Outpatient Visits or Parity Plan Prescription Drugs 80% after Deductible, Preventive Copay Option Out-of- Providers [2] Benefit Features Annual Deductible Individual $1,200 $2,400 $1,700 $3,400 $2,500 $5,000 $3,000 $6,000 Family [9] $2,400 $4,800 $3,400 $6,800 $5,000 $10,000 $6,000 $12,000 Annual Out-of-Pocket Maximum Amount Individual $2,500 $7,500 $3,500 $10,500 $4,000 $12,000 $5,000 $15,000 Family [9] $5,000 $15,000 $7,000 $21,000 $8,000 $24,000 $10,000 $30,000 Dependent Age Limit To age 26 Pre-Existing Condition Waiting Period [1] 12 months 4th Quarter Deductible Carryover Provision Optional 1. HIPAA regulations apply. A group enrollee s pre-existing condition waiting period can be reduced by the enrollee s applicable creditable coverage. (Pre-existing condition does not apply to members under age 19.) 2. Out-of-network benefit payment based on BlueCross BlueShield of Tennessee maximum allowable charge. You are responsible for paying any amount exceeding the maximum allowable charge. 3. Services require prior authorization. Benefits will be reduced to 50% for services received from network providers outside Tennessee and all out-of-network providers when prior authorization not obtained. 4. Surgeries include incisions, excisions, biopsies, injection treatments, fracture treatments, applications of casts and splints, sutures and invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy and endoscopy). 5. CAT scans, PET Scans, MRIs, nuclear medicine, and other similar technologies. 6. Includes services such as chemotherapy, radiation therapy, infusions, and renal dialysis. 7. Physical, speech, manipulative, and occupational therapies are limited to 20 visits per therapy type per annual benefit period. Cardiac and pulmonary rehabilitative therapies are limited to 36 visits per therapy type per annual benefit period. 8. Requires prior authorization. 9. Shared deductible and out-of-pocket maximum - if more than one person is covered under the group health plan, the full family deductible must be satisfied before benefits will be paid for the employee or any covered family members. Embedded deductible and out-of-pocket maximum - once an individual with family coverage meets his/her deductible, plan benefits are available to that individual. 14

17 HSA-Qualified HDHP Plans 100% Shared or Embedded Deductible [9] Benefits for Covered Services In- Benefits Out-of-network Benefits [2] Practitioner Office Services Office Visits Routine Diagnostic Lab, X-Ray, & Injections [3] [5] Advanced Radiological Imaging Preventive Health Care Services 100% after Deductible 80% after Deductible Well-Child Care, under age 6 Annual Well-Woman Exam 100% Annual Mammography Screening % after Deductible Annual Prostate Cancer Screening % Immunizations Wellcare Services age 6+ (Includes annual exam, periodic colorectal cancer screening Shared or Embedded Deductible [9] Services Received at a Facility Inpatient Services [3] Outpatient Surgery [4] Routine Diagnostic Services-Outpatient [3] [5] Advanced Radiological Imaging-Outpatient Other Outpatient Services [6] Skilled Nursing/Rehab Facility [3] (Limited to 60 days combined per year) Emergency Care Services 100% after Deductible 100% after Deductible 80% after Deductible 100% after Deductible Medical Equipment Durable Medical Equipment Prosthetics Orthotic Appliances Therapeutic Services [7] Therapy (Limited to visits per therapy type per year) 80% after Deductible 100% after Deductible 60% after Deductible 80% after Deductible Home Health Services [8] Limited to 60 visits per year 100% after Deductible 80% after Deductible Hospice Services 100% after Deductible 80% after Deductible Ambulance Service 100% after Deductible 100% after Deductible Behavioral Health 20 Inpatient Days, 25 Outpatient Visits or Parity Plan 100% after Deductible 80% after Deductible Prescription Drugs 100% after Deductible, Preventive Copay Option (If more than one person is covered under the group health plan, the full family deductible must be satisfied before benefits will be paid for the employee or any covered family members.) 1. HIPAA regulations apply. A group enrollee s pre-existing condition waiting period can be reduced by the enrollee s applicable creditable coverage. 2. Out-of-network benefit payment based on BlueCross BlueShield of Tennessee maximum allowable charge. You are responsible for paying any amount exceeding the maximum allowable charge. 3. Services require prior authorization. Benefits will be reduced to 50% for services received from network providers outside Tennessee and all out-of-network providers when prior authorization not obtained. 4. Surgeries include incisions, excisions, biopsies, injection treatments, fracture treatments, applications of casts and splints, sutures and invasive diagnostic services (e.g., colonoscopy, sigmoidoscopy and endoscopy). 5. CAT scans, PET Scans, MRIs, nuclear medicine, and other similar technologies. 6. Includes services such as chemotherapy, radiation therapy, infusions, and renal dialysis. 7. Physical, speech, manipulative, and occupational therapies are limited to 20 visits per therapy type per annual benefit period. Cardiac and pulmonary rehabilitative therapies are limited to 36 visits per therapy type per annual benefit period. 8. Requires prior authorization. 9. Shared deductible and out-of-pocket maximum - if more than one person is covered under the group health plan, the full family deductible must be satisfied before benefits will be paid for the employee or any covered family members. Embedded deductible and out-of-pocket maximum - once an individual with family coverage meets his/her deductible, plan benefits are available to that individual. 100% Shared or Embedded Deductible [9] Shared or Embedded Deductible [9] 2500 / 100% 3000 / 100% 4000 / 100% 5000 / 100% Out-of- Providers Out-of- Providers Out-of- Providers Out-of- Benefit Features Providers Providers [2] Providers [2] Providers [2] Providers [2] Annual Deductible Individual $2,500 $5,000 $3,000 $6,000 $4,000 $8,000 $5,000 $10,000 Family [9] $5,000 $10,000 $6,000 $12,000 $8,000 $16,000 $10,000 $20,000 Annual Out-of-Pocket Maximum Amount Individual $2,500 $7,500 $3,000 $9,000 $4,000 $12,000 $5,000 $15,000 Family [9] $5,000 $15,000 $6,000 $18,000 $8,000 $24,000 $10,000 $30,000 Dependent Age Limit To age 26 Pre-Existing Condition Waiting Period [1] 12 months 4th Quarter Deductible Carryover Provision Optional 15

18 Prescription Drug Plans Pharmacy Solutions to Help Control Costs As the cost of pharmaceuticals continues to rise, BlueCross BlueShield of Tennessee responds with solutions to help groups control costs and provide members with many convenient and affordable ways to purchase medications and treatment supplies. BlueCross BlueShield of Tennessee pharmacy benefits provide: Flexible, affordable plan designs BlueCross offers more standard pharmacy plans than any other carrier and a broad network of providers. And, these plan designs are backed by tools like the Preferred Drug List - aimed at maintaining the lowest net cost. All the advantages of a Pharmacy Benefits Manager (PBM) and more A partnership with one of the country s largest PBMs enables BlueCross to provide some of the industry s most advanced pharmacy and medical management programs to help groups limit prescription drug costs. The long-term savings associated with integrated benefits By combining a BlueCross health plan with a pharmacy plan design means only one member ID card and provides a more complete picture of a group s overall health. A more complete picture helps detect candidates for medical management programs and can help provide groups with tremendous cost savings in the long run. 16

19 Pharmacy Pharmacy Riders (for plans on pages 6-10) Three-Tiered Plans These plans allow members three levels of benefits for prescription drugs each time they have their prescriptions filled by a BlueCross BlueShield of Tennessee participating pharmacy. They choose the brand level that best meets their individual needs. The plans employers may choose from are: $10/$20/$40 Plan Brand Level Member Pays Generic Drugs $10 Copay Preferred Brand Name Drugs $20 Copay* Non-preferred Brand Name Drugs $40 Copay* Self-Administered Specialty Drugs Specialty Pharmacy $80 Copay Any Other Pharmacy $160 Copay $10/$35/$50 Plan Brand Level Member Pays Generic Drugs $10 Copay Preferred Brand Name Drugs $35 Copay* Non-preferred Brand Name Drugs $50 Copay* Self-Administered Specialty Drugs Specialty Pharmacy $100 Copay Any Other Pharmacy $200 Copay $8/$40/$60 Plan Brand Level Member Pays Generic Drugs $8 Copay Preferred Brand Name Drugs $40 Copay* Non-preferred Brand Name Drugs $60 Copay* Self-Administered Specialty Drugs Specialty Pharmacy $120 Copay Any Other Pharmacy $240 Copay $8/$35/$70 Plan Brand Level Member Pays Generic Drugs $8 Copay Preferred Brand Name Drugs $35 Copay* Non-preferred Brand Name Drugs $70 Copay* Self-Administered Specialty Drugs Specialty Pharmacy $140 Copay Any Other Pharmacy $280 Copay $10/$35/$50 Plan (with $200 brand-only deductible) Brand Level Member Pays Generic Drugs $10 Copay Preferred Brand Name Drugs $35 Copay* after Deductible Non-preferred Brand Name Drugs $50 Copay* after Deductible Self-Administered Specialty Drugs Specialty Pharmacy $100 Copay Any Other Pharmacy $200 Copay Self-Administered Specialty Drugs are not subject to Brand Deductible. Two-Tiered Plans These plans allow members two levels of benefits for prescription drugs each time they have their prescription filled by a BlueCross BlueShield of Tennessee participating pharmacy. They choose the brand level that best meets their individual needs. $10/$35 Plan Brand Level Member Pays Generic Drugs $10 Copay Brand Name Drugs $35 Copay* Self-Administered Specialty Drugs Specialty Pharmacy $70 Copay Any Other Pharmacy $140 Copay $10/50% Plan Brand Level Member Pays Generic Drugs $10 Copay Brand Name Drugs 50% Copay* ($4,000 annual out of-pocket maximum applies.) Self-Administered Specialty Drugs Specialty Pharmacy $100 Copay Any Other Pharmacy $200 Copay NOTE: Occasionally, a specialty drug will be a generic (1st tier) or preferred brand (2nd tier) drug. When a specialty drug is a generic (1st tier) or preferred brand (2nd tier) drug, then the member will pay 2 times the generic or preferred brand copay instead of the SRx copay. For example, in the $10/$35/$50 plan, a specialty drug that is a generic the member copay is $20 at a preferred specialty vendor or $40 at any other pharmacy. How Multi-Tiered Plans Work All plans require the members to pay a copay to the participating pharmacy for each prescription they have filled. The amount of the copay depends on the brand level of the drug they choose. Generic drugs offer the best value and require the lowest copay amount. These drugs are safe and effective alternatives to brand name drugs. Under a two-tiered plan, all brand name drugs require the highest copay amount.* For three-tiered plans, brand name drugs listed on the Preferred Drug List require the median copay amount. Members should talk to their doctor about using drugs on this list when possible. However, drugs that do not appear on this list are still covered but require the highest copay amount.* Percentage copay plans allow members a share in the savings when they choose generic or preferred brand drugs. They also share in the discounts available with the home delivery option. * When a member or their doctor/physician requests the brand drug when a generic equivalent is available, he or she will pay the generic drug copayment, plus the cost difference between the brand and generic drug. Please Note: Prescription drugs filled through Home Delivery or the Home Delivery Retail are subject to one copay per 30-day supply. This does not apply when the copay is percentage-based. 17

20 Pharmacy Pharmacy Riders One-Tiered Plan 50% Copay Plan This plan requires the member to pay 50% of the maximum allowable charge to a participating pharmacy for each prescription they have filled. The actual amount the member pays depends on the cost of the drug they choose. They choose the brand level that best meets their individual needs. Generic drugs offer the best value. A generic drug is a safe and effective alternative to a brand name drug. Brand Level Member Pays Generic Drugs 50% Copay Brand Name Drugs 50% Copay* ($4,000 annual out-of-pocket maximum applies.) Self-Administered Specialty Drugs Specialty Pharmacy $100 Copay Any Other Pharmacy $200 Copay Plans Traditional PPO Plans and Smart Consumer Plans Prescription drug benefits are provided at the same benefit levels as the base PPO medical plan. Appropriate deductibles and coinsurance apply. Members always pay for their prescriptions at the pharmacy. Once their deductible has been met, members are reimbursed less the applicable coinsurance amount. High-Deductible Health Plans The BlueCross and BlueShield of Tennessee claims system and the PBM s adjudication system exchange accumulator information so that at the pharmacy members pay the deductible and coinsurance at the same levels as the base medical plan. Once the deductible is met, members pay the pharmacy only the applicable coinsurance for their medications. $5/$25/$50 Preventive Drug Option for HDHP A Preventive Drug List benefit is available for HSAqualified HDHP plans. Members bypass the deductible and coinsurance when purchasing medications on the Preventive Drug List and pay only the copayment amounts required for the listed drugs. Specialty Pharmacy BlueCross BlueShield of Tennessee members with prescription drug coverage have a specialty pharmacy network. These specialty pharmacies are experienced in managing high-cost drugs and providing patient support for complex conditions such as Hepatitis C, Multiple Sclerosis, Arthritis and Hemophilia. Accredo Health Group Phone: Fax: Caremark Specialty Pharmacy Services Phone: Fax: Curascript Pharmacy Phone: Fax: Walgreens Specialty Pharmacy Phone: Fax: To get the highest level of benefits, members should obtain their self-administered specialty drugs from one of these specialty pharmacies. Provider-administered specialty drugs are covered as a medical benefit. For the specialty pharmacy drugs list, go to the pharmacy section of bcbst.com. Non-Participating Pharmacies If plan members have a prescription filled at a pharmacy that does not participate in the BlueCross BlueShield of Tennessee program, they will be responsible for paying all costs up front. They should then file the claim with BlueCross BlueShield of Tennessee. We will apply the appropriate benefit and reimburse the member up to our maximum allowable charge. Members will be responsible for charges in excess of the maximum allowable charge. * When a member or their doctor/physician requests the brand drug when a generic equivalent is available, he or she will pay the generic drug copayment, plus the cost difference between the brand and generic drug. Please Note: Prescription drugs filled through Home Delivery or the Home Delivery Retail are subject to one copay per 30-day supply. This does not apply when the copay is percentage-based. 18

21 Pharmacy Limited Formulary Option The Limited Formulary option gives accounts facing rising costs a creative solution to make pharmacy benefits more affordable. It combines a customized, generic-based drug formulary with alternative therapies and expanded tools to control utilization and costs for accounts and members. OTC Medications instead of Prescription Drugs To help control prescription drug costs, the Limited Formulary excludes coverage for certain classes of prescription drugs that have alternatives available over-the-counter (OTC): Non-sedating antihistamines (NSAs) for the treatment of allergies. Histamine 2 blockers (H2s) for the treatment of stomach disorders. Proton pump inhibitors (PPIs) also used for the treatment of stomach disorders. These OTC medications can have similar clinical results as their more expensive prescription counterparts, but provide significant cost savings for everyone. And members can purchase these popular medications when they need them most without a prescription. The chart below lists some of the name brand prescription drugs that are NOT covered by the Limited Formulary plan, selected OTC alternatives, and which drugs will be covered if certain medical criteria are met. Prescription Drugs OTC Alternatives NON-SEDATING ANTIHISTAMINES (NSAs) Allegra tablets and capsules Allegra D tablets Clarinex tablets Clarinex D tablets Clarinex syrup1 Zyrtec tablets Zyrtec D tablets Zyrtec syrup1 HISTAMINE 2 BLOCKERS (H2s) Axid2 cimetidine2 famotidine2 nizatidine2 Pepcid2 ranitidine2 Tagamet2 Zantac2 PROTON PUMP INHIBITORS (PPIs) AcipHex3 Nexium3 omeprazole3 pantoprazol Prevacid3 Prilosec3 Protonix3 Zegerid3 Alavert tablets Alavert D tablets Children s Claritin Claritin 24 Hour Claritin syrup Claritin tablets Claritin D tablets Claritin Reditabs 24 Hour Clear-Atadine Dimetapp Children s Non-Drowsy Allergy loratadine tablets Tavist ND tablets Axid AR tablets cimetidine tablets famotidine tablets Pepcid AC tablets and capsules Prilosec OTC ranitidine tablets Tagamet HB tablets Zantac 75 tablets Axid AR tablets cimetidine tablets famotidine tablets Pepcid AC tablets and capsules Prilosec OTC ranitidine tablets Tagamet HB tablets Zantac 75 tablets * Omeprazole is available over the counter, without a prescription. Some plans do not cover prescription drugs that have equivalents available over the counter. Check your benefit materials or call Customer Service for more information on your plan s coverage for omeprazole. LEGEND 1 Covered for ages 6 and under 2 Covered for ages 18 and under 3 Covered for ages 18 and under and for ages 19 and over if the following Prior Authorization criteria are met: 1. Grade III Erosive Esophagitis confirmed by endoscopy (circumferential erosions covered by hemorrhagic and pseudomembranus exudates) 2. Grade IV Erosive Esophagitis confirmed by biopsy (presence of chronic complications such as deep ulcers, strictures, or Barrett s metaplasia) 3. Zollinger-Ellison syndrome confirmed by a diagnostic test (such as fasting serum gastrin, basal 1 hour acid output, secretion stimulation test) Physicians may request prior authorization of a drug by calling Caremark at Step Therapy The Food and Drug Administration requires generic drugs to have the same strength and purity as brand-name drugs. And because generic drugs are less expensive than their name-brand counterparts, they represent significant cost savings for everyone. To help increase savings for accounts and members, the Limited Formulary requires Step Therapy for certain drug classes. Through Step Therapy, members try a less expensive drug that has proven to be effective for most people before using a similar but more expensive drug. Example: Doctor prescribes captopril (generic drug) to treat a member s high blood pressure. If the member has side effects or limited improvement, the doctor then prescribes the brand-name drug, Atacand. The Limited Formulary requires Step Therapy for the following drugs and drug classes: Before trying one of these Angiotensin II Receptors Atacand Benicar Cozaar Members must first try one of these captopril enalapril fosinopril lisinopril quinapril Angiotensin II Receptor Blockers with Diuretics Atacand HCT Benicar HCT Hyzaar Before taking Byetta onychomycosis (anti-fungal) drugs captopril/hydrochlorothiazide enalapril/hydrochlorothiazide fosinopril/hydrochlorothiazide lisinopril/hydrochlorothiazide quinapril/hydrochlorothiazide Members must be taking metformin, or a sulfonylurea or a thiazolidinedione (TZD) drug a diabetic or suffer from condition that compromises the immune system If members have already tried the similar, less expensive drugs without improvement or if providers believe the brand-name drug is medically necessary, an exception can be requested. If the request for an exception is approved, the more expensive drug will be covered. 19

22 Pharmacy Only Generics Covered in Specific Drug Classes To improve savings for members and employers, the Limited Formulary restricts coverage to generics for certain drug classes: ACE Inhibitors Antidepressants Antitussives/Expectorants Anxioloytics, Sedatives and Hypnotics HMG-CoA Reductase Inhibitors Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Quinolones A number of less expensive, proven generic alternatives are available in each of these drug classes to provide members with the treatment they need and savings for everyone. Limited Formulary Option Limited Formulary Plan Designs BlueCross BlueShield of Tennessee offers a variety of multi-tier pharmacy plan designs to give members more choice in the amount they pay for prescription drugs. Employers can pair the Limited Formulary with any of our standard pharmacy benefit plan designs listed on the Pharmacy Plan Designs page in this packet or at bcbst. com. Other flexible plan designs are available to meet the unique needs of larger, self-funded groups. 20

23 Behavioral Health Behavioral Health benefits are mandatory for groups with more than 25 employees. Behavioral Health Riders (For Traditional PPO Plan, not subject to Mental Health Parity.) 20/25I Plan Inpatient: 20 days per calendar year In- In-network deductible & coinsurance apply Out-of- Out-of-network deductible & coinsurance apply Behavioral Health Riders (For Copay PPO Plan, not subject to Mental Health Parity.) 20/25I Plan Inpatient: 20 days per calendar year In- $300 copay per admission Out-of- Out-of-network deductible & coinsurance apply Outpatient: 25 visits per calendar year In- In-network deductible & coinsurance apply Out-of- Out-of-network deductible & coinsurance apply 30/30I Plan Inpatient: 30 days per calendar year In- In-network deductible & coinsurance apply Out-of- Out-of-network deductible & coinsurance apply Outpatient: 30 visits per calendar year In- In-network deductible & coinsurance apply Out-of- Out-of-network deductible & coinsurance apply See blue box below for prior authorization requirements. Outpatient: 25 visits per calendar year In- $25 copay per visit Out-of- Out-of-network deductible & coinsurance apply 30/30I Plan Inpatient: 30 days per calendar year In- $200 copay per admission Out-of- Out-of-network deductible & coinsurance apply Outpatient: 30 visits per calendar year In- $20 copay per visit Out-of- Out-of-network deductible & coinsurance apply See blue box below for prior authorization requirements. Behavioral Health Riders (For Traditional PPO & Copay PPO Plans subject to Mental Health Parity) Inpatient: In-network Benefits match in-network Inpatient Hospital benefit Out-of-network Benefits match out-of-network Inpatient Hospital benefit Outpatient: In-network Out-of-network Benefits match in-network Physician Office Visit benefit (if split copays, PCP copay applies to outpatient Behavioral Health) Benefits match out-of-network Physician Office Visit benefit Prior Authorization is required for: 1. All inpatient levels of care. Inpatient levels of care include Acute care, residential care, partial hospital care, and intensive outpatient programs. 2. Electro-convulsive therapy (ECT) provided on an inpatient or outpatient basis. 3. Detoxification from narcotic pain medications provided on an inpatient or outpatient basis. Please Note 1) All plans include visits for prescribing and monitoring prescription medications. These visits do not apply toward the visit limits, if applicable. 2) Out-of-network benefits are provided at 50% when prior authorization is not obtained. 21

24 DentalBlue A Large with Savings You Can Smile About DentalBlue plans from BlueCross BlueShield of Tennessee offer flexibility, convenience and exceptional customer service all from one of the most trusted names in the business. Whether added as a complement to an existing health plan or as stand-alone coverage, DentalBlue advantages include: Largest dental PPO network in Tennessee; plus a comprehensive national solution A wide selection of comprehensive and preventive plans DentalBlue Select Plans (Voluntary) Reasonable and customary plans with no penalties for members going out of network Easier administration for groups with combined dental and medical plans; one member ID card and one bill The DentalBlue network is second to none, with more than 2,400 access points in Tennessee and growing. Nationwide, the number of network dentists grows to more than 100,000, giving our members great access to provider discounts across the country. And what is a network if it does not deliver savings? DentalBlue members save an average of more than 20 percent off the average submitted charge. 22

25 Choices for Groups of All Sizes DentalBlue is not one size fits all. DentalBlue is flexible and includes a variety of plan designs and options to meet the needs of any size group. DentalBlue Traditional Plans DentalBlue Traditional is a great option for groups with 50 percent or more employee participation and is available with or without employer contribution. Groups with 2-9 enrolled and groups with 10 or more enrolled can both choose from all plan designs. DentalBlue Select (Voluntary) Plans Groups with at least 30 percent participation can choose our DentalBlue Select and employer contribution is not required. Standard, Basic and Preventive plans give groups more choices for their employees. Consumer-Directed Dental Plans Consumer-Directed Dental Plans offer only two coinsurance levels, provide more coverage for major restorative dental procedures and a higher maximum to cover dental needs. For employees, it s a way to trade lower premiums in return for an increased level of responsibility and involvement in personal oral care decisions with the same great network and coverage. Health Maintenance Option Groups can exclude diagnostic and preventive services (coverage A ) from the annual maximum and help employees see the benefit of regular dental visits by eliminating cost barriers to preventive dental care. This feature may be added to any DentalBlue plan with very little impact to monthly rates. Non- Dental Options All plans have access to the DentalBlue network in Tennessee and more than 100,000 dentists nationwide. The out-of-network reimbursement has one of two options for many of the plan designs and is noted on each of the dental benefit plan pages. With the PPO Preferred Option, maximum claims savings is achieved through a discounted maximum allowable charge (MAC) payment schedule for non-network dentists. With the Freedom of Choice Option, or passive PPO, a higher usual and customary rate (UCR) schedule means employees have lower out-of-pocket costs at non-network dentists, compared to PPO Preferred. With the Choice Plus Option, plans have a lower coinsurance out-of-network, while maintaining the usual and customary rate (UCR) schedule. 23

26 DentalBlue Traditional Plans Groups 2-9 Enrolled BlueCross BlueShield of Tennessee offers flexible plan designs to meet your group s needs. DentalBlue Traditional plans are available with the Choice and Preferred Reimbursement Options. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. Plan Summary Standard Preventive Where To Receive Services Any Dentist Any Dentist Coverage A Exams, X-rays Cleanings, Fluoride 100% 100% Sealants, Space Maintainers Coverage B Basic Restorative Services Basic and Major Endodontics 80% 50% Basic and Major Periodontics Basic and Major Oral Surgery Coverage C Major Restorative, Prosthodontics & Implants 50% 0% Annual Deductible (Per Member, Max 3 per family) Not applicable to Coverage A $50 $25 Annual Maximum Benefit (Per Member) $1,000, $1,500 or $2,000 $500 Dependent age limit to age 26 Additional Features To Customize Your Plan Exclude Class A from Annual Maximum Coverage A services received do not count toward the annual maximum benefit Coverage D - Orthodontics Not available with Preventive Plan Coinsurance 50% Coinsurance, No Deductible Maximum $1,000 or $1,500 - Per Member, Per Lifetime Age Limit Child Only to age 18 Limitations 12-month waiting period applies [1] Plan Reimbursements [2] Freedom of Choice Option Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Usual and Customary Rate (UCR) PPO Preferred Option Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Maximum Allowable Charge (MAC) Plan Requirements Stand Alone Dental Minimum of five enrolled Group Participation Employer Contribution % enrolled No requirement if group has current dental coverage Waived at initial enrollment for those covered under prior carrier plan. Members are responsible for paying any amounts exceeding the UCR or MAC when Non- Dentists are used. 24

27 DentalBlue Traditional Choice Plus Groups 2-9 Enrolled BlueCross BlueShield of Tennessee offers flexible plan designs to meet your group s needs. With Choice Plus, members receive a higher coinsurance percentage when network dentists are used. Also with Choice Plus Plans, a higher Usual and Customary Rate (UCR) schedule means employees have lower out-of-pocket costs at non-network dentists. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. Standard Preventive Plan Summary Where To Receive Services In- Out-of- In- Out-of- In- Out-of- In- Out-of- Coverage A Exams, X-rays Cleanings, Fluoride 100% 100% 100% 100% 100% 100% 100% 100% Sealants, Space Maintainers Coverage B Basic Restorative Services Basic and Major Endodontics Basic and Major Periodontics 90% 80% 80% 70% 90% 80% 50% 40% Basic and Major Oral Surgery Coverage C Major Restorative, Prosthodontics & Implants 60% 50% 50% 40% 10% 0% 10% 0% Annual Deductible (Per Member, Max 3 per family) $50 $50 $50 $25 Not applicable to Coverage A Annual Maximum Benefit (Per Member) $1,000, $1,500 or $2,000 $1,000, $1,500 or $2,000 $500 or $1,000 $500 Dependent Age Limit to age 26 Additional Features To Customize Your Plan Exclude Class A from Annual Maximum Coverage A services received do not count toward the annual maximum benefit. Coverage D - Orthodontics Not available with Preventive Plan Coinsurance 50% Coinsurance, No Deductible Maximum $1,000 or $1,500 - Per Member, Per Lifetime Age Limit Child Only to age 18 Limitations 12-month waiting period applies [1] Plan Reimbursement [2] Freedom of Choice Option Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Usual and Customary Rate (UCR) Plan Requirements Stand Alone Dental Minimum of five enrolled Group Participation 50% enrolled Employer Contribution No requirement if group has current dental coverage 1 2 Waived at initial enrollment for those covered under prior carrier plan. Members are responsible for paying any amounts exceeding the UCR when Non- Dentists are used. 25

28 DentalBlue Traditional Plans Groups 10+ Enrolled BlueCross BlueShield of Tennessee offers flexible plan designs to meet your group s needs. DentalBlue Traditional plans are available with the Freedom of Choice and PPO Preferred Reimbursement Options. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. Plan Summary Deluxe Standard 60 Standard Basic Basic 10 Preventive 10 Preventive Where To Receive Services Any Dentist Any Dentist Any Dentist Any Dentist Any Dentist Any Dentist Any Dentist Coverage A Exams, X-rays Cleanings, Fluoride Sealants, Space Maintainers Coverage B [1] Basic Restorative Services Basic and Major Endodontics Basic and Major Periodontics Basic and Major Oral Surgery Coverage C [1] Major Restorative, Prosthodontics & Implants Annual Deductible (Not applicable to Coverage A) 100% 100% 100% 80% 100% 100% 100% 100% 90% 80% 80% 80% 50% 50% 80% 60% 50% 50% 10% 10% 0% $25 or $50 $25 or $50 $25 or $50 $25 or $50 $25 or $50 $0 or $25 $0 or $25 Annual Maximum Benefit (Per Member) $1,000, $1,250, $1,500 or $2,000 $1,000, $1,250, $1,500 or $2,000 $1,000, $1,250, $1,500 or $2,000 $1,000, $1,250, $1,500 or $2,000 $1,000, $1,250, $1,500 or $2,000 $500, $1,000 or $1,250 $500, $1,000 or $1,250 Dependent age limit to age 26 Additional Features To Customize Your Plan Exclude Class A from Annual Maximum Coverage A services received do not count toward the annual maximum benefit. Coverage D - Orthodontics Not available with Preventive Plan Coinsurance Maximum 50% Coinsurance, No Deductible $1,000 or $1,500 - Per Member, Per Lifetime Age Limit Child Only (to age 18) or No age limit (groups 26+) Waiting Period [2] 12 months or no waiting period Family Deductible Max 3 per family Per person no maximum Plan Reimbursements [3] Freedom of Choice Option Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Usual and Customary Rate (UCR) PPO Preferred Option Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Maximum Allowable Charge (MAC) Plan Requirements Multi-Option Groups with 26+ may offer two plans Group Participation 50% enrolled Employer Contribution No requirement if group has current dental coverage 1 Services may be moved between coverage levels in accordance with underwriting guidelines. 2 Waived at initial enrollment for those covered under prior carrier plan. 3 Members are responsible for paying any amounts exceeding the UCR or MAC when Non- Dentists are used. 26

29 DentalBlue Traditional Choice Plus Groups 10+ Enrolled BlueCross BlueShield of Tennessee offers flexible plan designs to meet your group s needs. With Choice Plus, members receive a higher coinsurance percentage when network dentists are used. Also with Choice Plus Plans, a higher usual and customary rate (UCR) schedule means employees have lower out-of-pocket costs at non-network dentists. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. Standard Preventive Plan Summary Where To Receive Services Coverage A Exams, X-rays Cleanings, Fluoride Sealants, Space Maintainers Coverage B [1] Basic Restorative Services Basic and Major Endodontics Basic and Major Periodontics Basic and Major Oral Surgery Coverage C [1] Major Restorative, Prosthodontics & Implants Annual Deductible (Not applicable to Coverage A) Annual Maximum Benefit (Per Member) In- Out-of- In- Out-of- In- Out-of- In- Out-of- 100% 100% 100% 100% 100% 100% 100% 100% 90% 80% 80% 70% 90% 80% 50% 40% 60% 50% 50% 40% 10% 0% 10% 0% $25 or $50 $25 or $50 $25 or $50 $0 or $25 $1,000, $1,250, $1,500 or $2,000 $1,000, $1,250, $1,500 or $2,000 Dependent age limit to age 26 Additional Features To Customize Your Plan $1,000, $1,250, $1,500 or $2,000 Exclude Class A from Annual Maximum Coverage A services received do not count toward the annual maximum benefit. Coverage D - Orthodontics Not available with Preventive Plan Coinsurance 50% Coinsurance, No Deductible Maximum $1,000 or $1,500 - Per Member, Per Lifetime Age Limit Child Only (to age 18) or No age limit (Groups 26+) Waiting Period [2] 12 months or no waiting period Family Deductible Max 3 per family Per person no maximum Plan Reimbursement Freedom of Choice Option [3] Dentists Paid at PPO Fee Schedule Non- Dentists Paid at Usual and Customary Rate (UCR) Plan Requirements Multi-Option Groups with 26+ may offer two plans Group Participation 50% enrolled Employer Contribution No requirement if group has current dental coverage Services may be moved between coverage levels in accordance with underwriting guidelines. Waived at initial enrollment for those covered under prior carrier plan. Members are responsible for paying any amounts exceeding the UCR when Non- Dentists are used. $500, $1,000 or $1,250 27

30 DentalBlue Select (Voluntary) Plans Groups 2+ Enrolled BlueCross BlueShield of Tennessee offers dental plans with lower participation requirements to meet your group s needs. DentalBlue Select (Voluntary) Plans are available with the Freedom of Choice and PPO Preferred Reimbursement options. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. Plan Summary Standard Basic Preventive Where To Receive Services Any Dentist Any Dentist Any Dentist Coverage A Exams, X-rays Cleanings, Fluoride 100% 80% 100% Sealants, Space Maintainers Coverage B Basic Restorative Services Basic Endodontics 80% 80% 50% Basic Periodontics Basic Oral Surgery Coverage C 12-month waiting period applies [1] Major Endodontics Major Periodontics 50% 50% 0% Major Oral Surgery Major Restorative, Prosthodontics & Implants Annual Deductible (Not applicable to Coverage A) $25 or $50 $25 or $50 $0 or $25 Annual Maximum Benefit (Per Member) [2] $1,000, $1,250 $1,500, or $2,000 $1,000, $1,250 $1,500, or $2,000 $500, $1,000, $1,250 Dependent Age Limit to age 26 Additional Features To Customize Your Plan Exclude Class A from annual maximum Coverage A services do not count toward the annual maximum benefit Coverage D - Orthodontics Not available with Preventive Plan Coinsurance 50% Coinsurance, No Deductible Maximum $1,000 or $1,500 - Per Member, Per Lifetime Age Limit Child Only (to age 18) or No age limit (Groups 26+) Waiting Period [2] 12 months or no waiting period Family Deductible Max 3 per family Per person no maximum Plan Reimbursements [3] Freedom of Choice Option (PPO fee schedule in-network; UCR out-of-network) PPO Preferred Option (PPO fee schedule in-network; percentage of PPO fee schedule out-of-network) Plan Requirements Stand Alone Dental Minimum of five enrolled Multi-Option Groups with 26+ may offer two plans Group Participation 30% enrolled Employer Contribution No requirement 1 Waived at intial enrollment for those covered under prior carrier plan. 2 $1,250 annual maximum available for groups with 10+ enrolled only 3 Members are responsible for paying any amounts exceeding the Maximum Allowable Charge or Usual and Customary Rate when Non- Dentists are used. 28

31 Consumer-Directed Dental Plans Groups 2+ Enrolled BlueCross BlueShield of Tennessee now offers consumer-directed Dental Plans to provide cost effective coverage with a higher annual maximum. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution. DentalBlue High-Deductible Dental Plan (HDDP) Plan Summary Standard Plans Copay Plans Preventive Dental Exams, X-rays Cleanings, fluoride Sealants, Space maintainers Annual Deductible (Per member, Max 2 or 3 per family) (Applies to basic and major dental services only) Basic & Major Dental Restorative (fillings & crowns) Endodontics (pulpotomy & root canals) Periodontics (scaling, root planing, gum & osseous surgery) Oral Surgery (extractions including impactions) Prosthodontics (bridges & dentures) Implants Annual Maximum Benefit Per Member (Applies to basic and major dental services only) 100% 100% 100% after $10 or $25 Copay per visit 100% after $10 or $25 Copay per visit $250 $250 $250 $250 70% 60% 70% 60% $2,500 $2,500 $2,500 $2,500 Dependent Age Limit To age 26 Additional Features To Customize Your Plan Orthodontics Coinsurance 50% Deductible None Maximum $1,000 per member per lifetime Age Limit To age 18 Waiting Period None or 12 months Plan Reimbursements Freedom of Choice Option (PPO fee schedule in-network; UCR out-of-network) [1] Plan Requirements Stand Alone Dental Multi-Option Group Participation Employer Contribution PPO Preferred Option (PPO fee schedule in-network, Percentage of PPO fee schedule out-of-network) 1 Minimum of five enrolled Groups with 26+ may offer two plans 50% enrolled No requirement if group has current dental coverage 1 Members are responsible for paying any amount exceeding the UCR or maximum allowable charge when non-network dentists are used. 29

32 Consumer-Directed Dental Plans Choice Plus Groups 2+ Enrolled BlueCross BlueShield of Tennessee now offers consumer-directed Dental Plans to provide cost effective coverage with a higher annual maximum. Regardless of which option a group chooses, employees will always benefit from the savings generated by the LARGEST dental PPO network in the state of Tennessee and access to our national PPO solution, outside of Tennessee and contiguous counties. DentalBlue High-Deductible Dental Plan (HDDP) with Choice Plus Plan Summary Standard Plans Copay Plans Preventive Dental Exams, X-rays Cleanings, fluoride Sealants, Space maintainers Annual Deductible (Per member, 2 or 3 per family) (Applies to basic and major dental services only) Dentist 100% 100% 100% after $10 or $25 Copay per visit 100% after $10 or $25 Copay per visit $250 $250 $250 $250 Non- Dentist Dentist Non- Dentist Dentist Non- Dentist Dentist Non- Dentist Basic & Major Dental Restorative (fillings & crowns) Endodontics (pulpotomy & root canals) Periodontics (scaling, root planing, gum & osseous surgery) Oral Surgery (extractions including impactions) Prosthodontics (bridges & dentures) Implants 70% 50% 60% 50% 70% 50% 60% 50% Annual Maximum Benefit Per Member (Applies to basic and major dental services only) $2,500 Dependent Age Limit To age 26 Plan Reimbursement Freedom of Choice Option (PPO fee schedule in-network; UCR out-of-network) [1] Additional Features To Customize Your Plan Orthodontics Coinsurance 50% Deductible None Maximum $1,000 per member per lifetime Age Limit To Age 18 Waiting Period None or 12 months Plan Requirements Stand Alone Dental Minimum of five enrolled Multi-Option Groups with 26+ may offer two plans Group Participation 50% enrolled Employer Contribution No requirement if group has current dental coverage 1 Members are responsible for paying any amounts exceeding the Usual and Customary Rate (UCR) when Non- Dentists are used. 30

33 DentalBlue - Covered Services, Limitations & Exclusions Exams Covered: Standard exams including comprehensive, periodic, detailed/extensive and periodontal oral evaluations (exams). Emergency exams, including limited oral evaluations (exams). Limitations: No more than one standard exam in any 6 month period. No more than one emergency exam in any 12 month period. No more than one comprehensive, detailed/ extensive, or periodontal exam in any 36 month period. Exclusions: Re-evaluations and consultations. X-rays Covered: Full mouth series, intraoral and bitewing radiographs (X-rays). Limitations: No more than one full mouth set of X-rays in any 36 month period. A full mouth set of X-rays is defined as either an intraoral complete series or panoramic X-ray. Benefits provided for either include benefits for all necessary intraoral and bitewing films taken on the same day. No more than four bitewing films in any 12 month period. Bitewing films must be taken on the same date of service. Exclusions: Extraoral, skull and bone survey, sialography, TMJ, and tomographic survey X-ray films, cephalometric films and diagnostic photographs. Cephalometric films and diagnostic photographs may be Covered as orthodontic benefits under Coverage D. Cleanings, Fluoride Treatment Covered: Adult and child prophylaxis (cleaning). Topical fluoride treatments, performed with or without a prophylaxis. Limitations: No more than one of any prophylaxis or periodontal maintenance procedure in any 6month period. Periodontal maintenance procedures are subject to additional limitations listed below under Basic Periodontics in Section VI, and may be subject to a different Coverage level under Attachment C: Schedule of Benefits. No more than one fluoride treatment in any 12 month period, for Members under age 19. Fluoride must be applied separately from prophylaxis paste. Sealants, Space Maintainers Covered: Other Preventive Services, including sealants, space maintainers. Limitations: No more than one sealant per first or second molar tooth per lifetime, for Dependents under age 16. Space maintainers for Dependents under age 14. No more than one recementation in any 12month period. Exclusions: Nutritional and tobacco counseling, oral hygiene instructions. Basic Restorative Services Covered: Basic restorative services, including amalgam restorations (silver fillings), resin composite restorations (tooth colored fillings), stainless steel crowns. Palliative (emergency) treatment for the relief of pain. Other restorative services, including repair of full and partial dentures. Limitations: No more than one amalgam or resin restoration per tooth surface in any 12 month period. Replacement of existing amalgam and resin composite restorations Covered only after 12 months from the date of initial restoration. Replacement of stainless steel crowns Covered only after 36 months from the date of initial restoration. No more than one repair per denture per 24 months. Exclusions: Gold foil restorations. Major Restorative Services Covered: Single tooth restorations, including crowns (resin, porcelain, ¾ cast, and full cast), inlays and onlays (metallic, resin and porcelain), and veneers. Limitations: Only for the treatment of severe carious lesions or severe fracture on permanent teeth, and only when teeth cannot be adequately restored with an amalgam or resin composite restoration (filling). For permanent teeth only. For Dependents under age 12, benefits will not be provided for cast crowns or laminate veneers. Replacement of single tooth restorations Covered only after 60 months from the date of initial placement. Exclusions: Temporary and provisional crowns. Prosthodontic Services - Fixed Bridges Covered: Fixed partial dentures (bridges), including pontics, retainers, and abutment crowns, inlays, and onlays (resin, porcelain, ¾ and full cast). Limitations: Only for treatment where a missing tooth or teeth cannot be adequately restored with a removable partial denture. For permanent teeth only, no benefits for Dependents under age 16. Replacement of fixed partial dentures Covered only after 60 months from the date of initial placement. Prosthodontic Services - Removable Dentures Covered: Complete, immediate and partial dentures. Limitations: If, in the construction of a denture, the Member and the Dentist decide on a personalized restoration or to employ special rather than standard techniques or materials, benefits provided shall be limited to those which would otherwise be provided for the standard procedures or materials (as determined by the Plan). Benefits are not provided for Dependents under age 16. Replacement of removable dentures Covered only after 60 months from the date of initial placement. Exclusions: Interim (temporary) dentures. Other Major Restorative & Prosthodontic Services Covered: Crown and bridge services including core buildups, post and core, recementation, and repair. Denture services including adjustment, relining, rebasing and tissue conditioning. Implants and supported prosthetics includes local anesthetic. Limitations: The benefits provided for crown and bridge restorations include benefits for the services of crown preparation, temporary or prefabricated crowns, impressions and cementation. Benefits will not be provided for a core build-up separate from those provided for crown construction, except in those circumstances where benefits are provided for a crown because of severe carious lesions or fracture is so extensive that retention of the crown would not be possible. Post and core services are Covered only when performed in conjunction with a Covered crown or bridge. Crown and bridge repair and re-cementation are Covered separately only after 12 months from the date of initial placement. Denture adjustments are Covered separately from the denture only after 6 months from the date of initial placement. No more than one denture reline or rebase in any 36 month period. Exclusions: Other major restorative services including sedative fillings and coping. Other prosthodontic services including overdenture, precision attachments, connector bars, stress breakers and coping metal. Basic Endodontics Covered: Pulpotomy, pulpal therapy. Limitations: For primary teeth only. Not Covered when performed in conjunction with major endodontic treatment. The benefits for basic endodontic treatment include benefits for X-rays, pulp vitality tests, and sedative fillings provided in conjunction with basic endodontic treatment. Exclusions: Pulpal debridement. Major Endodontics Covered: Root canal treatment and re-treatment, apexification, apicoectomy services, root amputation, retrograde filling, hemisection, pulp cap. Limitations: No more than one root canal treatment, re-treatment or apexification per tooth in 60month period. No more than one apicoectomy per root per lifetime. The benefits for major endodontic treatment include benefits for X-rays, pulp vitality tests, pulpotomy, pulpectomy and sedative fillings and temporary filling material provided in conjunction with major endodontic treatment. Exclusions: Implantation, canal preparation, and incomplete endodontic therapy. Basic Periodontics Covered: Non-surgical periodontics, including periodontal scaling and root planing, full mouth debridement and periodontal maintenance procedure. Limitations: No more that one periodontal scaling and root planing per quadrant in any 24month period. No more than one full mouth debridement per lifetime. No more than one of any prophylaxis (cleanings) or periodontal maintenance procedure in any 6month period. Cleanings are subject to additional limitations listed under Preventive Services, and may be subject to a different Coverage level under Attachment C: Schedule of Benefits. Benefits for periodontal maintenance are provided only after active periodontal treatment (surgical or non-surgical), and no sout-of-er than 90 days after completion of such treatment. Benefits for periodontal scaling and root planing, full mouth debridement, periodontal maintenance and prophylaxis are not provided when more than one of these procedures is performed on the same day. Exclusions: Provisional splinting, scaling in the presence of gingival inflammation, antimicrobial medication and dressing changes. Major Periodontics Covered: Surgical periodontics including gingivectomy, gingivoplasty, gingival flap procedure, crown lengthening, osseous surgery and bone and tissue grafting. Limitations: No more than one major periodontal surgical procedure in any 36month period. Benefits provided for major periodontics include benefits for services related to 90 days of postoperative care. Exclusions: Tissue regeneration and apically positioned flap procedure. Basic Oral Surgery Covered: Non-surgical or simple extractions. Limitations: Benefits provided for basic oral surgery include benefits or suturing and postoperative care. Exclusions: Benefits for general anesthesia or intravenous sedation when performed in conjunction with basic oral surgery. Major Oral Surgery Covered: Surgical extractions (including removal of impacted teeth and wisdom teeth), and other oral surgical procedures typically not Covered under a medical plan. Limitations: Benefits provided for major oral surgery include benefits for local anesthesia, suturing and postoperative care. Benefits for general anesthesia or intravenous (IV) sedation are provided only in connection with major oral surgery procedures, and only when provided by a Dentist licensed to administer such agents. Exclusions: Oral surgery typically covered under a medical plan, including but not limited to, excision of lesions and bone tissue, treatment of fractures, suturing, wound and other repair procedures, TMJ and related procedures. Orthognathic surgery and treatment for congenital malformations. Orthodontics Services Covered: Exams, photographic images, diagnostic casts, cephalometric X-rays, installation and adjustment of orthodontic appliances and treatment to reduce or eliminate an existing malocclusion. Limitations: The need for orthodontic services must be diagnosed, identifying a handicapping malocclusion that is both abnormal and correctable, and a Treatment Plan must be submitted to and approved by the Plan. The Plan reserves the right to review the Member s dental records, including necessary X-rays, photographs, and models to determine whether orthodontic treatment is Covered. Orthodontic services may be limited to Dependents under a specified age limit, as defined on Attachment C: Schedule of Benefits. Orthodontic services may be limited by a Maximum Allowable Charge, Calendar Year Deductible and lifetime maximum as defined on Attachment C: Schedule of Benefits. Multiple occurrences of orthodontic treatment may be allowed subject to the lifetime maximum. All orthodontic services shall be deemed to have been concluded on the last date treatment performed during Member s Coverage, even if a prior approved Treatment Plan has not been completed. Exclusions: Replacement or repair of any lost, stolen and damaged appliance furnished under the Treatment Plan. Surgical procedures to aid in orthodontic treatment. Other Exclusions From Coverage 1) Dental services received from a dental or medical department maintained by or on behalf of an Employer, mutual benefit association, labor union, trustee or similar person or group. 2) Charges for services performed by You or Your spouse, or Your or Your spouse s parent, sister, brother or child. 3) Services rendered by a Dentist beyond the scope of his or her license. 4) Dental services which are free, or for which You are not required or legally obligated to pay or for which no charge would be made if You had no dental Coverage. 5) Dental services to the extent that charges for such services exceed the charge that would have been made and collected if no Coverage existed hereunder. 6) Dental services covered by any medical insurance coverage, or by any other nondental contract or certificate issued by BlueCross BlueShield of Tennessee or any other insurance company, carrier, or plan. For example, removal of impacted teeth, tumors of lip and gum, accidental injuries to the teeth, etc. 7) Any court-ordered treatment of a Member unless benefits are otherwise payable. 8) Courses of treatment undertaken before You become Covered under this program. 9) Any services performed after You cease to be eligible for Coverage. 10) Dental care or treatment not specifically listed in Attachment C: Schedule of Benefits. 11) Any treatment or service that the Plan determines is not Necessary Dental Care, that does not offer a favorable prognosis that does not meet generally accepted standards of professional dental care, or that is experimental in nature. 12) Services or supplies for the treatment of work related illness or injury, regardless of the presence or absence of workers compensation coverage. This exclusion does not apply to injuries or illnesses of an employee who is (1) a sole-proprietor of the Group; (2) a partner of the Group; or (3) a corporate officer of the Group, provided the officer filed an election not to accept Workers Compensation with the appropriate government department. 13) Charges for any hospital or other surgical or treatment facility and any additional fees charged by a Dentist for treatment in any such facility. 14) Dental services with respect to congenital malformations or primarily for cosmetic or aesthetic purposes. This does not exclude those services provided under Orthodontic benefits (if applicable.) 15) Replacement of tooth structure lost from wear or attrition. 16) Dental services resulting from loss or theft of a denture, crown, bridge or removable orthodontic appliance. 17) Charges for a prosthetic device that replaces one or more lost, extracted or congenitally missing teeth before Your Coverage becomes effective under the Plan unless it also replaces one or more natural teeth extracted or lost after Your Coverage became effective. 18) Diagnosis for, or fabrication of, appliances or restorations necessary to correct bite problems or restore the occlusion or correct temporomandibular joint dysfunction (TMJ) or associated muscles. 19) Diagnostic dental services such as diagnostic tests and oral pathology services. 20) Adjunctive dental services including all local and general anesthesia, sedation, and analgesia (except as provided under major oral surgery). 21) Charges for the treatment of desensitizing medicaments, drugs, occlusal guards and adjustments, mouthguards, microabrasion, behavior management, and bleaching. 22) Charges for the treatment of professional visits outside the dental office or after regularly scheduled hours or for observation. 31

34 VisionBlue See the Advantages of BlueCross Vision Plans VisionBlue offers a large variety of plans to help groups provide quality vision benefits with a wide range of copay, frame allowance and frequency options. Vision plans are available on a non-voluntary arrangement with 50 percent employer contribution toward the employee cost or a voluntary basis. VisionBlue is available for groups of any size and can be combined with medical, dental and pharmacy coverage to create an excellent benefit package, all with a single member ID card. VisionBlue Member Advantages Comprehensive benefits that cover all routine vision needs Expansive network including private practitioners and nationally known retail outlets Plans that promote member eye health and wellness Savings of up to 40 percent off retail price Unlimited additional discounts after benefits have been used A single member ID card for mutiple coverages Coverage from one of the most trusted names in health care Now available with any BlueCross medical plan, including HDHP plans 32

35 VisionBlue Design a Plan Step 1: Pick an exam copay ($10 or $20) Stop here if you want an exam-only plan Step 2: Pick a materials copay ($10 or $25) Step 3: Pick a frame allowance level (low, standard or premium) View plan details below and on following page. Step 4: Pick a frame frequency (new frames every 12 or 24 months) VisionBlue Exam Only (Groups 2+ Enrolled; Employer Paid & Voluntary) Benefit In- Out-of- VISION EXAMINATION Comprehensive Eye Examination One exam within a 12-month period For each member covered under the plan Contact Lenses Fit And Follow-Up $10 or $20 Copayment up to $35 Retail Cost Vision Materials* Standard Plastic Lenses Single Vision $50 Bifocal $70 Trifocal $105 Standard Progressive Lens $135 Premium Progressive Lens 20% off retail price Frames 35% off retail price Contacts Conventional only - 15% off retail price Lens Options Standard Polycarbonate $40 UV Treatment $15 Tint $15 Standard Plastic Scratch Coating $15 Standard Anti-Reflective Coating $45 Other lens options 20% off retail price Not covered Requirements For groups with less than 10 enrolled, there is a minimum participation of 50% Must be sold with another BCBST product unless 151 or more employees are enrolled. * Frame, Lens, and Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. 33

36 VisionBlue Exam Plus Materials (Groups 2+ Enrolled; Employer Paid & Voluntary) Benefit In- Out-of- VISION EXAMINATION Comprehensive Eye Examination $10 or $20 Copayment up to $35 Contact Lenses Fit And Follow-Up [1] Standard $55 copay Premium 10% off retail N/A Vision Materials [2] Standard Plastic Lenses $10 or $25 Copayment N/A Single Vision Materials Copayment up to $30 Bifocal Materials Copayment up to $45 Trifocal Materials Copayment up to $60 Standard Progressive Additional $65 Copay up to $45 Premium Progressive Additional $65 Copay, 20% off retail less $120 allowance up to $45 Frames [3] Low $100 allowance up to $50 Standard $120 allowance up to $60 Premium $150 allowance up to $75 Conventional and Disposable Contacts [4] Low $0 Copay up to $100 up to $80 Standard $0 Copay up to $120 up to $96 Premium $0 Copay up to $150 up to $120 Medically Necessary Paid in Full up to $200 Lens Options Standard Polycarbonate $40 Copayment N/A Standard Polycarbonate (For covered Dependent children under 19) $0 Copayment up to $5 UV Treatment $15 Copayment N/A Tint $15 Copayment N/A Standard Plastic Scratch Coating $15 Copayment N/A Standard Anti-Reflective Coating $45 Copayment N/A Other lens options 20% off retail price N/A Frequency Examination Frame Lenses or Contact Lenses Once every 12 months Once every 12 or 24 months Once every 12 months Requirements For groups with less than 10 enrolled, there is a minimum participation of 50% Must be sold with another BCBST product unless 151 or more employees are enrolled. 1 Instead of paying retail or a small percentage discount, network providers may only charge a fixed fee for a standard contact fitting and followup services. 2 Additional complete pair eyeglasses purchases (frame, lens and lens options) receive 40% off retail price at network providers once benefit used. 3 Additional 20% off retail cost above allowance 4 Additional 15% off balance over allowance on conventional contact lenses. Contacts available in lieu of eyeglasses. 34

37 Vision Riders Vision - Plan 1 With these benefits, members may visit any vision care provider for a routine eye exam once a year. Because some vision providers will not file claims, members should be prepared to pay in full, up front. After the member files the claim, BlueCross BlueShield of Tennessee will reimburse them for the covered amount, minus their copayment. Members will not pay more than the $20 copayment for the vision exam. Benefits One vision exam per calendar year and follow-up care from an optometrist or ophthalmologist. $20 copayment per visit Exclusions Benefits will not be provided for the following services, supplies or charges: 1. Charges for vision testing examinations ordered while insured but not delivered within 60 days after coverage is terminated. 2. Charges for lenses or frames, or other hardware. 3. Charges filed for procedures determined by the plan to be special or unusual (e.g., orthoptics, vision training, subnormal vision aids, tonography, corneal refractive therapy, etc.). Vision - Plan 2 With these benefits, members may visit any vision care provider for a routine eye exam once a year. Because some vision providers will not file claims, members should be prepared to pay in full, up front. After the member files the claim, BlueCross BlueShield of Tennessee will reimburse them for the covered amount, minus their copayment. Members will not pay more than the $20 copayment for the vision exam. Benefits One vision exam per calendar year and follow-up care from an optometrist or ophthalmologist. $20 copayment per visit Prescription lenses including bi-focal, tri-focal, etc. 100% up to $85 (one set per calendar year) Prescription contact lenses in lieu of eyeglasses every calendar year 100% up to $150 One set of frames 100% up to $75 (once every two calendar years) Restrictions Prescription sunglass lenses, or sunglasses will be handled as other lenses, or eyeglasses. Exclusions Benefits will not be provided for the following services, supplies or charges: 1. Charges for vision testing examinations, lenses and frames ordered while insured but not delivered within 60 days after coverage is terminated. 2. Charges for sunglasses, photosensitive, anti-reflective or other optional charges when the charge exceeds the amount allowable for regular lenses. 3. Charges filed for procedures determined by the plan to be special or unusual (e.g. orthoptics, vision training, subnormal vision aids, aniseikonic lenses, tonography, corneal refractive therapy, etc.). 4. Charges for lenses that do not meet the Z80.1 or Z80.2 standards of the American National Standards Institute. 5. Charges for non-prescription lenses. 6. Charges in excess of the maximum allowable charge as established by the plan. 35

38 Other Available Riders COBRA Administration Available to Groups with 20 or more employees The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows employees and their eligible dependents, under certain conditions, to continue their group health care coverage once they are no longer eligible under the group contract. Depending on circumstances, coverage can be elected for up to 18, 29 or 36 months. BlueCross BlueShield of Tennessee offers a complete range of COBRA administration and billing services to group administrators. COBRA Administration Services Once an employer informs BlueCross BlueShield of Tennessee that an individual and his or her dependents are eligible for COBRA, BlueCross BlueShield of Tennessee provides several services to enable the individual to continue his/her coverage. Specifically, BlueCross BlueShield of Tennessee: Sends a COBRA notification letter to the eligible subscriber and/or dependents, along with enrollment forms and rate and benefit information. Mails monthly premium notices to the subscriber. Collects the premium directly from the COBRA beneficiary. Notifies the subscriber and employer of COBRA coverage termination, as well as the reason and effective date. Updates the employer s billing record. Notifies the terminated subscriber of any available conversion coverage. Initial Notification Option Sends initial notification letters to all newly hired employees that elect medical coverage, informing them of their COBRA rights. Well Care Services Included in all plans Each member age 6 and over may receive preventive health services. All services must be medically necessary and appropriate based on the plan s medical policy and preventive health care guidelines. All Well Care benefits listed are subject to the terms, conditions, limitations, and exclusions contained in the Group Agreement and the Evidence of Coverage. Well Care Benefits The following is a list of items that are covered as a part of the annual preventive health exam for persons age 6 and up: Annual health screening Childhood immunizations Blood pressure screening Periodic cholesterol screening Tetanus-diptheria (Td) booster Pneumoccocal immunization Other recommended adult immunizations and immunizations not completed in childhood Other prescribed X-ray and lab screenings associated with preventive care Vision and hearing screenings performed by the physician during the preventive health exam Colorectal cancer screenings Immunizations needed for travel to foreign countries. Most of these services are not needed every year or may be appropriate only for people of particular age groups, genders, or those who meet other specific health criteria. The employer is responsible for alerting BlueCross BlueShield of Tennessee when any qualifying events occur for an employee or dependents. And, as they would with regular employees, employers must notify COBRA beneficiaries of rate changes. $500 Special Accident Benefit (For Traditional PPO Plans Only) If members are accidentally injured, their deductible and coinsurance requirements are waived up to $500 of expenses for Covered Services per calendar year. Appropriate copays apply. Limitations Members will be responsible for any applicable copays. They will be responsible for the difference between billed charges and the maximum allowable charge if an out-of-network provider is used. Charges in excess of $500 will be subject to the deductible and coinsurance. The accident must occur on or after the date their coverage begins. Note: Not available with Plans that have an ER copay. 36

39 Ancillary Coverage from Preferred Vendors Ancillary Products, the Key to a Comprehensive Benefit Package Ancillary products from preferred vendors are the perfect complement to a BlueCross BlueShield of Tennessee plan. Ancillary products provide groups of any size the opportunity to offer a comprehensive employee benefit package that is flexible and affordable. By purchasing ancillary products from preferred vendors, groups can save money and administrative hassle; while offering more choices for their employees. Groups can pay some, all or none of the costs on behalf of their employees, and administration is convenient, with combined, single billing for health benefit coverage and select ancillary products. Group Products Group products enhance employees benefits packages. With these products, employers pay all or some of the costs. Product Market Size Features Group Benefits - Provided by USAble Life, Symetra Financial or Companion Life Term Life, AD&D, Dependent Life 2+ Guarantee issue Accelerated death benefit Seat belt benefits Air bag benefit Waiver of premium Short-Term and Long-Term Disability 2+ Benefit percentage - 50% - 66⅔% Maximum monthly benefit - up to $10,000 (LTD only) Integrated disability management Flexible Benefits Program 2+ Full service plans Assistance with 5500 Form Premium-only plans Medical and day care reimbursement plans Weekly claims processing Employee Assistance Program - Provided by Magellan Employee Assistance Program 2+ Face-to-face sessions Legal services Financial services 37