Ready to choose your benefits?

Transcription

1 Ready to choose your benefits? We can point you in the right direction. City of Manitowoc Well Priority POS Effective January 1, 2019 This guide is for information purposes only. You must enroll in a plan for your benefits to start ANMENABS 01/18

2 Let's take a look We know picking a health plan is a big deal, so this guide makes it easier for you to understand your benefit options. We ll explain how the plan works and give you other important details. That way you can enroll with confidence! In this guide, you'll find: The plan at a glance Your health care basics How to use your health plan Your pharmacy benefits Dental benefits Health and wellness programs Your privacy and rights Pay a visit to anthem.com to get an idea of what you can do once you re a member. Find a doctor, estimate care costs, sign up to get s instead of mail and much more!

3 The plan at a glance Here s a quick overview of the plan your employer is offering. 1 Well Priority POS The Accountable Care Organization (ACO) plan lets you see doctors and specialists without a referral from your regular doctor, also known as a primary care doctor. The plan often offers three different levels of benefits: 1. You pay less for care if you see a doctor in the ACO plan. 2. You pay a bit more if you see a doctor in the full Preferred Provider Organization (PPO) plan. 3. You pay a lot more if you see a doctor who isn t in the ACO or PPO plans. It s easy to get care in your plan You can fi nd doctors, hospitals, pharmacies and other health care professionals in our plans on anthem.com and they charge our members lower rates. 3 1 Each of our plans may have different rules, so always check your plan details for more specifi c information.

4 Know your health care basics Learn about the kinds of costs you ll share with your plan You reach your deductible You reach your out-of-pocket limit What you pay What we pay This chart is only an example. Your actual cost share will depend on your plan, the service you get and the doctor you choose. For your actual cost share, see your plan details. You pay your deductible. This is a set amount that you pay before we start sharing in the cost of the covered health care you receive. If your plan has copays (fl at fees like $30 for each visit) along with a deductible, you only need to pay the copay for most doctor visits. What happens after I pay my deductible? You pay a copay or a percentage of the cost, also called coinsurance, each time you receive care for covered services, and then your plan covers the rest. What s an out-of-pocket limit? Each year, there s a maximum amount you can pay out of your own pocket for covered services that s your out-ofpocket limit. Once you ve reached that limit it varies by plan we cover the rest for covered services. If you visit doctors or hospitals that aren t in your plan, you ll still have out-of-pocket costs. With some plans, you still have copays even after you reach your out-of-pocket limit. What about the money for the plan that gets taken out of my paycheck? That s what you pay for the plan. Think of it like a membership fee. It s separate from what you pay when you get care. 4

5 Using your health plan It s easy to get started with your plan and make the best of your benefi ts. Choose a doctor in your plan Avoid getting care from doctors outside of your plan; it will cost you more or your plan may not cover it at all. We ve made it easy for you to fi nd doctors in your plan. Visit anthem.com to look for a primary care doctor, hospitals, labs and other health care professionals in your plan. Use your ID card Once your plan begins, access your mobile ID card on the Anthem Anywhere app. It s like your passport to care and you use it just like you would use a paper ID card. Simply show it when you go to your doctor's appointment or the pharmacy. Register to use online tools and resources Register on the Anthem Anywhere app and anthem.com to get personalized information about your wellness programs and health plan. Use the self-service tools to: Access benefit information. Find a doctor and receive personalized reminders. Estimate your costs, before you step into the doctor s office. Check the price of a drug or refill a prescription. Get support managing your health conditions and tracking health goals. Preventive care is covered at no extra cost Preventive care from a doctor in your plan is covered at 100%. Getting these regular checkups, screenings and shots can help you stay healthy and catch problems early when they re easier to treat. So, talk to your doctor about what preventive care you may need to protect your health. Save emergency room visits for emergencies only Knowing where to go for care saves you time and money. So if you have a real emergency, head straight to the ER or call 911. Otherwise, visit your regular doctor or an urgent care center for minor medical issues. We re here for you When you become a member, we make it easy for you to get your questions answered in the way that works best for you. By phone: Call the Member Services number on your mobile ID card. Online: Use the Anthem Anywhere app to chat with a team member. Done driving to the doctor? Hey there, LiveHealth Online! You can visit a board-certifi ed doctor 24/7 for simple things like the cold, fl u, allergies and more with no appointments and no waiting room. All you need is the LiveHealth Online mobile app or a computer with a webcam to have a video visit with a doctor.* LiveHealth Online costs as little as an office visit or at most $49. Learn more at livehealthonline.com. * Prescription availability is defined by physician judgment.. 5

6 Your pharmacy benefits Here s an overview to help you enroll. Getting the medication you need is important for good health. Your plan will cover: Brand-name and generic drugs covered by your benefi ts. Your options include plans with different drug lists. Check your plan details to see which drug list the plan is using. You can find out if the drug you take is included on the National 4-tier Drug List by visiting anthem.com/national4tier. Understand how your pharmacy benefits work It s important to understand how your health plan works when you visit the pharmacy. Your annual deductible Your plan option doesn t require a pharmacy deductible. That means your plan helps pay for medicine before you reach your deductible. What you pay after meeting your deductible You pay a set amount, or copay, for medicine. Your copay will be based on which tier the drug is on. See Save money with Tier 1 drugs to learn more. Once you re a member, you can check the price of a drug at different pharmacies on anthem.com and see if there are lower-cost drugs. Save money with Tier 1 drugs Drugs are listed in groups called tiers. Your cost is based on which tier the drug is in. Lower-cost drugs and generics are usually in Tier 1 and 2. You can see from the chart that you ll save the most money when you use Tier 1 drugs. You ll pay more out of pocket for drugs in higher tiers. Drug type Preferred generic $ Cost Preferred brand name and newer, more expensive generic drugs $$ Non-preferred brand and generic drugs $$$ Preferred specialty drugs (brand and generic) $$$$ 6

7 Take advantage of your pharmacy benefits Choose a pharmacy that s in your plan. You have many retail pharmacies to choose from. Use a pharmacy that is in your plan to get the best price. To fi nd a pharmacy in your plan, visit anthem.com/pharmacyinformation/rxnetworks.html and choose the National Plus network list of pharmacies. Use generics for health and wealth. Talk to your doctor about using a generic versus a brand-name drug. Because generics cost less than brand-name drugs, they ll save you money. Use over-the-counter drugs when possible. For some health issues, you may not need to see a doctor for relief. Over-the-counter drugs can treat common health problems like allergies or an upset stomach. They aren t covered by your health plan, but you could save time and money without having to see a doctor for a prescription and they usually cost less. Keep a list of your over-the-counter drugs to show your doctor at the next visit, so he or she can make sure there are no drug interactions that could harm you. For more information about how your pharmacy benef ts work, i visit anthem.com/faqs then select your state then pharmacy. 7

8 Dental benefits When you enroll, you'll probably need to sign up separately for the benef ts in i this section. Dental Dental benefi ts not only protect your teeth, but can support overall health, too. Some conditions like heart disease, for example, can have warning signs in the mouth and gums. Our dental plan gives you all the benefi ts you need for a healthy mouth and more. Visit anthem.com/mydentalppo to watch a video and learn more about a dental PPO plan. Your dental plan benefits cover: Most preventive and diagnostic services at 100%. That includes things like cleanings and X-rays. More dental services, including an extra periodontal cleaning if you re enrolled in certain care management programs. Discounts through SpecialOffers@Anthem SM. Visit anthem.com or the Anthem Anywhere app to: Find a dentist in your plan and pay less. Order extra ID cards or use your mobile ID card through the Anthem Anywhere app. Find out the status of a claim. Get a health score for your gums and teeth using our Dental Health Assessment tool. a dental hygienist your dental questions through our Ask a Hygienist tool. See how much a treatment may cost with our Dental Care Cost Estimator. Your Anthem ID card gives you easy access to quality care from quality doctors. 8

9 Health and wellness programs support you along the way Your plan goes way beyond covering doctor visits We can help you reach your health goals and save money on health products and services. As a member, you have easy access to these programs and tools on the Anthem Anywhere app or by calling the Member Services number on your ID card. 24/7 NurseLine Our registered nurses can answer your health questions wherever you are any time, day or night. All you have to do is call. Future Moms Moms-to-be get one-on-one support from registered nurses to help them have a healthy pregnancy, a safe delivery and a healthy baby. LiveHealth Online Using LiveHealth Online, you can have a video visit with a board-certifi ed doctor or therapist on your smartphone, tablet or computer with a webcam. It s easy to use and there when you need it. All you have to do is sign up at livehealthonline.com or on the Anthem Anywhere app. 9

10 Your plan details In this next section, you ll find more information about your plan. 10

11 Your Summary of Benefits CITY OF MANITOWOC Well Priority POS Effective 01/01/2019 Covered Benefits Network Non-Network Deductible (Single/Family) (1) $2,000/$4,000 $4,000/$8,000 Out-of-Pocket Limit (Single/Family) (1) $4,250/$8,500 $8,500/$17,000 Physician Home and Office Services (PCP/SCP) (2) Primary Care Physician(PCP)/Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: Allergy injections (PCP and SCP) Allergy testing $80 / $130 20% 20% 40% 40% 40% MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, nonmaternity 20% 40% related Ultrasounds and Pharmaceuticals Preventive Care Services (3) No Cost Share 40% Services included but not limited to: Routine medical exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Hearing screenings and Vision screenings which are limited to Screening tests (i.e. Snellen eye chart) and Ocular Photo screening. Childhood Immunizations through age 18 Emergency and Urgent Care Emergency Room Services (facility/other covered services) (copayment waived if admitted) Urgent Care Center Services MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-Maternity related Ultrasounds and Pharmaceuticals Allergy injections Allergy testing Inpatient and Outpatient Professional Services Include but are not limited to: Medical Care visits, Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams $300/20% $180 20% 20% 40% 20% 40% 20% 40% Inpatient Facility Services (4) 20% 40% Unlimited days except for: 60 days Network/Non-Network combined for physical medicine / rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 60 days per admission Network/Non-Network combined for skilled nursing facility Outpatient Surgery Hospital / Alternative Care Facility 20% 40% Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): (5) 20% 40% Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment, Orthotics, and Prosthetics 20% 40% Physical Medicine Therapy Day Rehabilitation programs Hospice Ambulance Services 20% 20% $300/20% 40% 40% Life and Disability products underwritten by Anthem Life Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the 11 Blue Cross and Blue Shield Association. Anthem: Blue 11 Page: 3

12 Your Summary of Benefits CITY OF MANITOWOC Well Priority POS Effective 01/01/2019 Covered Benefits Network Non-Network Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits (PCP/SCP) Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: - applies to deductible and coinsurance Occupational therapy: Speech therapy: Cardiac Rehabilitation: 36 visits Pulmonary Rehabilitation: 36 visits Behavioral Health Services: (6) Mental Health and Substance Abuse Inpatient Facility Services Physician Home and Office Visits Other Outpatient Facility Services Human Organ and Tissue Transplants (7) Acquisition and transplant procedures, harvest and storage. Prescription Drugs (National): (8) $80 / $130 20% Benefits provided in accordance with Federal Mental Health Parity 40% 40% 40% 40% 40% No Cost Share 50% Network Tier structure equals 1/2/3/4 - Pharmacy Out-of-Pocket Limit $2,500/$5,000 $2,500/$5,000 Network Retail Pharmacies: (30 day supply) Includes diabetic test strip $10 / $40 / $60 / 20% $125 max / (min $75) 50% Home Delivery (90 day supply) (min $75) Includes diabetic test strip Specialty medications are limited to a 30 day supply regardless of whether they are retail or home delivery. - Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits. - Allows for up to 90 day supply for retail. $20 / $80 / $120 / 20% $125 max Not Covered Life and Disability products underwritten by Anthem Life Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the 12 Blue Cross and Blue Shield Association. Anthem: Blue 11 Page: 4

13 Your Summary of Benefits CITY OF MANITOWOC Well Priority POS Effective 01/01/2019 Notes: (1) Deductible/OOP All medical deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non-Network Human Organ and Tissue Transplant (HOTT) Services). Deductible(s) apply to covered medical services listed with a percentage (%) coinsurance. However, the deductible does not apply to Emergency Room Services where a copayment and a percentage (%) coinsurance applies and may not apply to some Behavioral Health services where coinsurance applies unless specifically noted on the option's cost share. Network and Non-network deductibles, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate towards each other. No Cost Share means no deductible/copayment/coinsurance up to the maximum allowable amount. 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment. (2) PCP/SCP PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/ gynecology, geriatrics and Chiropractors or any other Network provider as allowed by the plan. SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYN's, Geriatrics or any other Network Provider as allowed by the plan. When allergy injections are rendered with a Physicians Home and office visit, only the office visit cost share applies. (3) Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. (4) Hospital stay for Maternity Coverage will not be limited to less than 48 hours for a vaginal delivery or 96 hours for a caesarean section. (5) Other Outpatient Services Mammograms (diagnostic) have no copayment/coinsurance up to the maximum allowable amount in Network office and outpatient facility settings. Private Duty Nursing. (6) Behavioral Health: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. (7) Kidney and Cornea are treated the same as any other illness and subject to the medical benefits. (8) RX If applicable all prescription drug expenses except tier 1, (Network/Non-Network, Retail/Home-delivery combined) apply to the per individual RX deductible. Once the RX deductible is met, the appropriate copayment/coinsurance applies. Also, the Prescription Drug out of pocket maximum applies to Network Retail and Home-delivery combined. Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Dependent age: to the end of the month in which the child attains age 26. Benefit period = Calendar Year Life and Disability products underwritten by Anthem Life Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the 13 Blue Cross and Blue Shield Association. Anthem: Blue 11 Page: 5

14 Your Summary of Benefits CITY OF MANITOWOC Well Priority POS Effective 01/01/2019 Exclusions Your Plan does not provide coverage for the following: Services that are not Medically Necessary. Experimental/Investigative Services. Complications of, or services directly related to a service or treatment that is a non Covered Service under this Certificate because it was determined by Us to be Experimental/ Investigative or non Medically Necessary. Services received from a non-covered Provider. For any condition arising out of and in the course of employment if benefits are available under any Worker's Compensation Act or other similar law. Services provided by any governmental unit, unless otherwise required by law. For any illness or injury that occurs while serving in the armed forces, including as a result of any act of war, whether declared or undeclared. For a condition resulting from direct participation in a riot, civil disobedience, nuclear explosion, or nuclear accident. For court ordered testing or care unless Medically Necessary. For which you have no legal obligation to pay in the absence of this or like coverage. Charges that are not documented in Provider records. For mileage, lodging, and meals costs, and other Member travel related expenses, except as authorized by Us or specifically stated as a Covered Service. For which benefits are payable under Medicare. Charges in excess of Our Maximum Allowable Amounts. Incurred prior to your Effective Date or after coverage ends. For any procedures, services, Prescription Drugs, equipment, or supplies provided in connection with cosmetic services. This does not apply to services required as a result of an accident, to correct a birth defect, or as part of breast reconstruction following a mastectomy. Complications directly related to cosmetic services treatment or surgery are also not covered. For maintenance therapy, which is treatment given when no additional progress is apparent or expected to occur. Custodial Care, convalescent care or rest cures. For dental treatment, regardless of origin or cause, except as specified in the Certificate. Weight loss programs except as specifically listed in the Certificate. For bariatric surgery, regardless of the purpose it is proposed or performed for. Complications directly related to bariatric surgery are also not covered. For marital counseling. For prescription, fitting, or purchase of eyeglasses or contact lenses except as otherwise specifically stated in the Certificate. For hearing aids or examinations for prescribing or fitting them. This exclusion does not apply to hearing aids or examinations required for children under age 18 who are receiving the benefits described in the "Covered Services" section. For testing or treatment related to infertility. For personal hygiene, environmental control, or convenience items including but not limited to air conditioners, physical fitness equipment, or charges from a health spa or similar facility. For care received in an emergency room that is not Emergency Care, except as specified in the Certificate. For eye surgery to correct errors of refraction, such as near-sightedness, including without limitation LASIK, radial keratotomy or keratomileusis, or excimer laser refractive keratectomy. For Private Duty Nursing Services rendered in a Hospital or Skilled Nursing Facility. Nutritional or dietary supplements. For (services or supplies related to) alternative or complementary medicine, including but not limited to acupuncture, holistic medicine, hypnosis, massage therapy, and neurofeedback. Treatment of varicose veins or spider veins. Services for, and related to, many forms of immunotherapy including oral imunotherapy, low dose sublingual immunotherapy, and immunotherapy for food allergies. Spinal decompression devices. This includes, but is not limited to, Vertebral Axial Decompression (Vax-D) and DRX9000. Prescription Drugs dispensed by any Mail Service program other than Our Mail Service, unless prohibited by law. Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order. Drugs not approved by the FDA. Drugs not requiring a Prescription by federal law (including Drugs requiring a Prescription by state law, but not by federal law), except for injectable insulin. Drugs in quantities that exceed the limits established by the Plan, or which exceed any age limits established by Us. Foot orthotics, orthopedic shoes or footwear or support items unless used for a systemic illness affecting the lower limbs, such as severe diabetes. Gene therapy including Drugs, procedures, or services related to it that introduce genetic material to replace or correct faulty or missing genetic material. Physical exams and immunizations required for travel, enrollment in insurance, employment, licensing, sports programs, or other purposes that not required by law. We conduct a variety of quality improvement programs to evaluate, monitor and improve our plans. The purpose of these programs is to measure member satisfaction and quality of care. Providers are also required to participate in a strict certification process. If you have questions or concerns about the programs, you may contact us at (800) Precertification: Members are encouraged to always obtain prior approval when using Non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-Existing Exclusion Period: None This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. Life and Disability products underwritten by Anthem Life Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the 14 Blue Cross and Blue Shield Association. Anthem: Blue 11 Page: 6

15 Take care of yourself Use your preventive care benefits Getting regular checkups and exams can help you stay healthy and catch problems early when they re easier to treat. That s why our health plans offer all the preventive care services and immunizations below at no cost to you. 1 As long as you see a doctor or use a pharmacy or lab in the plan, you won t have to pay anything for these services and immunizations. If you want to visit a doctor or pharmacy outside the plan, you may have to pay out of pocket. Not sure which services make sense for you? Talk to your doctor. He or she can help you figure out what you need. Preventive vs. diagnostic care What s the difference? Preventive care helps protect you from getting sick. If your doctor recommends you have services even though you have no symptoms, that s preventive care. Diagnostic care is when you have symptoms and your doctor recommends services to determine what s causing those symptoms. Adult preventive care Preventive physical exams Screening tests: Alcohol misuse: related screening and behavioral counseling Aortic aneurysm screening (men who have smoked) Behavioral counseling to promote a healthy diet Blood pressure Bone density test to screen for osteoporosis Cholesterol and lipid (fat) level Colorectal cancer, including fecal occult blood test, barium enema, flexible sigmoidoscopy, screening colonoscopy and related prep kit, and computed tomography (CT) colonography (as appropriate) 3 Depression screening Hepatitis C virus (HCV) for people at high risk for infection and a one-time screening for adults born between 1945 and 1965 Type 2 diabetes screening* Eye chart test for vision 2 Immunizations: Diphtheria, tetanus and pertussis (whooping cough) Hepatitis A and hepatitis B Human papillomavirus (HPV) Influenza (flu) Measles, mumps and rubella (MMR) Hearing screening Height, weight and body mass index (BMI) HIV screening and counseling Lung cancer screening for those ages who have a history of smoking 30 packs per year and still smoke, or quit within the past 15 years 3 Obesity: related screening and counseling* Prostate cancer, including digital rectal exam and prostate-specific antigen (PSA) test Sexually transmitted infections: related screening and counseling Tobacco use: related screening and behavioral counseling Tuberculosis screening Violence, interpersonal and domestic: related screening and counseling Meningococcal (meningitis) Pneumococcal (pneumonia) Varicella (chickenpox) Zoster (shingles) Women s preventive care: Well-woman visits Breast cancer, including exam, mammogram, and genetic testing for BRCA 1 and BRCA 2 when certain criteria are met 4 Breastfeeding: primary care intervention to promote breastfeeding support, supplies and counseling 5,6,7 Contraceptive (birth control) counseling Food and Drug Administration (FDA)-approved contraceptive medical services, including sterilization, provided by a doctor Counseling related to chemoprevention for those with a high risk of breast cancer Counseling related to genetic testing for those with a family history of ovarian or breast cancer HPV screening Screening and counseling for interpersonal and domestic violence Pregnancy screenings, including gestational diabetes, hepatitis B, asymptomatic bacteriuria, Rh incompatibility, syphilis, HIV and depression 6 Pelvic exam and Pap test, including screening for cervical cancer These preventive care services are recommendations of the Affordable Care Act (ACA or health care reform law). They may not be right for every person, so ask your doctor what s right for you. This sheet is not a contract or policy with Anthem Blue Cross and Blue Shield. If there is any difference between this sheet and the group policy, the provisions of the group policy will rule. Please see your combined Evidence of Coverage and Disclosure Form or Certificate for exclusions and limitations. * CDC-recognized Diabetes Prevention programs are available for overweight or obese adults with abnormal blood glucose or who have abnormal CVD risk factors MUMENABS VPOD Rev. 10/17 15

16 Child preventive care Preventive physical exams Screening tests: Behavioral counseling to promote a healthy diet Blood pressure Cervical dysplasia screening Cholesterol and lipid level Depression screening Development and behavior screening Type 2 diabetes screening Hearing screening Height, weight and BMI Hemoglobin or hematocrit (blood count) Immunizations: Chickenpox Flu Haemophilus influenza type b (Hib) Hepatitis A and hepatitis B HPV Meningitis Lead testing Newborn screening Screening and counseling for obesity Counseling for those ages with fair skin about lowering their risk for skin cancer Oral (dental health) assessment when done as part of a preventive care visit Screening and counseling for sexually transmitted infections Tobacco use: related screening and behavioral counseling Vision screening when done as part of a preventive care visit 2 MMR } } Pneumonia Polio Rotavirus Whooping cough A word about pharmacy items For 100% coverage of your over-the-counter (OTC) drugs and other pharmacy items listed here, you must: Meet certain age requirements and other rules. Get prescriptions from plan providers and fill them at plan pharmacies. Have prescriptions, even for OTC items. Adult preventive drugs and other pharmacy items age appropriate: Aspirin use (81 mg and 325 mg) for the prevention of cardiovascular disease, preeclampsia and colorectal cancer by adults less than 70 years old. Colonoscopy prep kit (generic or OTC only) when prescribed for preventive colon screening Generic low to moderate dose statins for members that are years and have 1 or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) Tobacco-cessation products, including all FDA-approved brand and generic OTC and prescription products, for those ages 18 and older Vitamin D for adults over age 65 Child preventive drugs and other pharmacy items age appropriate: Dental fluoride varnish to prevent the tooth decay of primary teeth for children ages 0-5 Fluoride supplements for children ages 0-6 Women s preventive drugs and other pharmacy items age appropriate: Contraceptives, including generic prescription drugs, brand-name drugs with no generic equivalent and OTC items like female condoms and spermicides 6,8,9 Low-dose aspirin (81 mg) for pregnant women who are at increased risk of preeclampsia Folic acid for women ages 55 or younger who are planning and able to get pregnant Breast cancer risk-reducing medications, such as tamoxifen and raloxifene, that follow the U.S. Preventive Services Task Force criteria 3 1 The range of preventive care services covered at no cost share when provided by plan doctors is designed to meet state and federal requirements. The Department of Health and Human Services decided which services to include for full coverage based on U.S. Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents and women supported by Health Resources and Services Administration (HRSA) Guidelines. You may have additional coverage under your insurance policy. To learn more about what your plan covers, see your Certificate of Coverage or call the Member Services number on your ID card. 2 Some plans cover additional vision services. Please see your contract or Certifi cate of Coverage for details. 3 You may be required to get preapproval for these services. 4 Check your medical policy for details. 5 Breast pumps and supplies must be purchased from plan providers for 100% coverage. We recommend using plan durable medical equipment (DME) suppliers. 6 This benefit also applies to those younger than age Counseling services for breastfeeding (lactation) can be provided or supported by a plan doctor or hospital provider, such as a pediatrician, obstetrician/gynecologist or family medicine doctor, and hospitals with no member cost share (deductible, copay, coinsurance). Contact the provider to see if such services are available. 8 A cost share may apply for other prescription contraceptives, based on your drug benefits. 9 Your cost share may be waived if your doctor decides that using the multisource brand is medically necessary. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Anthem Blue Cross and Blue Shield is the trade name of Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 16

17 How to use LiveHealth Online on your computer and mobile device How to access LiveHealth Online on your computer You can access LiveHealth Online using a computer with a webcam. Simply visit livehealthonline.com to get started. What you need To enjoy the best experience on LiveHealth Online, make sure you have: High-speed Internet access A bandwidth of 500 kbps (1 Mb/s is best) A webcam or built-in camera Audio capability Browser Next, make sure you are using the right browser. LiveHealth Online works on: Google Chrome (latest version recommended; one version prior supported). Visit: Mozilla Firefox* (latest version recommended; one version prior supported). Visit: en-us/firefox/new/ Microsoft Internet Explorer (PC ONLY: minimum v9.0; maximum v11). Visit: Safari (Mac ONLY: latest version recommended; one version prior supported). Visit: com/downloads/safari Also, in your settings, turn on: JavaScript Cookies Software Before your visit, make sure you have the right software, too. LiveHealth Online works on: Windows (XP, Vista, 7 and 8) Macintosh OS X (10.6 or later) Linux OS (including Chromebook devices) are not supported. Finally, you will need: Adobe Flash Plug-in (10.1 or later) Visit Adobe Reader (7 or later) Visit Firefox users must have the latest version of flash installed. To get started Once you have everything you need, close all other programs, such as: WebEx Skype GoToMeeting These programs can interfere with LiveHealth Online. Next, it s easy to start talking to a doctor: Go to livehealthonline.com. 1. Select Sign Up if you don t have an account. 2. Select Login if you do have an account. 3. Search for a doctor in your area. 4. Fill out information about yourself and your health issue MUMENABS VPOD 7/

18 How to access LiveHealth Online on your mobile device You can access LiveHealth Online from your Android or ios mobile device using the native app. Simply visit Google Play TM or the Apple Store SM to locate the app for your service. Download the app and follow the instructions to get started! LiveHealth Online is not currently available using the Web browser on your mobile device. Device requirements To use your mobile device, ensure that your device meets the requirements below: Online Care app installed (see above) To support two-way video visits, your device must have a front-facing camera Operating System ios (v7.0 or later required): iphone 4S or later ipad 2 or later, ipad Mini or ipad Air ipod Touch fifth generation Operating System Android (Gingerbread v2.3.3 or above): Where to go for help Android phone Call the Customer Support Call Center Android tablet 24/7 at whenever Not supported: HTC mytouch and PantechP9070 you need help. LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 18

19 Your prescription drug plan Answers you want. From a name you can trust. It starts with you You want information that is personal to you like where you can fill your new prescription and how much it s going to cost. You want to know if you ve met your deductible or how to save on your medicines. We ve got it all covered. When you register at anthem.com, you can access pharmacy information that matters to you. This is the easiest and fastest way to get personalized information about what to expect before you go to the pharmacy. When you register at anthem.com, you can: See your drug claims history. Check your copay or coinsurance amounts. Check your out-of-pocket costs. Order refills of home delivery and specialty drugs. Look up drug information. Where to get your prescriptions filled It s simple. You choose what works best for you to get the medicines you need, when you need them. A drugstore near you: Most people use a local drugstore or pharmacy in a retail store to fill a prescription. When you use one that s in your network, you ll pay less. There are a lot of pharmacies in the network. You can find one near you by going online at anthem.com. Choose Prescription Benefits under Useful Tools on the home page and log in. On the Pharmacy page, choose Locate a Pharmacy. You ll be sent to the website of Express Scripts, the company that manages and processes your prescription drug claims. On this site, you can look for a network pharmacy that works for you. Just enter your ZIP code or city and state to search. From there, you can also learn how to switch to home delivery. Home delivery pharmacy: Some people use the home delivery pharmacy for prescriptions they have to take for a long time. Pharmacists call these drugs maintenance medications since they help maintain health. Using the home delivery pharmacy for these drugs may cost less. It can also be a more convenient option. Depending on your benefit plan, you can get up to a 90-day supply sent to your home. Your health plan may require you to use the home delivery pharmacy for maintenance medications. You can check your summary of benefits to see if you have to do this. When you fill a maintenance drug prescription at a retail pharmacy, you ll get a letter and phone call on how to use home delivery pharmacy. Specialty pharmacy: A specialty pharmacy provides medicine for people with chronic health conditions. Specialty drugs come in different forms like pills or liquids. And some need to be injected, inhaled or infused. These drugs often need special storage and handling, and may be given to you by a doctor or nurse. Your plan may require you to use Accredo Specialty Pharmacy. Accredo is part of Express Scripts. You can call the number on your member ID card to check. Specialty pharmacy network: Some health plans have a specialty pharmacy network that members use for their specialty drug medicines to be covered. You can see a list of specialty pharmacies on anthem.com/pharmacyinformation MUMENABS 12/14 19

20 Check how much your medicine will cost you How to save money on your prescriptions You can compare prices for brand-name and generic drugs, as well as the cost when you buy drugs at a retail pharmacy or through home delivery. There are three easy ways to check prices on your prescription drugs: 1. Go to anthem.com. Under Useful Tools, choose Prescription Benefits and log in to your account. You ll be sent to the Pharmacy page. In the Pharmacy Benefits section, choose Price a Medication. You will be sent to the Express Scripts website. Choose the name of the person whose drug you re pricing. In the space provided, enter at least the first three letters of the drug name and choose Search. Choose the drug from the list, including the proper dosage, and choose Continue. Fill in the information for quantity, days supply and reason for brand-drug preference (if asked), then choose Continue. The results will include what you ll pay for the drug at a participating retail pharmacy and through our preferred home delivery pharmacy. You can also see drug list alternatives, if they apply. 2. Go to your pharmacy. Before filling your prescription, your pharmacist can tell you how much it will cost. If you think the cost is too high, talk to your doctor about other drug choices. 3. Call us. You can get a price quote by calling the Customer Service number on your member ID card. You ll just need to give us the: Drug name Strength Form (such as tablet or capsule) Quantity and days supply (for example, 30 tablets per 30 days) 20 Generics help keep money in your pocket When you choose a generic drug over a brand-name drug, you may save money. The Food and Drug Administration (FDA) requires that brandname and generic drugs have the same active ingredients, strength, high-quality standards and dose. Generics might look a little different, but the active ingredients are the same. By choosing a generic drug, you ll get the same effect as a brand-name drug, but usually at a lower cost. Save time and money with over-the-counter drugs Do you suffer from occasional allergies or indigestion? If so, you may not need a prescription from a doctor to feel better. There are over-the-counter (OTC) drugs available to treat these common conditions. Although they aren t covered by your health plan, OTC drugs can save you time and money because you don t need to see a doctor for a prescription, and they cost less. Your doctor or pharmacy can tell you more. Keep a list of the OTC drugs you take and show it to your doctor at your next visit. Your doctor should know all of the drugs you take to make sure there are no drug interactions that may harm you. What you should know about our drug lists Our drug lists (sometimes called formularies) include the drugs covered by your plan. They are made up of hundreds of brand-name and generic drugs. Through detailed research, we find high-quality drugs that offer the best results. And we choose drugs that are safe, work well and offer the best value to help you get and stay healthy. We update our drug lists regularly, for instance when new drugs or new research becomes available. To see your cost-share for generic and brand-name drugs, check your benefits. To see the prescription drugs your plan covers, go to anthem.com/pharmacyinformation/.

21 What you should know about drug tiers Keep in mind Here are other items to note for your pharmacy benefit: The pharmacy may substitute a generic for a brand-name drug. If you or the doctor do not want the pharmacist to do this, the drug may cost more. Some drugs require our approval before the pharmacy can fill the prescription. This is called prior authorization. Usually, the pharmacist can talk to us for approval, or the pharmacist may need to contact the doctor who prescribed the drug. For some drugs, you may need to try a different drug that s just as effective instead. Trying drugs in a step-bystep way is called step therapy. Step therapy helps you and your doctor choose drugs that are safe, affordable and right for you. Taking too much medicine or using it too often is dangerous and costly. Your plan may limit how much of a medicine you can get each month. For example, a drug may have a limit of 30 pills for 30 days. This is called a quantity limit. Drugs are assigned to certain tiers. Several factors are used to decide into which tier a drug is placed. These can include, but are not limited to: How well the drug works compared to other drugs used for the same type of treatment The cost of the drug compared to other drugs used for the same type of treatment Whether there are generic or OTC choices available Tier 1 drugs usually have the lowest member cost-share, while Tier 4 drugs have the highest member cost-share. Your member cost-share for drugs in the different tiers might look like this example:* Tier 1 drugs: $15 copay Tier 2 drugs: $50 copay Tier 3 drugs: $90 copay Tier 4 drugs: 25% of the cost of the drug *For illustrative purposes only. Remember, you can see your cost-share for generic and brand-name drugs by checking your benefits. Questions? Ready to get the most from your prescription drug plan? Our programs can help you get the medicine you need to get healthy and stay healthy. If you want to know more, call us at the Customer Service number on your member ID card. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 21

22 Well Priority service area Utilizing the Blue Priority Network in collaboration with Ashland Iron Vilas Burnett Washburn Sawyer Price Oneida Forest Polk Barron Rusk Marinette Taylor Lincoln Langlade St. Croix Pierce Dunn Pepin Chippewa Eau Claire Clark Marathon Shawano Menominee Oconto Door Buffalo Trempealeau Jackson Wood Portage Waupaca Outagamie Brown Kewaunee = Hospital To view a complete listing of all the doctors, clinics and hospitals in the Blue Priority network, visit anthem.com. La Crosse Vernon Crawford Grant Monroe Richland Iowa Juneau Adams Sauk Dane Marquette Waushara Winnebago Calumet Columbia Green Lake Fond du Lac Dodge Jefferson Waukesha Sheboygan Manitowoc Ozaukee Washington Milwaukee Ashland County Memorial Medical Center Inc Maple Ln. Ashland, WI Brown County Aurora Baycare Medical Center 2845 Greenbrier Rd. Green Bay, WI Bellin Behavioral Health 301 E. St. Joseph St. Green Bay, WI Bellin Memorial Hospital 744 S. Webster Ave. Green Bay, WI Burnett County Burnett Medical Center 257 W. St. George Ave. Grantsburg, WI WIEENABS Rev. 08/17 Chippewa County St Joseph s 2661 County Hwy I Chippewa Falls, WI Crawford County Crossing Rivers Health Medical Center US Hwy 18 Prairie du Chien, WI Dane County American Family Children s Hospital 1675 Highland Ave. Madison, WI Meriter Hospital Inc. 202 S. Park St. Madison, WI University of Wisconsin Hospital 600 Highland Ave. Madison, WI Lafayette Green Rock Dodge County Watertown Regional Medical Center 125 Hospital Dr. Watertown, WI Eau Claire County Sacred Heart Hospital 900 W. Clairemont Ave. Eau Claire, WI Grant County Gundersen Boscobel Area Hospital 205 Parker St. Boscobel, WI Green Lake County Thedacare Medical Center Berlin 225 Memorial Drive Berlin, WI Walworth Racine Kenosha Iowa County Upland Hills Health 800 Compassion Way Dodgeville, WI Jefferson County Fort Memorial Hospital 611 E. Sherman Ave. Fort Atkinson, WI Juneau County Mile Bluff Medical Center 1050 Division St. Mauston, WI Kenosha County Aurora Medical Center Kenosha th St. Kenosha, WI 53142

23 La Crosse County Gundersen Lutheran Medical Center 1910 South Ave. La Crosse, WI Langlade County Langlade Hospital 112 E. 5th Ave. Antigo, WI Manitowoc County Aurora Medical Center Manitowoc 5000 Memorial Dr. Two Rivers, WI Marathon County Aspirus Wausau Hospital 333 Pine Ridge Blvd. Wausau, WI Marinette County Bay Area Medical Center 3100 Shore Dr. Marinette, WI Milwaukee County Aurora Psychiatric Hospital 1220 Dewey Ave. Wauwatosa, WI Aurora Sinai Medical Center 945 N. 12th St. Milwaukee, WI Aurora St. Luke s Medical Center 2900 W. Oklahoma Ave. Milwaukee, WI Aurora St. Luke s South Shore 5900 S. Lake Dr. Cudahy, WI Aurora West Allis Medical Center and Aurora Women s Pavilion 8901 W. Lincoln Ave. West Allis, WI Children s Hospital of Wisconsin 9000 W. Wisconsin Ave. Milwaukee, WI Oconto County Bellin Health Oconto Hospital 820 Arbutus Ave. Oconto, WI Outagamie County Thedacare Medical Center Appleton 1818 N. Meade St. Appleton, WI Ozaukee County Aurora Medical Center Grafton 975 Port Washington Rd. Grafton, WI Polk County Amery Regional Medical Center 265 Griffin St. East Amery, WI Price County Flambeau Hospital 98 Sherry Ave. Park Falls, WI Racine County Aurora Memorial Hospital of Burlington 252 McHenry St. Burlington, WI Rock County Beloit Memorial Hospital 1969 W. Hart Rd. Beloit, WI Rusk County Rusk County Memorial Hospital 900 College Ave. West Ladysmith, WI Sauk County Sauk Prairie Memorial Hospital th St. Prairie Du Sac, WI Sawyer County Hayward Area Memorial Hospital N. State Rd. 77 Hayward, WI Shawano County Thedacare Medical Center Shawano 309 N. Bartlett St. Shawano, WI Sheboygan County Aurora Sheboygan Memorial Medical Center 2629 N. 7th St. Sheboygan, WI Taylor County Aspirus Medford Hospital 135 S. Gibson St. Medford, WI Trempealeau County Tri-County Memorial Hospital Lincoln Ave. Whitehall, WI Vernon County St. Joseph s Health Services Inc. 400 Water Ave. Hillsboro, WI Vernon Memorial Hospital 507 S. Main St. Viroqua, WI Walworth County Aurora Lakeland Medical Center W3985 County Rd. NN Elkhorn, WI Washburn County Spooner Health System 819 Ash St. Spooner, WI Washington County Aurora Medical Center Hartford 1032 E. Sumner St. Hartford, WI Waukesha County Aurora Medical Center Summit Aurora Dr. Summit, WI Oconomowoc Memorial Hospital 791 Summit Avenue Oconomowoc, WI ProHealth Rehabilitation Hospital of Wisconsin 1625 Coldwater Creek Drive Waukesha, WI Waukesha Memorial Hospital 725 American Ave. Waukesha, WI Waupaca County ThedaCare Medical Center Waupaca 800 Riverside Dr. Waupaca, WI ThedaCare Medical Center New London 1405 Mill St. New London, WI Waushara County ThedaCare Medical Center Wild Rose Memorial Hospital 601 Grove Ave. Wild Rose, WI Winnebago County Aurora Medical Center Oshkosh 855 N. Westhaven Dr. Oshkosh, WI Children s Hospital of Wisconsin Fox Valley 130 2nd St. Neenah, WI Thedacare Medical Center Neenah 130 2nd St. Neenah, WI Wood County Aspirus Riverview Hospital 410 Dewey St. Wisconsin Rapids, WI To view a complete listing of all the doctors, clinics and hospitals in the Blue Priority network, visit anthem.com. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out-of-network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 23

24 Is your doctor in the Blue Priority network? Find out online it s fast and easy. 1 Welcome to the Blue Priority network! One of the first questions you may have is if your doctor is in the network. In just minutes, you can find out using our Find a Doctor online tool. You can even look for hospitals, labs and other health care providers in the network. Here s how: 1. Go to anthem.com and choose Individual & Family Under Care in the middle of the page, select Find a Doctor. 3. Choose Search by selecting a Plan or Network. 3 What if your doctor isn t in the plan? Give us a call at the phone number on the back of your ID Card. We ll help you get care that s covered and saves you money WIMENABS Rev. 07/18 24 Just a bit more to go. Read on to complete the steps.

25 4 4. Choose select a plan/network. 5. Select Medical as the type of care you are searching for. 6. Choose Wisconsin as the state you are searching in. 7. Select Blue Priority WI Network as the plan/network. 8. Click Continue Choose the type of provider you are looking for. 10. To narrow down your results even more, add the name of the provider. 11. Provide the city, state or ZIP code. 12. Enter the search distance. 13. You re almost there! Choose Search to see your results Find a doctor anytime, anywhere with the Anthem Anywhere app. It s quick, convenient and free! Download it from the App Store or Google Play TM. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWi), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWi underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 25

26 National and International Coverage 26

27 Peace of mind is something your employees can travel with anywhere they go BlueCard PPO and Blue Cross Blue Shield Global Core programs feature health care benefits that travel with your employees Through the BlueCard PPO and Blue Cross Blue Shield Global Core programs, your employees can access doctors and hospitals in their plan throughout the U.S., as well as around the world. Coverage in the U.S. BlueCard PPO gives them access to their PPO benefits when they use doctors and hospitals that contract with Blue Cross and/or Blue Shield in other states. We re talking about 96% of hospitals and 93% of doctors across the country. 1 The BlueCard program links them all together as one big network. Just like when they seek care at home, your employees may pay less out of pocket and we may cover more services when they get care from doctors and hospitals that are in a Blue Plan. Coverage around the globe For travel abroad, the Blue Cross Blue Shield Global Core program gives your employees access to doctors and hospitals in nearly 190 countries and territories around the world. 2 1 Blue Cross Blue Shield Association website, BlueFacts (accessed December 2016): bcbs.com/sites/default/files/ file-attachments/page/bcbs.facts_.pdf. 2 GeoBlue website, More than 20 years as a leader in international healthcare (accessed December 2016): about. geo-blue.com ANEENABS VPOD Rev. 12/16 27

28 Coast-to-coast coverage with BlueCard PPO The PPO-in-a-suitcase symbol on your employees member ID card is recognized by doctors and hospitals across the country. It identifies your employees as BlueCard PPO members so they can access their PPO benefits where they live and when they travel. Access made easy Finding a PPO doctor or hospital is easy. Your employees go to anthem.com to find a doctor or hospital in the BlueCard PPO program. They can also call the number on the back of their ID card to get names and addresses of the nearest doctor. Network doctors make life easier While your employees can choose in-network or out-of-network doctors each time they need medical care, having a long-term relationship with one network doctor has its advantages like: One doctor who knows them and can direct all of their health care A chance to save money Less paperwork If your employees have an emergency while traveling There s a difference between an emergency and a need for urgent care. Your employees should understand this difference and know how to access care in each case. Emergency care Emergencies are medical conditions that pose a serious risk to someone s health. Here are a few questions your employees should ask themselves: Are my symptoms severe and/or life-threatening? Did they happen all of the sudden and without warning? Is there a lot of bleeding, extreme pain, shortness of breath or broken bones? Using my best judgment, do I believe there may be serious impairment to bodily functions or serious dysfunction of a bodily organ/part without immediate medical attention? If the answer is yes to any of these questions, employees should call 911 or go to the nearest emergency room. Urgent care Urgent care is for medical symptoms, pain or conditions that need medical care right away but aren t severe or life-threatening. This includes an earache, sore throat, rash, sprained ankle, flu and fever of 104 and lower. When your employees need to call us before they seek medical care Sometimes, we ask that your employees call us before they get certain care or services so that we can be sure they get the right care in the right setting. This is called precertification. Emergency care doesn t require precertification, but we still need to know about it Precertification is not required for emergency care or admissions, but we do need to know about them. The employee or a relative must tell us within 24 hours or as soon as they can. Employees who don t let us know may have to pay more if we determine that certain services weren t medically necessary. 28

29 Services and equipment that need precertification Precertification is usually required for the following services. Your employees should see their benefits booklet for their plan s complete list and rules. Human organ and tissue transplants Hospital stays and stays at other facilities, except for childbirth Diagnostic services and advanced imaging Private-duty nursing services at home One-day surgery for: uvulopalatopharyngoplasty (UPPP) and certain plastic/reconstructive procedures Certain durable medical equipment/prosthetics including special wheelchairs and hospital beds, powered prosthetics and custom-made orthotics/braces Your employees are responsible for getting precertification. Even if their doctor offers to do it for them, it s a good idea for your employees to call us and confirm. How BlueCard works when employees need care while traveling in the U.S. Your employees should always carry an up-to-date ID card. When they need health care, your employees can search for the nearest BlueCard PPO doctors and hospitals by looking them up online. They can also call the number on the back of their ID card to find a BlueCard PPO doctor or hospital. Your employees are responsible for calling us for precertification. They should use the phone number on their ID card. When they get to the doctor s office or hospital, your employees should show their ID card, and the doctor or hospital will verify their membership and coverage information. After your employees get care, the claim is electronically sent to us for processing. BlueCard PPO doctors and hospitals are paid directly, and your employees normally only need to pay for out-of-pocket costs (noncovered services, deductible, copay or their percentage of the costs). They ll get a detailed explanation of benefits summary showing how the claim was processed. We re here to help If your employees have questions, they can call the Member Services number on the back of their ID card. We ll be happy to help them understand their BlueCard and Blue Cross Blue Shield Global Core benefits and how to use them. To learn more about how BlueCard PPO and Blue Cross Blue Shield Global Core can cover your employees when they re away from home, call your Sales representative. Employees can learn more about Blue Cross Blue Shield Global Core by: Calling the Member Services number on their ID card. Visiting bcbsglobalcore.com. Calling the Blue Cross Blue Shield Global Core service center toll free at or collect at

30 Coverage abroad with Blue Cross Blue Shield Global Core Whether traveling or living outside of the U.S., your employees can use the Blue Cross Blue Shield Global Core program when they need medical care. Here s what happens when employees need care while traveling or living abroad Before leaving the U.S., employees should call the Member Services number on the back of their ID card to find out how they re covered abroad. Your employees should always carry an up-to-date member ID card. In an emergency, employees should go to the nearest hospital. If your employees need help finding a doctor or hospital, or have any questions about getting care abroad, they should call the Blue Cross Blue Shield Global Core service center toll free at or collect at , 24 hours a day, seven days a week. An assistance coordinator, together with a medical professional, will arrange a doctor s appointment or hospital stay, if needed. If employees need to be admitted to the hospital, they should call the Blue Cross Blue Shield Global Core service center toll free at or collect at Besides contacting the Blue Cross Blue Shield Global Core service center, employees should call the Member Services number on their ID card for precertification. Note: This number is not the phone number listed above. Employees will need to pay up front for care received from an out-of-network doctor and/or out-of-network hospital. Then, they ll have to fill out a Blue Cross Blue Shield Global Core claim form and send it with the bill(s) to the Blue Cross Blue Shield Global Core service center (the address is on the form). Employees can download a claim form by visiting bcbsglobalcore.com and entering their three-digit alpha prefix. They can also get a form by calling the Blue Cross Blue Shield Global Core service center. 30 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

31 Extras 31

32 Anthem.com at your service when you need it! See your benefits Check what your plan covers and how much you might pay for care. Find a doctor Look for doctors in your plan and save on care. Check your claims See what s covered and what you owe for care. Get your medication Refill your prescriptions online. Get discounts Save on health-related products and services. Estimate your costs Compare costs and quality for common procedures. You can do more in less time just log in at anthem.com. Don t forget: You can have your health information at your fingertips anytime through the Anthem Anywhere mobile app. Manage your health care accounts Pay or reimburse yourself for health care expenses. See your account balance anytime. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association ANMENABS VPOD Rev. 05/16 32

33 You re on the go and so are we With the Anthem Anywhere app, you can manage your benefi ts anytime and anywhere you go. Just search for Anthem Anywhere and download the app. Find a doctor Search for a doctor, specialist, urgent care or hospital close by. Get your ID card Share, fax, or your ID card right from your smartphone. Check your claims Find out what your doctor billed, how much was paid and if you owe anything. Estimate your costs See what nearby doctors and facilities charge for a procedure. You can compare providers on cost and quality. View your medical benefits See your copays, deductibles, your percentage of the costs, and other important plan benefit information. Manage prescription benefits Check the cost of drugs, get refi lls or switch to our home delivery program. Access your mobile Health Record View your Health Record and share with your doctors whenever you go. Download the Anthem Anywhere app today. Together we can make healthy happen. Only available on Apple and Android devices Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association ANMENABS_WGS VPOD 04/16

34 Live life to the fullest without paying full price Save money with discounts at anthem.com Saving money is good. Saving money on things that are good for you that s even better. With SpecialOffers, you can get discounts on products and services that help promote better health and well-being.* It s just one of the perks of being a member. Check out how much you can save: Vision and hearing Glasses.com TM and CONTACTS Get the latest, brand-name frames for just a fraction of the cost at typical retailers every day. Plus, you get an additional $20 off orders of $100 or more, free shipping and free returns. Premier LASIK Save $800 on LASIK when you choose any featured Premier LASIK Network provider. Save 15% with all other in-network providers. Nations Hearing Get hearing screenings and in-home service at no additional cost, and up to 50% off all hearing aids from Nations Hearing, powered by the Beltone network. Hearing Care Solutions Digital instruments starting at $500. Free hearing exam. Thirty-one hundred locations and eight manufacturers. Three-year warranty, two years of batteries, unlimited visits for one year, from Hearing Care Solutions. Fitness and health Active&Fit Direct TM Active&Fit Direct allows you to choose from 9,000+ participating fi tness centers nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes). Offered through American Specialty Health Fitness, Inc. Jenny Craig Receive a free 3 month program and $70 in food savings OR save 50% off premium programs (food costs separate). With one on one support and nearly 100 Jenny Craig foods, you can lose three times more weight than dieting on your own with Jenny Craig s scientifi cally proven program. Restrictions apply. SelfHelpWorks Choose one of the online Living programs and save over 60% on coaching to help you lose weight, stop smoking, manage stress or face an alcohol problem. GlobalFit TM Discounts on gym memberships, fi tness equipment, coaching, and more from Global Fit. MANSH1231A VPOD Rev. 05/18 34 Check out more SpecialOffers on the other side.

35 SpecialOffers on anthem.com Family and home 23andMe Get $40 off each Health + Ancestry Service Kit. Your DNA says a lot about you. Save 20% on a 23andMe kit and learn about your wellness, ancestry, and more! Safe Beginnings Babyproof your home while saving 15% on everything from safety gates to outlet covers. Pet Insurance VPI is now Nationwide, the #1 choice in America for pet insurance! Receive an automatic 5% discount when you enroll through your company or organization. Save up to 15% when you enroll multiple pets. ASPCA Pet Insurance Get 5% off pet insurance. You can choose from three levels of care, including fl exible deductibles and custom reimbursements. WINFertility Save up to 40% on infertility treatment. WINFertility helps make quality treatment affordable. LifeMart Get great deals on beauty and skin care, diet plans, fi tness club memberships and plans, personal care, spa services and yoga classes, sports gear and vision care. Medicine and treatment Puritan s Pride A large selection of discounted vitamins, minerals and supplements from Puritan s Pride. Allergy Control products Save 20% on select Doctor Recommended Products such as allergy free bedding, air purifi ers and filters, asthma products, and more. Plus enjoy Free Shipping on all orders over $79 when shipping ground within the contiguous U.S. National Allergy supply Save 20% on select National Allergy Doctor Recommended Products! - Allergy bedding - Air purifiers and filters - Home allergy products - Personal care - Humidifiers and dehumidifiers - Vacuums and steam cleaners HelpCare Plus Save 10% to 50% for the entire family on Dental Services, Chiropractic Care, Vitamins, Natural Food and Senior Care at just 44 cents a day from HelpCare Plus. To fi nd the discounts that are available to you, log in to anthem.com and select Discounts. * All discounts are subject to change without notice. Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente que aparece al dorso de su tarjeta de identificación o en el folleto de inscr Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefi ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Company (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 35 anthem.com

36 Give your employees peace of mind 24/7 NurseLine has them covered anytime, anywhere Health issues can crop up at the most inconvenient times and places for your employees whether it s 3 a.m. at home or 10 a.m. while they re in the office. What if your employees had a nurse in their back pocket someone knowledgeable they could talk to any time of the day or night, 365 days a year, from anywhere in the U.S.? That s why Anthem Blue Cross and Blue Shield (Anthem) offers 24/7 NurseLine. With 24/7 NurseLine, your employees can ask registered nurses a variety of questions, including how to choose the right level of care. Choosing the best treatment option can mean cost savings for you and your employees. Good health is great for your business While 24/7 NurseLine may be the fi rst line of defense for the unexpected, it s also part of Anthem s whole-health approach to care. The registered nurses can give your employees allergy relief tips and explain why urgent care makes more sense than the emergency room (ER). By reaching for their phones fi rst, your employees can get the help they need. Qualified registered nurses can also: Help your employees find providers and specialists in the area. Give referrals to LiveHealth Online, a tool that allows your employees to have live video chats with board-certified doctors using a smartphone, tablet or computer and webcam. 1 Enroll your employees and their dependents in valuable care management programs for certain health conditions. Help your employees decide where to go for care when their doctor, dentist or eye doctor isn t available. Provide guidance during natural catastrophes and health outbreaks. Offer links to health-related educational videos or audio topics. 24/7 NurseLine is connected with Anthem s other health and wellness programs, so your employees have access to the best resources for the best health results. When your employees need answers, they can call the number located on the back of their ID card. It's that easy! Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefi ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 36 EANSH1283A VPOD 7/18 1 LiveHealth Online is available in most states and expected to expand to more in the near future. Visit the home page of livehealthonline.com to view the service map by state. LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.

37 Anthem Dental Complete 37

38 Your Summary of Benefits City of Manitowoc - Basic Dental Plan Anthem Dental Complete WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your employee benefits booklet. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum. YOUR DENTAL PLAN AT A GLANCE In-Network Out-of-Network Annual Benefit Maximum (Calendar Year) Per insured person $1,250 $1,250 Annual Deductible No deductible No deductible Deductible Waived for Diagnostic/Preventive Services Out-of-Network Reimbursement Dental Services Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays (once in 12 mos. for all ages) Intraoral X-rays Space Maintainers Palliative Emergency Treatment Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back Composite Filling, Simple Extractions Endodontics Root canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions Yes In-Network Anthem Pays: Yes 80th percentile Out-of-Network Anthem Pays: Waiting Period 100% coinsurance 100% coinsurance No waiting period Not covered Not covered N/A Not covered Not covered N/A Not covered Not covered N/A Not covered Not covered N/A Major Services Not covered Not covered N/A Crowns Prosthodontics Not covered Not covered N/A Dentures Bridges Dental Implants Prosthetic Repairs/Adjustments Not covered Not covered N/A This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your employee benefits booklet. In the event of a discrepancy between the information in this summary and the employee benefits booklet, the booklet will prevail. 38

39 Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem. To learn more about the program, please visit the International Emergency Dental Web site at Finding a dentist is easy. To select a dentist by name or location, do one of the following: Go to anthem.com/mydentalvision Call Anthem dental customer service at the toll-free number listed on the back of your ID card. TO CONTACT US: Call Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. Write Refer to the back of your plan ID card for the address. Limitations & Exclusions Limitations Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your employee benefits booklet for a full list. Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per Calendar Year Teeth cleaning (prophylaxis) Limited to two per Calendar Year Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Limited to once every three years Topical fluoride application Limited to once every 12 months for members through age 18 Sealants Limited to first and second molars once every 24 months per tooth for members through age 15; sealants may be covered under Diagnostic and Preventive or Basic Services. Basic and/or Major Services*** -No coverage The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), and Healthy Alliance Life Insurance Company (HALIC). RIT and certain affiliates administer non-hmo benefits underwritten by HALIC. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association /2015

40 Your Summary of Benefits City of Manitowoc-Enhanced Plan Anthem Dental Complete WELCOME TO YOUR DENTAL PLAN! This benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your employee benefits booklet. Dental coverage you can count on Your Anthem dental plan lets you visit any licensed dentist or specialist you want with costs that are normally lower when you choose one within our large network. Savings beyond your dental plan benefits you get more for your money. You pay our negotiated rate for covered services from in-network dentists even if you exceed your annual benefit maximum. YOUR DENTAL PLAN AT A GLANCE In-Network Out-of-Network Annual Benefit Maximum (Calendar Year) Per insured person $1,500 $1,500 Annual Maximum Carryover No No Orthodontic Lifetime Benefit Maximum Per eligible insured child $3,000 $3,000 Annual Deductible No deductible $0 $0 Out-of-Network Reimbursement Dental Services Diagnostic and Preventive Services Periodic oral exam Teeth cleaning (prophylaxis) Bitewing X-rays (once in 12 mos. for all ages) Intraoral X-rays Basic Services Amalgam (silver-colored) Filling Front composite (tooth-colored) Filling Back Composite Filling, alternated to amalgam allowance Simple Extractions Endodontics Root canal Periodontics Scaling and root planing Oral Surgery Surgical Extractions In-Network Anthem Pays: 80th percentile Out-of-Network Anthem Pays: Waiting Period 100% coinsurance 100% coinsurance No waiting period 80% coinsurance 80% coinsurance No waiting period 80% coinsurance 80% coinsurance No waiting period 80% coinsurance 80% coinsurance No waiting period 80% coinsurance 80% coinsurance No waiting period Major Services 80% coinsurance 80% coinsurance 12 months Crowns Prosthodontics 80% coinsurance 80% coinsurance 12 months Dentures Bridges Dental Implants (covered) Prosthetic Repairs/Adjustments 80% coinsurance 80% coinsurance 12 months Orthodontic Services Adults and dependent children* 50% coinsurance 50% coinsurance 12 months This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your employee benefits booklet. In the event of a discrepancy between the information in this summary and the employee benefits booklet, the booklet will prevail. 40

41 Emergency dental treatment for the international traveler As an Anthem dental member, you and your eligible, covered dependents automatically have access to the International Emergency Dental Program.** With this program, you may receive emergency dental care from our listing of credentialed dentists while traveling or working nearly anywhere in the world. ** The International Emergency Dental Program is managed by DeCare Dental, which is an independent company offering dental-management services to Anthem. To learn more about the program, please visit the International Emergency Dental Web site at Promoting healthy mouths for members who are pregnant or living with diabetes If you are pregnant or living with diabetes, you can sign up to receive one additional dental cleaning or periodontal maintenance procedure per year. Finding a dentist is easy. To select a dentist by name or location, do one of the following: Go to anthem.com/mydentalvision Call Anthem dental customer service at the toll-free number listed on the back of your ID card. TO CONTACT US: Call Refer to the toll-free number indicated on the back of your plan ID card to speak with a U.S.-based customer service representative during normal business hours. Calling after hours? We may still be able to assist you with our interactive voice-response system. Write Refer to the back of your plan ID card for the address. Limitations & Exclusions Limitations Below is a partial listing of dental plan limitations when these services are covered under your plan. Please see your employee benefits booklet for a full list. Diagnostic and Preventive Services Oral evaluations (exam) Limited to two per Calendar Year Teeth cleaning (prophylaxis) Limited to two per Calendar Year Intraoral X-rays, single film Limited to four films per 12-month period Complete series X-rays (panoramic or full-mouth) Limited to once every three years Topical fluoride application Limited to once every 12 months for members through age 18 Sealants Limited to first and second molars once every 24 months per tooth for members through age 15 Space Maintainers Limited to extracted primary posterior teeth once per lifetime per tooth for members through age 16 Emergency Palliative Treatment Basic and/or Major Services*** Fillings Limited to once per surface per tooth in any 24 months Crowns Limited to once per tooth in a seven-year period Fixed or removable prosthodontics dentures, partials, bridges, tooth implants Covered once in any seven-year period; benefits are provided for the replacement of an existing bridge, denture or partial for members age 16 or older if the appliance is seven years old or older and cannot be made serviceable. Root canal therapy Limited to once per lifetime per tooth; coverage is for permanent teeth only. Periodontal surgery Limited to one complex service per single tooth or quadrant in any 36 months, and only if the pocket depth of the tooth is five millimeters or greater Periodontal scaling and root planing Limited to once per quadrant in 36 months, when the tooth pocket has a depth of four millimeters or greater Brush biopsy (Covered) ***Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There may be a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan. ADDITIONAL LIMITATION FOR ORTHODONTIC SERVICES if Orthodontia is included as a benefit of your dental plan Orthodontia Limited to one course of treatment per member per lifetime Exclusions Below is a partial listing of noncovered services under your dental plan. Please see your employee benefits booklet for a full list. Services provided before or after the term of this coverage Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate Orthodontics (unless included as part of your dental plan benefits) Orthodontic braces, appliances and all related services Cosmetic dentistry Services provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist Drugs and medications Intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care Analgesia, analgesic agents, anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Extractions Surgical removal of third molars (wisdom teeth) that do not exhibit symptoms or impact the oral health of the member The in-network dental providers mentioned in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem Blue Cross Life and Health Insurance Company. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), and Healthy Alliance Life Insurance Company (HALIC). RIT and certain affiliates administer non-hmo benefits underwritten by HALIC. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association /2015

42 Choice of dentists While your dental plan lets you choose any dentist, you may end up paying more for a service if you visit an out-of-network dentist. Here s why: In-network dentists have agreed to payment rates for various services and cannot charge you more. On the other hand, out-of-network dentists don t have a contract with us and are able to bill you for the difference between the total amount we allow to be paid for a service called the maximum allowed cost and the amount they usually charge for a service. When they bill you for this difference, it s called balance billing. How Anthem dental decides on maximum allowed costs For services from an out-of-network dentist, the maximum allowed cost is determined in one of the following ways: Out-of-network dental fee schedule/rate developed by Anthem, which may be updated based on such things as reimbursement amounts accepted by dentists contracted with our dental plans, or other industry cost and usage data Information provided by a third-party vendor that shows comparable costs for dental services In-network dentist fee schedule Here s an example of higher costs for out-of-network dental services This is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the dentist who provides the services. Say Ted s dental plan allows him 50% coinsurance for either in- or out-of-network services... Ted chooses to get a crown from an out-of-network dentist who charges $1,200 for the service and bills Anthem for that amount. If Anthem s maximum allowed cost for this dental service is $800, this means there will be a $400 difference. The out-of-network dentist can balance bill Ted for that amount. Ted will also need to pay $400 coinsurance. Therefore, the total he will pay the out-of-network dentist is $800. Here s the math: Dentist s charge: $1,200 Anthem s maximum allowed cost: $800 Anthem pays 50%: $400 Ted pays 50% (coinsurance): $400 Balance Ted owes the provider: $1,200 - $800 = $400 Ted s total cost: $400 coinsurance + $400 provider balance = $800 In the example, if Ted had gone to an in-network dentist, his cost would be only $400 for the coinsurance because he would not have been balance billed the $400 difference. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), and Healthy Alliance Life Insurance Company (HALIC). RIT and certain affiliates administer non-hmo benefits underwritten by HALIC. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association /2015

43 Emergency dental care for the world traveler Whether you re on a vacation or just working abroad, the last thing you need to worry about is where to go for emergency dental care. With dental coverage from Anthem Blue Cross and Blue Shield (Anthem), you don t have to worry. As an Anthem dental member, you and your family have access to the International Emergency Dental Program. Anthem offers you this program through DeCare Dental.* With this program, you may get emergency dental care from our list of credentialed, English-speaking dentists while traveling or working abroad. Program services are listed on the wallet card below. Here s how it works If you need emergency dental care while traveling abroad, call us right away. (The attached card gives details on how to make that call.) Our English-speaking Customer Service reps can help you find a dentist. And they can even help with translation services when you call the dentist s office. Visit our website for a list of participating dentists For a list of participating dentists, visit decare.com. Under the drop-down menu on the left, choose DeCare Dental Products, then International Dental Program. From there you can check our list of participating dentists in the International Emergency Dental Program section. Payment for care Please pay the dentist and ask for a receipt. Then, print a claim form from our website at decare.com and send the filled out * DeCare Dental is an independent company offering dental administrative services to Anthem Blue Cross and Blue Shield plans. The International Emergency Dental Program is administered by DeCare Dental. No such relationship other than that of independent parties under an arrangement with each other solely for the purposes of providing dental care to Anthem Blue Cross and Blue Shield members may be deemed to exist between DeCare Dental and participating dentists. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association MUMENABS Rev. 09/14 43 form with the receipt to the address listed on the claim form. Claims are paid to members in U.S. funds. Please note that emergency dental care received from a dentist in this program is paid back in full and is not part of your yearly plan limit. Your claim will be paid at an out-of-network level if you: Get emergency dental care out of the country from a dentist who is not in this program. Get dental care that is not an emergency from any dentist outside of the U.S. Emergency dental care is offered 24 hours a day, 365 days a year For easy access to the International Emergency Dental Program cut out the card below, fold it in half and carry it with you while you travel outside of the U.S. Program services Only emergency care is provided by this program. Emergency care means dental services to: Treat or control severe infections. Treat injuries to, or trauma of, the teeth or structures that support the teeth.* Ease intense pain to make you feel better. Care for pain that lasts a long time or has not been diagnosed is not covered under this plan. Find the source of pain or infection, or the extent of trauma (diagnostic services). Find out the extent of a dental emergency through an exam. How to find a dentist in the country you are visiting Please note: This number is NOT toll-free. If you are using an international calling card, please follow the steps on the card first. Step 1: If you are in a hotel, office building or other place where you need to first press a number to make a call, do this first. Step 2: Then press the outbound calling code for the country you are calling from. (For instance, Switzerland is 00) plus If calling from Ireland, press (24 hours a day) Claim questions only (in the U.S.) fold fold *Dental injuries or trauma include: These are not emergency care services: Enamel fracture Routine exams Crown fracture Preventive dental services such as: Root fracture Dental cleanings Crown-root fracture Putting fluoride or sealants on teeth Luxation (put out of joint) Keeping the space for an adult tooth open if the baby tooth has been lost too early (space maintenance) Avulsion (torn off) Basic or major restorative dental services when there is Fracture of the upper or lower jaw no pain, trauma, or short-term infection bone (alveolar process) Periodontics (treating and preventing gum disease) Prosthodontics (use of bridges and dentures to replace missing teeth) Implants Orthodontics (use of braces to change the spacing between teeth)

44 If you are pregnant or have diabetes your teeth and gums need special care. Form Title Form Sub Title Sign up for extra dental benefits* at no extra cost using the form below. Your Anthem Blue Cross and Blue Shield dental plan helps you take extra good care of your mouth. Taking care of your teeth and gums is easy and can help keep your mouth free from infection. You should brush and floss daily, and see your dentist regularly. While your dental plan most likely provides coverage for preventive care services, by completing the form below you may be eligible* to get coverage for an extra dental cleaning (to help keep your teeth healthy) or an extra periodontal maintenance procedure (to help keep your gums healthy) each benefit year. For a healthy smile, sign up here. Simply fill out the form below and mail, or fax it to us whichever is easiest for you. Mail to: Clinical Integration Coordinator, PO Box 1115, Minneapolis, MN to: enroll@anthemdentaladmin.com Fax to: Dental Enrollment Request Form Member name: Member address: Member phone number: (h) (w) I have diabetes I am pregnant and my expected due date is: Subscriber name: Subscriber ID number: For Group business only Group name: Group number: To the best of my knowledge and belief, I am being treated for diabetes or was pregnant as of the below signature date and will provide proof of such condition if requested by Anthem Blue Cross and Blue Shield. Additionally, upon request, I will provide a written authorization to Anthem Blue Cross and Blue Shield to obtain medical records from my provider(s). If such condition cannot be verified, I will not be eligible for coverage for the additional dental procedures available under this program. Member signature: Today s date: Name of treating physician: Phone number of physician: Questions? Just call the customer service number on the back of your Anthem dental ID card. * Coverage for additional cleaning is an optional benefit that may not be included in your plan. Check with your benefit administrator for details. /1 44

45 WORK-IN-PROGRESS EXPLANATION Non-Orthodontic Services Work-In-Progress For all services other than orthodontics, (e.g., root canals, crowns, bridges, dentures) that started prior to the subscriber s effective date under the Prime and Complete dental plan, payment of the claim is based on the service completion date. The Prime and Complete dental plan will honor the prior carrier s pre-estimate, but only in determining coverage. Pricing and network status are not guaranteed and will be based on the provider s participating status with Prime and Complete. The provider/subscriber should attach the prior plan s pre-estimate to the claim when submitting to Prime and Complete dental for consideration. Orthodontic Work-In-Progress If a covered, dependent child is in the midst of active orthodontic treatment (bands have been placed), the provider needs to supply Anthem dental with a copy of the original claim that must include the following information: 1) 2) 3) 4) Treatment type (procedure number) Total fee for treatment Number of months treatment will take place Provider signature The amount of the benefit that will be paid will be pro-rated based on the number of months of active treatment remaining following the effective date of the child (minus any amount paid by the prior carrier if history is loaded.) Example: Treatment Plan Length and Cost: Remaining Months of Treatment: Monthly Treatment Cost: Ineligible Monthly Cost: Eligible Treatment Cost: Amount Paid by Anthem: 24 months for $5, months $5,200/24 months = $ monthly 14 months x $ = $3, $5,200 - $3, = $2, $2, x 50% = $1,083.38* The total amount paid will be limited to the total Lifetime Orthodontic Maximum minus any prior carrier history, if loaded. Standard Ortho Payment Schedule x $500-$1,500 Lifetime Orthodontic Maximum = 2 Equal Payments (banding & 6 months after banding) x $1,500+ Lifetime Orthodontic Maximum = 3 Equal Payments (banding, 6 months after banding, 12 months after banding) Anthem Dental Claims Mailing Address Anthem PO Box 1115 Minneapolis, MN Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ( BCBSWi ), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Work in Progress Explanation - Anthem 45

46 How to Guide: Find an Anthem Dental Complete Provider STEP 1: Go to STEP 2: Click on Find Dental Providers (middle of page) STEP 3: Click on Anthem Dental Complete STEP 4: Select a Specialty (if needed); Click Next STEP 5: Enter your criteria for the provider search and click on View Results STEP 6: To lookup a provider by name, click on Lookup by Name at the top of the page STEP 7: On the Search Results page, you can: Download Results; Print a PDF of your results; and Start a new search Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ( BCBSWi ), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Anthem_10_

47 Skip the drugstore have your medicine delivered to your home! Why wait in line at the drugstore if you don t have to? If you take prescribed medicine on a regular basis, you can get up to a 90-day supply delivered to your door. 1 And depending on your plan, you may save on copays because the cost of a 90-day supply of many drugs is usually less than three 30-day refills. On average, members save up to 25% on their copay when they use home delivery. 2 Standard shipping is free, and you can even set up automatic refills. Getting started with home delivery is easy: 1. Go online to get a prescription order form. 2. Get a new prescription from your doctor for home delivery. Visit anthem.com, choose Manage Your Prescriptions from the home page and log in with your username and password. If you haven t signed up on the site yet, you ll need to do that first. On your personal pharmacy page, select Start a New Prescription. That ll take you to the site of the company that helps manage our prescription benefi ts. 3 There, you can download and print the physician fax form or, if you already have a new prescription for a 90-day supply of medicine from your doctor, download the home delivery mail form. You ll use one of these forms to send in your prescription. You ll need an up-to-90-day supply prescription. Your doctor can send in your prescription through eprescribe or fax it using the physician fax form from step 1. Also ask your doctor for a 30-day prescription. Get this filled at your regular pharmacy to make sure you have enough medicine to last until you get your first home delivery prescription WIMENABS VPOD Rev. 2/17 47