Employer Health Plan PRODUCT GUIDE

Transcription

1 Employer Health Plan PRODUCT GUIDE 2019 PLANS EMPLOYERS WITH 1-50 EMPLOYEES

2 WE RE HERE TO HELP Our team is here to help you find the right health plans for your needs. Reach us at one of the following locations. Or visit azblue.com for more details on our products and services. PHOENIX TUCSON FLAGSTAFF (602) (800) , ext FAX (602) (520) (800) FAX (866) (928) (800) FAX (602) PLANS 2

3 2019 PLAN CHOICES THAT MOVE HEALTH FORWARD What s new for 2019? Network options for higher net savings Alliance is now available as an HMO network in Maricopa County. Virtual doctor visits through BlueCare Anywhere are included in all plan benefits. Employees can visit with boardcertified doctors, counselors, and psychiatrists using their smartphone, computer, or tablet. We are offering Balanced Funding, a self-funding solution for employers with 15 or more enrolled employees. Balanced Funding provides employers with financial predictability and control over monthly healthcare costs. 1 With Balanced Funding, employers pay a fixed, monthly amount that includes the cost of administrative services, stoploss insurance, and all claims coverage. 2 Balanced Funding may be a great option for employers whose employees are engaged in their healthcare and use their plan in a cost-efficient and effective manner. For more information on Balanced Funding health plans (included in a separate guide), ask your broker or BCBSAZ representative. Network choice provides access to quality care and is a key money-saver for employers and employees alike. Choosing a smaller network helps lower employees premiums Staying in-network lowers costs for medical services Knowing limits on out-of-network services, like emergencies, helps control costs PLAN OPTIONS NETWORKS PROVIDER AFFILIATIONS PPO Plans A wide selection of primary care providers (PCPs) and specialists No requirement to have an assigned PCP or get referrals before seeing a specialist Access to healthcare out of state with the BlueCard network when traveling or vacationing Out-of-network care covered, but at a higher cost HMO Plans Primary care provider (PCP) assignment is required PCP coordinates care with other in-network providers PCP referrals required for specialist visits (some exceptions apply) * Out-of-network services not covered except in emergencies and rare situations when preauthorized by BCBSAZ Statewide (Statewide) Alliance (Maricopa County) Statewide (Statewide) Alliance (Maricopa County) PimaConnect HMO (Pima County) Affiliations statewide Banner Health and HonorHealth Affiliations statewide Banner Health and HonorHealth Tucson Medical Center 1 Medical criteria are used to establish rates for Balanced Funded arrangements. Not all businesses will qualify. 2 With Balanced Funding, composite rates are fixed. Monthly payments may still change based on a business s employee census, as employees or dependents are added or removed. *Referrals not required for OB/GYN, chiropractic, and certain other in-network provider visits PLANS 3

4 A PLAN FOR ALL NEEDS AND BUDGETS Health plan options in 2019: EverydayHealth This popular product is a top choice for those who want comprehensive coverage. There are 14 PPO and seven HMO plan options that offer copays for many common services. Portfolio (HSA-qualified plan) There are six PPO and three HMO Portfolio plan options to choose from. When paired with a health savings account (HSA) from HealthEquity, * the high- PPO plan gives employees the flexibility to choose how their healthcare dollars are spent and offers potential tax savings. This plan is a popular choice for those who: Want to pair their health plan with a HSA and either, Don t expect frequent doctor visits or prescription, or Do expect higher medical costs and want to use a HSA for its tax advantages Employers benefit from HealthEquity s HSA integration in several ways: Easy Hassle-free account set up, management and eligibility data sharing Streamlined One bill captures monthly premiums and Health Equity HSA, administration fees Both plans offer coverage for most common healthcare needs, such as: Doctor visits Prescriptions Urgent care and ER visits Virtual visits with BlueCare Anywhere ** Surgeries Routine pediatric vision care Pediatric dental care from in-network providers Preventive care at $0 out-of-pocket cost from in-network providers Convenient 24-hour customer service for employers integrating HSAs, HRAs, and FSAs *Services from HealthEquity, an independent company. HealthEquity is contracted with BCBSAZ to administer financial services and is not affiliated in any way with BCBSAZ. ** Virtual visits do not provide emergency care. In an identified or probable emergency, the virtual visit provider will direct the patient to seek emergency care. This is only a brief summary of the benefit plans and is designed to help compare features of different plans. All plans are subject to the exclusions and limitations listed on page 10 of this summary. More detailed information about benefits, cost share, exclusions, and limitations is in the benefit plan booklets and plan Summary of Benefits and Coverage (SBC), which are available on request. If the terms of this summary differ from the terms of the benefit plan booklets, the terms of the booklets control and apply PLANS 4

5 Overall Deductible Platinum 500 In-network: $500/member and $1,000/family Platinum 750 In-network: $750/member and $1,500/family Gold 1000 In-network: $1,000/member and $2,000/family Gold 2000 In-network: $2,000/member and $4,000/family Gold 3000 In-network: $3,000/member and $6,000/family Silver 2000 In-network: $2,000/member and $4,000/family Silver 3000 In-network: $3,000/member and $6,000/family Provider Networks Available Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Coinsurance (Member) 10% 20% 20% 20% 20% 20% 20% Out-of-Pocket Maximum In-network: $2,000/member and $4,000/family In-network: $3,250/member and $6,500/family In-network: $5,250/member and $10,500/family In-network: $4,000/member and $8,000/family In-network: $6,000/member and $12,000/family In-network: $6,800/member and $13,600/family In-network: $7,000/member and $14,000/family Referral Required to Visit Specialist? No No No No No No No Primary Care (PCP) Visit $15 $15 $20 $20 $20 $40 $40 Specialist Visit $30 $30 $45 $55 $55 $85 $85 Urgent Care $60 $60 $60 $60 $60 $85 $85 Emergency Room Visit (In and Out of Network) 10% after $100 20% after $200 $250 20% after 20% after Emergency Transportation/ Ambulance (In and Out of Network) Inpatient Physician and Surgical Services 10% coinsurance, 10% after 20% after 20% after 20% after 20% after 20% after 20% after Rx Deductible (Tiers 2 & 3)* n/a n/a n/a n/a $250/member $350/member $350/member Rx Tier 1 $5 $15 $15 $20 $20 $35 $35 Rx Tier 2* $20 $30 $50 $60 $60 $100 $100 Rx Tier 3* $40 $60 $100 $120 $120 $200 $200 Specialty Drug Preventive Care/ Immunization/Screenings Pediatric Dental Telehealth No charge No charge No charge No charge No charge No charge No charge Medical Visit $10 $10 $10 $10 $10 $10 $10 Counseling Visit $20 $20 $20 $20 $20 $20 $20 Psychiatric Visit $30 $30 $45 $45 $45 $45 $45 Cost share amounts are for covered services by providers in the plan s network. Services by out-of-network providers are subject to higher cost share amounts. *Only formulary drugs are covered unless a formulary exception is approved. Members in plans with a copay drug benefit who pick a brand medication when a generic is available will pay the difference in cost plus the copay and any applicable. All plans are subject to the exclusions and limitations on page PLANS 5

6 continued Overall Deductible Silver 4000 In-network: $4,000/member and $8,000/family Silver 5000 In-network: $5,000/member and $10,000/family Silver 6000 In-network: $6,000/member and $12,000/family Bronze 6000 In-network: $6,000/member and $12,000/family Bronze 7900 In-network: $7,900/member and $15,800/family Silver 3000/70 In-network: $3,000/member and $6,000/family Silver 5500/100 In-network: $5,500/member and $11,000/family Provider Networks Available Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Coinsurance (Member) 20% 20% 30% 20% 0% 30% 0% Out-of-Pocket Maximum In-network: $7,000/member and $14,000/family In-network: $7,500/member and $15,000/family In-network: $7,900/member and $15,800/family In-network: $7,900/member and $15,800/family In-network: $7,900/member and $15,800/family In-network: $7,000/member and $14,000/family In-network: $7,500/member and $15,000/family Referral Required to Visit Specialist? No No No No No No No Primary Care (PCP) Visit $40 $40 $35 $45 $25 $40 $40 Specialist Visit $85 $85 $85 $90 $95 $85 $85 Urgent Care $85 $85 $85 $90 $95 $85 $85 Emergency Room Visit (In and Out of Network) $500 20% after 30% after 20% after No charge after $600 No charge after Emergency Transportation/ Ambulance (In and Out of Network) 30% coinsurance, No charge 30% coinsurance, Inpatient Physician and Surgical Services 20% after 20% after 30% after 20% after No charge after 30% after No charge after Rx Deductible (Tiers 2 & 3)* n/a $450/member $450/member $650/member n/a n/a n/a Rx Tier 1 $35 $35 $25 $40 $25 $35 $35 Rx Tier 2* $100 $100 $100 $100 No charge after $90 $90 Rx Tier 3* $200 $200 $200 $200 No charge after $200 $200 Specialty Drug Preventive Care/ Immunization/Screenings Pediatric Dental Telehealth No charge after No charge No charge No charge No charge No charge No charge No charge No charge Medical Visit $10 $10 $10 $10 $10 $10 $10 Counseling Visit $20 $20 $20 $20 $20 $20 $20 Psychiatric Visit $45 $45 $45 $45 $45 $45 $45 Cost share amounts are for covered services by providers in the plan s network. Services by out-of-network providers are subject to higher cost share amounts. *Only formulary drugs are covered unless a formulary exception is approved. Members in plans with a copay drug benefit who pick a brand medication when a generic is available will pay the difference in cost plus the copay and any applicable. All plans are subject to the exclusions and limitations on page PLANS 6

7 EverydayHealth HMO Overall Deductible Provider Networks Available EverydayHealth HMO Gold 1500 $1,500/member and $3,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Silver 2500 $2,500/member and $5,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Silver 3500 $3,500/member and $7,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Silver 4500 $4,500/member and $9,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Silver 5500 $5,500/member and $11,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Bronze 6500 $6,500/member and $13,000/family Statewide HMO, PimaConnect HMO, Alliance EverydayHealth HMO Bronze 7900 $7,900/member and $15,800/family Statewide HMO, PimaConnect HMO, Alliance Coinsurance (Member) 20% 20% 20% 20% 20% 20% 0% Out-of-Pocket Maximum $6,500/member and $13,000/family $7,250/member and $14,500/family $7,250/member and $14,500/family $7,500/member and $15,000/family $7,500/member and $15,000/family $7,900/member and $15,800/family $7,900/member and $15,800/family Referral Required to Visit Specialist? Yes Yes Yes Yes Yes Yes Yes Primary Care (PCP) Visit $35 $35 $35 $35 $35 $35 $25 Specialist Visit $75 $85 $85 $85 $100 $100 $95 Urgent Care $75 $85 $85 $85 $100 $100 $95 Emergency Room Visit (In and Out of Network) $200 20% after 20% after $500 20% after 20% after No charge after Emergency Transportation/ Ambulance (In and Out of Network) Inpatient Physician and Surgical Services 20% after 20% after 20% after 20% after 20% after 20% after No charge after Rx Deductible (Tiers 2 & 3)* n/a $250/member $350/member n/a $400/member $500/member n/a Rx Tier 1 $25 $35 $35 $35 $35 $35 $25 Rx Tier 2* $70 $80 $80 $80 $100 $100 No charge after Rx Tier 3* $140 $180 $180 $180 $200 $200 No charge after Specialty Drug Preventive Care/ Immunization/Screenings Pediatric Dental No charge No charge after No charge No charge No charge No charge No charge No charge No charge Telehealth Medical Visit $10 $10 $10 $10 $10 $10 $10 Counseling Visit $20 $20 $20 $20 $20 $20 $20 Psychiatric Visit $45 $45 $45 $45 $45 $45 $45 Cost share amounts are for covered services by providers in the plan s network. Services by healthcare professionals outside the network are generally not covered except for emergencies and other special circumstances when use is preapproved. Care from a non-designated primary care provider (PCP) will not be covered except for providers within the same practice. If a member does not obtain primary care services from their designated PCP, another provider in their practice, or a covering provider, the services will not be covered under this benefit plan (excludes emergency and urgent care). Members will be responsible for paying the provider s billed charges for those services. *Only formulary drugs are covered unless a formulary exception is approved. Members in plans with a copay drug benefit who pick a brand medication when a generic is available will pay the difference in cost plus the copay and any applicable. All plans are subject to the exclusions and limitations on page PLANS 7

8 Portfolio PPO HSA Qualified Portfolio PPO Silver 2700 Portfolio PPO Silver 3250 Portfolio PPO Silver 4000 Portfolio PPO Bronze 4250 Portfolio PPO Bronze 5500 Portfolio PPO Bronze 6750 Overall Deductible In-network: $2,700/member and $5,400/family In-network: $3,250/member and $6,500/family In-network: $4,000/member and $8,000/family In-network: $4,250/member and $8,500/family In-network: $5,500/member and $11,000/family In-network: $6,750/member and $13,500/family Provider Networks Available Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Statewide, Alliance Coinsurance (Member) 20% 10% 10% 20% 20% 0% Out-of-Pocket Maximum In-network: $5,000/member and $10,000/family In-network: $6,000/member and $12,000/family In-network: $6,500/member and $13,000/family In-network: $6,250/member and $12,500/family In-network: $6,550/member and $13,100/family In-network: $6,750/member and $13,500/family Referral Required to Visit Specialist? No No No No No No Primary Care (PCP) Visit 20% after 10% after 10% after 20% after 20% after No charge after Specialist Visit 20% after 10% after 10% after 20% after 20% after No charge after Urgent Care 20% after 10% after 10% after 20% after 20% after No charge after Emergency Room Visit (In and Out of Network) 20% after 10% after 10% after 20% after 20% after No charge after Emergency Transportation/ Ambulance (In and Out of Network) Inpatient Physician and Surgical Services 20% after 10% after 10% after 20% after 20% after No charge after 20% after 10% after 10% after 20% after 20% after No charge after Rx Deductible (Tiers 2 & 3)* n/a n/a n/a n/a n/a n/a Rx Tier 1 20% after 10% after 10% after 20% after 20% after No charge after Rx Tier 2* 20% after 10% after 10% after 20% after 20% after No charge after Rx Tier 3* 20% after 10% after 10% after 20% after 20% after No charge after Specialty Drug 20% after 10% after 10% after 20% after 20% after No charge after Preventive Care/ Immunization/Screenings No charge No charge No charge No charge No charge No charge Pediatric Dental No charge after ; Restorative & Orthodontia: 50% after No charge after ; Restorative & Orthodontia: 50% after No charge after ; Restorative & Orthodontia: 50% after No charge after ; Restorative & Orthodontia: 50% after No charge after ; Restorative & Orthodontia: 50% after No charge after ; Restorative & Orthodontia: 50% after Telehealth Medical Visit 20% after 10% after 10% after 20% after 20% after No charge after Counseling Visit 20% after 10% after 10% after 20% after 20% after No charge after Psychiatric Visit 20% after 10% after 10% after 20% after 20% after No charge after Cost share amounts are for covered services by providers in the plan s network. Services by out-of-network providers are subject to higher cost share amounts. *Only formulary drugs are covered unless a formulary exception is approved. All plans are subject to the exclusions and limitations on page PLANS 8

9 Portfolio HMO HSA Qualified Portfolio HMO Silver 3750 Portfolio HMO Silver 4250 Portfolio HMO Bronze 6750 Overall Deductible $3,750/member and $7,500/family $4,250/member and $8,500/family $6,750/member and $13,500/family Provider Networks Available Statewide HMO, PimaConnect HMO, Alliance Statewide HMO, PimaConnect HMO, Alliance Statewide HMO, PimaConnect HMO, Alliance Coinsurance (Member) 10% 10% 0% Out-of-Pocket Maximum $6,000/member and $12,000/family $6,500/member and $13,000/family $6,750/member and $13,500/family Referral Required to Visit Specialist? Yes Yes Yes Primary Care (PCP) Visit 10% after 10% after No charge after Specialist Visit 10% after 10% after No charge after Urgent Care 10% after 10% after No charge after Emergency Room Visit (In and Out of Network) Emergency Transportation/Ambulance (In and Out of Network) Inpatient Physician and Surgical Services 10% after 10% after No charge after 10% after 10% after No charge after 10% after 10% after No charge after Rx Deductible (Tiers 2 & 3)* n/a n/a n/a Rx Tier 1 10% after 10% after No charge after Rx Tier 2* 10% after 10% after No charge after Rx Tier 3* 10% after 10% after No charge after Specialty Drug 10% after 10% after No charge after Preventive Care/Immunization/Screenings No charge No charge No charge Pediatric Dental No charge after Restorative & No charge after Restorative & No charge after Restorative & Telehealth Medical Visit 10% after 10% after No charge after Counseling Visit 10% after 10% after No charge after Psychiatric Visit 10% after 10% after No charge after Cost share amounts are for covered services by providers in the plan s network. Services by healthcare professionals outside the network are generally not covered except for emergencies and other special circumstances when use is preapproved. *Only formulary drugs are covered unless a formulary exception is approved. All plans are subject to the exclusions and limitations on page PLANS 9

10 HELPFUL TERMS AND DEFINITIONS Allowed Amount Out-of-Pocket Costs These are expenses for medical care that aren t reimbursed by insurance. Out-of-pocket costs include s, coinsurance, and copayments for covered services, plus all costs for services that aren t covered. Not all out-of-pocket expenses are applied to the plan s out-of-pocket maximum benefits. Medications and Prescriptions BCBSAZ applies limitations to certain prescription medications obtained through the pharmacy benefit. A list of these medications and limitations is available online at azblue.com or by calling BCBSAZ. These limitations include, but are not limited to, quantity, age, gender, dosage, and frequency of refill limitations. Plans are also subject to: A restricted formulary A Step Therapy Program that requires members to take the generic version of certain medications before BCBSAZ and/ or the PBM will consider coverage of the brand-name version of that medication A requirement, for plans that include a copay drug benefit, to pay the difference in cost between a brandname and generic medication plus applicable copay and. BCBSAZ prescription medication limitations are subject to change at any time without prior notice. Business Size Definitions 1-50: These plans are offered to employers considered small for purposes of the Affordable Care Act (ACA) the average number of total employees on business days during the previous calendar year is 50 or fewer. These plans are also available to an employer considered large for purposes of the ACA, but considered small for purposes of Arizona law (on a typical business day, 50 or fewer employees are eligible for health benefit plan coverage). This is the amount of reimbursement that doctors, hospitals, and other providers who are in the plan s network have agreed to accept for services. Example: A doctor may normally charge $100 for a particular service. But, he has an agreement with the plan to accept only $80 as reimbursement for that service. The allowed amount is $80. The allowed amount includes any amount paid by the plan, plus any amount the member pays as a cost-share, including copays and s. Balance Bill This is the difference between the BCBSAZ allowed amount and a noncontracted provider s billed charge. Any time, except emergencies, a member sees a noncontracted provider, the member is responsible for the balance bill. Any amounts paid for balance bills do not count toward any, coinsurance, or out-of-pocket limit. Emergency Services For emergency services, members will pay their in-network cost share, even if services are received from out-of-network providers. Precertification Some services and medications require precertification. Except for emergencies, urgent care, and maternity admissions, precertification is always required for inpatient admissions (acute care, behavioral health, long-term acute care, extended active rehabilitation, and skilled nursing facilities), home health services, and most specialty medications. Precertification may be required for other covered services and medications PLANS 10

11 EXCLUSIONS AND LIMITATIONS PPO Excluded Services & Other Covered Services: Services our plans generally do NOT cover. (Check the policy or plan document for more information and a list of any other excluded services.) HMO Excluded Services & Other Covered Services: Services our plans generally do NOT cover. (Check the policy or plan document for more information and a list of any other excluded services.) Acupuncture Adult routine vision exam Care that is not medically necessary Cosmetic surgery, cosmetic services, and supplies Custodial care Dental care and orthodontic services (adult), except as stated in plan Durable medical equipment (DME) rental/repair charges that exceed DME purchase price Experimental and investigational treatments, except as stated in plan Eyewear, except as stated in plan Flat feet treatment and services Genetic and chromosomal testing, except as stated in plan Habilitation outpatient services exceeding 60 visits per calendar year Home healthcare and infusion therapy exceeding 42 visits (of up to four hours) per calendar year Homeopathic services Infertility medication and treatment Inpatient EAR and SNF treatment exceeding 90 days per calendar year Long-term care, except long-term acute care Massage therapy other than allowed under medical coverage guidelines Naturopathic services Non-emergency care when traveling outside the U.S. Orthodontic services (pediatric) that are not dentally necessary Out-of-network mail order, out-of-network specialty, and out-of-network 90-day retail supplies of drugs Pediatric dental checkups exceeding two checkups and cleanings per calendar year Pediatric glasses or contact lenses exceeding one pair of glasses or contact lenses per calendar year Private-duty nursing, except when medically necessary or when skilled nursing is not available Rehabilitation outpatient services exceeding 60 visits per calendar year Respite care Routine foot care Routine vision exam (child) exceeding one visit per calendar year Sexual dysfunction treatment and services Weight-loss programs Acupuncture Adult routine vision exam Care that is not medically necessary Chiropractic services exceeding 20 visits per calendar year Cosmetic surgery, cosmetic services, and supplies Custodial care Dental care and orthodontic services (adult), except as stated in plan Durable medical equipment (DME) rental/repair charges that exceed DME purchase price Experimental and investigational treatments, except as stated in plan Eyewear, except as stated in plan Flat feet treatment and services Genetic and chromosomal testing, except as stated in plan Habilitation outpatient services exceeding 60 visits per calendar year Home healthcare and infusion therapy exceeding 42 visits (of up to four hours) per calendar year Homeopathic services Infertility medication and treatment Inpatient EAR and SNF treatment exceeding 90 days per calendar year Long-term care, except long-term acute care Massage therapy other than allowed under medical coverage guidelines Naturopathic services Non-emergency care when traveling outside the U.S. Orthodontic services (pediatric) that are not dentally necessary Pediatric dental checkups exceeding two checkups and cleanings per calendar year Pediatric glasses or contact lenses exceeding one pair of glasses or contact lenses per calendar year Private-duty nursing, except when medically necessary or when skilled nursing is not available Rehabilitation outpatient services exceeding 60 visits per calendar year Respite care Routine foot care Routine vision exam (child) exceeding one visit per calendar year Services from providers outside the network, except in emergencies and other limited situations when use is preauthorized Sexual dysfunction treatment Weight-loss programs Other covered services. (Limitations may apply to these services. This isn t a complete list. Please see our plan document.) Other covered services. (Limitations may apply to these services. This isn t a complete list. Please see our plan document.) Bariatric surgery Chiropractic care Hearing aids, up to one per ear, per calendar year Non-emergency services Bariatric surgery Chiropractic care Hearing aids, up to one per ear, per calendar year 2019 PLANS 11

12 PEDIATRIC DENTAL Dental benefits for children who are under age 19 and covered by one of the plans described in this brochure for businesses with 1-50 employees. 1 Type I Covered Services Diagnostic and Preventive Oral exams Prophylaxis Cleanings X-rays Bitewing X-rays Periapical X-rays Full-mouth X-rays Panoramic X-rays Topical Fluoride Sealants Space Maintainers Two per year 2 in any combination of periodic, limited, or comprehensive exams Two per year Any combination of X-rays billed on the same date of treatment cannot exceed the allowed amount for a full-mouth X-ray benefit Two sets per year Covered One set per five-year period One set per five-year period. Panoramic X-rays accompanied by bitewing X-rays are considered a set of full-mouth X-rays and are subject to the full-mouth X-ray limit. Two treatments per year Permanent molars with no decay or restoration only. One application per three-year period. Temporary appliances to replace prematurely lost teeth until permanent teeth erupt Type II and III Covered Services Restorative All claims subject to processing based on the least expensive available treatment (LEAT) 3 Restorative Fillings Simple and Surgical Extractions Periodontics Non-surgical Prosthodontics Bridges and Dentures Amalgam and composite resin fillings covered Covered Periodontal scaling and root planing limited to one per quadrant per two-year period. Periodontal maintenance procedures limited to four per year; prophylaxis and cleanings count toward this limit. Five-year replacement limit General Anesthesia Limited coverage per BCBSAZ dental coverage guidelines 4 Endodontics Root Canal Crowns/Inlays/Onlays Periodontics Surgical Covered Five-year replacement limit One procedure per three-year period Implants Limited coverage per BCBSAZ dental coverage guidelines 4 Type IV Covered Services Orthodontia Cosmetic orthodontia not covered Orthodontics (dentally necessary) Limited coverage per BCBSAZ dental coverage guidelines 4 In-network services available through the BluePreferred Dental network. A listing of providers in the BluePreferred Dental network can be found at azblue.com. 1 These plans are offered to employers considered small for purposes of the Affordable Care Act (ACA). 2 All per-year benefits mean per calendar year. 3 Only the allowed amount, as based on least expensive available treatment (LEAT), if applicable (and not billed charges), counts to satisfy the. There may be several methods for treating a specific dental condition. All claims for restorative services such as fillings and crowns are subject to analysis for the least expensive available treatment (LEAT). Benefits for restorative procedures will be limited to the LEAT only. For these procedures, BCBSAZ will only pay benefits up to the LEAT fee. Members may elect to receive a service that is more costly than the LEAT, but the member will be responsible for cost-share based on the LEAT, and will also pay the difference between the fee for the LEAT and the more costly treatment (LEAT balance bill). Any payment made for this LEAT balance bill will not count toward the or out-of-pocket maximum. 4 BCBSAZ dental coverage guidelines are available upon request. Not all dentally necessary services are covered benefits PLANS 12

13 PEDIATRIC DENTAL EXCLUSIONS AND LIMITATIONS Examples of services not covered This is only a partial list of services that are limited or not covered by the health plans featured in this guide. Expenses for services that exceed the benefit limit are not covered. Detailed information about benefits, exclusions, and limitations is in the benefit plan booklet or rider and is available prior to enrollment, upon request. Alternative dentistry Athletic mouth guards Biopsies Bleaching of any kind CT scans (e.g., cone beam) and tomographic surveys Correction of congenital malformations, except as required by Arizona state law, for newborns, adopted children, and children placed for adoption Cosmetic services and any related complications Dental services and supplies not provided by a dentist, except as stated in plan Duplicate, provisional, and temporary devices, appliances, and services Experimental or investigational services Fixed pediatric partial dentures Genetic tests for susceptibility to oral diseases Inpatient or outpatient facility services Laboratory and pathology services Locally administered antibiotics Major restorative and prosthodontic services performed on other than a permanent tooth Maxillofacial prosthetics and any related services Medications dispensed in a dentist s office, except as stated in plan Non-dentally necessary services services that are not dentally necessary, as determined by BCBSAZ. BCBSAZ may not be able to determine dental necessity until after services are rendered. Occlusal guards for the treatment of temporomandibular joint syndrome or sleep apnea Oral hygiene instruction, plaque control programs, and dietary instructions Removal of appliances, fixed space maintainers, or posts Repair of damaged orthodontic appliances Replacement of lost or missing appliances Sealants for teeth other than permanent molars Services resulting from failure to comply with professionally prescribed treatment Telephonic and electronic consultations, except as required by law Therapy or treatment of the temporomandibular joint, orthognathic surgery, or ridge augmentation Tooth transplantation 2019 PLANS 13

14 THE CUSTOMER EXPERIENCE The BCBSAZ customer service team is dedicated to providing members with solutions quickly and accurately. Our Concierge Model of Customer Care delivers a one-and-done solution, which means customer service representatives handle benefit-related calls and inquiries about claims. Claims and Customer Service Provide help navigating the healthcare system Experienced staff with an average tenure of 12 years 1 Serves all members, regardless of resident state Call centers located in Tucson, Phoenix, Chandler, and Flagstaff Call centers are also walk-in centers for face-to-face meetings with Customer Service Representatives Mi Consejero Azul: My Blue Advisor Dedicated bilingual staff Experienced staff with an average tenure of 12 years 1 Calls answered in less than one minute, on average Highly utilized walk-in services 1 BCBSAZ internal data, PLANS 14

15 MEMBER ENGAGEMENT TOOLS AND RESOURCES We have tools and resources available for members to make educated decisions on their healthcare choices. Find a Doctor: Members can easily find a provider, hospital, or lab in their plan s network with this online tool. Blue365 Discounts : Discounts are available on national brands for fitness gear, wearables, gym memberships, healthy eating options, and more. HealthEquity * : Integrates health reimbursement and savings account portal to ease administration of funds for the member. Care Cost Estimator: Members can shop and compare costs for more than 1,600 procedures, such as common surgeries, diagnostic procedures, and prescription medications. Claims & Spending: Simplifies the tracking of claims and spending by combining all benefit plan activity into one monthly online statement. Mobile Access: Access to health plan information and resources is available through the MyBlue AZ mobile app. BlueCare Anywhere: Members can have virtual visits with providers any time, anywhere using BlueCare Anywhere teleheath services. Wellness: Online, self-paced wellness tools and resources are available for members of all ages. * Services from HealthEquity, an independent company. HealthEquity is contracted with BCBSAZ to administer financial services and is not affiliated in any way with BCBSAZ PLANS 15

16 CARE COORDINATION PROGRAMS BCBSAZ s care coordination programs support the patient-provider relationship and enhance the overall healthcare experience for our members. When we help members better manage their health, they are able to manage their daily activities, be productive at work, and reduce their (and your) healthcare costs. Members can take advantage of the following programs: Chronic Condition Management. Members with a chronic health condition, such as diabetes, congestive heart failure, asthma, COPD, coronary artery disease, or hypertension, have programs and resources to help them get the support they need, when they need it. These programs take into consideration the risk level of the condition and provide assistance based on the level. Case Management. When a complex, chronic, or catastrophic condition, such as a serious accident, cancer diagnosis, or high-risk pregnancy, impacts a member, a nurse case manager can help. The case manager will help coordinate their care among different providers, link them to community resources, and help them understand their benefits. Our case managers are registered nurses with an average of 16 years clinical experience in specialty areas such as oncology, cardiology, neonatology, rehabilitation, etc 1. Hospital to Home. When members are transitioning home from a critical care hospital stay, we help ensure that they re getting the care, medications, and equipment they need to reduce potential hospital readmissions. We will assess the need for home health care services, if not already in place, and help them find providers that are in their network, if needed. 1 BCBSAZ internal data, PLANS 16

17 HEALTH AND WELLNESS Whether members want to stay healthy or get on a path to better health, we have tools and resources designed to help them on their health journey. HealthyBlue is our suite of health and wellness programs designed to help improve the quality of life and productivity of our members. * They include: Health Assessment: Members complete an online assessment called My BluePrint and receive their personal wellness score, along with recommendations for health and wellness programs that can be tailored to meet their specific interests and needs. Coaching: Eligible members have access to coaches who provide one-on-one health or lifestyle support via phone or the internet, and guide them in setting goals and making healthy choices. Maternity Support: Members who are expecting or planning to have a baby can join the HealthyBlue Beginnings program for answers to common questions about pregnancy and childbirth. Members receive support until the baby is six weeks old. Nurse on Call: Members can connect with a nurse 24/7 to get answers to health questions about symptoms they are experiencing, minor illnesses and injuries, medical tests, or preventive care, as well as suggestions for next steps based on their situation. Nutrition Coaching: It can be hard to know what healthy eating really is. That s why we offer nutrition coaching to eligible members. They can learn how their food choices affect their health and how to make simple changes that can have a big impact on how they feel every day. * Not all programs are available to all members PLANS 17

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20 TO LEARN ABOUT OUR OTHER OPTIONS FOR YOUR BUSINESS, VISIT azblue.com OR CALL us. FOLLOW US ON D21223A 10/18 SGB