BCBSAZ Group PPO EverydayHealth 3000 Plan Attachment Alliance Network Off Exchange

Transcription

1 BCBSAZ Group PPO EverydayHealth 3000 Plan Attachment Alliance Network Off Exchange Suite E

2 PLAN NETWORK Your Plan Network is the Alliance Network. The BCBSAZ provider directory of Alliance Network providers is available online at If you do not have Internet access, or you have questions about a provider s network participation, please call Customer Service at the number on your ID card before you receive services. 2

3 PROVIDERS Know your provider s network and eligibility status before you receive services. Provider Eligibility and Network Status To be eligible for coverage, a service must be rendered by an eligible individual provider acting within his or her scope of practice, and, when applicable, performed at an eligible facility that is licensed or certified for the type of procedure and services rendered. Eligible Providers Not all medical professionals are eligible providers. Eligible providers include the properly licensed, certified or registered providers listed below, when acting within the scope of their practice and license. Scope of practice is determined by the regulatory oversight agency for each health profession. It means the procedures, actions, and processes that a licensed or certified medical professional is legally allowed to perform based on the individual s specific education and experience, and demonstrated competency. For example, neurosurgery would not be within the scope of practice for a dentist. Benefits may also be available from other health care professionals whose services are mandated by Arizona state law or federal law or who are accepted as eligible by BCBSAZ. The following are examples of ineligible providers: acupuncturists and doctors of naturopathy and homeopathy. Other provider types may also be ineligible. The fact that a service is rendered by an eligible provider does not mean that the service will be covered. Not all eligible providers are contracted to participate in the Alliance network. ELIGIBLE PROVIDER LIST Professional Facility Ancillary Board Certified Applied Behavioral Analyst (BCABA) Certified Nurse First Assist (CRNFA) Certified Nurse Midwife Certified Registered Nurse Anesthetist (CRNA) Doctor of chiropractic (DC) Doctor of dental surgery (DDS) Doctor of medical dentistry (DMD) Doctor of medicine (MD) Doctor of optometry (OD) Doctor of osteopathy (DO) Doctor of podiatry (DPM) First Assist (FA) Licensed clinical social worker Licensed independent substance abuse counselor Licensed marriage and family therapist Licensed nurse practitioner Ambulance Ambulatory Surgical Center (ASC) Audiology Center Birthing Center Clinical Laboratory Diagnostic Radiology Dialysis Center Durable Medical Equipment (DME) Extended Active Rehabilitation (EAR) Home Health Agency (HHA) Home Infusion Therapy Hospice Hospital, Acute Care Hospital, Long Term Acute Care (LTAC) Hospital, Psychiatric Orthotics/Prosthetics Rehabilitation Treatment Centers (substance abuse centers) Licensed optician Licensed professional counselor Physician Assistant (PA) Psychologist (PhD, EdD and PsyD) Perfusionist Retail, mail order and specialty pharmacies Skilled Nursing Facility Specialty Laboratory Sleep Lab Urgent Care Registered Dietician Registered Nurse First Assist (RNFA) Speech, occupational or physical therapist Surgical Assist (SA) Surgical Technician (ST) Eligible Providers for Pediatric Services Eligible providers for pediatric dental services include the following properly licensed providers, when acting within the scope of their practice: Doctor of medical dentistry (DMD) Doctor of dental surgery (DDS) 3

4 Eligible providers for pediatric vision services include the following properly licensed providers, when acting within the scope of their practice: Doctor of medicine (MD) Doctor of optometry (OD) Doctor of osteopathy (DO) Licensed optician Please call the Customer Service number on your ID card before you receive pediatric dental or vision services if you have any questions on a provider s eligibility or network participation status. Benefits may also be available from other dental or vision professionals whose services are mandated by Arizona state law or federal law or who are accepted as eligible by BCBSAZ or the pediatric benefits administrators. The fact that a service is rendered by an eligible provider does not mean that the service will be covered. Choosing a Provider Your costs will be lower when you use an in-network provider. Before receiving scheduled services, verify the network status of all providers who will be involved in your care, such as assistant surgeons, anesthesiologists and radiologists, as well as the facility where the services will be performed. Network Status (Pediatric Services Only) In-Network and Out-of-Network Providers for Pediatric Dental Services In-network providers are the following 1) Dentists in Arizona who are contracted with BCBSAZ, and 2) Dentists outside Arizona who participate in the BCBSAZ network through an arrangement between BCBSAZ and the pediatric dental benefits administrator. The pediatric dental benefits administrator is responsible for contractual arrangements with non-arizona dentists. Coverage for pediatric dental services is not available through the Blue Card program. Out-of-network providers are Arizona dentists who are not contracted with BCBSAZ, and dentists outside Arizona who do not have a contractual arrangement with the pediatric dental benefits administrator to provide pediatric dental services to BCBSAZ members outside Arizona. In-Network and Out-of-Network Providers for Pediatric Vision Services In-network providers are the following 1) For exams and evaluations provided in Arizona, physicians or optometrists who are contracted with BCBSAZ or the pediatric vision benefits administrator, 2) For exams and evaluations provided outside Arizona, physicians or optometrists contracted with the pediatric vision benefits administrator, and 3) For eyewear provided in Arizona or outside Arizona, optometrists or opticians contracted with the pediatric vision benefits administrator. Coverage for pediatric vision services is not available through the Blue Card program. Out-of-network providers are 1) Arizona providers who are not contracted with BCBSAZ or the pediatric vision benefits administrator to provide pediatric vision exams, evaluations and/or eyewear to BCBSAZ members in Arizona, and 2) Providers outside Arizona who are not contracted with the pediatric vision benefits administrator to provide exams, evaluations and/or eyewear to BCBSAZ members outside Arizona. Important Note: All remaining provisions in this Providers section (beginning with Network Status ) do not apply to providers contracted to offer pediatric dental services, or to providers contracted with the pediatric vision benefits administrator. Network Status In-Network Providers (Contracted) In-network providers are the following: (1) Except as stated in this benefit book, health care providers licensed in the United States who have an Alliance Network contract with BCBSAZ (or with a vendor that has contracted with BCBSAZ to provide or administer services for Alliance members); and (2) For purposes of determining cost-share and claim processing, and except as stated in this benefit book, out-of-state health care providers licensed in the United States who have a PPO contract with a Blue Cross and/or Blue Shield plan other than BCBSAZ. Except for emergency services, if the provider submitting a laboratory, DME/medical supply, and/or specialty pharmacy claim does not have an Alliance contract with BCBSAZ (when the claim is submitted to BCBSAZ) 4

5 or a PPO contract with the out-of-state Blue Cross and/or Blue Shield plan to which the claim is submitted, the claim will be processed as an out-of-network claim. Members are responsible for out-of-network costshare and any applicable balance bill. See the Out-of-Network Providers section below. Claims for services provided by independent clinical laboratory, durable medical equipment/medical supply, specialty pharmacy, and air ambulance providers are required to be filed as follows: Independent Clinical Laboratory & Specialty Pharmacy: Claims must be filed with the Blue Cross and/or Blue Shield plan in the state where the referring provider is located. Durable Medical Equipment/Medical Supplies: Claims must be filed with the Blue Cross and/or Blue Shield plan in the state where the equipment or supplies are shipped to or purchased in a retail store. Air Ambulance: Claims must be filed with the Blue Cross and/or Blue Shield plan in the state of the member pickup location. In-network providers will file your claims with BCBSAZ or the applicable out-of-state Blue Cross and/or Blue Shield plan. The provider s contract generally prohibits the provider from collecting more than the allowed amount for covered services, and you are responsible for paying your member cost-share. However, when there is another source of payment, such as liability insurance, all providers may be entitled to collect their balance bill from the other source, or from proceeds received from the other source. The provider s contract does allow the provider to collect up to the provider s billed charges for noncovered services. We recommend that you discuss costs with the provider before you obtain noncovered services. BCBSAZ and/or the out-ofstate Blue Cross and/or Blue Shield plan directly reimburse in-network providers for your benefit plan s portion of the allowed amount for covered services. Except for emergencies, in-network providers must render covered services in the United States for the services to be considered in-network and subject to in-network member cost-share. If an in-network provider renders covered services outside the United States, the services will be considered out-of-network and subject to out-of-network member cost-share, including balance bills (except for emergencies). Out-of-Network Providers (Contracted and Noncontracted) Out-of-network providers are: (1) Providers who are contracted with a Host Blue plan as Participating only providers; (2) Providers who are contracted with BCBSAZ but do not have an Alliance Network contract (such as BCBSAZ PPO-Only providers); (3) Eligible providers who have no contract with BCBSAZ or a Host Blue plan (Noncontracted providers); (4) Providers who are contracted with Blue Cross Blue Shield Global Core; and (5) Providers who submit a laboratory, DME/medical supply, air ambulance, or specialty pharmacy claim to a Host Blue plan and do not have a PPO contract with that plan. 1. Participating-Only Providers Participating-only providers are contracted with a Host Blue plan as Participating and are not contracted as PPO or Preferred providers. Participating-only providers are out-of-network providers. Participating-only providers will submit your claims to the Host Blue plan with which they are contracted. If you receive covered services from a Participating-only provider, you will pay out-of-network deductible and coinsurance and access fees. However, you will not have to pay the balance bill because the provider is contracted. 2. Providers Contracted with BCBSAZ Who Are Not in the Alliance Network Some BCBSAZ providers are contracted with BCBSAZ for certain networks, but are not contracted as Alliance Network providers. For purposes of the Alliance plan, they are considered noncontracted, and will be treated like any other noncontracted provider described below. For example, BCBSAZ PPO-Only providers are noncontracted providers. They may, but are not required to submit your claims to BCBSAZ. If you receive covered services from a provider who is contracted with BCBSAZ, but not contracted as an Alliance Network provider, you will pay out-of-network deductible and coinsurance. BCBSAZ will send any claim payments to you, and you are responsible to pay the provider. Because these providers are considered noncontracted for the Alliance plan, they may balance bill you like any other noncontracted provider. 3. Noncontracted Providers Eligible providers who have no provider participation agreement with BCBSAZ or any Host Blue plan are noncontracted providers. Noncontracted providers are out-of-network providers. 5

6 If you receive covered services from an eligible noncontracted provider, you will pay out-ofnetwork deductible and coinsurance, access fees and the balance bill. Noncontracted providers may bill you up to their full billed charges. The difference between the noncontracted provider s billed charges and payment under this benefit plan may be substantial. Please check with the noncontracted provider regarding the amount of your financial responsibility before you receive services. BCBSAZ does not send claim payments to noncontracted providers. BCBSAZ will send payment to you for whatever benefits are covered under your benefit plan. You are responsible for paying the noncontracted provider. A noncontracted provider will not receive a copy of your explanation of benefits (EOB) and will not know the amount this benefit plan paid you for the claim. 4. Providers Contracted with Blue Cross Blue Shield Global Core Providers who are contracted with Blue Cross Blue Shield Global Core are out-of-network providers. For covered services from these providers, you will pay out-of-network deductible and coinsurance and access fees (except for emergency services), plus the balance bill. Provider contract status Providers contracted with BCBSAZ as Alliance Network providers* Providers contracted with another Blue Cross or Blue Shield Plan ( Host Blue ) as PPO providers* Providers contracted with Host Blue as Participating only providers* Providers contracted with Blue Cross Blue Shield Global Core Noncontracted providers (in Arizona and out-ofstate, including providers who are contracted with BCBSAZ but not for the Alliance Network) (must be eligible providers)* Eligible Provider Status and Payment Summary Table Subject to all terms and conditions noted in this section. Network Provider Accept BCBSAZ Payee for Reimbursement status and required to Allowed Amount applicable file claim on and do not cost-share member s Balance Bill behalf In-network Yes Yes BCBSAZ reimburses the provider the allowed amount, less any member cost-share In-network Yes Yes The Host Blue, on behalf of BCBSAZ, reimburses the provider the allowed amount less any member cost-share Out-of-network Yes Yes The Host Blue, on behalf of BCBSAZ, reimburses the provider the allowed amount less any member cost-share Out-of-network Yes No Blue Cross Blue Shield Global Core reimburses the provider the allowed amount less any member cost-share Out-of-network No (provider may elect to do so as courtesy to member) No. May collect up to full billed charges. Difference between billed charges and BCBSAZ member reimbursement may be substantial BCBSAZ reimburses the member the allowed amount, less any member cost-share. Provider does not get copy of member s EOB or know reimbursement amount. *Except for emergency services, if the provider submitting a laboratory, DME/medical supply, air ambulance, and/or specialty pharmacy claim does not have an Alliance contract with BCBSAZ (when the claim is submitted to BCBSAZ) or a PPO contract with the out-of-state Blue Cross and/or Blue Shield plan to which the claim is submitted, the claim will be processed as an out-of-network claim. Members are responsible for out-of-network cost-share and any applicable balance bill. Sample Differences in Financial Responsibility Based on Provider Choice The following example shows how out-of-pocket expenses can differ depending on the provider you choose. This example is provided for demonstration purposes only. Your savings may vary depending on your benefit plan and your chosen provider. In this example, the member has already satisfied the calendar-year deductible and has a 20 percent coinsurance for an in-network provider and 40 percent coinsurance for an out-of-network provider. 6

7 Billed Charges Allowed Amount Financial Responsibility In-Network Providers 20% Coinsurance $1,000 $400 BCBSAZ pays: $320 $240 Out-of-Network (noncontracted) Providers 40% Coinsurance Locating an In-Network Provider You pay: $ 80 coinsurance amount $160 coinsurance +600 balance bill $760 Check the Alliance Network provider directory at to locate an in-network provider who offers the services you are seeking and contact the provider for an appointment. If you cannot get an appointment with an in-network provider, contact Customer Service at the number on your ID card. Precertifications for Out-of-Network Providers BCBSAZ does not guarantee that every specialist or facility will be in the Alliance Network. Not all providers will contract with health insurance plans. If you believe or have been told there is no in-network provider available to render covered services that you need, you may ask your treating provider to request precertification of in-network cost-share for services from an out-of-network provider. BCBSAZ will not issue this precertification if we find that an in-network provider is available to treat you. The section on precertification explains how to make this request. Continuing Care from an Out-of-Network Provider You may be able to receive benefits at the in-network level for services provided by an out-of-network provider, under the circumstances described below. Continuity of care benefits are subject to all other applicable provisions of your benefit plan. To request continuity of care, call BCBSAZ Customer Service at the number listed on your ID card. Current and New Members: If a network provider s contract with BCBSAZ is terminated or non-renewed, except for reasons of medical incompetence or unprofessional conduct, a current or new member may continue an active course of treatment with that provider until the treatment is complete or for ninety (90) days, whichever is shorter. This continuity of care timeframe extends through a new policy year period if the member remains enrolled in this benefit plan. New Members: If a new member is receiving an active course of treatment from an out-of-network provider at the time of the member s enrollment, the member may continue the active course of treatment with that provider until the treatment is complete or for ninety (90) days, whichever is shorter. Active course of treatment means: An ongoing course of treatment for a life-threatening condition, defined as a disease or condition for which likelihood of death is probable unless the course of the disease or condition is interrupted; An ongoing course of treatment for a serious acute condition, defined as a disease or condition requiring complex ongoing care which the covered person is currently receiving, such as chemotherapy, radiation therapy, or post-operative visits; The second or third trimester of pregnancy, through the postpartum period; or An ongoing course of treatment for a health condition for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes. Members will pay in-network cost-share for these services. This continuity of care provision is subject to all applicable provisions of BCBSZ s Grievance and Appeal Guidelines. Out-of-Area Services Overview BCBSAZ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called Inter-Plan Arrangements. These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association ( Association ). Whenever you access healthcare services outside the geographic area BCBSAZ serves, the claim for those services may 7

8 be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below. When you receive care outside of BCBSAZ s service area, you will receive it from one of two kinds of providers. Most providers ( participating providers ) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area ( Host Blue ). Some providers ( nonparticipating providers ) don t contract with the Host Blue. We explain below how BCBSAZ pays both kinds of providers. Inter-Plan Arrangements Eligibility Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental care benefits (except when paid as medical claims/benefits), and those prescription drug benefits or vision care benefits that may be administered by a third party contracted by BCBSAZ to provide the specific service or services. BlueCard Program Under the BlueCard Program, when you receive Covered Services within the geographic area served by a Host Blue, BCBSAZ will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive Covered Services outside BCBSAZ s service area and the claim is processed through the BlueCard Program, the amount you pay for Covered Services is calculated based on the lower of: The billed charges for Covered Services; or The negotiated price that the Host Blue makes available to BCBSAZ. Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price BCBSAZ has used for your claim because they will not be applied after a claim has already been paid. Special Cases: Value-Based Programs BlueCard Program If you receive Covered Services under a Value-Based Program inside a Host Blue s service area, you will not be responsible for paying the provider for any of the provider incentives, risk-sharing, and/or care coordinator fees that are a part of such an arrangement, except when a Host Blue passes these fees to BCBSAZ through average pricing or fee schedule adjustments. Additional information is available upon request. Provider incentives, risk-sharing and care coordinator fees are incorporated into the premium and/or contribution percentage members pay for coverage. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured individual and group health plans and/or self-funded accounts. If applicable, BCBSAZ will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside BCBSAZ s Service Area Liability Calculation When Covered Services are provided outside of BCBSAZ s service area by nonparticipating providers, the amount you pay for such services will normally be based on either the Host Blue s nonparticipating provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be responsible for the difference between the amount that the nonparticipating provider bills and the payment BCBSAZ will make for the Covered Services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of- network emergency services. 8

9 Exceptions In certain situations, BCBSAZ may use other payment methods, such as billed charges for Covered Services, the payment we would make if the healthcare services had been obtained within our service area, or a special negotiated payment to determine the amount BCBSAZ will pay for services provided by nonparticipating providers. In these situations, you may be liable for the difference between the amount that the nonparticipating provider bills and the payment BCBSAZ will make for the Covered Services as set forth in this paragraph. Blue Cross Blue Shield Global Core If you are outside the United States (hereinafter BlueCard service area ), you may be able to take advantage of Blue Cross Blue Shield Global Core when accessing Covered Services. Blue Cross Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although Blue Cross Blue Shield Global Core assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. Inpatient Services In most cases, if you contact the Service Center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts. In such cases, the hospital will submit your claims to the Service Center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for Covered Services. You must contact BCBSAZ to obtain precertification for non-emergency inpatient services. Outpatient Services Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for Covered Services. Submitting a Blue Cross Blue Shield Global Core Claim When you pay for Covered Services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider s itemized bill(s) to the Service Center (the address is on the form) to initiate claims processing. The claim form is available from BCBSAZ, the Service Center or online at If you need assistance with your claim submission, you should call the Service Center at BLUE (2583) or call collect at , 24 hours a day, seven days a week. Services Received on Cruise Ships If you receive healthcare services while on a cruise ship, you will pay in-network cost-share, and the allowed amount will be based on billed charges. A cruise ship claim is not considered an out-of-country claim. Claims should be submitted and processed through BCBSAZ, not through the Blue Cross Blue Shield Global Core program. Please call the BCBSAZ Customer Service department at the phone number listed in the front of this book for more information, or mail copies of your receipts to the BCBSAZ general correspondence address listed at the front of this book. 9

10 MEMBER COST-SHARING & OTHER PAYMENTS Members pay part of the costs for benefits received under this plan. Depending on your particular benefit plan, the service you receive and the provider you choose, you may have an access fee, balance bill, coinsurance, copay, deductible or some combination of these payments. Each cost-share type and other payment type is explained below. This section, the benefit descriptions in this book and your SBC will explain which cost-share types and other payments apply to each benefit. BCBSAZ uses your claims to track whether you have met some cost-share obligations. We apply claims based on the order in which we process the claims and not based on date of service. Access Fee An access fee is a fixed fee you pay to a provider for certain covered services, usually at the time of service. If an access fee applies to a particular service, you must pay the access fee plus any other applicable costshare for the service. Access fees do not count toward meeting your calendar-year deductible. Allowed Amount The allowed amount is the total amount of reimbursement allocated to a covered service and includes both the BCBSAZ payment and the member cost-share payment. Generally, BCBSAZ calculates deductible and coinsurance based on the allowed amount, less any access fees or precertification charges. BCBSAZ applies deductible, coinsurance, copays and access fees toward any out-of-pocket maximum that applies to the member s benefit plan. The allowed amount does not include any balance bills from noncontracted providers. The allowed amount is neither tied to, nor necessarily reflective of, the amounts providers in any given area usually charge for their services. The table below shows how BCBSAZ determines the allowed amount. Type of Provider Type of Claim Basis for Allowed Amount Providers contracted with BCBSAZ as Alliance providers Emergency and non-emergency Generally, the lesser of the provider s billed charges or the applicable Alliance fee schedule, with adjustments for any negotiated contractual arrangements and certain claim editing Providers contracted with a vendor Providers contracted with another Blue Cross or Blue Shield Plan ( Host Blue ) Noncontracted providers in Arizona, including providers contracted with another BCBSAZ network, but not with the Alliance network Noncontracted providers outside Arizona Noncontracted providers (in Arizona and out-ofstate) Emergency and non-emergency Emergency and non-emergency Non-emergency claims and emergency ground ambulance claims Non-emergency claims and emergency ground ambulance claims Emergency procedures and pricing guidelines Generally, the lesser of the provider s billed charges or the vendor s fee schedule, with adjustments for any negotiated contractual arrangements Lesser of the provider s billed charges or the price the Host Blue plan has negotiated with the provider Lesser of the provider s billed charges or the applicable Alliance fee schedule, with adjustments for certain claim editing procedures and pricing guidelines. For emergency ground ambulance claims, the allowed amount is generally based upon the ambulance provider s billed charges. Generally, the pediatric vision benefits administrator bases the allowed amount on a percentage of the applicable fee schedule. Lesser of the provider s billed charges or the price the Host Blue plan has negotiated with the provider. For emergency ground ambulance claims, the allowed amount is generally based upon the ambulance provider s billed charges. Generally, the pediatric vision benefits administrator bases the allowed amount on a percentage of the applicable fee schedule, with adjustments as required to comply with state law outside Arizona. Billed charges Allowed Amount for Pediatric Dental Benefits BCBSAZ or its contracted vendor bases the allowed amount on the lesser of the dentist s billed charges or the applicable fee schedule, with adjustments for any negotiated contractual arrangements and certain claim editing procedures and pricing guidelines. 10

11 Balance Bill The balance bill refers to the amount you may be charged for the difference between a noncontracted provider s billed charges and the allowed amount. Any amounts paid for balance bills do not count toward deductible, coinsurance or the out-of-pocket maximum. Noncontracted providers have no obligation to accept the allowed amount. You are responsible to pay a noncontracted provider s billed charges, even though BCBSAZ will reimburse your claims based on the allowed amount. Depending on what billing arrangements you make with a noncontracted provider, the provider may charge you for full billed charges at the time of service or seek to balance bill you for the difference between billed charges and the amount that BCBSAZ reimburses you on a claim. Benefit Maximums Some benefits may have a specific benefit maximum or limit based on the number of days or visits, type, timeframe (calendar year or benefit plan), age, gender or other factors. If you reach a benefit maximum, any further services are not covered under that benefit and you may have to pay the provider s billed charges for those services. However, if you reach the benefit maximum on a particular line of a claim, you will be responsible for paying only up to the allowed amount for the remaining charges on that line of the claim. All benefit maximums are included in the applicable benefit description. Calendar-Year Deductible (Individual and Family) A calendar-year deductible is the amount each member must pay for covered services each January through December before the benefit plan begins to pay for covered services. The deductible applies to every covered service unless the specific benefit section says it does not apply. The deductible is calculated based on the allowed amount. Amounts you pay for copays and access fees do not count toward the deductible. If you have family coverage, there is also a calendar-year deductible for the family. Amounts counting toward an individual s calendar-year deductible will also count toward any family deductible. When the family satisfies its calendar-year deductible, it also satisfies the deductible for all the individual members. An individual member cannot contribute more than his or her individual deductible toward the family s deductible. Coinsurance Coinsurance is a percentage of the allowed amount that you pay for certain covered services after meeting any applicable deductible. BCBSAZ subtracts any applicable access fees and precertification charges from the allowed amount before calculating coinsurance. Coinsurance applies to every covered service unless the specific benefit section says it does not apply. In most cases, your coinsurance percentage is higher when you use an out-of-network provider. BCBSAZ normally calculates coinsurance based on the allowed amount. There is one exception. If a hospital provider s billed charges are less than the hospital s reimbursement, BCBSAZ will calculate your coinsurance based on the lesser billed charge. Copay A copay is a specific dollar amount you must pay to the provider for some covered services. If a copay applies to a covered service, you must pay it when you receive services. Different services may have different copay amounts and are shown on your SBC. Usually, if a copay does not apply, you will pay applicable deductible and coinsurance. Out-of-Pocket Maximum (Individual & Family) An out-of-pocket maximum is the amount each member must pay each year before the plan begins paying 100 percent of the allowed amount on covered services, for the remainder of the calendar year. The payments listed below do not count toward the out-of-pocket maximum. You must keep paying them even after you reach your out-of-pocket maximum: Amounts above a benefit maximum Any amounts for balance billing Any amounts for noncovered services Any charges for lack of precertification 11

12 If you have family coverage, there is an out-of-pocket maximum for your family. Amounts applied to each member s out-of-pocket maximum also apply to the family out-of-pocket maximum. The family maximum is applied in the same way as the individual maximum described above and is subject to the same rules. When the family has met its family out-of-pocket maximum, it also satisfies the out-of-pocket maximum requirements for all the individual members. Pediatric Dental Benefit Cost-Shares LEAT Processing for Pediatric Dental Services Coverage for restorative (Type II and III) services is subject to Least Expensive Available Treatment (LEAT) processing. BCBSAZ determines whether a restorative service is subject to LEAT processing based upon its LEAT Guidelines, which are available to you upon request. If a restorative service is subject to LEAT processing, the least expensive available treatment for the restorative service is a covered service under this benefit plan (the Covered Restorative Service ). The more expensive available restorative treatment is not a covered service under this benefit plan (the Non-Covered Restorative Service ). Your cost-share is based upon the allowed amount for the Covered Restorative Service. The difference between the allowed amount for the Covered Restorative Service and the dentist s billed charges for the Non- Covered Restorative Service is the LEAT Balance Bill. If LEAT processing applies and you choose the Non-Covered Restorative Service, you will pay both the cost-share for the Covered Restorative Services and the LEAT Balance Bill. This is true even if you receive the Non-Covered Restorative Service from an in-network dentist. The LEAT Balance Bill does not count toward deductible or the out-of-pocket maximum. Predetermination of Benefits for Pediatric Dental Services Your dentist may ask BCBSAZ or its contracted vendor to estimate the benefits that will be available to cover a proposed treatment plan. Upon request, BCBSAZ or its contracted vendor will send a predetermination of benefits to your dentist. Because BCBSAZ or its contracted vendor will require detailed information, including the procedure codes for your proposed treatment, BCBSAZ or its contracted vendor will accept predetermination requests only from dentists. BCBSAZ or its contracted vendor will provide a non-binding estimate of your benefits that would be available under your plan, based on the information available to us at the time the request is submitted. Your claim may process differently from the predetermination of benefits for reasons that include, but are not limited to, whether BCBSAZ or its contracted vendor processes additional claims after the predetermination is issued, whether there are any changes to your eligibility status between the date of the predetermination of benefits and the date of service, whether your dentist submits a claim with different procedures or codes than were submitted with the predetermination request, and whether coordination of benefits applies. You may want to ask your dentist to submit a predetermination request if you are considering an extensive course of treatment. If least expensive available treatment (LEAT) analysis would apply to your proposed treatment, the predetermination will provide an estimate of your cost-share based on the LEAT. You will be responsible for any balance bill. However, BCBSAZ or its contracted vendor does not require predeterminations for any services covered under this plan. Predeterminations are not the same as precertifications, which are required prior to receipt of certain covered medical services. Your dentist may call BCBSAZ or its contracted vendor at the Customer Service number on your ID card for information on how to request a predetermination of benefits. Pharmacy Deductible (Individual) A pharmacy deductible is the amount each member must pay for Level 2 and Level 3 medications covered under the Pharmacy benefit each January through December before the benefit plan begins to pay for those medications. After meeting the pharmacy deductible, you pay copays for Level 2 and Level 3 medications. The pharmacy deductible is calculated on the medication allowed amount. Precertification Charges If your out-of-network provider does not obtain precertification from BCBSAZ for a service that requires it, you are subject to a precertification charge or complete loss of benefit as shown on your SBC. Amounts applied as precertification charges do not count toward the calendar-year deductible or out-of-pocket maximum. 12

13 COST-SHARE GRID AND TABLE The following table shows your cost-share for covered services. For most services, you will pay Plan Deductible and Plan Coinsurance, or a copay. Services Out-of-Pocket Maximum In-Network Calendar Year Plan Deductible Out-of-Network Calendar Year Plan Deductible In-Network Plan Coinsurance Out-of-Network Plan Coinsurance Primary Care Physician (PCP) Copay Cost-Share In-Network $6,250 per member $12,500 per family Out-of-Network $12,500 per member $25,000 per family $3,000 per member $6,000 per family $3,500 per member $7,000 per family Corresponding Cost-Share Table Benefit Number 1-35, 37, 39-42, 43-44, 45, , 8-11, 13-15, 17-21, 23-29, 32-35, 37, , 13-21, 23-29, 31-33, 35, 37, 39-42, 43-44, 45, 46 20% 1-6, 8-15, 17-29, 32-35, 37 50% $40 Specialist Copay $85 Bariatric Surgery Access Fee $1,000 18, 24 Pharmacy Deductible $300 per member 30 Level 1 Pharmacy Copay $35 30 Level 2 Pharmacy Copay $80 after deductible 30 Level 3 Pharmacy Copay $180 after deductible 30 Specialty Medication Coinsurance 50% 30 Urgent Care Copay $85 37 Pediatric Routine Vision Copay $ , 12-29, 31-33, 35, 37, 39-42, 43-44, 45, 46 2, 4-5, 8, 10, 14, 21, 23-24, 27-28, 32-35, 37 2, 4-6, 8, 10, 14, 21, 23-24, 27-28, 32-35, 37 13

14 COST-SHARE TABLE Benefit In-Network Cost-Share Out-of-Network Cost-Share 1. AMBULANCE SERVICES Deductible is waived. You pay In-Network Plan Coinsurance. 2. BEHAVIORAL AND MENTAL HEALTH SERVICES (Outpatient Facility and Professional Services) You pay one copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. Your copay will vary depending on whether you see a PCP or a Specialist. In-Network Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a 3. BEHAVIORAL AND MENTAL HEALTH SERVICES (Inpatient) 4. BEHAVIORAL THERAPY SERVICES FOR THE TREATMENT OF AUTISM SPECTRUM DISORDER 5. CATARACT SURGERY & KERATOCONUS 6. CHIROPRACTIC SERVICES 7. CHRONIC DISEASE EDUCATION AND TRAINING (Diabetes and Asthma Education and Training) walk-in clinic. Facility and Professional Services: You pay In-Network Plan Deductible and In- Network Plan Coinsurance. You pay one copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. Your copay will vary depending on whether you see a PCP or a Specialist. In-Network Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walk-in clinic. In-Network Plan Coinsurance for professional services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. You pay a Specialist Copay per member, per provider, per day for services provided during an office, home or walk-in clinic visit. You pay In-Network Plan Deductible and In-Network Plan Coinsurance for services delivered in locations other than the provider s office, the member s home or a walk-in clinic. Your cost-share is waived. 8. CLINICAL TRIALS In-Network Plan Coinsurance for professional services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. 9. DENTAL SERVICES BENEFIT MEDICAL 10. DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES AND PROSTHETIC APPLIANCES AND ORTHOTICS In-Network Plan Coinsurance. For services received in a physician s office, you pay a PCP Copay or a Specialist Copay. You pay In-Network Plan Deductible and In-Network Plan Coinsurance for services received outside a physician s office. Your cost-share is waived for one FDA-approved manual or electric breast pump and breast pump supplies per member, per calendar year. Facility and Professional Services: You pay Out-of-Network Plan Deductible and Out-of-Network Plan Coinsurance. You also pay the balance bill for services 14

15 Benefit In-Network Cost-Share Out-of-Network Cost-Share 11. EMERGENCY (PROFESSIONAL AND You pay your in-network cost-share for emergency services, even for services from out- of-network providers. FACILITY CHARGES) Emergency Services Provided in the Emergency Room, Inpatient Hospital or Other Location: In-Network Plan Coinsurance. If you receive emergency services from a noncontracted facility or professional provider, BCBSAZ will base the allowed amount used to calculate your cost-share on the provider s billed charges. 12. EOSINOPHILIC GASTROINTESTINAL DISORDER 13. FAMILY PLANNING (CONTRACEPTIVES AND STERILIZATION) For all non-emergency services following the emergency treatment and stabilization, see the Physician Services, Inpatient Hospital, and Outpatient Services cost-share sections of this benefit book. The cost-share amount will depend on the provider s network status and the place you receive services. If you receive non-emergency services from a noncontracted provider, you also pay the balance bill, which may be substantial. You pay the lesser of In-Network Plan Coinsurance or 25 percent of the allowed amount for amino-acid based formula ( Formula ). Implanted Devices: Your cost-share is waived for professional charges for implantation and/or removal (including follow-up care) of FDA-approved implanted contraceptive devices when the purpose of the procedure is contraception, as documented by your provider on the claim, and the device is inserted and/or removed in a physician office. You pay In- Network Plan Deductible and In-Network Plan Coinsurance when the location of service is outside a physician office. You pay the lesser of Out-of-Network Plan Coinsurance or 25 percent of the allowed amount for Formula. If you buy Formula from a noncontracted provider, the allowed amount is based on the provider s billed charges. Sterilization Procedures: Your cost-share is waived for professional and facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception, as documented by your provider on the claim. Hormonal Contraceptive Methods: Your cost-share is waived for oral contraceptives, patches, rings and contraceptive injections. See the Physician Services and Pharmacy Benefit sections for benefits. Emergency Contraception: Your costshare is waived for FDA-approved over- the-counter emergency contraception when prescribed by a physician or other provider. See the Physician Services section for benefits. Barrier Contraceptive Methods: Your costshare is waived for diaphragms, cervical caps, cervical shields, condoms, sponges and spermicides. See the Physician Services and the Pharmacy Benefit sections for benefits. 14. HEARING SERVICES In-Network Plan Coinsurance for professional services provided in a facility, for inpatient and outpatient facility charges, and for hearing devices. For physician office visits, you pay a PCP Copay or a Specialist Copay. 15

16 Benefit In-Network Cost-Share Out-of-Network Cost-Share In-Network Plan Coinsurance. 15. HOME HEALTH SERVICES If you believe you have paid more for a self-administered version of a Cancer Treatment Medication than for an injected or intravenously administered version of a Cancer Treatment Medication, please contact the Customer Service number listed in the front of this benefit book. 16. HOSPICE SERVICES Your cost-share is waived. Out-of-Network Plan Deductible and Outof-Network Plan Coinsurance are waived. You pay the balance bill for services 17. INPATIENT AND OUTPATIENT DETOXIFICATION 18. INPATIENT HOSPITAL You pay a Bariatric Surgery Access Fee for all bariatric surgeries in addition to applicable deductible and coinsurance. The Bariatric Surgery Access Fee applies toward the professional charges for bariatric surgery. 19. INPATIENT REHABILITATION SERVICES EXTENDED ACTIVE REHABILITATION (EAR) AND SKILLED NURSING FACILITY (SNF) SERVICES 20. LONG-TERM ACUTE CARE (INPATIENT) 21. MATERNITY Global Charge is a fee charged by the delivering provider that includes certain prenatal, delivery and postnatal services. 22. MEDICAL FOODS FOR INHERITED METABOLIC DISORDERS In-Network Plan Coinsurance. In-Network Plan Coinsurance. Your costshare is waived for facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception, as documented by your provider on the claim. In-Network Plan Coinsurance. In-Network Plan Coinsurance. Inpatient Services: You pay In-Network Plan Deductible and In-Network Plan Coinsurance. Outpatient Services: You pay one (1) physician visit copay for your first prenatal office or home visit, which covers all physician services included in the physician s Global Charge. You pay one copay, per member, per provider, per day for other physician office or home visits not included in the Global Charge. Your copay will vary depending on whether you see a PCP or a Specialist. You pay In- Network Plan Deductible and Plan Coinsurance for professional services in an outpatient facility, and for outpatient facility charges. You pay the lesser of In-Network Plan Coinsurance or 50 percent of the allowed amount. You pay the lesser of Out-of-Network Plan Coinsurance or 50 percent of the allowed amount. If Medical Foods are purchased from a noncontracted provider, the allowed amount is based on the provider s billed charges. 16

17 Benefit In-Network Cost-Share Out-of-Network Cost-Share In-Network Plan Coinsurance for professional services provided in a facility, and for inpatient and outpatient facility charges. For physician office visits, you pay a PCP Copay or a Specialist Copay. 23. NEUROPSYCHOLOGICAL AND COGNITIVE TESTING 24. OUTPATIENT SERVICES You pay a Bariatric Surgery Access fee for all bariatric surgeries, in addition to applicable deductible and coinsurance. The Bariatric Surgery Access fee applies toward the professional charges for bariatric surgery. Diagnostic Laboratory Services: You pay a PCP Copay or a Specialist Copay for services in a physician s office (copay is waived if you receive only covered laboratory services during your visit), except professional services provided by a pathologist or dermapathologist will be subject to In-Network Plan Deductible and In-Network Plan Coinsurance. You pay In- Network Plan Deductible and In-Network Plan Coinsurance for services provided in other locations. Radiology Services: You pay a PCP Copay or a Specialist Copay for services in a physician s office, except professional services provided by a radiologist will be subject to In-Network Plan Deductible and In-Network Plan Coinsurance. You pay In- Network Plan Deductible and In-Network Plan Coinsurance for services provided in other locations. Outpatient Facility Services (Including Outpatient Surgery): You pay In-Network Plan Deductible and In-Network Plan Coinsurance. Your cost-share is waived for facility charges for FDA-approved sterilization procedures when the purpose of the procedure is contraception as documented by your provider on the claim. Sleep Studies: You pay In-Network Plan Deductible and In-Network Plan Coinsurance. 25. PHYSICAL THERAPY (PT) - OCCUPATIONAL THERAPY (OT) - SPEECH THERAPY (ST) COGNITIVE THERAPY (CT) - CARDIAC AND PULMONARY REHABILITATION SERVICES 26. PHYSICAL THERAPY (PT) - OCCUPATIONAL THERAPY (OT) - SPEECH THERAPY (ST) COGNITIVE THERAPY (CT) - CARDIAC AND PULMONARY HABILITATION SERVICES Medications Administered in an Outpatient Facility: You pay In-Network Plan Deductible and In-Network Plan Coinsurance. In-Network Plan Coinsurance. In-Network Plan Coinsurance. 17