Regence HSA Individual Direct Plan Highlights Silver HSA, Bronze HSA 100 1/1/15

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1 Plan Features Provider choice: Members have direct access to their choice of providers. Member coinsurance levels are lowest for In Network providers. If a member chooses an Out of Network provider, the member may be required to pay costs above the allowed amount. Family coverage: no one family member is eligible for benefits until the entire family deductible is met. No one family member is eligible for 10 coverage until the entire family out of pocket maximum is met. Members get access to Optimum Value Medication List generics and certain medications for chronic conditions, before satisfying a deductible on the Silver HSA plan. Calendar Year Deductible Silver HSA Bronze HSA 100 Separate deductible amounts per calendar year for In Network / Out of Network providers. Applies to all covered expenses except where noted Single $2,000/$5,000 Family $4,000/$10,000 Single $6,300/$12,600 Family $12,600/$25,200 Calendar Year Out of Pocket Maximums Separate Out of Pocket maximum amounts for In Network / Out of Network providers. Applies to all covered expenses except where noted. When the out of pocket maximum is reached, this plan provides benefits at 10 of the allowed amount for the remainder of the calendar year. Single $5,000/$10,000 Family $10,000/$20,000 Single $6,300/$12,600 Family $12,600/$25,200 1

2 MEMBER RESPONSIBILITY Covered Services Silver HSA Bronze HSA 100 Office Visits Outpatient Radiology and Laboratory Diagnostic imaging including X rays. Chemical Dependency/Mental Health (Inpatient and Outpatient) Preventive Care and Immunizations In Network not subject to deductible Biofeedback 10 visits per lifetime for migraine headaches and urinary incontinence combined. Cardiac Rehabilitation Inpatient and outpatient services 36 visits per lifetime for outpatient (Phase II) services. Emergency Room Services In Network deductible, coinsurance and In Network out of pocket maximum apply regardless of provider network. Habilitative Services (Inpatient) 30 days per calendar year Habilitative Services (Outpatient) 30 visits per calendar year Hospital Services/Ambulatory Surgical Center Inpatient and outpatient services and supplies. Home Health Member responsibility for In Network services is indicated above, after In Network deductible is met and until out of pocket maximum is met, except where noted. Member responsibility for Out of Network services is 5 Silver HSA and Bronze HSA 100 after Out of Network deductible is met and until out of pocket maximum is met, except where noted. 2

3 Hospice Respite care limited to a maximum of five consecutive days and 30 days inpatient/outpatient per lifetime. Maternity Rehabilitation Services (Inpatient) 30 days per calendar year Neurodevelopmental therapy limited to children up to age 18 Rehabilitation Services (Outpatient) 30 visits per calendar year Neurodevelopmental therapy limited to children up to age 18 Skilled Nursing Facility 60 inpatient days per calendar year. Prescription Medications Silver HSA Bronze HSA 100 Deductible (per calendar year) In Network medical deductible applies unless otherwise specified Medical deductible applies Medical deductible applies Tier 1: Generics (Category 1) Retail/15% Mail Retail/ Mail Tier 2: Generics (Category 2) and Brand Name (Category 1) 35% Retail/3 Mail Retail/ Mail Tier 3: Brand Name (Category 2) 5 Retail/4 Mail Retail/ Mail Tier 4: Specialty Medications 4 Out of Pocket Maximum Drug List Other All out of pocket expenses go towards In Network Medical Out of Pocket Maximum. Essential Formulary Specialty medications covered at participating retail pharmacies for first fill only. After first fill members use specialty pharmacies. Members can receive a 5% discount for prescription medications at Preferred Pharmacies. Retail: Up to 30 day supply and up to 90 day supply at Preferred Pharmacies. Mail Order: Up to 90 day supply. Specialty Medications and Self Administrable Cancer Chemotherapy: Up to 30 day supply per fill. 3

4 Pediatric Dental Services Covered for members up to age 19 Various limits apply Pediatric Vision Services Covered for members up to age 19 One routine eye exam per calendar year. One pair (two lenses) and one standard frame per calendar year. Contacts covered in lieu of glasses Member responsibility for both In Network/Out of Network: Preventive: / Basic: / Major: 5 Deductible waived on all services Applies to In Network out of pocket maximum Member responsibility for both In Network/Out of Network: Eye Exam: / Vision Hardware: 5 Deductible waived on all services Applies to In Network out of pocket maximum Optional Benefits Available Silver HSA Bronze HSA 100 PACKAGE OPTION: Adult Dental, Adult Vision and IAP Adult Dental and Adult Vision covered for members age 19 and older Adult dental waiting periods for enrollees with no prior Regence dental coverage: 6 months for Basic Services and 12 months for Major Services. Coinsurance does not apply to the respective out of pocket maximum. Adult Dental No deductible and for Preventive care $50 deductible per calendar year for Basic and Major Care for Basic care 5 for Major care $750 annual maximum (When services incurred are less than $750, an additional benefit of $250 may be rewarded the following year, not to exceed a total benefit of $1,500) Adult Vision No deductible One routine exam, per calendar year no member responsibility up to the specified limit Frames, contacts and lenses: $150 limit per calendar year Individual Assistance Program (IAP) Eight sessions no member responsibility Reliant Behavioral Health Network 4

5 Additional Information Outside the Service Area Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country and worldwide through the BlueCard Program. Out of Network plan benefits apply as described above. 5

6 General Medical Exclusions Complementary Care: Acupuncture and spinal manipulations. Cosmetic/Reconstructive Services and Supplies except as necessary for reconstruction for functional injury and disease or as required by state/federal mandates such as reconstructive breast surgery following a mastectomy for cancer; to correct a congenital anomaly for Members up to age 26; to correct a craniofacial anomaly; to restore a physical bodily function lost as a result of Injury or Illness; for one attempt to correct a scar or defect that resulted from an accidental Injury or treatment for an accidental Injury, provided the attempt is made within 18 months of the accidental Injury or treatment causing the scar or defect (or, if delay is medically necessary, as soon thereafter as correction is appropriate); or for one attempt to correct a scar or defect on the head or neck that resulted from a surgery, provided the attempt is made within 18 months of the surgery causing the scar or defect (or, if delay is medically necessary, as soon thereafter as correction is appropriate). Counseling in the absence of illness unless a covered benefit or required by law. Custodial Care: Non skilled care and helping with activities of daily living unless member is eligible for Palliative Care benefits. Dental Examinations and Treatments except when covered under the Pediatric Dental benefit or any dental option. Fees, Taxes, Interest: Charges for shipping and handling, postage, interest, or finance charges that a provider might bill. Government Programs: Benefits that are covered, or would be covered in the absence of this plan, by any federal, state or governmental program. Infertility except to the extent covered services are required to diagnose such condition. Investigational Services: Treatment or procedures (health interventions) and services, supplies, and accommodations provided in connection with investigational treatments or procedures. Military Service Related Conditions: The treatment of any condition caused by or arising out of a member's active participation in a war or insurrection or conditions incurred in or aggravated during performance in the Uniformed Services. Motor Vehicle Coverage and Other Insurance Liability Non Direct Patient Care including appointments scheduled and not kept, charges for preparing medical reports, itemized bills or claim forms, and visits or consultations that are not in person, including telephone consultations and exchanges. Non Duplication of Medicare: Services and supplies to the extent payable under Medicare, when by law, the plan would not be primary to Medicare had the member properly enrolled in Medicare when first eligible regardless of whether or not the member actually enrolled. Obesity or Weight Reduction/Control: Medical treatment, medication, surgical treatment (including reversals), programs, or supplies that are intended to result in or relate to weight reduction, regardless of diagnosis. Orthognathic Surgery except for injury, sleep apnea or congenital anomaly. Personal Comfort Items: Items that are primarily for comfort, convenience, cosmetics, environmental control, or education. Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other such facilities; applies even if the program, equipment, or membership is recommended by the member s provider. Private Duty Nursing including ongoing shift care in the home. Riot, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury or condition caused by a member s voluntary participation in a riot, armed invasion, or aggression, insurrection, or rebellion or sustained by a member while committing an illegal act or felony. 6

7 Routine Foot Care Routine Hearing Exams Self Help, Self Care, Training, or Instructional Programs including, but not limited to control weight, or provide general fitness (childbirth classes); Programs that teach a person how to use durable medical equipment or how to care for a family member. Services and Supplies Provided by a Member of Your Family Services and Supplies That Are Not Medically Necessary Services to Alter Refractive Character of the Eye Sexual Dysfunction: Regardless of cause, except for counseling provided by covered, licensed mental health practitioners. Temporomandibular Joint Disorders (TMJ) Third Party Liability: Services and supplies for treatment of illness or injury for which a third party is responsible. Travel and Transportation Expenses other than covered ambulance services and for transplant services for the patient and caregiver. Work Related Conditions except for subscribers and spouses only who both are owners, partners or corporate officers and are exempt from L&I coverage. This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract. 7

8 Individual Direct Plan Options Gold+, Silver+, Silver HSA and Bronze HSA 100 Adult Dental, Adult Vision, Individual Assistance Program (IAP) Features Includes Adult Dental and Adult Vision coverage for members age 19 and older Adult dental services do not apply to the out of pocket maximum of the policy Individual Assistance Program coverage provides members with a variety of personal support resources and is available to all family members, regardless of age Adult Dental Waiting Periods Deductible Maximum benefit per calendar year 6 months for Basic Services and 12 months for Major Services for members with no prior Regence dental coverage No Deductible for Preventive Dental Services $50 deductible per calendar year for Basic and Major Services $150 per family (3 times the insured amount) $750 annual maximum (when services incurred are less than $750, an additional benefit of $250 may be rewarded the following year, not to exceed a total benefit of $1,500) Important note: The dental deductible is calculated separately from any other deductible of the policy. Covered Dental Services (per insured) Preventive dental services X rays Bitewing X rays: 2 sets per calendar year Complete intra oral mouth X rays: One series in a 3 year period Panoramic mouth X rays: One series in a 3 year period Cleanings: 2 per calendar year (including periodontal maintenance) Oral examinations: 2 per calendar year Basic dental services Endodontic services including root canal treatment, pulpotomy and apicoectomy Emergency treatment for pain relief Fillings consisting of composite and amalgam restorations General dental anesthesia Member Responsibility (no deductible) (after deductible) JANUARY_2015_OR INDY METAL DVIAP 1

9 Individual Direct Plan Options Gold+, Silver+, Silver HSA and Bronze HSA 100 Adult Dental, Adult Vision, Individual Assistance Program (IAP) Basic dental services (continued) Uncomplicated and complex oral surgery procedures Periodontal maintenance: 2 per calendar year (including prophylaxis) Periodontal debridement: One full mouth debridement in a 3 year period Periodontal scaling and root planing: Once per quadrant in a 2 year period Major dental services Bridges: Once within a seven year period after placement Crowns, inlays and onlays: Once within a seven year period after placement Dentures (full and partial): Once within a seven year period after placement Implants (endosteal): 4 per insured lifetime (after deductible) 5 (after deductible) Adult Vision Deductible No deductible Covered Services Individual Assistance Program (IAP) Routine eye exam: one per calendar year, no member responsibility up to the specified limit Frames, contacts and lenses: $150 limit per calendar year Covered Services Eight counseling sessions per incident at no member cost Access to a toll free 24 hour crisis help line Free financial and legal consultation, and identity theft recovery Family support services for parenting, elder and child care 24/7 online access to assessments, articles and newsletters JANUARY_2015_OR INDY METAL DVIAP 2

10 Individual Direct Plan Options Gold+, Silver+, Silver HSA and Bronze HSA 100 Adult Dental, Adult Vision, Individual Assistance Program (IAP) This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions including exclusions, refer to the contract. JANUARY_2015_OR INDY METAL DVIAP 3