Geneva Woods Surgical Center Inc. Balance Select Bronze HSA

Transcription

1 Geneva Woods Surgical Center Inc. Balance Select Bronze HSA

2 WELCOME Thank you for choosing for your healthcare coverage. This benefit booklet tells you about this plan s benefits and how to make the most of them. Please read this benefit booklet to find out how your healthcare plan works. Some words have special meanings under this plan. Please see Definitions at the end of this booklet. In this booklet, the words we, us, and our mean. The words you and your mean any member enrolled in the plan. The word plan means your healthcare plan with us. Please contact Customer Service if you have any questions about this contract or your healthcare plan. We are happy to answer your questions and hear any of your comments. On our website at premera.com you can also: Learn more about this plan Find a healthcare provider near you Look for information about many health topics We look forward to serving you and your family. Thank you again for choosing Premera. HOW TO CONTACT US Please call or write Customer Service for help with the following: Questions about the benefits of this plan Questions about your claims Questions or complaints about care or services you receive Change of address or other personal information CUSTOMER SERVICE Mailing Address: (Premera) For Claims Only P.O. Box Anchorage, AK Physical Address: 2550 Denali St. #1404 Anchorage, AK Telephone Numbers: Local and toll-free number: Local and toll-free TDD number for the hearing-impaired: WHERE TO SEND CLAIMS Mail Your Claims To: Premera Blue Cross P.O. Box Anchorage, AK PBCBSAK SCER ( ) Balance Select Bronze HSA 5250

3 PRESCRIPTION DRUG CLAIMS Mail Your Prescription Drug Claims To Express Scripts P.O. Box Cincinnati, OH Contact the Pharmacy Benefit Administrator at: COMPLAINTS AND APPEALS Premera Blue Cross Attn: Appeals Department P.O. Box Seattle, WA Local and toll-free number: Fax: BLUECARD BLUE(2583) WEBSITE Visit our website at premera.com for information and secure online access to claims information TELADOC Log on to your account at member.teladoc.com/premera or call Group Name: Geneva Woods Surgical Center Inc. Effective Date: March 1, 2016 Group Number: Plan: Alaska Balance Select Certificate Form Number: PBCBSAK SCER ( ) PBCBSAK SCER ( ) Balance Select Bronze HSA 5250

4 INTRODUCTION This benefit booklet is for members enrolled in this plan. This benefit booklet describes the benefits and other terms of this plan. It replaces any other benefit booklet you may have received. We know that healthcare plans can be hard to understand and use. We hope this benefit booklet helps you understand how to get the most from your benefits. The benefits and provisions described in this plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with us. This benefit booklet is a part of the contract on file at the employer s office. This plan will comply with state laws and the federal health care reform law, called the Affordable Care Act (see Definitions), including any applicable requirements for distribution of any medical loss ratio rebates and actuarial value requirements. If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the calendar year, this plan will comply even if they are not or are in conflict with a statement made in this benefit booklet. Medical and payment policies. These policies are used to administer the terms of this plan. Medical policies are generally used to further define medical necessity or investigational status for specific procedures, drugs, biological agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicare Services (CMS). Our policies are available to you and your provider on our website at premera.com or by calling Customer Service. TRANSLATION SERVICES If you need an interpreter to help with oral translation services, please call us. Customer Service will be able to guide you through the service. HOW TO USE THIS BENEFIT BOOKLET Every section in this benefit booklet has important information. You may find that the sections below are especially useful. HOW TO CONTACT US Our website, phone numbers, mailing addresses and other contact information are located on the inside front cover of this benefit booklet. SUMMARY OF YOUR COSTS Lists your costs for covered services. IMPORTANT PLAN INFORMATION Describes the applicable cost-shares, out-of-pocket maximums and allowed amount. HOW PROVIDERS AFFECT YOUR COSTS How your choice of a provider affects your benefits and your out-of-pocket costs. CARE MANAGEMENT Describes prior authorization, clinical review provisions and personal health support programs. COVERED SERVICES A detailed description of what is covered under this plan. EXCLUSIONS Describes services that are limited or not covered under this plan. OTHER COVERAGE - Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness. SENDING US A CLAIM Instructions on how to send in a claim. COMPLAINTS AND APPEALS What to do if you want to share ideas, ask questions, file a complaint, or send in an appeal. ELIGIBILITY AND ENROLLMENT Information on who is eligible for the plan and how to enroll. TERMINATION OF COVERAGE Describes when coverage ends under this plan. OTHER PLAN INFORMATION Lists the general information about how this plan is administered and required state and federal notices. DEFINITIONS Specific meanings of words and terms used in this plan. PBCBSAK SCER ( ) Balance Select Bronze HSA 5250

5 TABLE OF CONTENTS SUMMARY OF YOUR COSTS...1 IMPORTANT PLAN INFORMATION...8 Allowed Amount...8 Calendar Year Deductible...9 Coinsurance...9 Out-of-Pocket Maximum...9 HOW PROVIDERS AFFECT YOUR COSTS...10 Medical Services...10 CARE MANAGEMENT...12 Prior Authorization...12 Clinical Review...15 Personal Health Support Programs...15 COVERED SERVICES...15 Common Medical Services...16 Other Covered Services...25 EMPLOYEE WELLNESS...33 EXCLUSIONS...33 OTHER COVERAGE...37 Coordinating Benefits With Other Plans...37 Subrogation and Reimbursement...39 SENDING US A CLAIM...39 COMPLAINTS AND APPEALS...41 ELIGIBILITY AND ENROLLMENT...44 Who Is Eligible For Coverage...44 When Coverage Begins...45 Special Enrollment...46 TERMINATION OF COVERAGE...48 Events That End Coverage...48 CONTINUATION OF COVERAGE...48 OTHER PLAN INFORMATION...49 DEFINITIONS...52 PBCBSAK SCER ( ) Balance Select Bronze HSA 5250

6 SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to all of the following: The allowed amount. This is the most this plan allows for a covered service. The coinsurance. This is the amount you pay after your deductible is met. The deductibles. Most of your cost shares are subject to the deductible. Sometimes the deductibles are waived and these are shown below. When covered services are subject to the Preferred INN Provider coinsurance, the Preferred INN Provider deductible applies. Preferred (Preferred INN) Hospitals and other Non-Hospital Providers Non-Preferred and Non- Participating Hospitals Individual deductible: $5,250 $10,500 Family deductible: $10,500 $21,000 The out-of-pocket maximum. This is the most you pay each calendar year for services from Preferred INN hospitals and non-hospital providers. There is no out-of-pocket maximum for Non-Preferred and Non- Participating hospitals. Preferred (Preferred INN) Hospitals and other Non-Hospital Providers Non-Preferred and Non-Participating Hospitals Individual out-of-pocket maximum: $6,450 Not applicable Family out-of-pocket maximum: $12,900 Not applicable Prior authorization. Some services must be authorized by us in writing before you get them. See Prior Authorization for details. The conditions, time limits and maximum limits described in this contract. Some services have special rules. See Covered Services for these details. YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS NON-PREFERRED HOSPITAL NON- PARTICIPATING HOSPITAL COMMON MEDICAL SERVICES Office and Clinic Visit Includes office, clinic, e-visit, home and telehealth visits Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% You may have additional costs for things such as x-rays, lab and therapeutic injections. See those covered services for details. Preventive Care Limited to how often you can get them based on your age and if you are male or female Routine care, such as exams, screenings, immunizations, contraceptive management 0%, deductible waived 0%, deductible waived 0%, deductible waived PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

7 COVERED SERVICES and nutritional therapy Seasonal immunizations you get at a pharmacy or other mass immunizer, health education and nicotine cessation programs PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS 0%, deductible waived YOUR COSTS OF THE ALLOWED AMOUNT NON-PREFERRED HOSPITAL 0%, deductible waived NON- PARTICIPATING HOSPITAL 0%, deductible waived Facility charges Deductible then 30% Deductible then 40% Deductible then 60% You may have additional costs for things such as x-rays, lab and therapeutic injections. See those covered services for details. Pediatric Care Limited to members under age 19 Vision Exams and Hardware Routine exams limited to one per calendar year One pair of lenses for glasses or hard contact lenses, or 12-month supply of disposable contact lenses per calendar year One pair of frames per calendar year One comprehensive low vision evaluation every five years and four follow up visits in any five year period Low vision devices, high powered spectacles, magnifiers and telescopes when medically necessary 10%, deductible waived 0%, deductible waived 0%, deductible waived 10%, deductible waived 0%, deductible waived Diagnostic X-ray, Lab and Imaging See Preventive Care for preventive screening cost share Professional services Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% Surgery Services Includes the surgeon, assistant surgeon, anesthesiology and facility services Professional services, office surgeries and ambulatory surgical center Deductible then 30% Deductible then 30% Deductible then 30% Inpatient and outpatient hospital Deductible then 30% Deductible then 40% Deductible then 60% Emergency Room Deductible then 30% Emergency Ambulance Services Emergency air and surface (ground and water) ambulance services, and nonemergency ground or water transport Non-emergency air ambulance services, including transfer from one facility to another facility Deductible then 30% Deductible then 30% Deductible then 40% Deductible then 60% PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

8 YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS NON-PREFERRED HOSPITAL NON- PARTICIPATING HOSPITAL Urgent Care Centers Office visits Deductible then 30% Deductible then 30% Deductible then 30% Services from centers based in a hospital facility or emergency room Services from centers not based in a hospital facility or emergency room. You may have additional costs for other services such as x-rays, lab and therapeutic injections. See those covered services for details. Hospital Services Professional inpatient and outpatient services Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 30% Deductible then 30% Deductible then 30% Facility - inpatient and outpatient services Deductible then 30% Deductible then 40% Deductible then 60% Mental Health, Behavioral Health and Substance Abuse Services to treat mental health, behavioral health and substance abuse conditions apply to this benefit, including services such as physical, speech or occupational therapy. Office visits You may have additional costs for facility charges. Deductible then 30% Deductible then 30% Deductible then 30% Other professional services Deductible then 30% Deductible then 30% Deductible then 30% Facility services Deductible then 30% Deductible then 40% Deductible then 60% Maternity and Newborn Care Prenatal, postnatal, delivery and inpatient care Professional services Deductible then 30% Deductible then 30% Deductible then 30% Hospital, birthing centers or short-stay facilities, diagnostic tests during pregnancy Deductible then 30% Deductible then 40% Deductible then 60% Home Health Care Limited to 130 visits per calendar year. Hospice Care Limited to a lifetime maximum of 6 months. All hospice services are subject to the lifetime maximum. Unlimited hospice home visits 10 days of inpatient care 240 hours of respite care Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 30% Deductible then 40% Deductible then 60% Rehabilitation Therapy Neuropsychological testing to diagnose is not subject to any maximum. See Mental Health, Behavioral Health and Substance Abuse for PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

9 YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES therapies provided for mental health conditions such as autism. Habilitation Therapy includes neurodevelopmental therapy. Outpatient services to treat non-chronic conditions limited to 45 visits per calendar year Outpatient services to treat chronic conditions, unlimited Inpatient services limited to 30 days per calendar year Habilitation Therapy Outpatient services to treat non-chronic conditions limited to 45 visits per calendar year Outpatient services to treat chronic conditions, unlimited Inpatient services limited to 30 days per calendar year Skilled Nursing Facility and Care Limited to 60 days per calendar year Home Medical Equipment (HME), Orthotics, Prosthetics and Supplies Foot orthotics and orthopedic shoes for other conditions other than diabetes are limited to $300 per calendar year. PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS NON-PREFERRED HOSPITAL NON- PARTICIPATING HOSPITAL Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 30% Deductible then 40% Deductible then 60% OTHER COVERED SERVICES (Alphabetical Order) Acupuncture Services Limited to 12 visits per calendar year Office visits You may have additional costs for hospital facility charges Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% Air or Surface Transportation (Commercial) Limited to the member needing the transportation and to 3 round trip transports per medical occurrence per calendar year. Deductible then 30% Allergy Testing and Treatment Deductible then 30% Deductible then 40% Deductible then 60% Chemotherapy, Radiation Therapy and Kidney Dialysis Chemotherapy includes infusion and injectable drug services you get as an inpatient or outpatient PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

10 YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS NON-PREFERRED HOSPITAL NON- PARTICIPATING HOSPITAL Professional services Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% You may have additional costs for hospital facility charges. Clinical Trials Office visits Deductible then 30% Deductible then 30% Deductible then 30% Other professional services Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% Transportation for Cancer Clinical Trials only Deductible then 30% You may have additional costs for hospital facility charges. Dental Accidents Limited to services you get within 12 months of the accident Office visits Deductible then 30% Deductible then 30% Deductible then 30% Other professional services Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% Foot Care Routine care that is medically necessary for treatment of diabetes Hearing Hearing Exam Limited to one exam every two calendar years Hearing Test Limited to one test every two calendar years Hearing Hardware Limited to $1,000 every three calendar years Your cost shares for hearing services do not accrue to the out-of-pocket maximum. Deductible then 30% Deductible then 40% Deductible then 60% Deductible then 20% 10%, deductible waived Deductible then 20% Infusion Therapy (Outpatient) Deductible then 30% Deductible then 40% Deductible then 60% Mastectomy and Breast Reconstruction Deductible then 30% Deductible then 40% Deductible then 60% Medical Travel Support Limited to: Deductible then 0% One round-trip commercial air transportation for member and companion per episode Surface transportation and parking limited up to $35 per day plus mileage expenses Ferry transportation limited to up to $50 per person each way PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

11 YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN HOSPITALS AND OTHER NON- HOSPITAL PROVIDERS NON-PREFERRED HOSPITAL NON- PARTICIPATING HOSPITAL Lodging limited up to $50 per day per person Psychological and Neuropsychological Testing Deductible then 30% Deductible then 40% Deductible then 60% Spinal Manipulation Services Limited to 12 visits per calendar year Office visits You may have additional costs for hospital facility charges Deductible then 30% Deductible then 30% Deductible then 30% Facility charges Deductible then 30% Deductible then 40% Deductible then 60% Therapeutic Injections Deductible then 30% Deductible then 40% Deductible then 60% Transplants Donor covered services are limited to $75,000 per transplant. Office visit, you may have additional costs for facility charges. See Hospital Services for details. Other outpatient care services and inpatient services $7,500 for travel and lodging expenses per transplant Deductible then 30% Not covered Not covered Deductible then 30% Not covered Not covered 0% YOUR COSTS OF THE ALLOWED AMOUNT COVERED PRESCRIPTION DRUGS IN-NETWORK PHARMACIES OUT-OF-NETWORK PHARMACIES Prescription Drugs Retail Pharmacy Limited up to a 90-day supply. Preventive drugs limited to prescribed drugs required by health care reform and to HSA generic preventive drugs Nicotine cessation drugs, oral generic and single-source brand name contraceptive drugs and devices 0%, deductible waived 0%, deductible waived Formulary generic drugs Deductible then 30% Formulary preferred brand name drugs Deductible then 30% Formulary non-preferred brand name drugs Deductible then 30% Prescription Drugs Mail Order Pharmacy Limited up to a 90-day supply. Preventive drugs limited to prescribed drugs required by health care reform and to HSA generic preventive drugs 0%, deductible waived Not covered Formulary generic drugs Deductible then 30% Not covered PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

12 YOUR COSTS OF THE ALLOWED AMOUNT COVERED PRESCRIPTION DRUGS IN-NETWORK PHARMACIES OUT-OF-NETWORK PHARMACIES Formulary preferred brand name drugs Deductible then 30% Not covered Formulary non-preferred brand name drugs Deductible then 30% Not covered Prescriptions Specialty Pharmacy Limited up to a 30-day supply for formulary and limited to our specialty pharmacies Deductible then 30% Not covered PBCBSAK SSYC Balance Select Bronze HSA 5250 Geneva Woods Surgical Center Inc.,

13 IMPORTANT PLAN INFORMATION This plan is a Preferred Provider Plan (PPO) and provides you benefits for covered services from providers within the HeritageSelect network in Alaska. You have access to one of the many providers included in our network of providers for covered services included in this plan without referral. Please see How Providers Affect Your Costs for more information. You also have access to facilities, emergency rooms, surgical centers, equipment vendors or pharmacies providing covered services throughout the United States and wherever you may travel. ALLOWED AMOUNT This plan provides benefits based on the allowed amount for covered services. The allowed amount is described below. Providers In Alaska and Washington Who Have Agreements With Us For any given service or supply, the allowed amount is the lesser of the following: The provider s billed charge; or The fee that we have negotiated as a reasonable allowance for medically necessary covered services and supplies. Contracting providers agree to seek payment from us when they furnish covered services to you. You will be responsible only for any applicable cost-sharing, including deductibles, copays, coinsurance, charges in excess of the stated benefit maximums and charges for services and supplies not covered under this plan. Providers Outside Alaska and Washington Who Have Agreements With Other Blue Cross Blue Shield Licensees For covered services and supplies received outside Alaska and Washington or in Clark County, Washington, allowed amount is determined as stated in BlueCard Program. Providers Who Do Not Have Agreements With Us Or Another Blue Cross Blue Shield Licensee The allowed amount shall be defined as indicated below. When you receive services from a provider who does not have an agreement with us or another Blue Cross Blue Shield Licensee, you are responsible for any amounts not paid by us, including amounts over the allowed amount. In determining the allowed amount, we establish a profile of billed charges, using statistically creditable data for a period of 12 months by examining the range of charges for the same or similar service from providers within each geographical area for which we receive claims. The allowed amount will be no less than 80 th percentile of billed charges for that service. If we are unable to obtain sufficient data from a given geographical area, we will use a wider geographical area. If inclusion of the wider geographical area still does not provide sufficient data, we will set the allowed amount to no less than the equivalent of the 80 th percentile or no lower than 250% of Medicare allowed amount for the same services or supplies, whichever is greater. Using this methodology, the allowed amount will be the least of the following: An amount that is no less than the lowest amount we pay for the same or similar service from a comparable provider that has a contracting agreement with us 250% of the fee schedule determined by the Centers for Medicare and Medicaid Services (Medicare), if available The provider s billed charges In no case will the allowed amount be less than the 80 th percentile of charges in the geographical area where services are received, or as otherwise required by law. Pediatric Dental Services Providers Who Have Signed A Contracting Agreement With Us The allowed amount is the fee that we have negotiated with contracting dental providers. Providers Who Have Not Signed A Contracting Agreement With Us The allowed amount will be the maximum allowed amount in the geographical area where the services were provided. In no case will the allowed amount be less than the 80 th percentile or no higher than the 90 th percentile of provider fees in that area where the services are received. Emergency Services Consistent with the requirements of the Affordable Care Act the allowed amount will be the greater of the following: The median amount providers who contract with us have agreed to accept for the same services The amount Medicare would allow for the same services The amount calculated by the same method the plan uses to determine payment to providers who do not have contracting agreements with us In addition to your applicable cost-sharing, you PBCBSAK SCER Balance Select Bronze HSA 5250

14 will be responsible for charges above the allowed amount when services are received from providers who do not have contracting agreements with us. CALENDAR YEAR DEDUCTIBLE A deductible is what you pay for covered services each calendar year before this plan provides benefits. See Summary of Your Costs for your deductible amounts. Individual Deductible This plan includes an individual deductible for Preferred INN hospitals and non-hospital providers and a separate individual deductible for Non- Preferred and Non-Participating hospitals. After you have met the individual deductible for services received from Preferred INN providers, this plan will begin paying for your covered services from these providers for the remainder of the calendar year. After you have met the individual deductible for services received from Non-Preferred and Non- Participating providers combined, this plan will begin paying for your covered services from these providers for the remainder of the calendar year. Family Deductible Preferred INN Hospitals and Other Providers This plan includes a family deductible for Preferred INN Hospitals and non-hospital provider services. This plan limits the total deductible that must be met by all family members on this plan for Preferred INN hospitals. If you add or drop dependents from coverage during the calendar year, your calendar year deductible will change to the individual or family calendar year deductible, as appropriate. If two enrolled family members meet their individual deductibles for services from Preferred INN providers, we will consider the family deductible to have been met for the year and this plan will begin paying for covered services for all enrolled family members. Non-Preferred and Non-Participating Hospitals There is no family deductible for services received from Non-Preferred and Non-Participating hospitals. If two enrolled family members meet their individual deductibles for services from Non- Preferred providers and Non-Participating providers combined, we will consider the family deductible to have been met for the year and this plan will begin paying for covered services from Non-Preferred and Non-Participating providers for all enrolled family members. The individual and family deductibles (if any) are subject to the following: Deductibles add up during a calendar year, and renew each year on January 1 There is no carry over provision. Amounts credited to your deductible during the current year will not carry forward to the next year s deductible. Amounts credited to the deductible will not exceed the allowed amount Copays, if any, do not apply to the deductible Prior authorization penalties do not apply to the deductible Amounts credited toward the deductible do not add to benefits with an annual dollar maximum Amounts credited toward the deductible accrue to benefits with annual visit limits and other annual durational maximums COINSURANCE Coinsurance is the percentage of the allowed amount that you pay for covered services. This plan s coinsurance is shown on the Summary of Your Costs. OUT-OF-POCKET MAXIMUM The out-of-pocket maximum is the most you or your family pays each calendar year for covered services from Preferred INN Hospitals and non-hospital providers. See the Summary of Your Costs for your out-of-pocket maximum. If you add or drop dependents from coverage during the year, your out-of-pocket maximum will change to the family or individual out-of-pocket maximum as required by the change in family status. Individual Out-of-Pocket Maximum This plan includes an individual out-of-pocket maximum for covered services when you use Preferred INN hospitals and non-hospital providers. The out-of-pocket maximum is the total amount of deductible, coinsurance and copays you must pay each year. Once you meet this maximum, the benefits of this plan that are subject to the out-ofpocket maximum will be provided to you at 100% of the allowed amount for covered services from Preferred INN providers for the remainder of the calendar year. Family Out-of-Pocket Maximum This plan includes a family out-of-pocket maximum for covered services if you and one or more of your family members are enrolled in this plan. The family out-of-pocket maximum applies to covered services when you use Preferred INN hospitals and nonhospital providers. The copays (if applicable), deductibles and coinsurance your family pays count toward this limit. If two family members meet their individual out-of-pocket maximums, we will consider the individual out-of-pocket maximum of all your enrolled family members to be met for that calendar year. Benefits will then be paid at 100% of the PBCBSAK SCER Balance Select Bronze HSA 5250

15 allowed amount for covered services from Preferred INN providers for all of your enrolled family members for the remainder of the calendar year. There is no family out-of-pocket maximum for services you get from Non-Preferred and Non- Participating hospitals. You and your enrolled family members must always pay your cost-share for services you get from these providers. Expenses that do not apply to the Individual and Family out-of-pocket maximums include: Charges above the allowed amount Services above any benefit maximum limit or durational limit Services not covered by this plan Covered services provided by Non-Preferred and Non-Participating hospitals. You must always pay your cost-share when you see these providers for care. Prior authorization penalties Any benefit shown on the Summary of Your Costs as not applying to the out-of-pocket limit HOW PROVIDERS AFFECT YOUR COSTS MEDICAL SERVICES This plan is a Preferred Provider Plan (PPO). That means that this plan provides you benefits for covered services from providers of your choice. Throughout this section you will find information on how to control your out-of-pocket costs and how the providers you see for covered services can affect your plan benefits. To help you manage the cost of healthcare, we have a network of healthcare providers. You have access to one of the many providers included in our HeritageSelect network. In Alaska your network includes any provider that has signed a contract with Blue Cross Blue Shield of Alaska. You also have access to qualified practitioners, facilities, emergency rooms, surgical centers, equipment vendors or pharmacies providing covered services throughout the United States and wherever you may travel. See BlueCard Program below. Hospitals, physicians and other providers in these networks are called "in-network providers." A list of network providers is available in our provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help you select a provider that is right for you. We update this directory regularly but it is subject to change. We suggest that you call us for current information and to verify that your provider, their office location or provider group is included in our network before you receive services. The HeritageSelect provider directory is available any time on our website at premera.com. You may also request a copy of this directory by calling Customer Service at the number located on the inside front cover or on your Premera ID card. Preferred INN Hospitals In order to receive the highest level of benefits available under this plan for non-emergent hospital services, you must use a Preferred INN hospital. Preferred INN hospitals have agreed to accept the allowed amount as payment in full. They have also agreed to bill us directly for the covered portion of the services you receive, and we make payments directly to them. Your portion of the charges for covered services you get from Preferred INN hospitals will be the lowest. Other Providers Covered services you receive from providers other than hospitals will be reimbursed at the highest percentage, and you will not be responsible for amounts over the allowed amount. Non-Preferred Hospitals Non-Preferred hospitals are not included in our network, but do have a contract with Premera. Your medical bills will be reimbursed at a lower percentage than a Preferred INN hospital when you use a Non-Preferred hospital. This means that your out-of-pocket costs will be higher because your benefit level is lower. You are not responsible for any charges over the allowed amount. These providers also bill us directly for your care. Non-Participating Hospitals Non-Participating hospitals are not in our provider network and do not have a contract with Premera. This means that your out-of-pocket costs will be the highest because your benefit level is the lowest and you are responsible for any charges over the allowed amount. Amounts in excess of the allowed amount do not count toward your deductible or coinsurance. You may have to pay for services and send us a claim for reimbursement. Accepted Rural Providers Accepted Rural Providers are providers practicing in a medically under-served area of Alaska. They do not contract with us and are not in our network. Your cost-shares for services you get from Accepted Rural Providers are the same as the cost-shares for Preferred INN providers. Because accepted rural providers are not in our network, you must also pay for any charges over the allowed amount. You may also have to pay for services and send us a claim for reimbursement. PBCBSAK SCER Balance Select Bronze HSA 5250

16 Finding a Network Provider A list of network providers is available in our HeritageSelect provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help you select a provider that is right for you. We update this directory regularly and it is subject to change. We suggest that you call us for current information and to verify that your provider, their office location or provider group is included in the HeritageSelect network before you get services. The HeritageSelect provider directory is available any time on our website at premera.com. You may also request a copy of this directory by calling Customer Service at the number located on the inside front cover of this benefit booklet or on your Premera ID card. Special Circumstances The following services and/or providers will always be covered at the Preferred INN provider benefit level based on the allowed amount: Emergency care Non-emergency care services received from a Non-Preferred or a Non-Participating provider in Alaska when the nearest Preferred INN Provider is more than 50 miles from your home. We suggest that you contact us before you receive non-emergency care covered services from a Non-Preferred or Non-Participating provider. See Prior Authorization for additional information. Care received from Non-Preferred or Non- Participating providers for covered stays at Preferred INN hospitals when you have no choice as to who performs the services Certain categories of providers that we do not have contracting agreements You must pay your deductibles, coinsurance and charges over the allowed amount. See Prior Authorization for more information on requesting the Preferred INN provider benefit level when you receive other covered services from Non- Participating providers. WHEN YOU RECEIVE CARE IN WASHINGTON You have access to a network of providers when you receive care in Washington. Like Preferred Innetwork providers in Alaska, you will receive the highest benefit level and lowest out-of-pocket costs when you see these providers. All the requirements of your plan described in this booklet apply to services received in Washington. To find an in-network provider in Washington, see our provider directory at premera.com, or call Customer Service. PROVIDER STATUS A provider s agreement with us is subject to change at any time. Therefore, it is important to verify a provider s status before you receive services. This will help you avoid additional out-of-pocket costs. You can call our Customer Service Department at the number listed on the inside front cover of this contract booklet to verify a provider s status. If you are outside Alaska, Washington or Clark County, Washington, call BLUE (2583) to locate or verify the status of a provider. If you are seeing a provider and their written agreement with us is terminated while you are receiving pregnancy care or other active treatment, we will consider the provider to still have an agreement with us for the purpose of that care until one of the following occurs: This plan is terminated The provider s status will change on the date the provider s medically necessary treatment of a terminal condition ends. Terminal means that the patient is expected to live less than one year from the date the provider s agreement is terminated. In all other cases, the provider s status will change on the last of 3 dates to occur: The 90th day after the date the provider s agreement is terminated The date the current plan year ends The date postpartum care is completed WHEN YOU ARE OUTSIDE OF ALASKA AND WASHINGTON If you are outside Alaska and Washington, you may receive covered services from any provider licensed to provide the service. For non-emergent hospital services in Washington (except Clark County, Washington), you will receive the higher level of benefit available under this plan when you use network hospitals. Except as stated below, for the same services outside of Alaska and Washington or in Clark County, Washington, you will receive the higher level of benefits available by using hospitals with PPO agreements with the Blue Cross or Blue Shield Licensee in the area where you are receiving services. THE BLUECARD PROGRAM The BlueCard Program allows you to obtain out-ofarea covered services from contracting providers within the geographic area of a Host Blue. We will still honor our contract with the Group. The Host Blue will contract with, and submit claims received from, its providers that provide your care directly to PBCBSAK SCER Balance Select Bronze HSA 5250

17 us. We will base the amount you pay on these claims processed through the BlueCard Program on the lower of: The provider s billed charges for your covered services; or The allowed amount that the Host Blue makes available to us. Often, this allowed amount is a discount that reflects an actual price that the Host Blue pays to the provider. In some cases it may be an estimated price that takes into account a special arrangement with a single provider or a group of providers. In other cases, it may be an average price, based on a discount that results in expected average savings for services from similar types of providers. For estimated and average prices, Host Blues may use a number of factors to establish these prices. These may include types of settlements; incentive payments; and/or other credits or charges. Host Blues may also need to adjust their prices to correct for over- or under-estimation of past prices. We will not apply any further adjustments to the price on the claim that we will use to determine the amount you pay now. Also, federal and/or state law may require a Host Blue to add other items, including a surcharge, to the price of a claim. If that occurs, we will calculate what you owe for any covered services according to applicable law. Clark County Providers Services you get in Clark County, Washington are processed through the BlueCard Program. Some providers in Clark County do have contracts with us. These providers will submit claims directly to us, and benefits will be based on our allowed amount for the covered service or supply. Out-of-Area Services Out-of-Network Providers In certain situations, you may receive covered services from out-of-network providers outside of our service area that do not have a contract with the Host Blue ( non-contracting providers). In most cases we will base the amount you pay for such services on the payment we would make if the services had been obtained within our service area or the pricing arrangements under applicable state law. In some cases, we may base the amount you pay for such services on billed covered charges, Medicare s fee or a special negotiated payment, when allowed by law. In these situations, you may owe the difference between the amount that the out-of-network provider bills and the payment we will make for the covered services as set forth above. BlueCard Worldwide If you are outside the United States, Puerto Rico, and the U.S. Virgin Islands, you may be able to take advantage of BlueCard Worldwide. BlueCard Worldwide is unlike the BlueCard Program available in the United States, Puerto Rico, and the U.S. Virgin Islands in some ways. For instance, although BlueCard Worldwide has a network of contracting inpatient hospitals, it offers only referrals to doctors and other outpatient providers. Also, when you receive care from doctors and other outpatient providers outside the United States, Puerto Rico and the U.S. Virgin Islands, you will most likely have to send us the claims yourself. Benefits for covered services received from providers located outside the United States, Puerto Rico and the U.S. Virgin Islands are provided at the highest level of benefits available under the plan. For the most current information on network providers, please see premera.com or call Customer Service. If you are outside Alaska and Washington or in Clark County, Washington, call BLUE(2583). More Questions If you have questions or need to find out more about the BlueCard Program, please call our Customer Service Department. To find a provider in another Blue Cross and/or Blue Shield Licensee service area, go to premera.com or call BLUE (2583). You can also get BlueCard Worldwide information by calling the toll-free phone number. CARE MANAGEMENT Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from personal health support program. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved by us before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons PBCBSAK SCER Balance Select Bronze HSA 5250

18 why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required: Before you receive certain medical services and drugs, or prescription drugs Before you schedule a planned admission to certain inpatient facilities When you want to receive the Preferred INN provider benefit level for services you receive from a Non-Preferred or Non-Participating provider Each situation has different requirements. How To Ask For Prior Authorization The plan has a specific list of services or supplies that must have prior authorization with any provider. The detailed list of medical services requiring prior authorization can be obtained by contacting Customer Service, or at our website at premera.com. Services from Preferred INN Providers and Non- Preferred Providers: It is your Preferred INN provider or Non-Preferred provider s responsibility to get prior authorization. They must call us at the number listed on your ID card to request a prior authorization. Services from Non-Participating Providers: It is your responsibility to get prior authorization for any of the services on the Prior Authorization list when you see a Non-Participating provider. You or your provider must call us at the number listed on your ID card to request a prior authorization. The detailed list of medical services requiring prior authorization can be obtained by contacting Customer Service, or on our website at premera.com. The following are types of services that require prior authorization, including but not limited: Planned admission into hospitals or skilled nursing facilities Planned admission to an inpatient rehabilitation facility Non-emergency air or ambulance transport Transplant and donor services Injectable medications you get in a healthcare provider s office Prosthetics and orthotics other than foot orthotics or orthopedic shoes Reconstructive surgery, including repairs of defects caused by injury and correction of functional disorders Home medical equipment costing $500 or more Selected surgical, medical therapeutic, diagnostic and reconstructive procedures, such as: Abdominoplasty/Panniculectomy Bone anchored and implantable hearing aids Cardiac devices, including implantation Cardiac Percutaneous Interventions Corneal remodeling Deep brain stimulation Endoscopy Upper Gastrointestinal Hysterectomy Knee arthroplasty and arthoscopy Implantation or application of electric stimulator Radiation therapy such as gamma knife, proton beam, intensity modulated radiation therapy (IMRT), interoperative radiation therapy Spine surgery/treatments, such as cervical spinal fusion and lumbar spinal fusion Blepharoplasty (eyelid surgery), non-cosmetic Breast surgeries, such as certain implant removals, mastectomy, prophylactic mastectomy, and reduction mammoplasty Cochlear implantation Hyperbaric oxygen therapy Facility based sleep studies (Polysomnography) Radiofrequency tumor ablation Outpatient Imaging Tests Positron Emission Tomography (PET and PET/CT) Contrast Enhanced Computed Tomography (CT) Angiography of the heart Computed Tomography (CT) Scans Magnetic Resonance Imaging (MRI) Magnetic Resonance Angiography (MRA) Magnetic Resonance Spectroscopy Nuclear Cardiology Echocardiograms Certain prescription drugs. See Prior Authorization for Prescription Drugs below. You can also see the Pharmacy section on our website at premera.com. We will respond to your request for prior authorization within 72 hours of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded PBCBSAK SCER Balance Select Bronze HSA 5250

19 to as soon as possible, but no later than 24 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you don t receive the service or supply within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from Preferred INN Providers and Non-Preferred Providers These providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing by us before you receive the services. For Services from Non-Participating Providers It is your responsibility to get prior authorization for any of the services on the Prior Authorization list when you receive services from these providers. If you do not get prior authorization, you will pay a penalty. The penalty is in addition to any deductibles, copays or coinsurance this plan requires for covered services. The prior authorization penalty is 50 percent of the allowed amount. The maximum penalty is $1,500 per occurrence. The prior authorization penalty does not count toward this plan s deductibles or out-of-pocket maximum. Exceptions: The following services are not subject to this prior authorization requirement, but they have other requirements: Emergency hospital admissions, including admissions for drug or alcohol detoxification. They do not require prior authorization, but you must notify us as soon as reasonably possible. If you are admitted to a Non-Preferred or Non- Participating hospital due to an emergency condition, those services will always be covered at the Preferred INN cost-share. We will continue to cover those services until you are medically stable and can safely transfer to a Preferred INN hospital. If you choose to remain at the Non- Preferred or Non-Participating hospital after you are stable to transfer, coverage will revert to the Non-Preferred or Non-Participating benefit level. We pay services based on our allowed amount. If the hospital is non-contracted, you may be billed for charges over the allowed amount. Childbirth admission to a hospital, or admissions for newborns who need medical care at birth. They do not require prior authorization, but you must notify us as soon as reasonably possible. Admissions to a Non-Preferred or Non- Participating Provider hospital will be covered at the Non-Preferred or Non-Participating Provider cost-shares unless the admission was an emergency. Prior Authorization for Prescription Drugs Certain prescription drugs you receive through a pharmacy must have prior authorization before you get them at a pharmacy, in order for us to provide benefits. Your provider can ask for a prior authorization by faxing a prior authorization form to us. This form is on the pharmacy section of our website at premera.com. You can find out if a specific drug requires prior authorization by contacting Customer Service, or checking our website at premera.com. If your prescription drug requires prior authorization and you do not get prior authorization when you go to a network pharmacy to fill your prescription, your pharmacy will tell you that it needs to be prior authorized. You or your pharmacy should call your provider to let them know. Your provider can fax us a prior authorization form for review. You can buy the prescription drug before it is prior authorized, but you must pay the full cost. If the drug is authorized after you bought it, you can send us a claim for reimbursement. Reimbursement will be based on the allowed amount. See Sending Us a Claim for details. The list below includes examples of drug categories that require prior authorization. This list does not include specific drugs and it may change from time to time. You can call Customer Service or check the Pharmacy Section at premera.com for a detailed list of drugs that require authorization. Androgens, Estrogens, Hormones and related drugs Angiotensin II Receptor Blockers Anticonvulsants Antidepressant agents Antipsoriatic/Antiseborrheic Antipsychotics Drugs with significant changes in product labeling Glaucoma drugs Growth hormones Headache therapy Hypnotic agents Hypoglycemic agents Interferons Intranasal steroids Miscellaneous analgesics Miscellaneous antineoplastic drugs Miscellaneous antivirals PBCBSAK SCER Balance Select Bronze HSA 5250