Get the Most from Your Health Plan

Transcription

1 Enrollment Guide Cicero Public Schools District #99 PPO/BaHMO/HMOI/PPO Dental/DHMO 07/01/2018

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3 Get the Most from Your Health Plan Welcome to Blue Cross and Blue Shield of Illinois (BCBSIL), a leader in health care benefits. We have been helping people like you get the most from their health care plans for many years. Read this guide to learn about benefits your employer is offering. Think about how you and your family will use these benefits. Learn more about products, services and how to be a smart health care user at bcbsil.com. Your ID Card After you enroll, you will get a member ID card in the mail. Show this ID card when you see a doctor, visit the hospital or go to any other place for care. The back of the card has phone numbers you might need. Blue Access for Members SM Go to bcbsil.com/member and sign up for the secure member website, Blue Access for Members. Find the Log In tab and click Register Now. Use the information on your ID card to complete the process. On this site, you can check your claims, order more ID cards, get health information and much more. Save Money Stay In-Network Using independently contracted network providers can help you save. Look at your ID card to find your network. Then go to bcbsil.com to look for doctors, hospitals and other places for care. Call Customer Service for Help Our team knows your health plan and can help you get the most from your benefits. Just call the toll-free number on the back of your ID card

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5 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/ /30/2019 Cicero Public Schools District #99: PPO Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call or at For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at Glossary-508-MM.pdf or call to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? For In-Network: $400 Individual/$1,200 Family For Out-of-Network: $800 Individual/$2,400 Family Yes. Certain preventive care, services that charge a copay, prescription drugs, and emergency room services are covered before you meet your deductible. Yes. $250 deductible for Out-of-Network hospital admission. There are no other specific deductibles. For In-Network: $1,200 Individual/$2,400 Family For Out-of-Network: $4,800 Individual/$9,600 Family Prescription drug expense limit: $1,200 Individual/$2,400 Family Premiums, balanced-billed charges, and healthcare this plan doesn t cover. Yes. See or call for a list of network providers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out-of-pocket limit This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your provider before you get services. No. You can see the specialist you choose without a referral. 1 of 6

6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization In-Network Provider (You will pay the least) $20 copay/visit; deductible does not apply $30 copay/visit; deductible does not apply No Charge; deductible does not apply What You Will Pay Out-of-Network Provider (You will pay the most) 40% coinsurance None 40% coinsurance None 40% coinsurance Diagnostic test (x-ray, blood work) No Charge 40% coinsurance None Imaging (CT/PET scans, MRIs) No Charge 40% coinsurance None Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs $10 copay/prescription (retail) $20 copay/prescription (mail order) deductible does not apply $40 copay/prescription (retail) $80 copay/prescription (mail order) deductible does not apply $60 copay/prescription (retail) $120 copay/prescription (mail order) deductible does not apply $60 copay/prescription (retail) deductible does not apply $10 copay/prescription (retail) deductible does not apply $40 copay/prescription (retail) deductible does not apply $60 copay/prescription (retail) deductible does not apply Not Covered Limitations, Exceptions, & Other Important Information You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. 34-day supply at Retail 90-day supply at Mail Order Rx Out-of-Pocket Expense Limit: $1,200 Individual/$2,400 Family For Out-of-Network drug provider, you are responsible for 25% of the eligible amount after the copay. Certain women s preventive services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. Coverage based on group policy. Prior authorization may be required. * For more information about limitations and exceptions, see the plan or policy document at 2 of 6

7 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance None Physician/surgeon fees 20% coinsurance 40% coinsurance None Emergency room care 20% coinsurance; deductible does not apply 20% coinsurance; deductible does not apply None Emergency medical transportation 20% coinsurance 20% coinsurance None Urgent care 20% coinsurance 40% coinsurance None Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Physician/surgeon fees 20% coinsurance 40% coinsurance None Limitations, Exceptions, & Other Important Information $250 deductible per admission Out-of- Network providers. If you need mental health, behavioral health, or substance abuse services If you are pregnant Outpatient services 20% coinsurance 40% coinsurance None Inpatient services 20% coinsurance 40% coinsurance Office visits Childbirth/delivery professional services $20 copay/visit; deductible does not apply 40% coinsurance 20% coinsurance 40% coinsurance Childbirth/delivery facility services 20% coinsurance 40% coinsurance $250 deductible per admission Out-of- Network providers. Copay applies to first prenatal visit (per pregnancy). Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) $250 deductible per admission Out-of- Network providers. * For more information about limitations and exceptions, see the plan or policy document at 3 of 6

8 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need In-Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Home health care 20% coinsurance 40% coinsurance None Rehabilitation services 20% coinsurance 40% coinsurance Limited to 30 visits per benefit period for occupational therapy, 20 visits per benefit Habilitation services 20% coinsurance 40% coinsurance period for speech therapy, and unlimited visits for physical therapy. Skilled nursing care 20% coinsurance 40% coinsurance Durable medical equipment 20% coinsurance 40% coinsurance Hospice services 20% coinsurance 40% coinsurance Children s eye exam Not Covered Not Covered None Children s glasses Not Covered Not Covered None Children s dental check-up Not Covered Not Covered None $250 deductible per admission Out-of- Network providers. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). $250 deductible per admission Out-of- Network providers. Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Hearing aids Long term care Routine eye care (Adult) Routine foot care Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the U.S. Private-duty nursing * For more information about limitations and exceptions, see the plan or policy document at 4 of 6

9 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at , U.S. Department of Labor s Employee Benefits Security Administration at EBSA (3272) or or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois at or visit or contact the U.S. Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( ): Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6

10 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $400 Specialist copayment $30 Hospital (facility) coinsurance 20% Other coinsurance 20% The plan s overall deductible $400 Specialist copayment $30 Hospital (facility) coinsurance 20% Other coinsurance 20% The plan s overall deductible $400 Specialist copayment $30 Hospital (facility) coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: Cost Sharing Deductibles $400 Copayments $20 Coinsurance $800 What isn t covered Limits or exclusions $60 The total Peg would pay is $1,280 In this example, Joe would pay: Cost Sharing Deductibles $400 Copayments $700 Coinsurance $100 What isn t covered Limits or exclusions $60 The total Joe would pay is $1,260 In this example, Mia would pay: Cost Sharing Deductibles $400 Copayments $90 Coinsurance $200 What isn t covered Limits or exclusions $0 The total Mia would pay is $690 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

11 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/ /30/2019 Cicero Public School District #99: BA HMO Plan Coverage for: Individual + Family Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call or at For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call to request a copy. Important Questions Answers Why This Matters: What is the overall See the Common Medical Events chart below for your costs for services this plan $0 deductible? covers. Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a Referral to see a specialist? No. You will have to meet the deductible before the plan pays for any services. No. You don t have to meet deductibles for specific services. $1,500 Individual/$3,000 Family Prescription drug expense limit: $1,000 Individual/$3,000 Family Premiums, balanced-billed charges, and healthcare this plan doesn t cover. Yes. See or call for a list of participating providers. Yes. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Even though you pay these expenses, they don t count toward the out of pocket limit This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a Referral before you see the specialist. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG of 6

12 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Primary care visit to treat an injury or illness Participating Provider (You will pay the least) What You Will Pay $15 copay/visit Not Covered Non-Participating Provider (You will pay the most) Specialist visit $25 copay/visit Not Covered Referral required. Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) No Charge Not Covered No Charge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No Charge Not Covered Referral required. Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs $10 copay/prescription (retail) $20 copay/prescription (mail order) $40 copay/prescription (retail) $80 copay/prescription (mail order) $60 copay/prescription (retail) $120 copay/prescription (mail order) $10/$40/$60 copay /prescription (retail) Not Covered Not Covered Not Covered Not Covered Limitations, Exceptions, & Other Important Information Services or supplies that are not ordered by your Primary Care Physician or Women s Principal Health Care Provider, except emergency and routine vision exams, are not covered. You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Dispensing limit may apply to certain drugs. Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 30 day retail/90 day mail. RX Out-of-Pocket Expense Limit: $1,000 Individual/$3,000 Family. Coverage based on group policy. Prior authorization may be required. * For more information about limitations and exceptions, see the plan or policy document at 2 of 6

13 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Facility fee (e.g., ambulatory surgery center) Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) No Charge Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Limitations, Exceptions, & Other Important Information Emergency room care $250 copay/visit $250 copay/visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Urgent care $15 copay/visit Not Covered Facility fee (e.g., hospital room) $250 copay/visit Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Must be affiliated with member s chosen medical group or referral required. If you need mental health, behavioral health, or substance abuse services Outpatient services $15 copay/visit Not Covered Unlimited visits. Referral required. Inpatient services $250 copay/visit Not Covered Unlimited days. Referral required. If you are pregnant Office visits $15 copay/visit Not Covered Childbirth/delivery professional services No Charge Not Covered Cost sharing does not apply for preventive services. Depending on the type of services, a copayment may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery facility services $250 copay/visit Not Covered Referral required. * For more information about limitations and exceptions, see the plan or policy document at 3 of 6

14 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Home health care No Charge Not Covered Referral required. Limitations, Exceptions, & Other Important Information Rehabilitation services $15 copay/visit Not Covered 60 visits combined for all therapies. Habilitation services $15 copay/visit Not Covered Referral required. Skilled nursing care $250 copay/visit Not Covered Excludes custodial care. Referral required. Durable medical equipment No Charge Not Covered Referral required. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice services No Charge Not Covered Inpatient copay may apply. Referral required. Children s eye exam No Charge Not Covered Children s glasses Not Covered Not Covered None Children s dental check-up Not Covered Not Covered None Limited to one exam every 12 months at participating providers. Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Cosmetic surgery Custodial care Dental care (Adult) Hearing aids Long term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care (with the exception of person with diagnosis of diabetes) Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Most coverage provided outside the United States. See Routine eye care (Adult) Weight loss programs (except when nonmedically supervised) * For more information about limitations and exceptions, see the plan or policy document at 4 of 6

15 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at , U.S. Department of Labor s Employee Benefits Security Administration at EBSA (3272) or or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois at or visit or contact the U.S. Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( ): Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6

16 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $0 Specialist copayment $25 Hospital (facility) $250 Other $0 The plan s overall deductible $0 Specialist copayment $25 Hospital (facility) $250 Other $0 The plan s overall deductible $0 Specialist copayment $25 Hospital (facility) $250 Other $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: Cost Sharing Deductibles $0 Copayments $300 Coinsurance $0 What isn t covered Limits or exclusions $60 The total Peg would pay is $360 In this example, Joe would pay: Cost Sharing Deductibles $0 Copayments $1,000 Coinsurance $0 What isn t covered Limits or exclusions $60 The total Joe would pay is $1,060 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $400 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $400 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

17 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/ /30/2019 Cicero Public School District #99: HMOI Plan Coverage for: Individual + Family Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call or at For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call to request a copy. Important Questions Answers Why This Matters: What is the overall See the Common Medical Events chart below for your costs for services this plan $0 deductible? covers. Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a Referral to see a specialist? No. You will have to meet the deductible before the plan pays for any services. No. You don t have to meet deductibles for specific services. $1,500 Individual/$3,000 Family Prescription drug expense limit: $1,000 Individual/$3,000 Family Premiums, balanced-billed charges, and healthcare this plan doesn t cover. Yes. See or call for a list of participating providers. Yes. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Even though you pay these expenses, they don t count toward the out of pocket limit This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a Referral before you see the specialist. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL HMO LG of 6

18 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Primary care visit to treat an injury or illness Participating Provider (You will pay the least) What You Will Pay $20 copay/visit Not Covered Non-Participating Provider (You will pay the most) Specialist visit $30 copay/visit Not Covered Referral required. Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) No Charge Not Covered No Charge Not Covered Referral required. Imaging (CT/PET scans, MRIs) No Charge Not Covered Referral required. Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs $10 copay/prescription (retail) $20 copay/prescription (mail order) $40 copay/prescription (retail) $80 copay/prescription (mail order) $60 copay/prescription (retail) $120 copay/prescription (mail order) $10/$40/$60 copay/ prescription (retail) Not Covered Not Covered Not Covered Not Covered Limitations, Exceptions, & Other Important Information Services or supplies that are not ordered by your Primary Care Physician or Women s Principal Health Care Provider, except emergency and routine vision exams, are not covered. You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Dispensing limit may apply to certain drugs. Certain women s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service. 30 day retail/90 day mail. RX Out-of-Pocket Expense Limit: $1,000 Individual/$3,000 Family. Coverage based on group policy. Prior authorization may be required. * For more information about limitations and exceptions, see the plan or policy document at 2 of 6

19 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Facility fee (e.g., ambulatory surgery center) Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) No Charge Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Limitations, Exceptions, & Other Important Information Emergency room care $250 copay/visit $250 copay/visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Urgent care $20 copay/visit Not Covered Facility fee (e.g., hospital room) $250 copay/visit Not Covered Referral required. Physician/surgeon fees No Charge Not Covered Referral required. Must be affiliated with member s chosen medical group or referral required. If you need mental health, behavioral health, or substance abuse services Outpatient services $20 copay/visit Not Covered Unlimited visits. Referral required. Inpatient services $250 copay/visit Not Covered Unlimited days. Referral required. If you are pregnant Office visits $20 copay/visit Not Covered Childbirth/delivery professional services No Charge Not Covered Cost sharing does not apply for preventive services. Depending on the type of services, a copayment may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Childbirth/delivery facility services $250 copay/visit Not Covered Referral required. * For more information about limitations and exceptions, see the plan or policy document at 3 of 6

20 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Home health care No Charge Not Covered Referral required. Limitations, Exceptions, & Other Important Information Rehabilitation services $20 copay/visit Not Covered 60 visits combined for all therapies. Habilitation services $20 copay/visit Not Covered Referral required. Skilled nursing care $250 copay/visit Not Covered Excludes custodial care. Referral required. Durable medical equipment No Charge Not Covered Referral required. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Hospice services No Charge Not Covered Inpatient copay may apply. Referral required. Children s eye exam No Charge Not Covered Children s glasses Not Covered Not Covered None Children s dental check-up Not Covered Not Covered None Limited to one exam every 12 months at participating providers. Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Cosmetic surgery Custodial care Dental care (Adult) Hearing aids Long term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine foot care (with the exception of person with diagnosis of diabetes) Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Most coverage provided outside the United States. See Routine eye care (Adult) Weight loss programs (except when nonmedically supervised) * For more information about limitations and exceptions, see the plan or policy document at 4 of 6

21 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the plan at , U.S. Department of Labor s Employee Benefits Security Administration at EBSA (3272) or or Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross and Blue Shield of Illinois at or visit or contact the U.S. Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( ): Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6

22 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $0 Specialist copayment $30 Hospital (facility) $250 Other $0 The plan s overall deductible $0 Specialist copayment $30 Hospital (facility) $250 Other $0 The plan s overall deductible $0 Specialist copayment $30 Hospital (facility) $250 Other $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: Cost Sharing Deductibles $0 Copayments $300 Coinsurance $0 What isn t covered Limits or exclusions $60 The total Peg would pay is $360 In this example, Joe would pay: Cost Sharing Deductibles $0 Copayments $1,000 Coinsurance $0 What isn t covered Limits or exclusions $60 The total Joe would pay is $1,060 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $400 Coinsurance $0 What isn t covered Limits or exclusions $0 The total Mia would pay is $400 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6

23 The PPO Plan With the PPO plan, you can choose any doctor whenever you need care. The PPO plan offers a wide range of benefits and the flexibility to choose any doctor or hospital when you need care. The plan includes an annual deductible that you must satisfy before your benefits begin. Qualified medical expenses are applied toward your deductible. PPO Network Access to the large network of contracting providers is one of the many reasons to select the PPO plan. The network includes hospitals, physicians, therapists, behavioral health professionals and alternative care practitioners. You and your covered dependents can receive care from any licensed doctor, hospital or other provider. However, when you use a contracting network provider, you will pay less out of pocket, you won t have to file any claims and you will receive the highest level of benefits. If you use a doctor outside the network, you ll still be covered, but your out-of-pocket costs may be significantly higher. To find a contracting doctor or hospital, just go to bcbsil.com and use the Provider Finder, or call BlueCard Access at BLUE ( ) for help. Once you become a member, you can also call the toll-free Customer Service number on the back of your member ID card. Medical Care Your benefits may include coverage for*: physician office visits breast cancer screenings cervical cancer screenings inpatient hospital services muscle manipulation services outpatient hospital services physical, speech and occupational therapies outpatient surgery and diagnostic tests maternity care behavioral health and substance abuse hospital emergency medical and accident treatment *Coverage levels vary by health plan, so refer to your plan documents for details

24 The HMO Plans HMOs offer valuable benefits with the security of predictable copayments. The HMOs of Blue Cross and Blue Shield of Illinois (BCBSIL) provide the valuable benefits, member services and flexibility, along with the security of predictable copayments, so there are no financial surprises. Unlike other plans, BCBSIL s HMOs do not require you to pay a deductible. Your employer may offer you the HMO Illinois plan, the Blue Advantage HMO SM plan or a choice between the two. When you join one of the HMOs of BCBSIL, you choose a contracting medical group within your network and then a family practitioner, internist or pediatrician from your chosen medical group to serve as your primary care physician (PCP). Your PCP provides or coordinates your health care, helps you make informed decisions and, when necessary, makes referrals to specialists who are usually within your medical group network. Each specialist referral is authorized for a specific number of visits or timeframe (up to one year). In addition to their PCP, female members also have the option of choosing a woman s principal health care provider (WPHCP) to provide or coordinate their health care services. Your WPHCP and PCP must be affiliated with or employed by your participating medical group. Physicians in the same medical group do have a referral arrangement. You do not need a PCP referral to see your WPHCP. HMO Networks HMO Illinois offers access to one of the largest contracting health care provider networks in Illinois. In fact, your regular doctor may already be part of the network. If your doctor is not in the network and you are undergoing a course of evaluation or medical treatment or are in the second or third trimester of pregnancy when you join the plan, you may request transition of care benefits. Benefits for transitional services may be authorized for up to 90 days. After this period, all care must be transferred to a new PCP or medical group in the HMO network. Contact Customer Service at the number on your BCBSIL ID card for more information. The Blue Advantage HMO contracting provider network is a subset of the HMO Illinois network. Although smaller, it offers a broad choice of contracting providers and is for members who are looking for a more affordable health care plan. Blue Advantage HMO members also have access to the same contracting Illinois hospitals as HMO Illinois members for specialty care, with an approved referral from the member s contracting medical group. If you have a question, visit bcbsil.com or call Customer Service at

25 Medical Care The range of benefits includes coverage for: Physician office visits Outpatient surgery and diagnostic tests Breast cancer screening Cervical cancer screening Prostate cancer screening Colon cancer screening Inpatient hospital services Maternity care Outpatient hospital services Mental health and substance use disorder inpatient and outpatient treatment Rehabilitative therapy (such as physical, speech and occupational therapy) Inpatient and outpatient treatments To find a medical group and PCP in the network, go to bcbsil.com and click on Find a Doctor. You also can refer to a printed directory. You can request a directory by calling Customer Service at the number on your BCBSIL ID card. Each covered family member can choose a different medical group or PCP from the network. It s also easy to change your PCP or medical group for any reason. To select a different PCP within your existing medical group, just call the medical group. To change your medical group, call Customer Service or use the Blue Access for Members SM online service at bcbsil.com. See Your Health Care Benefit Program booklet or call Customer Service for more information. Preventive Care Another HMO benefit is coverage for preventive health services for children and adults, such as routine physicals, screenings, tests and immunizations, including childhood immunizations. Also, BCBSIL sends reminders to members to schedule flu shots, mammograms and Pap tests, and to have early childhood immunizations completed. Vision Care Your vision care benefits are available through EyeMed Vision Care, a leading national provider of vision care programs. You have access to one of the nation s largest networks of independent eye doctors and well-known retail providers with many in-network providers offering extended weeknight and weekend hours. Call Customer Service at the number on the back of your ID card or visit eyemed.com for more information. BlueCard This program covers HMO members traveling outside of Illinois who need medical attention. To learn more about this benefit, please call the number on your ID card. To find a contracting provider in the area in which you are traveling, call the BlueCard program toll-free at BLUE ( ) or search the Blue Cross and Blue Shield Association s website at bcbs.com. You can then call the provider directly to make an appointment. You pay the applicable copayment at the time of service and don t need to submit claim forms. If you have a question, visit bcbsil.com or call Customer Service at

26 Emergency Care If you, as a prudent layperson with an average knowledge of health and medicine, need to go to the emergency room of any hospital, your care will be covered. When a medical emergency occurs, first try to call your PCP. Someone from your medical group is available 24 hours a day, seven days a week. Your PCP or another doctor in your medical group may be able to treat you in the office. If you are unable to call your PCP, go directly to the nearest hospital emergency room and notify your PCP as soon as possible. If you are admitted, someone must contact your PCP immediately upon admission. Your emergency room copayment will be waived, but you will have to pay your inpatient hospital copayment, if applicable. Emergency care benefits are limited to the initial emergency treatment. To receive additional benefits, your PCP must provide or coordinate follow-up care. Reconstructive Surgery Federal and State of Illinois legislation require that group health plans and health insurers provide coverage for reconstructive surgery following a mastectomy. These laws state that health plans covering mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment for physical complications for all stages of mastectomy care, including lymphedemas. The HMOs of BCBSIL cover these procedures and annual mammograms when ordered by a member s PCP or WPHCP, subject to the terms of the member s applicable health care benefit coverage. Visit us at bcbsil.com or call Customer Service for more information. Utilization Management The HMOs of BCBSIL support the belief that the best people to determine what medical care you need are you and your doctor. BCBSIL does not get involved in deciding your course of treatment. This sets it apart from most other HMOs. Your doctor is encouraged to listen to your concerns and discuss all treatment options with you to help you make informed decisions. Your network medical group may review certain referrals or procedures for appropriateness of care. Your HMO doesn t get involved unless you request an appeal from BCBSIL because you disagree with decisions made by your PCP or medical group. Substance Use Disorder Treatment for substance use disorder (also known as substance abuse) is covered in your benefit plan. Please contact your PCP for a referral to a specialist. If you have a question, visit bcbsil.com or call Customer Service at EyeMed Vision Care is an independent company that administers the vision benefits for Blue Cross and Blue Shield of Illinois. This document is for comparison purposes only and is a brief summary of benefits. For full benefit information, please refer to your contract or certificate (Health Care Benefit Program booklet)

27 BlueCare Dental PPO SM BlueCare Dental PPO offers you and your family access to one of the largest national dental PPO networks 1. This network includes general and specialty dentists in Illinois as well as across the country. As a BlueCare Dental PPO plan member, you can go to any dentist. However, you ll save money and get more from your benefits when you use an in-network dentist. These in-network dentists have agreed to: Accept set fees for covered services Not bill you for costs over the negotiated fees (except copayments, coinsurance and deductibles) You can choose an out-of-network dentist, but he or she may have higher fees and charge you for amounts not covered by your insurance. Finding an In-Network Dentist is Easy For a list of in-network general and specialty dentists, go to bcbsil.com and use the Provider Finder tool. You can search for a dentist near your home, school or office and easily download a map with driving directions. BlueCare Dental Connection SM As an enhanced service, Blue Cross and Blue Shield of Illinois (BCBSIL) offers BlueCare Dental Connection. This service provides educational information and other resources to help you make choices about your dental care at no extra cost. To help you learn about good oral health, BlueCare Dental Connection offers: Educational mailings 24-hour online access to the Dental Wellness Center*, which offers educational articles and special tools The Dental Wellness Center allows you to: Ask dental-related questions through Ask a Dentist* Find an in-network dentist using Provider Finder Research dental fees in your area with the Dental Cost Advisor* Search the Dental Dictionary* of common clinical terms View animations on different dental topics in the Treatment and Procedure* tool To access the Dental Wellness Center, log in to Blue Access for Members SM at bcbsil.com and click on the My Health tab. Dedicated to Customer Service After signing up, you will get more detailed information about your dental plan. Look at your plan materials for complete details. Customer Service can answer questions about eligibility, claims, benefits and providers. Just call between 8 a.m. and 6 p.m. (CT), Monday through Friday. In addition, you can find general benefit information at bcbsil.com. 1 Dental Network of America, LLC. (DNoA), a separate company and the network manager providing access to the national network. Source: Netminder, February 2015 * The Dental Wellness Center, Dental Cost Advisor, Ask a Dentist, Dental Dictionary and Treatment and Procedure are provided by DNoA, a separate company that acts as the administrator of Blue Cross and Blue Shield of Illinois dental programs. DNoA is solely responsible for the products or services it offers. BCBSIL assumes no liability or responsibility for damage or injury to persons or property arising from the use of any product, information, idea or instruction mentioned in DNoA s content

28 BlueCare Dental HMO SM Get the most from your dental HMO benefits Flexibility and Savings Blue Cross and Blue Shield of Illinois (BCBSIL) has offered dependable dental plans for more than 35 years and currently serves almost 1.5 million dental members. BlueCare Dental HMO offers coverage for specified preventive and diagnostic care. To receive coverage, you and your family members each need to choose a primary care dentist from the BlueCare Dental HMO network. This dentist will give you a referral if you need specialty care. Dentists who are contracted to participate in the BlueCare Dental HMO network have agreed to accept set fees for covered services. Most dental and preventive care is covered at 100 percent. For more information about your dental benefits, refer to your benefit booklet. For more information about your BlueCare Dental HMO, visit bcbsil.com or call Customer Service at Finding a Dentist Is Easy With one of the largest dental HMO networks in Illinois, BlueCare Dental HMO offers you flexibility in choosing a dentist that maximizes your benefits. To find a primary care dentist*, visit bcbsil.com, where you can create and print a custom dentist directory with driving directions. Or call Customer Service at to get help finding a dentist that can help you maximize your benefits. To change your primary care dentist, just call Customer Service by the 20th of the month. The change will be effective the first day of the next month

29 Convenience in Payment With BlueCare Dental HMO, once you pay the copayment at your dentist office: Your in-network dentist cannot bill you for the balance not covered by your dental plan. You ll have no deductible or annual maximum benefit. You won t have to fill out and submit any claim forms. Dedicated to Service Our Customer Service center can answer questions about eligibility, claims, coordination of benefits and provider information. Call Customer Service from 7:30 a.m. to 6 p.m. (CT), Monday through Friday, at You may also refer to your plan materials for complete details. BlueCare Dental Connection SM BCBSIL offers BlueCare Dental Connection to members with both BCBSIL medical and dental plans. This service provides educational information and other resources to help you make important decisions about your dental care. The Dental Wellness Center allows you to: Ask dental questions through Ask a Dentist ** Locate a dentist using Provider Finder Search the Dental Dictionary ** for common dental terms View animations on various dental topics in the Treatment and Procedure ** tool To help members understand the importance of taking care of their teeth and gums, BlueCare Dental Connection provides 24/7 online access to the Dental Wellness Center**, which offers articles and special tools to help members with their oral care. To access the Dental Wellness Center, log in to Blue Access for Members SM at bcbsil.com and click on the My Health tab. * Blue Cross and Blue Shield of Illinois does not guarantee the services of any dentist or health care provider. Contracting dentists are not employees, agents or legal representatives of Blue Cross and Blue Shield of Illinois. ** The Dental Wellness Center, Dental Cost Advisor, Ask a Dentist, Dental Dictionary and Treatment and Procedure are provided by DNoA, a separate company that acts as the administrator of Blue Cross and Blue Shield of Illinois dental programs. DNoA is solely responsible for the products or services it offers. BCBSIL assumes no liability or responsibility for damage or injury to persons or property arising from the use of any product, information, idea or instruction mentioned in DNoA s content

30 Other Benefits for Non-HMO Plans Your health care benefit plan travels with you wherever you go across the country or around the world. Preventive Care Your coverage may include preventive care benefits for children and adults, including physical exams, diagnostic tests and immunizations. Check your group plan for specific coverage. Emergency Care If you, as a prudent layperson (with an average knowledge of health and medicine) need to go to the emergency room of any hospital, your care will be covered subject to your plan s deductible and any applicable copayments or coinsurance. In an emergency, you should seek care from an emergency room or other similar facility. Call 911 or other community emergency resources to obtain assistance in life-threatening situations. Your group plan may require that you, a family member or friend contact Blue Cross and Blue Shield of Illinois (BCBSIL) if you are admitted to the hospital. National Coverage You have nationwide access to contracting providers in networks linked through the BlueCard program when you or your covered dependents live, work or travel anywhere in the country. The national network includes most physicians and hospitals in the country. Be sure to use a BlueCard network provider to receive the highest level of benefits. With the BlueCard program, there are two ways to locate contracting doctors and hospitals: Visit the website at bcbsil.com to find provider names and locations using Provider Finder. Maps and driving directions are also available. Call Customer Service at the toll-free number on the back of your ID card

31 Reconstructive Surgery Following Mastectomy Federal and State of Illinois legislation require group health plans and health insurers to provide coverage for reconstructive surgery following a mastectomy. Specifically, these laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications for all stages of mastectomy, including lymphedemas. Your coverage may also include benefits for baseline and annual mammograms. Check your group plan documents for details. Illinois Dependent Eligibility Mandate Under Federal law, your dependents are eligible for health and dental coverage up to the dependent limiting age and may not be denied coverage due to marital, student or employment status before age 26. Check with your employer for additional details regarding eligibility requirements. In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you elect Blue Choice Select SM coverage, your dependents must live within the defined service area. This Illinois law applies to all individual plans and insured group medical and dental plans, as well as self-insured municipalities, counties and schools. The law does not apply to self-funded national account groups or local non-municipal self-funded groups. If you have questions about this law, contact your benefits administrator. International Coverage When you travel outside the United States and need medical assistance services, call BLUE ( ) or call collect to for information. Blue Cross and Blue Shield has contracts with doctors and hospitals in more than 190 countries. An assistance coordinator, in conjunction with a medical professional, can arrange your doctor s appointment or hospitalization, if necessary. Providers that participate in the Blue Cross Blue Shield Global Core* program, in most cases, will not require you to pay up front for inpatient care. You are responsible for the out-of-pocket expenses such as a deductible, copayment, coinsurance and non-covered services. The doctor or hospital should submit your claim. You also have coverage at non-contracting hospitals, but you will have to pay the doctor or hospital for care at the time of service, then submit an international claim form with original bills. Call Customer Service at the toll-free customer service number on your ID card for the address to send the claim. You can get a claim form from your employer, Customer Service or online at bcbsil.com. *The Blue Cross Blue Shield Global Core program was formerly known as BlueCard WorldWide

32 Blue Access for Members SM Get all the advantages your health plan offers Get information about your health benefits, anytime, anywhere. Use your computer, phone or tablet to access the Blue Cross and Blue Shield of Illinois (BCBSIL) secure member website, Blue Access for Members (BAM SM ). With BAM, you can: Check the status or history of a claim View or print Explanation of Benefits statements Locate a doctor or hospital in your plan s network Find Spanish-speaking providers Request a new ID c ard or print a temporary one It s easy to get started 1. Go to bcbsil.com/member 2. Click Register Now 3. Use the information on your BCBSIL ID card to complete the registration process. Text* BCBSILAPP to to get the BCBSIL App that lets you use BAM while you re on the go. *Message and data rates may apply

33 Find what you need with Blue Access for Members My Coverage: Review benefit details for you and family members covered under your plan. Claims Center: View and organize details such as payments, dates of service, provider names, claims status and more. My Health: Make more informed health care decisions by reading about health and wellness topics and researching specific conditions. 4 Doctors & Hospitals: Use Provider Finder to locate a network doctor, hospital or other health care provider, and get driving directions Forms & Documents: Use the form finder to get medical, dental, pharmacy and other forms quickly and easily. Message Center: Communicate with a Customer Service Advocate here. You can also learn about updates to your benefit plan and receive promotional information via secure messaging. Quick Links: Go directly to some of the most popular pages, such as medical coverage, replacement ID cards, manage preferences and more. View My Plan: See the details of your current health plan, as well as other plans you ve had in the past. Settings: Set up notifications and alerts to receive updates via text and , review your member information and change your secure password at anytime. Help: Look up definitions of health insurance terms, get answers to frequently asked questions and find Health Care School articles and videos. Contact Us: Here you can find contact information to reach a Customer Service Advocate with any questions you may have about your plan

34 Medical Plan Frequently Asked Questions Q. Are my medical records kept confidential? A. Yes. Blue Cross and Blue Shield of Illinois (BCBSIL) is committed to keeping all specific member information confidential. Anyone who may have to review your records is required to keep your information confidential. Your medical records or claims data may have to be reviewed (for example, as part of an appeal that you request). If so, precautions are taken to keep your information confidential. In many cases, your identity will not be associated with this information. Q. Who do I call with questions about my benefits? A. Call the toll-free Customer Service number on the back of your ID card. Q. How do I find a contracting network doctor or hospital? A. Go to bcbsil.com and use Provider Finder, or call Customer Service at the toll-free number on the back of your ID card. Q. What do I do when I need emergency care? A. Call 911 or seek help from any doctor or hospital. BCBSIL will coordinate your care with the emergency provider. Some options for non-emergency care include: Your doctor s office for health exams, routine shots, colds, flu and other minor illnesses or injuries. Walk-in retail health clinics available in retail stores. Many have a physician assistant or nurse practitioner who can help treat ear infections, rashes, minor cuts and scrapes, allergies, colds and other minor health problems. Urgent or immediate care clinics for more serious health issues, such as when you need an X-ray or stitches. Urgent Care or Freestanding Emergency Room? Urgent care centers and freestanding ERs can be hard to tell apart. Freestanding ERs often look a lot like urgent care centers, but costs are higher, just as if you went to the ER at a hospital. Here are some ways to know if you are at a freestanding ER. Freestanding ERs: Look like urgent care centers, but have EMERGENCY in the facility name. Are separate from a hospital but are equipped and work the same as an ER. Are staffed by board-certified ER physicians and are subject to the same ER copay. Find urgent care centers 1 near you by texting 2 URGENTIL to and then type in your ZIP code. 1 The closest urgent care center may not be in your network. Be sure to check Provider Finder to make sure the center you go to is in-network. 2 Message and data rates may apply. Read terms, conditions and privacy policy at bcbsil.com/mobile/text-messaging

35 Q. What should I bring to my first appointment with a new doctor? A. Your first appointment is an opportunity to share information about your health with your new doctor. Bring as much medical information as possible, including: Medical records and insurance card If you are undergoing treatment at the time you change doctors, your medical records are important to your new doctor. Your insurance card provides information about copayments, billing and Customer Service phone numbers. Medications Give your new doctor information about prescription and over-the-counter medications, including any herbal medications you take. Be sure to include the name of the medication, the dosage, how often you take it and why you take it. Special needs Make a list of any equipment or devices you use including wheelchairs, oxygen, glucose monitors and the glucose strips. Be prepared to explain how you use them, not only to make sure you have the equipment you need, but also to make sure that there is no disruption in your care. Q. What questions should I ask if I am selecting a new doctor? A. In addition to preliminary questions you might ask a new doctor such as Are you accepting new patients? here are some questions to help you evaluate whether a doctor is right for you. What is the doctor s experience in treating patients with the same health problems that I have? Where is the doctor s office? Is there convenient and ample parking, or is it close to public transportation? What are the regular office hours? Does the office have drop-in hours if I have an urgent problem? How long should I expect to wait to see the doctor when I m in the waiting room? Are routine lab tests and X-rays performed in the office, or will I have to go elsewhere? Which hospitals does the doctor use? If this is a group practice, will I always see my chosen doctor? How long does it usually take to get an appointment? How do I get in touch with the doctor after office hours? Can I get advice about routine medical problems over the phone or by ? Does the office send reminders for routine preventive tests like cholesterol checks? Q. What if I m already in treatment when I enroll and my provider isn t in the network? A. We ll work with you to provide the most appropriate care for your medical situation, especially if you are pregnant or receiving treatment for a serious illness. You may still be able to see your out-of-network provider for a period of time. Call the toll-free Customer Service number on the back of your ID card for more information

36 Health Insurance Fraud What You Should Know Fraud affects everyone Fraud may cost the health care industry (public and private payers) more than $200 billion each year. As a member of Blue Cross and Blue Shield of Illinois (BCBSIL ), this fraud may cause you to face rising premiums, increased copayments and deductibles, and the elimination of certain benefits. Don t Be a Victim In addition to losing money through fraud, members may also experience physical and mental harm. This can result from health care fraud schemes in which a provider performs unnecessary or dangerous procedures. Identifying Fraud Commonly identified schemes involving providers include: Misrepresenting services Intentionally billing procedures under different names or codes to obtain coverage for services that aren t included in a member s plan. Upcoding Deliberately charging for more complex or more expensive services than those actually provided. Non-rendered or free services Some providers intentionally bill for tests or services never provided. This can also mean that the provider offered free services to bill the insurance company for services not performed or needed. Kickbacks, bribes or rebates Referring patients to a provider or facility where the referring provider has a financial interest. Commonly identified member schemes include: Identity swapping Allowing an uninsured individual to use your insurance card. Identity theft Using false identification to gain employment and the health insurance benefits that come with it. Non-eligible members Adding someone to a policy who is not eligible or failing to remove someone when that person becomes ineligible. Prescription medicine abuse and diversion Controlled substances can be obtained through deception or dishonesty for personal use or sale on the street. Prescription medications can be obtained through doctor shopping, visiting several emergency rooms or stealing doctors prescription pads. Fraud increases costs and decreases benefits

37 Fighting Fraud Our Special Investigations Department is one of the most effective in the industry. BCBSIL offers these tips: Know your own benefits and scope of coverage. Review all Explanation of Benefits (EOB) statements. Make sure the exams, procedures and tests billed were the ones you actually had with the provider who treated you. Understand your responsibility to pay deductibles and copayments, and what you can and cannot be balance-billed for once your claim has been processed. Guard your health insurance card and personal insurance information. Notify BCBSIL immediately if your card or insurance information is lost or stolen. Sign and date only one claim form per office visit. Never lend your member ID card to another person. Don t give out insurance or personal information if services are offered as free. Be sure you understand what is free and what you or your employer will be charged for. Ask your doctors exactly what tests or procedures they want you to have and why. Ask why the tests or procedures are necessary before you have them. Be sure any referrals you receive from your network provider are to other network doctors or facilities. If you re not sure, ask. Monitor your prescription utilization via the BCBSIL website or your Pharmacy Benefit Manager (PBM). Make sure the medications billed to your insurance are accurate. Preventing Health Care Fraud BCBSIL created the Special Investigations Department (SID) to fight fraud and help lower health care costs. The staff includes individuals with medical, insurance and law enforcement backgrounds as well as data analysts experienced in detecting fraudulent billing schemes. The SID aggressively investigates allegations of fraud and refers appropriate cases for criminal prosecution. Fraud Isn t Fair Help Us Fight It Reducing health care fraud is a collaborative effort between BCBSIL, its providers and its members. Additional information including a fighting fraud checklist is available through the SID website at bcbsil.com/sid. We also encourage you to report any suspected incidents of fraud by calling our Health Care Fraud Hotline, completing a form online or sending us a note in the mail. Suspicions of fraud can be reported to the SID anonymously. 3 Ways to Report Fraud to BCBSIL The SID is here to help you. You can contact the SID in any of the following ways: The toll-free Fraud Hotline operates 24 hours a day, seven days a week. You can remain anonymous or provide information if you want to be contacted by a member of the SID. 2. bcbsil.com/sid/reporting This website address links to an online fraud-reporting form that you can complete and send to the SID electronically. 3. U.S. Mail You can write the SID at: Blue Cross and Blue Shield of Illinois Special Investigations Department 300 E. Randolph Street Chicago, Illinois

38 Understanding Your Explanation of Benefits An Explanation of Benefits (EOB) is a notification provided to members when a health care benefits claim is processed by Blue Cross and Blue Shield of Illinois (BCBSIL). The EOB shows how the claim was processed. The EOB is not a bill. Your provider may bill you separately. The EOB has THREE MAJOR sections: Subscriber Information and Total of Claim(s) includes the member s name, address, member ID number and group name and number. The Total of Claims table shows you the amount billed, any applied discounts, reductions and payments and the amount you may owe the provider. Service Detail for each claim includes: - Patient and provider information - Claim number and when it was processed - Service dates and descriptions - The amount billed - The discounts or other reductions subtracted from amount billed - Total amount covered - The amount you may owe (your responsibility) Summary - Shows you what the plan covers for each claim and your responsibility, including: Plan Provisions - The amount covered - Less any amounts you may owe, like deductible, copay and coinsurance Your Responsibility - Deductible and copay amount - Your share of coinsurance - Amount not covered, if any - Amount you may owe the provider. You may have paid some of this amount, like your copay, at the time you received the service. The EOB may include additional information: Amounts Not Covered will show what benefit limitations or exclusions apply. Out-of-Pocket Expenses will show an amount when a claim applies toward your deductible or counts toward your out-of-pocket expenses. Fraud Hotline is a toll-free number to call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity. An explanation of your right to appeal if your health plan doesn t cover a health care claim. Your EOBs Are Available Online! Sign up for Blue Access for Members SM (BAM SM ) at bcbsil.com for convenient and confidential access to your claim information and history. Choose to opt out of receiving EOBs by mail to save time and resources. Go to BAM and click on Settings/Preferences to change your preferences. Available in English and Spanish

39 Sample EOB 1. Member s name and mailing address 2. Member ID and group number 3. Summary box for all claims including total billed by the provider, and discounts, reductions or payments made, and the amount you may owe 4. Detailed claim information for each claim 5. Patient name and service date 6. Provider information 7. Claim number and date the claim was processed 8. Service description 9. Amount billed for each service 10. The amount covered (allowed) for each service and the discounts or reductions subtracted from the amount your provider billed 11. Your share of the costs 12. Claim summary with amount covered less your responsibility 13. Deductible and/or out-of-pocket expense information 14. Health Care Fraud Hotline P.O. Box Dallas, TX Not all EOBs are the same. The format and content of your EOB depends on your benefit plan and the services provided. Deductible and copayment amounts vary.

40 Choosing the Right Care for You and Your Family Tiered Benefit Product for Members Blue Distinction Centers for specialty health care services include: Blue Distinction Centers Hospitals recognized for their expertise in delivering specialty care Blue Distinction Centers+ Hospitals recognized for their expertise and efficiency in delivering specialty care Blue Distinction Centers (BDCs) are hospitals that are recognized for delivering care safely and effectively for certain specialties. When you use a BDC, you will receive the most from your benefits and know that the facility has a record of providing proven, effective specialty care. Blue Distinction Centers for Bariatric Surgery Inpatient care, postoperative care, follow-up and patient education Blue Distinction Centers for Cardiac Care Inpatient cardiac care, cardiac rehabilitation, cardiac catheterization and cardiac surgery Blue Distinction Centers for Knee and Hip Replacement Inpatient knee and hip replacement surgeries and services Blue Distinction Centers for Maternity Care Childbirth services, including both vaginal delivery and cesarean section Blue Distinction Centers for Spine Surgery Inpatient spine surgery services, including discectomy, fusion and decompression procedures Blue Distinction Centers for Transplants Transplant and support services

41 Hospitals with Expertise in Specialty Care To learn more about Blue Distinction, visit bcbs.com/ why-bcbs/blue-distinction/ or call the Customer Service number on the back of your member ID card. High Quality, Lower Cost At a BDC or a BDC+ facility, you may get a better outcome and have lower out-of-pocket costs*, depending on your plan. Although your plan may require you to get treatment at a BDC or BDC+ facility, you may still be covered at a non-bdc facility, but your out-of-pocket costs will usually be higher. The Blue Distinction Center tiered benefit product offers the highest level of benefits when you visit a Blue Distinction Center for the following conditions: Specialty Program BDC BDC+ Bariatric Surgery Cardiac Care Knee and Hip Replacement Maternity Care Spine Surgery Transplants Now Available Additional benefits of using a BDC and BDC+ include: Nationwide Access There are approximately 1,900 BDCs nationwide. To find a BDC near you, use the Blue Cross and Blue Shield of Illinois (BCBSIL) Provider Finder tool. Go to bcbsil.com Click on Find A Doctor Select Search by Provider Type Select State Select Health Plan Select Provider Type No Claims to File When you get care at a Blue Distinction Center, you usually won t have to file claims. Be sure to show your member ID card to your Blue Distinction provider. This card provides information about copayments and billing. bcbsil.com * Costs vary. Please see your benefit booklet for details. Note: Designation as BDC means these facilities overall experience and aggregate data met objective criteria established in collaboration with expert clinicians and leading professional organizations recommendations. Individual outcomes may vary. To find out which services are covered under your policy at any facilities, please call your local Blue Cross and Blue Shield Plan. Call your provider before making an appointment to verify the most current information on its network participation status. Neither Blue Cross and Blue Shield Association nor any of its licensees are responsible for any damages, losses or noncovered charges that may result from receiving care from a provider designated as a Blue Distinction Center

42 The BCBSIL App! Stay connected with Blue Cross and Blue Shield of Illinois (BCBSIL) and access important health benefit information wherever you are. Find an in-network doctor, hospital or urgent care facility Access your claims, coverage and deductible information View and your member ID card Log in securely with your fingerprint Access Health Care Accounts and Health Savings Accounts Download and share your Explanation of Benefits* Get Push Notifications and access to Message Center* Available in Spanish Text** BCBSILAPP to to get the app. * Currently only available on iphone. iphone is a registered trademark of Apple Inc. ** Message and data rates may apply. Terms and conditions and privacy policy at bcbsil.com/mobile/text-messaging POD

43 Because Your Health Counts It s Important to Know Where to Go When You Need Care Sometimes it s easy to know when you should go to an emergency room (ER), at other times, it s less clear. You have choices for receiving in-network care that will work with your schedule and also give you access to the kind of care you need. Know when to use each for non-emergency treatment. Your Doctor s Office Your own doctor may be the best place to go for non-emergency care, such as health exams, routine shots, colds, flu and minor injuries. Your doctor knows your health history, the medicine you take, your lifestyle and can decide if you need tests or specialist care. Your doctor can also help you with care for a chronic health issue, such as asthma or diabetes. Retail Health Clinic When you can t get to your regular doctor, walk-in clinics available in many retail stores can be a lower-cost choice for treatment. Many stores have a physician assistant or nurse practitioner who can help treat ear infections, rashes, minor cuts and scrapes, allergies and colds. Urgent/Immediate Care Clinic These facilities can treat you for more serious health issues, such as when you need an X-ray or stitches. You will probably have a lower out-of-pocket cost than at a hospital ER, and you may have a shorter wait. Hospital Emergency Room Any life-threatening or disabling health problem is a true emergency. You should go to the nearest hospital ER or call 911. When you use the ER for true emergencies, you help keep your out-of-pocket costs lower

44 Knowing where to go for care can make a big difference in cost and time. Here s how your options compare : Average Costs Average Wait Times Examples of Health Issues Your Doctor s Office Your doctor knows your medical history best $ 24 minutes* Fever, colds and flu Minor burns Ear or sinus pain Shots Sore throat Stomach ache Physicals Minor allergic reactions Retail Health Clinic Convenient, low-cost care in stores and pharmacies $ 15 minutes Infections Minor injuries or pain Flu shots Skin problems Cold and flu Shots Sore and strep throat Allergies Urgent Care Clinic Immediate care for issues that are not life-threatening $$$$ minutes** Migraines or headaches Abdominal pain Urinary tract infection Back pain Cuts that need stitches Sprains or strains Animal bites Hospital Emergency Room For serious or life-threatening conditions $$$$$$ 4 hours, 7 minutes*** Chest pain, stroke Head or neck injuries Fainting, dizziness, weakness Problem breathing Seizures Sudden or severe pain Uncontrolled bleeding Broken bones *Medical Practice Pulse Report 2009, Press Ganey Associates **Urgent Care Benchmarking Study Results. Journal of Urgent Care Medicine. January ***Emergency Department Pulse Report 2010 Patient Perspectives on American Health Care. Press Ganey Associates. Urgent Care or Freestanding Emergency Room Urgent care centers and freestanding ERs can be hard to tell apart. Freestanding ERs often look a lot like urgent care centers but costs are higher. A visit to a freestanding ER often results in surprise medical bills that can be four to five times the rate charged by urgent care centers for the same services 1. Here are some ways to know if you are at a freestanding ER. Freestanding ERs: Look like urgent care centers, but have EMERGENCY in the facility name. Are separate from a hospital but are equipped and work the same as an ER. Are staffed by board-certified ER physicians and are subject to the same ER copay. Find urgent care centers 2 near you by texting 3 URGENTIL to and then type in your ZIP code. Need help finding a network provider? Use Provider Finder at bcbsil.com or call the Customer Service number on the back of your member ID card. If you need emergency care, call 911 or seek help from any doctor or hospital right away. Relative costs described are for independently contracted network providers. Costs for outof-network providers may be higher. 1 Freestanding ERs: The Need for Greater Transparency and More Consumer Protections. (2016). The Texas Association of Health Plans. 2 The closest urgent care center may not be in your network. Be sure to check Provider Finder to make sure the center you go to is in-network. 3 Message and data rates may apply. Read terms, conditions and privacy policy at bcbsil.com/mobile/text-messaging. The information provided is not intended as medical advice, nor meant to be a substitute for the individual medical judgment of a doctor or other health care professional. Please check with your doctor for advice. Coverage may vary depending on your specific benefit plan and use of network providers. For questions, please call the Customer Service number on the back of your ID card. This information is intended solely as a general guide to what services may be available. The actual availability of services may vary greatly from location to location. The information is not intended to be medical advice. If you have questions about any health concern, you should discuss them with your health care provider

45 Looking for the right doctor? Provider Finder is the quick and easy way to make better health care decisions for you and your family. Provider Finder from Blue Cross and Blue Shield of Illinois (BCBSIL) is an innovative tool for helping you choose a provider, plus estimate and manage health care costs. By logging in to Blue Access for Members SM (BAM) you can use Provider Finder to: Find a network primary care physician, specialist or hospital. Filter search results by doctor, specialty, ZIP code, language and gender even get directions. Estimate the cost of hundreds of procedures, treatments and tests and your out-of-pocket expenses. You re in charge with more information. Do you want to know more about the providers who take care of you or your family? Do you need to know the estimated cost of a medical service? Do you want to know what feedback other patients had on a provider? Determine if Blue Distinction Center (BDC), BDC+ or Blue Distinction Total Care is an option for treatment. View patient feedback or add your review for a provider. Review providers certifications and recognitions. It s easy, immediate, secure and available at bcbsil.com POD

46 Informed Choice. Cost Management. More Options. Choose your provider and estimate the cost for hundreds of medical procedures. It s easy to get started with Provider Finder by registering for Blue Access for Members SM (BAM): 1. Go to bcbsil.com. 2. Click the Log In tab, and then click the Register Now link. 3. Use the information on your BCBSIL ID card to complete the process. 4. Then, log in to BAM. Provider Finder is located under the Doctors & Hospitals tab. You can also call a BCBSIL Customer Service Advocate at the toll-free telephone number on the back of your member ID card for help in locating a provider. Screen shots are for illustrative purposes only. Get assistance while you re away from home. Go to bcbsil.com and register or log in to BAM. You can stay connected to your claims activity, member ID card and coverage details you can also receive prescription reminders and health tips via text messages. Get it on the go! POD

47 Prescription Drug and Wellness Information

48

49 A home-delivery pharmacy service you can trust. Prim by Walgreens Mail Service delivers your long-term (or maintenance) medicines right where you want them. No driving to the pharmacy. No waiting in line for your prescriptions to be filled. Savings Walgreens Mail Service delivers up to a 90-day supply of long-term medicines. This may reduce what you pay out of pocket, and includes free standard shipping. Convenience Prescriptions are delivered to the address of your choice, within the U.S. You can order from the comfort of your home either online or over the phone. Your doctor can fax or send your prescription electronically to Walgreens Mail Service. You can receive up to a 90-day supply of longterm medicine at a time. You can ask for refills online or over the phone. Plain-labeled packaging protects your privacy. Service You can receive notification by , by phone or through the mail your choice when your prescription is received and when your orders are shipped. To select your notification preference, register online at Walgreens.com/ Prim or call Member service agents are available 24/7. Licensed, U.S.-based pharmacists are available seven days a week. Choose to receive refill reminder notifications by phone or . Standard delivery is included at no additional cost. Walgreens Mail Service pharmacies are located in the U.S. Walgreens Mail Service will notify you when your prescription is received, when it ships and when it is due for a refill

50 Getting Started with Prim by Walgreens Mail Service Online and Mobile Visit Walgreens.com/Prim to fill or refill a prescription. Sign in if you have a current Walgreens account. Click register now to create an account, and follow the directions. Over the Phone Call , 24/7, to refill, transfer a current prescription or get started with home delivery. Please have your member ID card, prescription information and your doctor s contact information ready. Through the Mail To send a prescription order through the mail, visit bcbsil.com and log in to Blue Access for Members SM (BAM SM ). Complete the mail order form. Mail your prescription, completed order form and payment to Walgreens Mail Service. Talk to Your Doctor Ask your doctor for a prescription for a 90-day supply of each of your long-term medicines. You can ask your doctor to send your prescription electronically to Walgreens Mail Service or fax a prescription request to If you need to start your medicine right away, request a prescription for up to a one-month supply you can fill at a local retail pharmacy. Refills Are Easy Refill dates are shown on each prescription label. You can choose to have Walgreens Mail Service remind you by phone or when a refill is due. Choose the reminder option that best suits you. Questions? Visit bcbsil.com. Or call the Pharmacy Program number on the back of your member ID card. Medicines may take up to 10 days to deliver after Walgreens Mail Service receives and verifies your order. Walgreens Mail Service is a pharmacy that is contracted to provide mail pharmacy services to members of Blue Cross and Blue Shield of Illinois (BCBSIL). Prime Therapeutics LLC is a pharmacy benefit management company, contracted by BCBSIL to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC

51 Q&A: Prescription Drug List What is a prescription drug list? Your prescription drug benefit plan is based on the Blue Cross and Blue Shield of Illinois (BCBSIL) drug list. It is a regularly updated list of drugs selected based on the recommendations of a committee of individuals from throughout the country who hold a medical or pharmacy degree. U.S. Food and Drug Administration (FDA)-approved drugs are chosen based on their safety, cost and how well they work. The Enhanced Drug List is a smaller version of the Basic Drug List. It includes mostly generic and select preferred brand drugs. The Performance Drug List, Performance Select Drug List and 2018 Drug List (for Metallic plans) show all covered drugs. Drugs that are not shown on these lists are not covered. Major drug classes are covered on all drug lists. Why should I use the drug list? Your copayment/coinsurance amount for covered preferred brand drugs is usually lower than for nonpreferred brand drugs. If your benefits are based on the Basic or Enhanced Drug List, most medicines may be covered that are not on the drug list, but you may pay more out of pocket. If your benefits are based on the Performance Drug List, Performance Select Drug List or 2018 Drug List (for Metallic plans), medicines that are not on these drug lists will not be covered. You will need to pay for the full cost of the medicine. The drug list is a reference for your doctor when prescribing medicines. But it is solely up to you and your doctor to decide the medicine that is best for you. How do I know if a drug is on the drug list and what my cost will be? The other side of this flier lists some commonly prescribed generic and preferred brand drugs. If a drug you are looking for is not on the list, search the drug list at bcbsil.com or call the Pharmacy Program number on the back of your ID card. Your prescription drug benefit plan and whether the drug is on the drug list will determine the amount you may pay out of pocket. To find out what you will pay, visit bcbsil.com or call the Pharmacy Program number on the back of your ID card. What are dispensing limits? Based on FDA-approved dosage regimens and manufacturer s research, certain drugs have dispensing limits. This means that these drugs have a limit on how much medicine can be filled per prescription or in a given time span. For example, coverage for the osteoporosis drug Actonel (risedronate) is limited to 30 tablets per 30 days because the FDA-approved labeling states that the recommended dose is one 5 mg oral tablet taken daily. What if I have questions? Call the Pharmacy Program number on the back of your ID card, 24 hours a day, 7 days a week, or visit bcbsil.com. What are the advantages of using generic drugs? Generics are recognized as safe and effective medicines. Generics often cost less than a brand drug. A generic can usually be substituted for a brand drug if it has the same active ingredients, the same strength and dosage form and produces the same results. Talk to your doctor or pharmacist to find out if a generic drug is available and right for you

52 April 2018 Commonly Prescribed Drugs This list is a sample of commonly prescribed generic and preferred brand drugs. Refer to the BCBSIL prescription drug lists at bcbsil.com for a more comprehensive and up-to-date list. The online drug list (Basic Drug List, Enhanced Drug List, Performance Drug List, Performance Select Drug List) is updated quarterly. The online 2018 Drug List (for Metallic plans) may be updated monthly. The drug list may contain medications not covered under your prescription drug benefit plan. In addition, prescription versions of over-the-counter (OTC) medications may not be covered based on your prescription drug benefit plan. If you have questions about your prescription drug benefit, call the Pharmacy Program number on the back of your ID card. ANTIHYPERTENSIVES Angiotensin Converting Enzyme (ACE) Inhibitors and Combinations benazepril benazepril/hydrochlorothiazide captopril enalapril enalapril/hydrochlorothiazide fosinopril fosinopril/hydrochlorothiazide lisinopril lisinopril/hydrochlorothiazide moexipril moexipril/hydrochlorothiazide perindopril quinapril quinapril/hydrochlorothiazide ramipril trandolapril Angiotensin II Receptor Antagonist (ARBs) and Combinations candesartan candesartan/hydrochlorothiazide irbesartan irbesartan/hydrochlorothiazide losartan losartan/hydrochlorothiazide olmesartan olmesartan/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide valsartan valsartan/hydrochlorothiazide Beta Blockers and Combinations acebutolol atenolol atenolol/chlorthalidone bisoprolol bisoprolol/hydrochlorothiazide carvedilol labetolol metoprolol succinate ext-release metroprolol/hydrochlorothiazide metoprolol tartrate nadolol pindolol propranolol ext-release propranolol tabs Calcium Channel Blockers and Combinations amlodipine amlodipine/benazepril amlodipine/valsartan amlodipine/valsartan /hydrochlorothiazide diltiazem diltiazem ext-release felodipine ext-release nifedipine ext-release verapamil 40 mg, 80 mg, 120 mg verapamil ext-release ASTHMA / COPD ADVAIR albuterol, 0.63 mg/3ml, 1.25 mg/3ml albuterol inhal soln, 0.083%, 0.5% albuterol syrup, tabs ANORA ELLIPTA ARNUITY ELLIPTA ASMANEX BREO ELLIPTA budesonide DULERA FLOVENT DISKUS FLOVENT HFA INCRUSE ELLIPTA ipratropium inhal soln ipratropium/albuterol levalbuterol montelukast PROAIR HFA PROAIR RESPICLICK QVAR SEREVENT DISKUS SPIRIVA HANDIHALER SPIRIVA RESPIMAT STIOLTO RESPIMAT STRIVERDI RESPIMAT SYMBICORT terbutaline theophylline ext-release VENTOLIN HFA zafirlukast

53 April 2018 Commonly Prescribed Drugs continued CHOLESTEROL atorvastatin cholestyramine choline fenofibrate delayed-release colestipol ezetimibe fenofibrate fenofibrate micronized fenofibric acid delayed-release gemfibrozil lovastatin niacin ext-release pravastatin rosuvastatin simvastatin DEPRESSION amitriptyline bupropion bupropion ext-release citalopram clomipramine desipramine doxepin duloxetine delayed-release escitalopram fluoxetine fluvoxamine imipramine mirtazapine nortriptyline caps paroxetine paroxetine ext-release phenelzine sertraline tranylcypromine trazodone venlafaxine venlafaxine ext-release caps venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150 mg DIABETES acarbose BAYER /ASCENCIA TEST STRIPS glimepiride glipizide glipizide ext-release glipizide/metformin GLUCAGON EMERGENCY KIT glyburide glyburide/metformin glyburide, micronized INVOKAMET INVOKAMET XR INVOKANA JARDIANCE KOMBOGLYZE XR LANTUS LEVEMIR metformin metformin ext-release nateglinide NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 pioglitazone pioglitazone/metformin repaglinide TOUJEO SOLOSTAR TRESIBA FLEXTOUCH VICTOZA

54 Understanding Your Generic Drugs Generics Deliver: Safety Generic drugs are safe. Brand-name and generic drugs sold in the United States are approved and regulated by the U.S. Food and Drug Administration (FDA). The standards are the same. That s safety you can count on. Quality Generic drugs work the same way. When the FDA approves a generic drug, this means the generic drug is the same as its brand-name counterpart in dosage, performance, safety, strength, quality and usage. Savings Generic drugs cost less. When the patent expires on a brand-name drug, other companies may begin making and selling the drug as a generic. Generic manufacturers don t have to pay for the costly research and marketing that was done for the brand-name product. Lower prices mean more savings for you. Same quality + lower cost = better value It s a fact generic drugs work in the same way as brand-name drugs. Don t believe the myths. The proof is in the facts: MYTH: Generic drugs are not as safe as brand-name drugs. FACT: The FDA requires that all drugs be safe and effective. Generics use the same active ingredients and work the same way in the body. This means generic drugs have the same risks and benefits as their brand-name counterparts. MYTH: Generic drugs are not as strong as brand-name drugs. FACT: The FDA requires generics to have the same quality and strength. Generic drugs work in the same way and in the same amount of time as brand-name drugs. MYTH: Generic drugs are likely to cause more side effects than brand-name drugs. FACT: There is no evidence that generic drugs cause more side effects. The FDA monitors reports of adverse drug reactions and has found no difference in the rates between generic and brand-name drugs. MYTH: My doctor or pharmacy wants me to take generic drugs just to save money. FACT: Your doctor and pharmacist want you to take drugs that are safe, effective and affordable. In most cases, generics are the best option when you compare price and quality. MYTH: Brand-name drugs are made in modern manufacturing facilities and generic drugs are often made in substandard facilities. FACT: The FDA won t permit drugs to be made in substandard facilities. All generic manufacturing, packaging and testing sites must pass the same quality standards as those of brand-name drugs. The FDA conducts about 3,500 inspections a year to ensure standards are met

55 Do You Need Specialty Medications? Blue Cross and Blue Shield of Illinois (BCBSIL) has arranged for AllianceRx Walgreens Prime* to support members who need self-administered specialty medication and help them manage their therapy. Specialty drugs are often prescribed to treat chronic, complex or rare conditions, such as multiple sclerosis, hepatitis C and rheumatoid arthritis. These drugs may be given by infusion (intravenously), injection, taken by mouth or some other way. Specialty drugs often call for carefully following a treatment plan (or taking them on a strict schedule). These medications have special handling or storage needs and may not be stocked by retail pharmacies. They often cost more than non-specialty prescriptions. Examples of Self-Administered Specialty Medications This chart shows some conditions self-administered specialty drugs may be used to treat, along with sample medications. This is not a complete list and may change from time to time. Visit bcbsil.com to see the up-to-date list of specialty drugs. Condition Sample Medications *** Some specialty drugs must be given by a health care professional, while others are approved by the U.S. Food and Drug Administration (FDA) for self-administration (given by yourself or a care giver). Medications that call for administration by a professional are often covered under your medical benefit. Your doctor will order these medications. Coverage for self-administered specialty drugs is usually provided through your pharmacy benefit. Your doctor should write or call in a prescription for self-administered specialty drugs to be filled by a specialty pharmacy. Your plan may require you to get your self-administered specialty drugs through AllianceRx Walgreens Prime or another in-network specialty pharmacy. If you do not use these pharmacies, you may pay higher out-ofpocket costs. ** Osteoporosis Cancer (oral) Growth Hormones Hepatitis C Multiple Sclerosis Rheumatoid Arthritis/Psoriasis Forteo, Tymlos Gleevec, Nexavar, Sprycel, Sutent, Tarceva Increlex, Omnitrope Epclusa, Harvoni, Mavyret and Vosevi Betaseron, Copaxone, Rebif Enbrel, Humira, Stelara POD

56 Support in Managing Your Condition: AllianceRx Walgreens Prime Through AllianceRx Walgreens Prime, you can have your covered, self-administered specialty drugs delivered straight to you. When you get your specialty drugs through AllianceRx Walgreens Prime, you get one-on-one support in managing your therapy at no additional charge including: Convenient delivery of drugs to you or your doctor s office Information to help you stay on track with your therapy and help you manage any side effects you may feel Syringes, sharps containers and other supplies with each shipment for self-injectable drugs 24/7/365 specialty pharmacy access Ordering Through AllianceRx Walgreens Prime You can order a new prescription or transfer your existing prescription for a self-administered specialty drug to AllianceRx Walgreens Prime. To start using AllianceRx Walgreens Prime, call , Monday-Friday, 8 a.m. - 8 p.m. ET. When switching pharmacies, have your ID card and be ready with your: Name, address, phone number Name of medication Current pharmacy s name and phone number (for existing prescriptions), and the prescription number Doctor s name, phone and fax numbers Your doctor may also order select specialty drugs that must be given to you by a health professional through AllianceRx Walgreens Prime. Receiving Specialty Medications Since many specialty drugs have unique shipping or handling needs, shipments will be arranged with you through AllianceRx Walgreens Prime. Medications are shipped in plain, secure, tamper-resistant packaging. Before your scheduled refill date, you will be contacted to: Confirm your drugs, dose and the delivery location Check any prescription changes your doctor may have ordered **** Discuss any changes in your condition or answer any questions about your health **** You can reach AllianceRx Walgreens Prime at Certain coverage exclusions and limitations may apply, based on your health plan. For some medicines, members must meet certain criteria before prescription drug benefit coverage may be approved. Check your benefit materials for details, or call the number on the back of your ID card with questions. * Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and home delivery company. ** The BCBSIL specialty pharmacy network includes AllianceRx Walgreens Prime as well as other in-network specialty pharmacies for select specialty drugs. BCBSIL HMO members have a separate specialty pharmacy network. Based on the benefit plan, members may be responsible for the full cost of the specialty drug for not using an in-network specialty pharmacy. You can log in to your Blue Access for Members SM account to find an in-network specialty pharmacy near you. ***Third-party brand names are the property of their respective owners. ****Treatment decisions are between you and your doctor POD

57 Have You Been Vaccinated? You can help protect yourself by getting a vaccine. Blue Cross and Blue Shield of Illinois (BCBSIL) wants to help you protect yourself from illnesses such as the flu, pneumonia, shingles, hepatitis B, tetanus, diphtheria, pertussis, meningitis and HPV. As part of your BCBSIL prescription drug benefit, you and your covered family members may get these select vaccinations at participating pharmacies. * Find Participating Pharmacies Many national chain, regional chain and independent pharmacies contract with the vaccine network. To find a participating pharmacy: Visit bcbsil.com and log in to Blue Access for Members SM (BAM SM ). Click Prescription Drugs in the Quick Links box. This takes you to MyPrime.com, the member website of BCBSIL s pharmacy benefit manager. Select Find a Pharmacy and filter for vaccine pharmacies in your network. You may also call the Pharmacy Program number on the back of your BCBSIL ID card for help in finding a participating pharmacy near you. Before You Go Age limits, restrictions or other requirements may apply. Ask your doctor if you should get any of these vaccinations. You can also visit the Centers for Disease Control and Prevention website at for immunization guidelines. Call your chosen pharmacy location for complete details and confirm: The location s participation Vaccine supply Hours vaccines may be given If an appointment is needed Remember to hand your ID card to the pharmacist when you visit a participating pharmacy to get a vaccination. The pharmacist will submit a claim and collect any copayments, if necessary. Check your plan materials or call the Pharmacy Program number on the back of your ID card to find out what may apply for your particular health plan. * This applies to BCBSIL members with prescription drug benefits that include coverage for these vaccinations. If you are a member whose prescription drug plan is not administered through BCBSIL, or coverage for these vaccinations are not included in your particular plan, please contact your employer group benefits administrator for information about the availability of vaccinations through your health plan. MyPrime.com is an online resource offered by Prime Therapeutics LLC, a pharmacy benefit manager contracted by BCBSIL to administer your prescription drug benefit POD

58 24/7 Nurseline Nurses available anytime you need them Health happens good or bad, 24 hours a day, seven days a week. That is why we have registered nurses waiting to talk to you whenever you call our 24/7 Nurseline. Our nurses can answer your health questions and try to help you decide whether you should go to the emergency room or urgent care center or make an appointment with your doctor. You can also call the 24/7 Nurseline whenever you or your covered family members need answers to health questions about: Call the 24/7 Nurseline with any health questions. Toll-free: Hours of Operation: Anytime Asthma Back pain Diabetes Dizziness or severe headaches High fever A baby s nonstop crying Cuts or burns Sore throat And much more Note: For medical emergencies, call 911. This program is not a substitute for a doctor s care. Talk to your doctor about any health questions or concerns. Plus, when you call, you can access an audio library of more than 1,000 health topics from allergies to surgeries with more than 500 topics available in Spanish. Blue Care Connection

59 A New Way to Experience Wellness Well ontarget offers personalized tools and resources to help you no matter where you may be on the path to health and wellness. Well ontarget can give you the support you need to make healthy choices while rewarding you for your hard work. Member Wellness Portal The heart of Well ontarget is the member portal, available at wellontarget.com. It uses the latest technology to offer you an enhanced online experience. This engaging portal links you to a suite of innovative programs and tools. Self-directed courses: These courses let you work at your own pace to reach your health goals. Learn more about nutrition, fitness, losing weight, quitting smoking and managing stress. Track your progress and reach your milestones as you make your way through each lesson. Reach your milestones and earn Blue Points SM. * Health and wellness content: The health library teaches and empowers through evidence-based, reader-friendly articles. Tools and trackers: These resources can help keep you on course while making wellness fun. Use a food and exercise diary, symptom checker and health trackers. * Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well ontarget Member Wellness Portal at wellontarget.com for further information. Start experiencing the new wellness today. Go to wellontarget.com sec

60 Wellness Coaching Certified health coaches offer you guidance on nutrition, fitness and stress management. You can interact with your coach by phone or via secure messages through the portal. Health Assessment (HA) The HA uses adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. This confidential report offers you tips for living your healthiest life. Your answers will help tailor the Well ontarget portal with the programs that may help you reach your goals. Blue Points Program Blue Points can help motivate you to maintain a healthy lifestyle. Earn points for participating in wellness activities. You can redeem points in the online shopping mall. The program gives you points instantly, so you can use them right away. If you want a larger reward, you can purchase additional points when you check out. Fitness Tracking Track your fitness activity using popular fitness devices and mobile apps. Online Wellness Challenges Challenge yourself to meet your wellness, stress management, fitness and nutrition goals. Plus, team challenges let you join forces with others to compete in monthly contests. Fitness Program* Fitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of more than 9,000 fitness centers. If you want, you can choose one gym close to home and one near work. And you can visit gyms while you re on vacation or traveling for work. Other program perks include: No long-term contract: Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member. Blue Points: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. Convenient payment: Monthly fees are paid via automatic credit card or bank account withdrawals. Web resources: You can go online to locate gyms and track your visits. Health and wellness discounts: Save money through a nationwide complementary and alternative medicine network of 40,000 health and well-being providers, such as massage therapists, personal trainers and nutrition counselors. It s easy to join the Fitness Program! Just call the toll-free number BLUE (2583) Monday through Friday, from 8 a.m. to 9 p.m. in any continental U.S. time zone. Wellness Program Questions? Call Customer Service at * The Fitness Program is provided by Healthways, Inc., an independent contractor that administers the Prime Network of fitness centers. The Prime Network is made up of independently owned and operated fitness centers. Take Wellness on the Go Check out the Well ontarget mobile app, available for iphone and Android TM smartphones. It can help you work on your health and wellness goals anytime and anywhere.

61 Take Your Health Personally Take the Health Assessment What do you take personally in life? Your family? Your work? A hobby? Add your health to the list by taking the Well ontarget Health Assessment. Just a few minutes and a few personal details how you eat, how you sleep, how you live your life can give you a personalized map to your best health. You can find out your risks and your best options to avoid them. Your customized Personal Wellness Report can tell you how to go from good to better. The Health Assessment (HA) consists of nine modules, which you can complete all at once or over time, as your schedule permits. These modules include questions about your: Diet Physical activity Tobacco use Emotional health Health at work and on the road While it s not necessary, it would be helpful to have a few personal details on hand when you begin the HA, including your: Current height and weight Systolic blood pressure (top number) and diastolic blood pressure (bottom number) Total cholesterol level HDL cholesterol level Triglyceride level Blood sugar level Waist measurement in inches

62 Take Your Health Assessment Today You can earn 2,500 Blue Points SM* for taking your HA. Follow these simple steps to get started: 1. Visit wellontarget.com and log in. If you have an existing Blue Access for Members SM (BAM) account, use your BAM username and password. If you aren t a registered user yet, click Register Now to create an account. 2. If you have not taken your HA, there will be a pop-up notification after you log in. You can also take your HA by clicking on Start in the Health Assessment box at the top of your dashboard. Once you have completed the HA, your reports will be available in this section. How Will the Health Assessment Be Personalized? You will begin by answering a few basic questions. Then, the HA will ask you more detailed questions based on your answers to the first set of questions. Your health status and lifestyle will determine which questions you will be asked. Your answers will help tailor the Well ontarget Member Wellness Portal with programs that could help you reach your health goals. You can check your progress and earn Blue Points twice a year. What Should I Do with My Results? After completing the HA, you will receive a confidential Personal Wellness Report. This can help take the guesswork out of wellness. The report will show you how you are doing and give you healthy tips. You can even print out a Provider Report to share with your doctor. When you know your risks, you can choose your best options to avoid them. When you know your strengths, you can decide to build on them. Have questions about the HA or the Well ontarget program? Call * Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well ontarget Member Wellness Portal at wellontarget.com for further information. Take Your Health Assessment on the Go Check out the Well ontarget mobile app, available for iphone and Android TM smartphones. You can complete your HA and work on your health and wellness goals anytime and anywhere.

63 Wellness Coaching Provides Personalized Guidance and Support It s no secret that the best teams look to their coaches for help in reaching the top. Now you can, too. With Well ontarget s Wellness Coaching, you can find the support you need to be your best. Our Wellness Coaching is based on evidence-based guidelines and proven techniques of motivation and goal setting. Your Trusted Ally A Wellness Coach works with you to design a plan to help you determine your wellness goals. First, your coach will take a look at your lifestyle and habits. Your coach can help you figure out what s most important to you and what you need to be successful. Best of all, your coach can offer you inspiration and ideas. Reaching Out Through the Well ontarget Member Wellness Portal at wellontarget.com, you can exchange secure messages with your coach. By calling the phone number on your portal dashboard, you can speak directly with your coach or request a callback. These convenient options make it easy for you to keep in regular contact with your coach. You can also contact your coach through the Well ontarget mobile app. With Well ontarget s Wellness Coaching, you can form trusted relationships that could give you the added support you need to take action

64 Program Descriptions Our team is made up of credentialed and certified health experts, including dietitians, nurses, personal trainers and other specialists. Coaches can work one-on-one with you to discuss three core areas stress, physical activity and nutrition. You can sign up for one program at a time. Stress Management Program Find out how to look at the stress in your life and learn what s causing it. Your coach can help you find creative, healthy ways of thinking and acting that could combat stress. Learn relaxation techniques you can use. Online trackers let you record and chart your daily stress levels, which you can share with your coach. Physical Activity Program Sometimes, the hardest thing about exercising is making working out a key part of your day. Your coach will help you make a plan that s right for your fitness level, lifestyle and goals. This plan consists of a mix of cardio, strength training and flexibility exercises. Trackers can help you log your progress, which you can share with your coach. Nutrition Program We can put you in touch with a registered dietitian, who can help you understand your relationship with food. Your coach can share ideas for making healthy eating choices. Online trackers let you log the food you eat, learn the nutritional value of your meals and share the information with your coach. Prioritize your coaching. Take the Health Assessment today to find out which program is right for you.

65 Make Your Fitness Program Membership Work for You! Fitness can be easy, fun and affordable. Well ontarget makes it possible with the Fitness Program. Since you are a Blue Cross and Blue Shield of Illinois member, the Fitness Program is available exclusively to you and your covered dependents (age 18 and older). The program gives you unlimited access to a nationwide network of more than 10,000 fitness locations. If you want, you can choose one gym close to home and one near work. You can visit gyms while you re on vacation or traveling for work. Other program perks include: No long-term contract: Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member.* Complementary and Alternative Medicine (CAM) discounts: Save money through a nationwide network of 40,000 health and well-being providers, such as acupuncturists, massage therapists and personal trainers. Blue Points SM : Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. You can redeem points for apparel, books, electronics, health and personal care items, music and sporting goods. ** Web resources: You can go online to locate gyms and track your visits. Convenient payment: Monthly fees are paid via automatic credit card or bank account withdrawals

66 Are You Ready for Fitness? It s easy to sign up: 1. Go to bcbsil.com and log in to Blue Access for Members SM. 2. Under Quick Links, choose Fitness Program. On this page, you can enroll, search for nearby fitness centers and learn more about the program. 3. Click Enroll Now. Then search and select the fitness location that is best for you. Remember, you can visit any participating fitness location after you sign up. 4. Verify your personal information and method of payment. Print or download your Fitness Program membership ID card. You may also request to receive the ID card in the mail. 5. Visit a fitness location today! Prefer to sign up by phone or have questions about the Fitness Program? Just call the toll-free number BLUE (2583) Monday through Friday, from 7 a.m. to 7 p.m. CT, (6 a.m. to 6 p.m. MT). * The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes. ** Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well ontarget Member Wellness Portal for more information. The Fitness Program is provided by Tivity Health TM, an independent contractor that administers the Prime Network of fitness locations. The Prime Network is made up of independently owned and operated fitness locations. Find fitness buddies, take a class and try something new! Join the Fitness Program today to help you reach your health and wellness goals.

67 Blue Care Connection Be your healthiest you! Do you want help trying to become healthier, manage your weight or quit tobacco? Our three Lifestyle Management Programs may have just what you need. When you join one of our Lifestyle Management Programs Metabolic Syndrome, Tobacco Cessation or Weight Management you ll be assigned a health care professional known as a Lifestyle Management specialist. Through telephone coaching sessions, you and your Lifestyle Management specialist will come up with a personalized plan designed to help you reach your goals. During regular coaching sessions, you ll learn how different choices may affect your health, and you ll get the support you need. To enroll, call and choose Lifestyle Management

68 Blue365 A Discount Program for You Blue365 is just one more advantage you have by being a Blue Cross and Blue Shield of Illinois (BCBSIL) member. With this program, you may save money on health and wellness products and services from top retailers that are not covered by insurance. There are no claims to file and no referrals or pre-authorizations. Once you sign up for Blue365 at blue365deals.com/bcbsil, weekly Featured Deals will be ed to you. These deals offer special savings for a short period of time. Below are some of the ongoing deals offered through Blue365. EyeMed Davis Vision You may save on eye exams, eyeglasses, contact lenses and accessories. You have access to national and regional retail stores and local eye doctors. You may also get possible savings on laser vision correction. TruHearing Beltone You may get possible savings on hearing tests, evaluations and hearing aids. Discounts may also be available for your immediate family members. Dental Solutions SM You may get dental savings with Dental Solutions. You may receive a dental discount card that provides access to discounts of up to 50 percent at more than 61,000 dentists and more than 185,000 locations*. Jenny Craig Seattle Sutton s Nutrisystem Help reach your weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), nutritional products and services. Retrofit SM Receive 15 percent off Retrofit s online, private weight loss coaching sessions. Retrofit includes the use of a wireless Fitbit device and smart-scale, one-on-one videoconferencing with a personal team of experts and unlimited online support. You will enjoy flexibility in scheduling and the ability to meet with coaches anywhere there is an Internet connection. See all the Blue365 deals and learn more at blue365deals.com/bcbsil POD

69 For more great deals or to learn more about Blue365, visit blue365deals.com/bcbsil. Reebok SKECHERS Reebok, a trusted brand for more than 100 years, makes top athletic equipment for all people, from professional athletes to kids playing soccer. SKECHERS, an awardwinning leader in the footwear industry, offers exclusive pricing on select Performance, Sport, Work and Corporate Casual styles. You will enjoy discounts and free shipping opportunities. Holly Clegg trim&terrific Cookbooks Save 25% on Holly Clegg s best-selling trim&terrific cookbooks with popular, easy, 30-minute delicious recipes made healthier perfect for the busy person. All books include nutritional information and diabetic exchanges and highlight freezer-friendly and vegetarian recipes. Snap Fitness Join Snap Fitness for a 50 percent discount off the best current enrollment offer (no processing fees) and a five percent discount on monthly dues. You may also get 10 percent off up to five personal-training sessions, complimentary access to Snap Fitness online workout tools, one month of online nutrition and meal-planning services and biannual fitness assessments. A 30-day trial membership is also available for $8.95. The relationship between these vendors and Blue Cross and Blue Shield of Illinois (BCBSIL) is that of independent contractors. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by the above-mentioned vendors. * Dental Solutions requires a $9.95 signup and $6 monthly fee. Blue365 is a discount program only for BCBSIL members. This is NOT insurance. Some of the services offered through this program may be covered under the health plan you choose to offer. Employees should check their benefit booklet or call the customer service number on the back of their ID card for specific benefit facts. Use of Blue365 does not change monthly payments, nor do costs of the services or products count toward any maximums and/or plan deductibles. Discounts are only given through vendors that take part in this program. BCBSIL does not guarantee or make any claims or recommendations about the program s services or products. Members should consult their doctor before using these services and products. BCBSIL reserves the right to stop or change this program at any time without notice POD

70 Blue365 EyeMed Vision Discount Program Blue Cross and Blue Shield of Illinois (BCBSIL) is pleased to offer you a vision discount program through EyeMed Vision Care. What? The EyeMed Vision Discount through Blue365 offers savings on eyeglasses, contact lenses, eye exams, accessories and laser vision correction. See the back page for a full list of discounts. Who? The EyeMed network consists of major national and regional retail locations, such as LENSCRAFTERS, PEARLE VISION, Target Optical, Sears Optical and JCPenney Optical, as well as independent ophthalmologists and optometrists. Additionally, you may go online to in-network providers at contactsdirect.com. Where? Visit eyemedexchange.com/blue365, click Find a Provider and begin your search. Be sure the Advantage network is selected. For more information about Blue365, log in to Blue Access for Members SM (BAM) at bcbsil.com. Click the My Coverage tab at the top, and then click the Discounts link on the left. Referral? You don t need a referral. Simply visit any EyeMed provider and show your BCBSIL medical ID card. Program Features Discounts on vision care services and materials No limit to the number of times the member can receive discounts on purchases Access to large provider network Convenient evening and weekend hours Note: This in not insurance. When contacting EyeMed or any retailer or provider in the Eyemed Advantage network, be sure to refer to the discount program. See all the Blue365 deals and learn more at blue365deals.com/bcbsil

71 For more information, visit eyemedexchange.com/blue365 or call EyeMed s automated help line at EyeMed Vision Discounts Vision Care Services Exam with dilation as necessary: Cost $50 routine exam $10 off contact lens fit and follow-up Complete Pair of Glasses Purchase: frame, standard plastic lenses, and lens options must be purchased in the same transaction to receive full discount Frames * Any frame available at provider location 35% off retail price Standard Plastic Lenses * Single-vision $50 Bifocal $70 Trifocal $105 Lenticular $105 Standard Progressive $135 Premium Progressive 30% off retail price Lens Options * UV Coating $12 Tint (Solid and Gradient) $12 Standard Scratch-resistance $12 Standard Polycarbonate $35 Standard Anti-reflective $40 Other Add-ons and Services * Items purchased separately will be discounted 20% off of the retail price. 30% off retail price Contact Lens Materials (applied to materials only) Conventional Laser Vision Correction Lasik or PRK Frequency Examination Frame Lenses Contact Lenses 15% off retail price 15% off retail price or 5% off promotional price Unlimited Unlimited Unlimited Unlimited Discounts are only available through participating vendors. The relationships between Blue Cross and Blue Shield of Illinois (BCBSIL) and EyeMed are that of independent contractors. Blue365 is a discount program available to BCBSIL members. This is NOT insurance. Some of the services offered through Blue365 may be covered under your health plan. Please refer to your benefit booklet or call the Customer Service number on the back of your ID card for specific benefit information under your health plan. Use of Blue365 does not affect your premium, nor do costs of Blue365 s services or products count toward any maximums and/or plan deductibles. BCBSIL does not guarantee or make any claims or recommendations regarding the services or products offered under Blue365. You may want to consult with your physician prior to use of these services and products. Services and products are subject to availability by location. BCBSIL reserves the right to discontinue or change this discount program at any time without notice

72 Health Care Reform

73 Take Advantage of Preventive Services Your family's race to better health begins with a single step: Taking advantage of preventive health care services Preventive check-ups and screenings can help find illnesses and medical problems early and improve the health of you and everyone in your family. Your health plan covers screenings and services with no out-of-pocket costs like copays or coinsurance as long as you visit a doctor in your plan s provider network. This is true even if you haven t met your deductible. For more details on what preventive services are covered at no cost to you, refer to the back of this flier for a listing of services, or see your benefits materials. Learn more on immunization recommendations and schedules by visiting the Centers for Disease Control and Prevention website at Some examples of preventive care services covered by your plan include general wellness exams each year, recommended vaccines, and screenings for things like diabetes, cancer or depression. Preventive services are provided for women, men and children of all ages

74 These preventive services are covered by your plan at no cost to you 1 FOR ADULTS Annual preventive medical history and physical exam SCREENINGS FOR Abdominal aortic aneurysm Alcohol abuse and tobacco use Colorectal, skin and lung cancer Depression Falls prevention and vitamin D use for stronger bones High blood pressure, high cholesterol, obesity, diabetes and depression Sexually transmitted infections, HIV, HPV and hepatitis COUNSELING FOR Alcohol misuse Domestic violence Healthy diet counseling Obesity Sexually transmitted infections Skin cancer prevention Tobacco use, including certain medicine to stop Use of aspirin to prevent heart attacks FOR CHILDREN Annual preventive medical history and physical exam SCREENINGS FOR Autism Cervical dysplasia Depression Developmental delays Dyslipidemia (for children at higher risk) Hearing loss, hypothyroidism, sickle cell disease and phenylketonuria (PKU) in newborns Hematocrit or hemoglobin Lead poisoning Obesity Sexually transmitted infections and HIV Tuberculosis Visual acuity ASSESSMENTS AND COUNSELING Obesity counseling Oral health risk assessment, dental caries prevention fluoride varnish and oral fluoride supplements Skin cancer prevention counseling JUST FOR WOMEN Breast cancer screening, genetic testing and counseling Breastfeeding support, supplies and counseling Certain contraceptives and medical devices, morning after pill, and sterilization to prevent pregnancy Cervical cancer screening Chlamydia, gonorrhea, syphilis, HIV and hepatitis B screenings Counseling for alcohol and tobacco use during pregnancy Folic acid supplementation during pregnancy Human papillomavirus (HPV) DNA test Osteoporosis screening Screenings during pregnancy, including screenings for anemia, gestational diabetes, bacteriuria, Rh(D) compatibility CERTAIN VACCINES Learn more on immunization recommendations ns and schedules by visiting: Diphtheria, Pertussis, Tetanus Haemophilus Influenzae Type B (Hib) Hepatitis A and B Human Papillomavirus (HPV) Inactivated Poliovirus (Polio) Influenza (Flu) Measles, Mumps, Rubella (MMR) Meningitis Pneumococcal Rotavirus Varicella (Chicken Pox) Zoster (Herpes, Shingles) 1 Non-grandfathered health plans are required by the Affordable Care Act to provide coverage for preventive care services without cost-sharing only when the member uses a network provider. You may have to pay all or part of the cost of preventive care if your health plan is grandfathered. To find out if your plan is grandfathered or non-grandfathered, call the Customer Service number listed on your member ID card.

75 Important Notices I. Initial Notice About Special Enrollment Rights in Your Group Health Plan A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about very important provisions in the plan. You have the right to enroll in the plan under its special enrollment provision without being considered a late enrollee if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Section I of this notice may not apply to certain self-insured, non-federal governmental plans. Contact your employer or plan administrator for more information. A. SPECIAL ENROLLMENT PROVISIONS Loss of Other Coverage (Excluding Medicaid or a State Children s Health Insurance Program) If you are declining enrollment for yourself or your eligible dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 31 days after your or your dependents other coverage ends (or move out of the prior plan s HMO service area, or after the employer stops contributing toward the other coverage). Loss of Coverage For Medicaid or a State Children s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents coverage ends under Medicaid or a state children s health insurance program. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. Eligibility for State Premium Assistance for Enrollees of Medicaid or a State Children s Health Insurance Program If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents determination of eligibility for such assistance. To request special enrollment or obtain more information, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.

76 II. Additional Notices Other federal laws require we notify you of additional provisions of your plan. NOTICES OF RIGHT TO DESIGNATE A PRIMARY CARE PROVIDER (FOR NON-GRANDFATHERED HEALTH PLANS ONLY) For plans that require or allow for the designation of primary care providers by participants or beneficiaries: If the plan generally requires or allows the designation of a primary care provider, you have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. For plans that require or allow for the designation of a primary care provider for a child: For children, you may designate a pediatrician as the primary care provider. For plans that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider: You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in pediatrics, obstetrics or gynecology, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

77 Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability. To receive language or communication assistance free of charge, please call us at If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance. Office of Civil Rights Coordinator Phone: (voic ) 300 E. Randolph St. TTY/TDD: th Floor Fax: Chicago, Illinois CivilRightsCoordinator@hcsc.net You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services Phone: Independence Avenue SW TTY/TDD: Room 509F, HHH Building 1019 Complaint Portal: Washington, DC Complaint Forms:

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80 bcbsil.com Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association