Emergency Tooth Doctor, PC. LifeWise Passport Silver PPO

Transcription

1 Emergency Tooth Doctor, PC LifeWise Passport Silver PPO

2 HOW TO CONTACT US Please call or write Our Customer Service staff for help with the following: Questions about the benefits of Your Plan; Questions about Your Claims; Questions or complaints about care or Services You receive; and Change of address or other personal information. Customer Service Mailing Address Bend P O Box 7709 Bend, OR Portland 2020 SW Fourth Avenue, Suite 1000 Portland, OR Local and toll-free phone numbers: TDD number for the hearing impaired (503) TDD number for the hearing impaired You'll find answers to most of Your questions about Your Plan in this benefit booklet. You can also explore Our Web site at anytime You want to: Learn more about how to use Your Plan; Locate a health care provider near You; Gain knowledge about diseases, illnesses, medications, treatment, nutrition, fitness and many other health topics. You can also call Our Customer Service staff at the numbers listed above. We are happy to answer Your questions and appreciate any comments You want to share. Group Name: Emergency Tooth Doctor, PC Effective Date: June 1, 2016 Group Number: Plan: LifeWise Passport Silver PPO 2000 Certificate Form Number: LWO SG LWO SG Rev LifeWise Passport Silver PPO 2000

3 INTRODUCTION This Benefit Booklet is for Members enrolled in this Plan. This Benefit Booklet describes the benefits and other terms of this Plan. It replaces any other Benefit Booklet You may have received. We know that healthcare Plans can be hard to understand and use. We hope this Benefit Booklet helps You understand how to get the most from Your benefits. The benefits and provisions described in this Plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with Us. This benefit booklet is a part of the contract on file at the employer s office. This plan will comply with state and federal laws. If clarifications are made by regulators, this plan will comply even if they are not stated or are in conflict with a statement made in this benefit booklet. Translation Services If you need an interpreter to help with oral translation services, please call us. The Customer Service Area will be able to guide you through the service. HOW TO USE THIS BENEFIT BOOKLET Every section in this Benefit Booklet has important information. You may find that the sections below are especially useful. How to Contact Us Our website, phone numbers, mailing addresses and other contact information are inside the front cover Summary of Your Costs Lists your costs for covered services Important Plan Information Describes deductibles, Copays, Coinsurance, out-of-pocket maximums and Allowed Amounts How Providers Affect Your Costs How using an in-network provider affects Your benefits Prior Authorization and Emergency Admission Notifications Describes Our Prior Authorization and Emergency Admission Notifications provision Utilization Review Describes Our Utilization Review provision Personal Health Support Programs Describes Our Personal Health Support Programs provision Continuity of Care Describes how to continue care at the in-network level of benefits when a provider is no longer in the network Covered Services A detailed description of what is covered Employee Wellness Describes a program to help improve wellness Exclusions Describes Services that are not covered Other Coverage Describes how benefits are paid when You have other coverage or what You must do when a third party is responsible for an injury or Illness Sending Us a Claim Instructions on how to send in a Claim Grievance and Appeals What to do if You want to share ideas, ask questions, file a complaint, or submit an appeal Eligibility and Enrollment Describes who can be covered Termination of Coverage Describes when coverage ends Continuation Coverage Describes how You can continue coverage after Your group Plan ends Other Plan Information Lists general information about how this Plan is administered and required state and federal notices Definitions Meanings of words and terms used LWO SG Rev LifeWise Passport Silver PPO 2000

4 TABLE OF CONTENTS SUMMARY OF YOUR COSTS...1 IMPORTANT PLAN INFORMATION...7 Calendar Year Deductible...7 Out-of-Pocket Maximum...7 Allowed Amount...7 HOW PROVIDERS AFFECT YOUR COSTS...8 Network Providers...8 Care Outside the Service Area...9 PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION...9 UTILIZATION REVIEW...11 Personal Health Support Programs...12 Continuity of Care...12 COVERED SERVICES...13 Common Medical Services...13 Prescription Drugs...15 Other Covered Services...25 Employee Wellness...28 EXCLUSIONS...28 OTHER COVERAGE...31 Coordination Of Benefits...31 Third Party Liability...34 SENDING US A CLAIM...35 GRIEVANCE AND APPEALS...36 ELIGIBILITY AND ENROLLMENT...39 When Coverage Begins...41 Enrollment Provisions for Late and Special Enrollees...41 TERMINATION OF COVERAGE...43 CONTINUATION OF COVERAGE...44 OTHER PLAN INFORMATION...45 DEFINITIONS...48 LWO SG Rev LifeWise Passport Silver PPO 2000

5 SUMMARY OF YOUR COSTS This is a summary of Your costs for Covered Services. Your costs are subject to the all of the following: The allowed amount. This is the most this Plan allows for a Covered Service. The Copay. This is an amount You pay at the time you get Services. The deductible. This is the amount You pay before Our cost share of the allowed amount is applied. Deductibles are waived for some Services. The amount of the deductible for this Plan is: In-network Providers Individual deductible: Family deductible: Out-of-network Providers Individual deductible: Family deductible: $2,000 per Member $4,000 per Family $4,000 per Member $8,000 per Family The out-of-pocket maximum. This is the most You pay each Year for Services from in-network providers. Individual out-of-pocket maximum: $6,850 per Member Family out-of-pocket maximum: $13,700 per Family The out-of-pocket maximum. This is the most You pay each Year for Services from out-of-network providers. Individual out-of-pocket maximum: $13,700 per Member Family out-of-pocket maximum: $27,400 per Family Prior authorization. Some Services must be authorized by Us in writing and before You get them. See the Prior Authorization and Emergency Admission Notification section for details. The conditions, time limits and maximum limits described in this contract. Some Services have special rules. See Covered Services for these details. COVERED SERVICES COMMON MEDICAL SERVICES Office and Clinic Visit Your designated Primary Care Provider Office visit with Your OB/GYN (even if not Your selected Primary Care Provider) Specialist visits and other Primary Care Provider visits/additional visits/includes non-hospital urgent care centers. Facility charges You may have additional costs for things such as x- IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) 0%, deductible waived for 50% the first 2 visits during the Year. For visits in excess of the first 2 visit limit per Year, $20 Copay. $20 copay 50% $45 copay 50% 25% 50% OUT-OF-NETWORK PROVIDERS LWO SG SYC 1 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

6 COVERED SERVICES COMMON MEDICAL SERVICES rays, lab and therapeutic injections. See those Covered Services for details. Preventive Care Limited to how often You can get them based on Your age and if You are male or female. IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) Routine exams, well baby care and immunizations $0, deductible waived Not covered Women s pelvic exams, pap smear, clinical breast exams and mammograms Pregnant women s Services, diabetic supplies, electric breast pumps and supplies $0, deductible waived 50% $0, deductible waived 50% Men s prostate screening, including PSA $0, deductible waived 50% Colon cancer screening, outpatient lab and radiology for preventive screening and tests Flu shots, flu mist, immunizations for shingles, pneumonia and Pertussis at a pharmacy Contraceptive management, elective sterilization, tubal ligation and vasectomy Nicotine dependency programs and health education for conditions other than diabetes $0, deductible waived 50% OUT-OF-NETWORK PROVIDERS $0, deductible waived 0%, deductible waived $0, deductible waived 50% $0, deductible waived Not covered Fall prevention age 65 and older $0, deductible waived Not covered Diabetes health education $0, deductible waived Not covered Nutritional therapy $0, deductible waived 50% Pediatric Care Vision care, limited to members up to age 19 Routine exams limited to one per Year $45 copay $45 copay Frames, limited to one pair every two Years 0%, deductible waived 0%, deductible waived Lenses (standard and non-correction) limited to one pair every two Years Contact lenses in lieu of glasses, limited to one pair every two Years Hearing Aids and hardware, limited to Members under the age of 19 or Dependents age 19 up to age 26. Limited to one hearing aid per impaired ear every three years. Diagnostic X-ray, Lab and Imaging X-ray and lab, including MRI, MRA, PET and CT Scans Prescription Drugs Retail Pharmacy Limited up to a 90-day supply. Some contraceptives may be allowed up to a 12-month supply. You pay one Copay for each 30-day supply. Preventive drugs, limited to prescribed drugs required by health care reform, and insulin during pregnancy 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived 0%, deductible waived 25% 50% $0, deductible waived Not covered LWO SG SYC 2 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

7 COVERED SERVICES COMMON MEDICAL SERVICES Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) $0, deductible waived Not covered Formulary generic drugs $20 copay Not covered Formulary preferred brand name drugs $65 copay Not covered Formulary non-preferred brand name drugs $120 copay Not covered Prescriptions Mail Order Pharmacy Limited up to a 90-day supply. Some contraceptives may be allowed up to a 12-month supply. You pay one Copay for each 90-day supply. Preventive drugs, limited to prescribed drugs required by health care reform and insulin during pregnancy Nicotine cessation drugs, oral generic and single source brand name contraceptive drugs and devices $0, deductible waived Not covered $0, deductible waived Not covered Formulary generic drugs $60 copay Not covered Formulary preferred brand name drugs $195 copay Not covered Formulary non-preferred brand name drugs $360 copay Not covered Prescriptions Specialty Pharmacy Limited up to a 30-day supply for formulary, generic and brand name drugs Outpatient Surgery Services Hospitals, ambulatory surgery center, doctor s office and the professional Services Emergency Room Includes emergency room and Hospital Urgent Care facilities. The Copay is waived if You are admitted as an Inpatient through the emergency room. 25% Not covered 25% 50% OUT-OF-NETWORK PROVIDERS $250 copay, applies to the out-of-pocket Maximum, then benefits are subject to deductible and coinsurance. Emergency room Physician 25% Emergency Ambulance Services Emergency air and ground ambulance Services 25% Urgent Care Centers, affiliated with Your PCP Includes facility and professional Services You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. Urgent Care Centers, non-affiliated with Your PCP Includes facility and professional Services You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. 0%, deductible waived for the first 2 visits during the Year. For visits in excess of the first 2 visit limit per Year, $20 Copay. 50% $45 copay 50% LWO SG SYC 3 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

8 COVERED SERVICES COMMON MEDICAL SERVICES Urgent Care Centers, facility based You may have additional costs for things such as x- rays, lab and therapeutic injections. See those Covered Services for details. IN-NETWORK PROVIDERS See Emergency Room YOUR COSTS (of the allowed amount) Hospital Services 25% 50% Mental Health, Behavioral Health and Substance Abuse Office visits See Office and Clinic Visits Outpatient facility Services 25% 50% Inpatient Hospital, partial hospitalization, residential facilities Maternity and Newborn Care Prenatal, postnatal care, delivery and Inpatient care. 50% 25% 50% 25% 50% Home Health Care 25% 50% Hospice Care Respite care is limited to 5 consecutive days up to a lifetime maximum of 30 days. Rehabilitation Therapy Limited to a combined 30 Outpatient visits and a combined 30 Inpatient visits/days per Year. An additional 30 visits will be allowed for stroke and spinal cord/head injury. Limits do not apply to Mental Health Services. 25% 50% Outpatient office Services 25% 50% Inpatient facility Services 25% 50% Outpatient facility Services 25% 50% Habilitation Therapy Limited to physical therapy, occupational therapy and speech therapy up to a combined 30 Outpatient visits and a combined 30 inpatient days per Year. An additional 30 visits per condition may be allowed for stroke and spinal cord/head injury. Limits do not apply to Mental Health Services. Outpatient office Services 25% 50% Inpatient facility Services 25% 50% Outpatient facility Services 25% 50% Cardiac Rehabilitation Limited to 36 sessions per Year. Skilled Nursing Facility Limited to 60 days per Year. 25% 50% 25% 50% OUT-OF-NETWORK PROVIDERS LWO SG SYC 4 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

9 COVERED SERVICES COMMON MEDICAL SERVICES Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Foot Orthotics for conditions other than diabetes are limited to 1 pair or 2 units per Year. IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) 25% 50% OUT-OF-NETWORK PROVIDERS COVERED SERVICES OTHER COVERED SERVICES (Alphabetical Order) Allergy Testing and Treatment Alternative Care Acupuncture, Chiropractic and Naturopathy Services, combined limit of $1,500 visits per Year. Biofeedback Chemotherapy and Radiation Therapy Chemotherapy includes infusion and injectable drugs IN-NETWORK PROVIDERS Covered based on the type of Services You get See Office and Clinic Visits Covered based on the type of Services You get YOUR COSTS (of the allowed amount) 50% 50% 50% 25% 50% Prescribed oral chemotherapy drugs 25%, deductible waived 50% Clinical Trials Community Wellness and Safety Programs Limited to $250 per Year. Craniofacial Anomalies Dental Accidents Outpatient Visits Dental Anesthesia - Outpatient Limited to the following: Members under age 7 with a disability Members with a medical condition and it is not safe to do the treatment outside a Hospital or ambulatory surgical center. Dialysis Services Dialysis Services for End-Stage Renal Disease (ESRD) Foot Care Routine care that is Medically Necessary for treatment of diabetes Covered based on the type of Services You get 50% 0%, deductible waived Not covered Covered based on the type of Services You get Covered based on the type of Services You get 50% 50% 25% 50% 25% 50% 25% 50% OUT-OF-NETWORK PROVIDERS LWO SG SYC 5 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

10 COVERED SERVICES OTHER COVERED SERVICES (Alphabetical Order) IN-NETWORK PROVIDERS YOUR COSTS (of the allowed amount) Infusion Therapy (Outpatient) 25% 50% Mastectomy and Breast Reconstruction Routine Vision Exam/Care Limited to Members age 19 and older Exams, limited to one exam per Year Frames and lenses, contact lenses, limited to $150 per Year Covered based on the type of Services You get $25 copay, does not accrue to out-of-pocket maximum. 50% OUT-OF-NETWORK PROVIDERS $25 copay, does not accrue to out-of-pocket maximum. 0%, deductible waived 0%, deductible waived Sleep Studies - Outpatient 25% 50% Telehealth Virtual Care Services Telemedicine Services Office visits See Office and Clinic Visits See Office and Clinic Visits Facility costs 25% 50% Therapeutic Injections 25% 50% Transplants Donor Covered Services 25% Not covered Office Visits Inpatient facility, Outpatient care and related Services Two round trip tickets, plus two weeks of accommodations for travel and lodging expenses per transplant 50% 50% See Office and Clinic Not covered Visits 25% Not covered 0% 0% LWO SG SYC 6 LifeWise Passport Silver PPO 2000 Emergency Tooth Doctor, PC/

11 IMPORTANT PLAN INFORMATION This Plan is a Preferred Provider Plan (PPO). Your Plan provides You the flexibility to receive Covered Services from providers without referrals. However, You will receive a lower cost share when You designate a Primary Care Provider (PCP). Please see How Providers Affect Your Costs for more information. You have access to one of the many providers included in Our network of providers for Covered Services included in Your Plan. You also have access to facilities, emergency rooms, surgical centers, equipment vendors or pharmacies providing Covered Emergency Services throughout the United States and wherever You may travel. This section includes important information about this Plan, such as Your deductibles, out-of-pocket maximum and the allowed amount. CALENDAR YEAR DEDUCTIBLE A deductible is the amount You pay for Covered Services for each Year before this Plan provides benefits. Individual Deductible This Plan includes an individual deductible when You see in-network providers and a separate individual deductible when You see out-of-network providers. After You pay this amount, this Plan will begin paying for Your Covered Services. See the Summary of Your Costs for Your individual deductible amount. Family Deductible This Plan limits the total deductible that must be met by all family Members on this Plan. Any amount that We count toward a Member s individual deductible also counts toward the family deductible. When the family deductible is met, all individual deductibles are also met. This is true even if some Members did not meet their individual deductible. The individual and family deductibles, if any, are subject to the following: Deductibles accrue during a Year, January 1 through December 31 There is no carry over provision. Amounts credited to Your deductible during the current Year will not count toward the next Year s deductible. Amounts credited to the deductible will not be more than the allowed amount Copays are not applied to the deductible Amounts credited toward the deductible do not accrue to benefits with a dollar maximum Amounts credited toward the deductible accrue to benefits with visit limits OUT-OF-POCKET MAXIMUM Individual Out-of-Pocket Maximum This Plan includes an individual out-of-pocket maximum for Covered Services when You use innetwork providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much You pay each Year. The deductibles, Coinsurance and Copays You pay count toward this limit. After You meet the out-of-pocket maximum, benefits for Covered Services are paid at 100% of the allowed amount for the rest of that Year. Family Out-of-Pocket Maximum This Plan includes a family out-of-pocket maximum for Covered Services when You use in-network providers as shown on the Summary of Your Costs. The out-of-pocket maximum is a limit on how much Your family pays each Year. The deductibles, Coinsurance and Copays You pay count toward this limit. After Your family out-of-pocket maximum has been met, benefits for Covered Services are provided at 100% of the allowed amount for the rest of that Year. Expenses that do not apply to the individual or family out-of-pocket maximum include: Charges above the allowed amount Services above the any benefit maximum limit or durational limit Services not covered by this Plan Covered Services or benefits that do not apply to the out-of-pocket maximum. These are shown on the Summary of Your Costs. Covered Services provided by out-of-network providers Services that are not prior authorized ALLOWED AMOUNT This Plan provides benefits based on the allowed amount for Covered Services. The allowed amount is described below: NON-EMERGENCY SERVICES In-Network Providers The allowed amount is the fee that LifeWise has negotiated with its in-network providers for Covered Services. Out-of-Network Providers The allowed amount is the lesser of the following: The provider s billed charge No less than 125% of the fee schedule determined by the Centers for Medicare and Medicaid Services (CMS). LifeWise will use fee schedules from CMS 7 LifeWise Passport Silver PPO 2000

12 in setting the allowed amount. In the event CMS does not have a fee for a given Service, We will request additional information from Your provider. We will evaluate this information to determine the amount that CMS would reimburse for similar Services. The allowed amount will be the lesser of the amount that CMS would reimburse for similar Services or the out-of-network provider's billed charges. EMERGENCY SERVICES Consistent with the requirements of the Affordable Care Act (federal health care reform) the allowed amount will be the greater of the following: The median amount in-network providers have agreed to accept for the same Services The amount Medicare would allow for the same Services The amount calculated by the same method the Plan uses to determine payment to out-of-network providers In addition to Your deductible, Copay and Coinsurance, You will be responsible for charges received from out-of-network providers above the allowed amount. If You have questions about this information, please call Us at the number listed on Your LifeWise ID card. HOW PROVIDERS AFFECT YOUR COSTS Throughout this section You will find information on how to control Your out-of-pocket cost and how the providers You see for Covered Services can affect Your Plan benefits. NETWORK PROVIDERS You Can Benefit By Designating A Primary Care Provider We believe wellness and overall health is enhanced by working closely with one provider. Although this Plan does not require the use or selection of a primary care provider (PCP) or a referral for specialty care, We encourage You to designate a PCP at the time You enroll in this Plan and notify Us of Your selection. Selecting a PCP gives You a partner to help You manage Your care. How Do I Pay The Lowest Copay When You use Your designated PCP You will have a lower cost share than seeing other PCPs or Specialists in Our network. In-network OB/GYN providers are always covered at the lower cost share, no matter if You have selected a PCP or not. Here is an example: When You select a PCP and visit Your PCP for a cut that needs stitches: You will pay the lower Copay amount for the office visit After You pay Your Copay amount for the visit, You will also have to pay Your deductible and/or Coinsurance amount for the stitching procedure. However, in this example, if You do not select a PCP, Your office visit Copay will be the higher Copay, which means Your overall cost share will be more for the visit. Please see the Summary of Your Costs for more information. Who May I Select As My Designated PCP A designated PCP must be an in-network provider and choices include the following providers: General practice Family practice Internal medicine Pediatrics Geriatric medicine Nurse practitioners Obstetrics and Gynecology (OB/GYN) Physician assistants Naturopaths How To Designate A PCP You can designate any PCP in Our network as Your designated PCP. The PCP decides if they have the ability to accept You or Your family Members as patients. Each enrolled family Member may select a different PCP. To find a PCP, You can choose a provider from Our online Provider Directory, located on Our website at lifewiseor.com, or contact Our Customer Service for assistance. Customer Service can be reached by calling the phone number listed on Your LifeWise ID card. Once You choose a PCP, You will need to tell Us who You and Your family chose. We will update Our records with Your selections. Please note, if the provider You or Your family Members choose is not accepting new patients, You will need to designate a different PCP. What If Your PCP Is Not Available If You need to see Your PCP and Your PCP is not available, You may see a PCP within the same clinic and You will only be responsible for the lower cost share, or If Your PCP is a sole practitioner, You may see a PCP that Your provider has asked to cover in their absence and You will only be responsible for the lower cost share. What If I Want To Change My PCP You have the option to change Your PCP. Change 8 LifeWise Passport Silver PPO 2000

13 requests received by the 15 th of each month take effect on the first of the next month. Requests received after the 15 th of each month take effect on the 1 st of the following month. Example: If We received a request on April 10 th, Your change will take effect on May 1 st ; if we receive Your request on April 20 th, Your change will take effect on June 1 st. In-Network Providers In-network providers are networks of Hospitals, Physicians, Specialists and other providers that We contract with to provide medical Services at a negotiated fee. We have in-network providers in all categories of Services, such as laboratory and x-ray Specialists and medical specialties. You benefit in two ways when You receive Covered Services from an in-network provider. Your medical bills will be reimbursed at a higher percentage (the innetwork provider benefit level), and Our in-network providers will not charge more than the allowed amount. This means, the amount You pay of the charges for Covered Services will be lower. Contracted Providers Who Offer Unique Services We have contracted with some health care systems of providers to provide unique Services that are not available from Our network of contracted providers. We contract with these health care systems to provide Covered Medical Services at negotiated fees. When these providers offer their unique Services to Our Members, We will allow their charges at the highest (in-network) benefit level and You will not be balance billed for any charge over the allowed amount. Out-of-Network Providers Out-of-network providers are providers that do not have a contract with LifeWise. Your medical bills will be reimbursed at the lower level of benefits (out-ofnetwork) and the provider may bill You for charges above the allowed amount. This means that Your out-of-pocket costs will be higher because Your benefit level is lower and You will be responsible for any charges over the allowed amount. How to Select a LifeWise In-Network Provider A list of Our in-network providers is available in Our provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help You select a provider that is right for You or Members of Your family. We update this directory regularly, but it is subject to change. We suggest that You call Us for current information and to verify that Your provider, their office location or provider group is included in the LifeWise network before You get Services. The LifeWise Provider Directory is available any time on Our website at lifewiseor.com. You may also request a copy of this directory by calling Customer Service at the number located in the front of this Benefit Booklet or on Your LifeWise ID card. The Covered Services listed below are only available from in-network providers, as shown on the Summary of Your Costs. Community Wellness Other Health Education Services Prescription Drugs Preventive Care Tobacco Use Cessation Programs Transplants CARE OUTSIDE THE SERVICE AREA LifeWise Members have access to a nationwide network of providers when outside the Service Area. Our Service Area is Oregon. These providers will not charge You for amounts over the allowed amount, and they will submit Claims directly to Us. Out of Area Members Out of area Members are Members who live outside of Our Service Area. Out of area Members include: Eligible Employees who do not live in the Service Area A Dependent who lives outside the Service Area A Dependent who is attending school outside the Service Area You or Your Employer must notify Us when You or Your Dependent moves back into the Service Area. At that time, You or Your Dependent must designate a PCP to receive the lower cost share for office visits when seeing a PCP. You may select a PCP; however, You will always pay the lower cost share under this Plan when You live out of Our Service Area. The availability of these providers may vary by location. For more information on care outside the Service Area, contact Customer Service. PRIOR AUTHORIZATION AND EMERGENCY ADMISSION NOTIFICATION Your coverage for some Services depends on whether the Service is approved by Us before You receive it. This process is called Prior Authorization. A planned Service is reviewed to make sure it is Medically Necessary and eligible for coverage under 9 LifeWise Passport Silver PPO 2000

14 this Plan. We will let You know in writing if the Service is authorized. We will also let You know if the Service is not authorized and the reasons why. If You disagree with the decision, You can request an appeal. See the Grievances and Appeals section or call us. There are three situations where Prior Authorization is required: Before You receive certain medical Services or prescription drugs Before You schedule a planned admission to certain inpatient facilities When You want to receive the higher benefit level for Services You receive from an out-of-network provider How to Ask for Prior Authorization This Plan has a specific list of Services that must have Prior Authorization with any provider. Before You receive Services, We suggest that You review the list of Services requiring Prior Authorization. You can get a detailed list of medical Services requiring Prior Authorization by calling Customer Service at the number on the back of Your ID card or on Our website at lifewiseor.com. Services From In-Network Providers: It is Your innetwork provider s responsibility to get Prior Authorization for planned Services and before Services are provided. Your in-network provider can call Us at the number listed on Your ID card to request a Prior Authorization. Services from Out-of-Network Providers: It is Your responsibility to get Prior Authorization for any of the Services on the Prior Authorization list when You see an out-of-network provider. You or Your out-ofnetwork provider can call Us at the number listed on Your ID card to request a Prior Authorization. Responding to Prior Authorizations We will respond to a request for Prior Authorization within 2 business days of receipt of all information necessary to make a decision. If Your situation is clinically urgent (meaning that Your life or health would be put in serious jeopardy if You did not receive treatment right away), You may request to have your Prior Authorization reviewed as expedited. Once We have been given all the necessary information to make a decision. We will provide Our decision in writing. The Prior Authorization will be binding to Us when related to eligibility and obtained no more than five business days before the date of Service. Our Prior Authorization will be valid for 30 calendar days for benefit coverage and Medical Necessity determinations. This 30 calendar day period is subject to Your continued coverage under the Plan. If You do not receive the Services within that time, You or Your provider will have to ask Us for another Prior Authorization. Services that must be Prior Authorized The following are types of Services that require Prior Authorization. You can see the detailed list on Our website lifewiseor.com or You can call Customer Service. The following types of Services require Prior Authorization: Planned Inpatient admission into Hospitals, Skilled Nursing Facilities, and rehabilitation facilities Non-emergency ground, air, or ambulance transport Transplant and donor services Injectable medications You get from a healthcare provider s office Prosthetics and Orthotics other than foot Orthotics or orthopedic shoes Reconstructive surgery Home Medical Equipment (HME), costing $500 or more Selected surgical, medical therapeutic, and diagnostic procedures Outpatient advanced imaging, such as MRI, CT, and echocardiograms Some Outpatient Services. See the detailed list on Our website at lifewiseor.com. Certain Prescription Drugs. See the Pharmacy section on our website at lifewiseor.com. Prior Authorization Penalty For Services from In-Network Providers In-network providers will get a Prior Authorization for You. You should verify with Your provider that a Prior Authorization request has been approved in writing by Us before You receive the Services. For Services From Out-of-Network Providers It is Your responsibility to get Prior Authorization for any Services on the Prior Authorization list when You see an out-of-network provider. If You do not get Prior Authorization, the Services will not be covered. The out-of-network provider can bill You and You will have to pay the total cost for the Services. Your costs for this penalty do not count toward Your Plan deductibles and out-of-pocket maximum. Services listed below are not subject to a Prior Authorization penalty: Emergency hospital admissions. See Emergency Hospital Admission Notification described below. 10 LifeWise Passport Silver PPO 2000

15 Prescription Drugs. See Prior Authorization for Prescription Drugs described below. Non-Emergency Services from out-of-network providers. See Non-Emergency Services From Out-of-Network Providers described below. Prior Authorization for Prescription Drugs Certain Prescription Drugs require a Prior Authorization before You get them at a pharmacy. You or Your provider can ask for a Prior Authorization by faxing a Prior Authorization form to Us. This form is in the Pharmacy section of Our website at lifewiseor.com. Your provider can tell You if a new Prescription Drug requires Prior Authorization. Your provider can check with Us to see if Prior Authorization is required. You may also view Our list of Prescription Drugs that require Prior Authorization through the Member portal on Our website at lifewiseor.com. Once You Signin, please go to My Plan Information then, select the Pharmacy tab, and finally You ll select View drugs that require Prior Authorization. You can also find the Prior Authorization form that Your Physician can completes and sends to Pharmacy Services with their request for a Prior Authorization. Sometimes You may not know if a Prescription Drug needs Prior Authorization. For example, You may go directly from Your provider s office to the pharmacy with a new prescription. If the pharmacy tells you that the Prescription Drug Your provider prescribed requires Prior Authorization, You or Your pharmacy should call Your provider to let them know. Your provider will then need to fax Us a completed Prior Authorization form for review. While your provider s request is in review, You have the option to buy the Prescription Drug before it is Prior Authorized, but You must pay the full cost. Once the Prior Authorization is reviewed, if the drug is authorized after You bought it, You can send Us a Claim for reimbursement. However, the amount of reimbursement will be based on the allowed amount. See the Sending Us A Claim section for details. Non-Emergency Services from Out-of-Network Providers There may be times when You want to see an out-ofnetwork provider for non-emergency Services. In some cases out-of-network benefits may be paid at the in-network cost share if the Services are Medically Necessary and only available from an out-of-network provider. You must ask for a Prior Authorization before You see the out-of-network provider. The Prior Authorization request must include the following: A statement that the out-of-network provider has unique skills that are Medically Necessary for Your care You cannot get the same care from an in-network provider Medical records supporting Your request If We approve Your request, the Services will be covered at the in-network cost share. In addition to Your usual cost share, You will also pay any amounts over the allowed amount. If there are in-network providers who can give You the same care, Your Prior Authorization request will not be approved. Your costs for these Services will be at the out-of-network provider cost share. Emergency Admission Notification The following Services do not need authorization, but they have separate requirements: Emergency Hospital admissions, including admissions for drug or alcohol Detoxification. They do not require Prior Authorization, but You must notify Us soon as reasonably possible. If You are admitted to an out-of-network Hospital due an Emergency Medical Condition, those Services will always be covered under Your innetwork cost share. We will continue to cover those Services until You are medically stable and can safely transfer to an in-network Hospital. If You chose to remain at the out-of-network Hospital after You are medically stable to transfer, coverage will revert to the out-of-network cost share of benefits. We pay for Covered Services based on Our allowed amount. If the Hospital is not contracted with Us, You may be billed for charges over the allowed amount. Childbirth admission to a Hospital, or admissions for newborns that need medical care at birth. They do not require Prior Authorization, but You must notify Us as soon as reasonably possible. Admissions to an out-of-network Hospital will be covered at the out-of-network cost share of benefits, unless the admission was an emergency. UTILIZATION REVIEW LifeWise has developed or adopted guidelines and medical policies that outline clinical criteria used to make Medical Necessity determinations. The clinical criteria is reviewed annually and is updated as needed to ensure Our determinations are consistent with current medical practice standards and follows national and regional norms. Practicing community doctors are involved in the review and development of Our internal criteria. You or Your provider may request a copy of the criteria used to make a Medical Necessity decision for a particular condition, treatment or procedure. To obtain the information, 11 LifeWise Passport Silver PPO 2000

16 please send Your request to: LifeWise Utilization Review P.O. Box 7709 Bend, OR Fax LifeWise reserves the right to deny payment for Services that are not Medically Necessary or that are considered Experimental/Investigational. A decision by LifeWise following this review may be appealed in the manner described in the Grievance and Appeals section. When there is more than one alternative available, coverage will be provided for the least costly among medically appropriate alternatives. PERSONAL HEALTH SUPPORT PROGRAMS LifeWise s personal health support programs are designed to help make sure Your health care and treatment improve Your health. You will receive individualized and integrated support based on Your specific needs. These Services could include working with You and Your doctor to ensure appropriate and cost-effective medical care, to consider effective alternatives to hospitalization, or to support both of You in managing chronic conditions. Your participation in a treatment plan through Our personal health support programs are voluntary. To learn more about these programs, contact Customer Service at the number listed on your LifeWise ID card. CONTINUITY OF CARE You may be able to continue to receive Covered Services from an in-network provider for a limited period of time at the in-network benefit level after the provider ends their contract with LifeWise. To be eligible for continuity of care You must be covered under this Plan, in an active treatment plan and receiving Covered Services from an in-network provider at the time the provider ends his/her contract with LifeWise. The treatment must be Medically Necessary and You and this provider agree that it is necessary for You to maintain continuity of care. We will not provide continuity of care if Your provider: Will not accept the reimbursement rate applicable at the time the provider contract terminates Retired Died No longer holds an active license Relocates out of the Service Area Goes on sabbatical Is prevented from continuing to care for patients because of other circumstances Terminates the contractual relationship in accordance with provisions of contract relating to quality of care and exhausts his/her contractual appeal rights We will not provide continuity of care if You are no longer covered under this Plan. We will notify You no later than 10 days after Your provider s LifeWise contract ends if We reasonably know that You are under an active treatment plan. If We learn that You are under an active treatment plan after Your provider s contract termination date, We will notify You no later than the 10th day after We become aware of this fact. To receive continuity of care, You must request continuity of care from Us. You can call Us at or send Your request to: LifeWise Utilization Review P.O. Box 7709 Bend, OR Fax Duration of Continuity Of Care If You are eligible for continuity of care, You will get continuity of care until the earlier of the following: The day after You complete the active course of treatment entitling You to continuity of care The 120th day after We notified You that Your provider s contract ended, or the date Your request for continuity of care was received or approved by Us, whichever is earlier If You are pregnant and become eligible for continuity of care after commencement of the second trimester of the pregnancy, You will receive continuity of care until the later of: The 45th day after the birth As long as You continue under an active course of treatment, but no later than the 120th day after We notified You that Your provider s contract ended, or the date Your request for continuity of care was received or approved by Us, whichever is earlier When continuity of care terminates, You may continue to receive Services from this same provider; however, We will pay benefits at the out-of-network benefit level subject to the allowed amount. Please refer to the How Providers Affect Your Costs for an illustration 12 LifeWise Passport Silver PPO 2000

17 about benefit payments. If We deny Your request for continuity of care, You may request an appeal of the denial. Please refer to the section titled Grievance and Appeals for information on how to submit a grievance review request. COVERED SERVICES This section describes the Services this Plan covers. Covered Service means Medically Necessary Services (see Definitions) and specified preventive care Services You get when You are covered for that benefit. This Plan provides benefits for Covered Services only if all of the following are true when You get the Services: The reason for the Service is to prevent, diagnose or treat a covered Illness, disease or injury The Service takes place in a Medically Necessary setting. This Plan covers Inpatient care only when You cannot get the Services in a less intensive setting. The Service is not excluded The provider is working within the scope of their license or certification This Plan may exclude or limit benefits for some Services. See the specific benefits in this section and the Exclusions section for details. Benefits for Covered Services are subject to the following: Copays Deductibles Coinsurance Benefit limits Prior Authorization. Some Services must be authorized in writing by Us before You get them. These Services are identified in this section. For more information see the Prior Authorization and Emergency Admission Notification section. Medical and payment policies. The Plan has policies used to administer the terms of the Plan. Medical policies are generally used to further define Medical Necessity or investigational status for specific procedures, drugs, biologic agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards, accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicaid Services (CMS). Our policies are available to You and Your provider on Our website at lifewiseor.com or by calling Customer Service. If You have any questions regarding Your benefits and how to use them, call Customer Service at the number listed on the inside cover of this booklet or on Your LifeWise ID card. COMMON MEDICAL SERVICES The Services listed in this section are covered as shown on the Summary of Your Costs. Please see the Summary of Your Costs for Your Copays, deductible, Coinsurance and benefit limits. Office and Clinic Visits This Plan covers professional office and home visits. The visits can be for examination, consultation and diagnosis of an Illness or injury by Your primary care provider or a Specialist. Some Outpatient Services You get from a Specialist must be Prior Authorized. See the Prior Authorization and Emergency Admission Notification section for details. Primary Care Visits For this Plan, primary care providers include general practice, family practice, internal medicine, pediatric, geriatric and obstetrical and gynecology (OB/GYN) Physicians, nurses, nurse practitioners and Physician Assistants and naturopaths. This Plan provides benefits for the first 2 primary care visits with Your designated PCP as described on the Summary of Your Costs. Urgent Care, Telehealth, preventive and specialty visits are not included in this limit. Specialist Visits For this Plan, a Specialist includes providers such as surgeons, anesthesiologists, psychologists, psychiatrists. You may have to pay a separate Copay or Coinsurance for other Services You get during a visit. This includes Services such as, but not limited to, x- rays, lab work, therapeutic injections and office surgeries. Preventive Care This Plan covers preventive care as described below. Covered Services include preventive care Services with a rating of A or B set by the United States Preventive Task Force; immunizations recommended by the Centers for Disease Control and Prevention and as required by state law; and preventive care and screenings recommended by the Health Resources and Services Administration (HRSA). These Services have limits on how often You should get them. These limits are based on Your age and if You are a male or female. Some of the Services You get as part of a routine exam may not meet these 13 LifeWise Passport Silver PPO 2000

18 guidelines. You can get a complete list of the preventive care Services with these limits on Our website at lifewiseor.com or call Us at the number listed on Your LifeWise ID card for a list. You may also review the federal guidelines at brecs.htm and This list may be changed as required by law. Covered Services include: Routine exams and well-baby care. Exams for school, sports and employment are also covered. Women s pelvic exam. Pap smear and clinical breast exams. Mammograms. See Diagnostic Lab, X-ray and Imaging for mammograms needed because of a medical condition. Pregnant women s Services such as breast feeding counseling before and after delivery and maternity diagnostic screening, diabetic supplies from conception to six weeks postpartum. Electric breast pumps and supplies. Includes the purchase of a non-hospital grade breast pump or 12-month rental of a hospital grade breast pump. The cost of the rental cannot be more than the purchase price. Prostate cancer screening. Includes digital rectal exams and prostate-specific antigen (PSA) tests. Colon cancer screening. Includes exams, colonoscopy, sigmoidoscopy, double contrast barium enemas, removal of polyps in the colon and fecal occult blood tests. Including anesthesia services performed in connection with preventive colonoscopy, when the attending provider determines anesthesia is medically appropriate for the individual. Outpatient lab and radiology for preventive screening and tests Routine immunizations and vaccinations as recommended by Your Physician. You can also get flu shots, flu mist, and immunizations for shingles, pneumonia and Pertussis at a pharmacy or other center. Contraceptive management. Includes exams, treatment You get at Your provider s office, emergency contraceptives, supplies and devices. Tubal ligation and vasectomy are also covered. See Prescription Drugs for prescribed oral contraceptives and devices. Health education and training for covered conditions such as diabetes, high cholesterol and obesity. Includes Outpatient self-management programs, training, classes and instruction. Nutritional therapy. Includes Outpatient visits with a Physician, nurse, pharmacist or registered dietitians. The purpose of the therapy must be to manage a chronic disease or condition such as diabetes, high cholesterol and obesity. Preventive drugs required by federal law. See Prescription Drugs. Approved tobacco use cessation programs recommended by Your Physician. After You have completed the program, please provide Us with proof of payment and a completed reimbursement form. You can get a reimbursement form on Our website at lifewiseor.com. See Prescription Drugs for covered drug benefits. Fall prevention age 65 and older This benefit does not cover: Charges for Services that do not meet federal guidelines. This includes Services provided more often that the guidelines allow. Oral prescription contraceptives dispensed and billed by Your provider or a Hospital Over the counter (OTC) drugs, contraceptive foams, jellies, sponges or condoms, unless prescribed by a physician. See Prescription Drugs for prescribed oral contraceptives and devices. Gym memberships or exercise classes and programs Inpatient newborn exams while the child is in the Hospital following birth. See Maternity and Newborns for those Covered Services. Facility charges. When You get preventive Services at a hospital based Physician s office or clinic and they charge a separate facility fee in addition to the Service, You must pay Your deductible and Coinsurance for the facility charges. See Hospital Services for those costs. Lab and Pathology Services for colonoscopy or sigmoidoscopy. See Diagnostic Lab, X-ray and Imaging. Physical exams for basic life or disability insurance Work-related disability evaluations or medical disability evaluations The use of an anesthesiologist for monitoring and administering general anesthesia for colon health screenings, unless Medically Necessary when specific medical conditions and risk factors are present PEDIATRIC CARE This Plan covers hearing and vision Services for covered children as stated in the Summary of Your Costs, unless otherwise stated below. 14 LifeWise Passport Silver PPO 2000