A guide to choosing your Anthem Blue Cross and Blue Shield health plan Pharmacare LTD Lumenos H.S.A POS Effective January 1, 2016

Transcription

1 A guide to choosing your Anthem Blue Cross and Blue Shield health plan Pharmacare LTD Lumenos H.S.A POS Effective January 1, MUMENMUB REV 01/14 This guide is information only. You must enroll to be covered ANMENABS 02/15

2 An Anthem Blue Cross and Blue Shield ID card means something It means you have access to quality care from quality doctors. It means you can always get your questions answered. It means you have our support before you ever need health care. And that s what this guide is for. We want you to have everything you need to make a good decision.

3 Getting started with health insurance Let's start with how health insurance works in general How most health plans work Deductible Out-of-pocket limit What you pay What we pay 1. If you pay your deductible. This is a set amount that you pay before your plan starts paying for covered services. 2. After you meet your deductible, you and your plan share the cost of covered services. You pay coinsurance (a percentage of the cost) each time you get care. Your insurance covers the rest. 3. You re protected by your plan s out-of pocket limit. That s the most you pay for covered health services each year. What about the money for health insurance that gets deducted from your paycheck? That s your premium. Think of it like a membership fee. It s separate from what you pay when you get care. Remember, this chart is only an example. Your actual costs will depend on the type of plan you choose, the service you get and the doctor. To see your actual costs, please refer to your plan information. 3

4 More coverage for you When you enroll, you ll probably need to opt-in for the coverage options in this section. Vision With Blue View Vision SM, you have access to a network of over 30,000 doctors and more than 25,000 locations across the country, including convenient retail stores like LensCrafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision stores. Your new vision coverage includes a routine eye exam, frames and either eyeglass lenses or contact lenses. My Anthem ID card means I have access to quality care from quality doctors 4

5 Frequently asked questions (FAQs) You can register at anthem.com your simple and convenient solution to managing your health Can I keep my current doctor? Yes, you can. But keep in mind that you get the most out of your plan if your doctor is part of the network. Some plans cover only services from network doctors, which means you pay for the full cost if you see a doctor outside the network. Other plans cover services from doctors outside the network but your plan pays more of the cost when you see a network doctor. Be sure to check the details of your plan. To fi nd out if your doctor is in our network, or to find a new doctor or pharmacy in our network, go to our Find a Doctor tool on anthem.com. You can search by specialty and check a doctor s training, certifi cations and member reviews. Be ready to enter your plan name to view the network that serves your plan. You can also use Find a Doctor on your smartphone. What prescription drugs are covered? View the drugs we cover at And here's a tip: you'll often pay less for generic versions of higher-cost name brand drugs. To learn more about pharmaceutical programs that may apply to your coverage, check out the Customer Support section on anthem.com. Then go to FAQs > Pharmacy. How do I use my health plan when I need care? After you enroll, your member ID card will come in the mail. Be sure to bring it with you to the doctor. Is preventive care covered? Yes, preventive care from a network provider is covered at 10. It s very important to take care of your health with regular checkups even when you feel fi ne. So talk to your doctor about screenings and immunizations that you may need to protect your health. Can I manage my health care on the Web? Yes. As soon as you become a member, you ll be able to register at anthem.com. It s designed to help you manage your health care and your coverage simply and conveniently. Many of our members find these self-service tools helpful: Check on your claims. Find a doctor or pharmacy. Check the price of a drug and refill a prescription. Track your health care spending. Compare quality and costs at hospitals and other facilities. Go paperless. Download the free anthem.com mobile app so you can manage your health care on the go! Visit anthem.com/guidedtour to watch a video explaining how our website can help you. Do I have health and wellness benefits with my plan? Yes. In fact, we have a set of tools and resources that can help you reach your health goals. They can also save you money on products and services for your health. Just go to anthem.com and click the Health & Wellness tab. Once you re a member, you can log in and see more. Check out these health and wellness programs your employer is providing in addition to your health insurance benefits: 24/7 NurseLine Our registered nurses can answer your health questions wherever you are any time, day or night. Future Moms Moms-to-be get personalized support and guidance from registered nurses to help them have a healthy pregnancy, a safe delivery and a healthy baby. Healthy Lifestyles Take charge of your total wellness through a personalized Well-Being Plan and custom trackers that help you manage your physical and mental health. How can my plan help me save money? You'll save money every time you go to a doctor in network they've agreed to charge lower rates for Anthem members. But we'll also help save you money before you go to the doctor. 5

6 Frequently asked questions (FAQs) At anthem.com, you can compare how much a medical procedure will cost at different locations. Plus, all members get discounts on health-related products. Home Delivery Pharmacy You can save money and time by having your prescriptions delivered to your home. Learn how to get started with Home Delivery. Cost and Quality If you re getting an imaging test (like an X- ray), a sleep test, colonoscopy orendoscopy, we ll work with you and your doctor to give you choices so you can fi nd quality facilities at low prices. Anthem Health Rewards Reward yourself for healthy behavior. Get valuable incentives if you participate in wellness programs or condition management programs. LiveHealth Online - Connect to doctors without appointments, waiting rooms or high costs. All you need is a computer, web cam and Internet connection. You ll enjoy immediate, live-video doctor visits with your choice of U.S. board-certified doctors any day of the year. Enroll today for free at livehealthonline.com. 6

7 Your plan details In this next section, you ll find more information about your plan.

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9 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E3 with Rx Option BW Effective 01/01/2016 This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. Network Covered Benefits Single: $3,000 Deductible Family: $6,000 The single deductible applies to the Family deductible. Once the single deductible has been satisfied, benefits for that member are payable subject to coinsurance. Once the family deductible has been satisfied, benefits for the family are payable subject to coinsurance. Single: $4,000 Out-of-Pocket Limit Family: $8,000 Physician Home and Office Services Including Office Surgeries, allergy serum, allergy injections and allergy testing No Cost Share Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Hearing screenings and Vision screenings which are limited to Screening tests (i.e. Snellen eye chart) and Ocular Photo screening. Childhood Immunizations through age 18 Emergency and Urgent Care Emergency Room Services (facility/other covered services) Urgent Care Center Services Inpatient and Outpatient Professional Services Include but are not limited to: Medical Care visits, Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services Unlimited days except for: 60 days Network/Non-Network combined for physical medicine / rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 30 days Network/Non-Network combined for skilled nursing facility Outpatient Surgery Hospital / Alternative Care Facility Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment, Orthotics, and Prosthetics Physical Medicine Therapy Day Rehabilitation programs Ambulance Services Non-Network Single: $6,000 Family: $12,000 Single: $12,000 Family: $24, In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 9 Anthem: HSA Lumenos 8

10 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E3 with Rx Option BW Effective 01/01/2016 Covered Benefits Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: 20 visits Occupational therapy: 20 visits Speech therapy: 20 visits Cardiac Rehabilitation: 36 visits Pulmonary Rehabilitation: 20 visits Accidental Dental Coverage $3000 per accident Behavioral Health Services: Mental Health and Substance Abuse Inpatient Facility Services Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage. Prescription Drugs: Network Retail Pharmacies: (30 day supply) Includes diabetic test strip Home Delivery (90 day supply) Includes diabetic test strip *4th Tier per script max- 30 day supply. Specialty medications are limited to a 30 day supply regardless of whether they are retail or home delivery. -Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits. - Member may be responsible for additional cost when not selecting the available generic drug. Network Non-Network $10 / $50 / $75 / 25% $250 max* 5, min $75(1) $10 / $125 / $225 / 25% $250 max* Not Covered Notes: All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non-Network Human Organ and Tissue Transplant (HOTT) Services). Deductible(s) apply only to all covered medical services listed with a percentage (%) coinsurance and copayment, including prescription drug cost shares. Deductible applies to all prescription drug expenses. Once the deductible is met the appropriate copayment/coinsurance applies. Network and Non-network deductibles, coinsurance, and out of pocket maximums are separate and do not accumulate towards each other. Network and non-network deductibles are combined for 500 series plans. Dependent age: to the end of the month in which the child attains age 26. No cost share means no deductible/copayment/coinsurance up to the maximum allowable amount. means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment. Benefit period = Calendar Year Hospital stay for Maternity Coverage will not be limited to less than 48 hours for a vaginal delivery or 96 hours for a caesarean section Behavioral Health: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing - $50,000 per Benefit Period and $100,000 Lifetime Additional vision services covered as part of Preventive Services on series 500 plans. Hospice: Network copayment/coinsurance up to the maximum allowable amount. In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 10 Anthem: HSA Lumenos 8

11 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E3 with Rx Option BW Effective 01/01/2016 (1)Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Exclusions Your Plan does not provide coverage for the following: Services that are not Medically Necessary. Experimental/Investigative Services. Complications directly related to a service or treatment that is a non Covered Service under this Certificate because it was determined by Us to be Experimental/ Investigative or non Medically Necessary. Services received from a non-covered Provider. For any condition arising out of and in the course of employment if benefits are available under any Worker's Compensation Act or other similar law. Services provided by any governmental unit, unless otherwise required by law. For any illness or injury that occurs while serving in the armed forces, including as a result of any act of war, whether declared or undeclared. For a condition resulting from direct participation in a riot, civil disobedience, nuclear explosion, or nuclear accident. For court ordered testing or care unless Medically Necessary. For which you have no legal obligation to pay in the absence of this or like coverage. For any Pre-Existing Condition for the time period specified in the Certificate. Charges that are not documented in Provider records. For mileage, lodging, and meals costs, and other Member travel related expenses, except as authorized by Us or specifically stated as a Covered Service. For which benefits are payable under Medicare. Charges in excess of Our Maximum Allowable Amounts. Incurred prior to your Effective Date or after coverage ends. For any procedures, services, Prescription Drugs, equipment, or supplies provided in connection with cosmetic services. This does not apply to services required as a result of an accident, to correct a birth defect, or as part of breast reconstruction following a mastectomy. Complications directly related to cosmetic services treatment or surgery are also not covered. For maintenance therapy, which is treatment given when no additional progress is apparent or expected to occur. Custodial Care, convalescent care or rest cures. Care provided or billed by residential treatment centers or facilities, unless those centers or facilities are required to be covered under state law. For dental treatment, regardless of origin or cause, except as specified in the Certificate. Weight loss programs except as specifically listed in the Certificate. For bariatric surgery, regardless of the purpose it is proposed or performed for. Complications directly related to bariatric surgery are also not covered. For marital counseling. For prescription, fitting, or purchase of eyeglasses or contact lenses except as otherwise specifically stated in the Certificate. For hearing aids or examinations for prescribing or fitting them. This exclusion does not apply to hearing aids or examinations required for children under age 18 who are receiving the benefits described in the "Covered Services" section. For testing or treatment related to infertility. For personal hygiene, environmental control, or convenience items including but not limited to air conditioners, physical fitness equipment, or charges from a health spa or similar facility. For care received in an emergency room that is not Emergency Care, except as specified in the Certificate. For eye surgery to correct errors of refraction, such as near-sightedness, including without limitation LASIK, radial keratotomy or keratomileusis, or excimer laser refractive keratectomy. For Private Duty Nursing Services rendered in a Hospital or Skilled Nursing Facility. Nutritional or dietary supplements. For (services or supplies related to) alternative or complementary medicine, including but not limited to acupuncture, holistic medicine, hypnosis, massage therapy, and neurofeedback. Treatment of varicose veins or spider veins. Services for, and related to, many forms of immunotherapy including oral immunotherapy, low dose sublingual immunotherapy, and immunotherapy for food allergies. Spinal decompression devices. This includes, but is not limited to, Vertebral Axial Decompression (Vax-D) and DRX9000. Prescription Drugs dispensed by any Mail Service program other than Our Mail Service, unless prohibited by law. Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order. Drugs not approved by the FDA. Drugs not requiring a Prescription by federal law (including Drugs requiring a Prescription by state law, but not by federal law), except for injectable insulin. Drugs in quantities that exceed the limits established by the Plan, or which exceed any age limits established by Us. Drugs to eliminate or reduce dependency on, or addiction to tobacco and tobacco products. We conduct a variety of quality improvement programs to evaluate, monitor and improve our plans. The purpose of these programs is to measure member satisfaction and quality of care. Providers are also required to participate in a strict certification process. If you have questions or concerns about the programs, you may contact us at (800) Precertification: Members are encouraged to always obtain prior approval when using Non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-Existing Exclusion Period:None. This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 11 Anthem: HSA Lumenos 8

12 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E9 with Rx Option BW Effective 01/01/2016 This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. Network Covered Benefits Single: $5,000 Deductible Family: $10,000 The single deductible applies to the Family deductible. Once the single deductible has been satisfied, benefits for that member are payable subject to coinsurance. Once the family deductible has been satisfied, benefits for the family are payable subject to coinsurance. Single: $6,550 Out-of-Pocket Limit Family: $13,100 Physician Home and Office Services Including Office Surgeries, allergy serum, allergy injections and allergy testing No Cost Share Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Hearing screenings and Vision screenings which are limited to Screening tests (i.e. Snellen eye chart) and Ocular Photo screening. Childhood Immunizations through age 18 Emergency and Urgent Care Emergency Room Services (facility/other covered services) Urgent Care Center Services Inpatient and Outpatient Professional Services Include but are not limited to: Medical Care visits, Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services Unlimited days except for: 60 days Network/Non-Network combined for physical medicine / rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 30 days Network/Non-Network combined for skilled nursing facility Outpatient Surgery Hospital / Alternative Care Facility Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment, Orthotics, and Prosthetics Physical Medicine Therapy Day Rehabilitation programs Ambulance Services Non-Network Single: $10,000 Family: $20,000 Single: $20,000 Family: $40, In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 12 Anthem: HSA Lumenos 8

13 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E9 with Rx Option BW Effective 01/01/2016 Covered Benefits Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: 20 visits Occupational therapy: 20 visits Speech therapy: 20 visits Cardiac Rehabilitation: 36 visits Pulmonary Rehabilitation: 20 visits Accidental Dental Coverage $3000 per accident Behavioral Health Services: Mental Health and Substance Abuse Inpatient Facility Services Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage. Prescription Drugs: Network Retail Pharmacies: (30 day supply) Includes diabetic test strip Home Delivery (90 day supply) Includes diabetic test strip *4th Tier per script max- 30 day supply. Specialty medications are limited to a 30 day supply regardless of whether they are retail or home delivery. -Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits. - Member may be responsible for additional cost when not selecting the available generic drug. Network Non-Network $10 / $50 / $75 / 25% $250 max* 5, min $75(1) $10 / $125 / $225 / 25% $250 max* Not Covered Notes: All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non-Network Human Organ and Tissue Transplant (HOTT) Services). Deductible(s) apply only to all covered medical services listed with a percentage (%) coinsurance and copayment, including prescription drug cost shares. Deductible applies to all prescription drug expenses. Once the deductible is met the appropriate copayment/coinsurance applies. Network and Non-network deductibles, coinsurance, and out of pocket maximums are separate and do not accumulate towards each other. Network and non-network deductibles are combined for 500 series plans. Dependent age: to the end of the month in which the child attains age 26. No cost share means no deductible/copayment/coinsurance up to the maximum allowable amount. means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment. Benefit period = Calendar Year Hospital stay for Maternity Coverage will not be limited to less than 48 hours for a vaginal delivery or 96 hours for a caesarean section Behavioral Health: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing - $50,000 per Benefit Period and $100,000 Lifetime Additional vision services covered as part of Preventive Services on series 500 plans. Hospice: Network copayment/coinsurance up to the maximum allowable amount. In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 13 Anthem: HSA Lumenos 8

14 Your Summary of Benefits Pharmacare LTD Lumenos Health Savings Accounts POS Option E9 with Rx Option BW Effective 01/01/2016 (1)Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Exclusions Your Plan does not provide coverage for the following: Services that are not Medically Necessary. Experimental/Investigative Services. Complications directly related to a service or treatment that is a non Covered Service under this Certificate because it was determined by Us to be Experimental/ Investigative or non Medically Necessary. Services received from a non-covered Provider. For any condition arising out of and in the course of employment if benefits are available under any Worker's Compensation Act or other similar law. Services provided by any governmental unit, unless otherwise required by law. For any illness or injury that occurs while serving in the armed forces, including as a result of any act of war, whether declared or undeclared. For a condition resulting from direct participation in a riot, civil disobedience, nuclear explosion, or nuclear accident. For court ordered testing or care unless Medically Necessary. For which you have no legal obligation to pay in the absence of this or like coverage. For any Pre-Existing Condition for the time period specified in the Certificate. Charges that are not documented in Provider records. For mileage, lodging, and meals costs, and other Member travel related expenses, except as authorized by Us or specifically stated as a Covered Service. For which benefits are payable under Medicare. Charges in excess of Our Maximum Allowable Amounts. Incurred prior to your Effective Date or after coverage ends. For any procedures, services, Prescription Drugs, equipment, or supplies provided in connection with cosmetic services. This does not apply to services required as a result of an accident, to correct a birth defect, or as part of breast reconstruction following a mastectomy. Complications directly related to cosmetic services treatment or surgery are also not covered. For maintenance therapy, which is treatment given when no additional progress is apparent or expected to occur. Custodial Care, convalescent care or rest cures. Care provided or billed by residential treatment centers or facilities, unless those centers or facilities are required to be covered under state law. For dental treatment, regardless of origin or cause, except as specified in the Certificate. Weight loss programs except as specifically listed in the Certificate. For bariatric surgery, regardless of the purpose it is proposed or performed for. Complications directly related to bariatric surgery are also not covered. For marital counseling. For prescription, fitting, or purchase of eyeglasses or contact lenses except as otherwise specifically stated in the Certificate. For hearing aids or examinations for prescribing or fitting them. This exclusion does not apply to hearing aids or examinations required for children under age 18 who are receiving the benefits described in the "Covered Services" section. For testing or treatment related to infertility. For personal hygiene, environmental control, or convenience items including but not limited to air conditioners, physical fitness equipment, or charges from a health spa or similar facility. For care received in an emergency room that is not Emergency Care, except as specified in the Certificate. For eye surgery to correct errors of refraction, such as near-sightedness, including without limitation LASIK, radial keratotomy or keratomileusis, or excimer laser refractive keratectomy. For Private Duty Nursing Services rendered in a Hospital or Skilled Nursing Facility. Nutritional or dietary supplements. For (services or supplies related to) alternative or complementary medicine, including but not limited to acupuncture, holistic medicine, hypnosis, massage therapy, and neurofeedback. Treatment of varicose veins or spider veins. Services for, and related to, many forms of immunotherapy including oral immunotherapy, low dose sublingual immunotherapy, and immunotherapy for food allergies. Spinal decompression devices. This includes, but is not limited to, Vertebral Axial Decompression (Vax-D) and DRX9000. Prescription Drugs dispensed by any Mail Service program other than Our Mail Service, unless prohibited by law. Drugs in quantities exceeding the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription Order. Drugs not approved by the FDA. Drugs not requiring a Prescription by federal law (including Drugs requiring a Prescription by state law, but not by federal law), except for injectable insulin. Drugs in quantities that exceed the limits established by the Plan, or which exceed any age limits established by Us. Drugs to eliminate or reduce dependency on, or addiction to tobacco and tobacco products. We conduct a variety of quality improvement programs to evaluate, monitor and improve our plans. The purpose of these programs is to measure member satisfaction and quality of care. Providers are also required to participate in a strict certification process. If you have questions or concerns about the programs, you may contact us at (800) Precertification: Members are encouraged to always obtain prior approval when using Non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-Existing Exclusion Period:None. This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. In Wisconsin, Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Life and disability benefits are underwritten by Anthem Life Insurance Company (ALIC). BCBSWi, Compcare and ALIC are independent licensees of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association. 14 Anthem: HSA Lumenos 8

15 WELCOME TO BLUE VIEW VISION! Good news your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what s covered, your discounts, and much more! Blue View Vision SM Option 26 Your Blue View Vision network Anthem Blue Cross and Blue Shield vision members have access to one of the nation s largest vision networks. Blue View Vision is the only vision plan that gives members the ability to use their innetwork benefits at CONTACTS, or choose a private practice eye doctor, or go in store to LensCrafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision locations. Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply. YOUR BLUE VIEW VISION PLAN AT-A-GLANCE VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK Routine eye exam once every 12 months $10 copay $42 allowance Eyeglass frames Once every 24 months you may select an eyeglass frame and receive an allowance toward the purchase price Eyeglass lenses (Standard) Once every 12 months you may receive any one of the following lens options: Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair) Eyeglass lens enhancements When obtaining covered eyewear from a Blue View Vision provider, you may choose to add any of the following lens enhancements at no extra cost. Lenses (for a child under age 19) Standard d Polycarbonate (for a child under age 19) Factory Scratch Coating Contact lenses once every 12 months Prefer contact lenses over Elective Conventional Lenses; or glasses? You may choose contact lenses instead of eyeglass lenses and Elective Disposable Lenses; or receive an allowance toward the cost of a supply of contact lenses. Non-Elective Contact Lenses Contact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period. $130 allowance, then 2 off any remaining balance $20 copay $20 copay $20 copay $0 copay $0 copay $0 copay $130 allowance, then 15% off any remaining balance $130 allowance (no additional discount) Covered in full $45 allowance $40 allowance $60 allowance $80 allowance No allowance on lens enhancements when obtained out-of-network $105 allowance $105 allowance $210 allowance BLUE VIEW VISION MEMBER EXCLUSIVE! You may use your in-network benefit to order your contact lenses from CONTACTS offers a huge in-stock inventory, unbeatable prices, outstanding customer service and free shipping. Just call CONTACTS or go to 1800contacts.com for fast and easy ordering of your contact lenses. EXCLUSIONS & LIMITATIONS (not a comprehensive list) Combined Offers. Not to be combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing. Transitions and the swirl are registered trademarks of Transitions Optical, Inc. 15

16 OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay) Retinal Imaging - at member s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies. lenses (Adults) Standard Polycarbonate (Adults) Tint (Solid and Gradient) UV Coating Progressive Lenses 1 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Anti-Reflective Coating 2 Standard Premium Tier 1 Premium Tier 2 Other Add-ons and Services Additional Pairs of Eyeglasses Complete Pair Anytime from any Blue View Vision network provider Eyeglass materials purchased separately Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 10/13 $75 $40 $15 $15 $65 $85 $95 $110 $45 $57 $68 2 off retail price 4 off retail price 2 off retail price 2 off retail price Standard contact lens fitting 3 Up to $55 Premium contact lens fitting 4 1 off retail price Conventional Contact Lenses Discount applies to materials only 15% off retail price SOME OF THE ADDITIONAL SAVINGS AVAILBLE THROUGH OUR SPECIAL OFFERS PROGRAM After your benefits for the coverage period have been used, you can save on contact lenses with this offer. 5 Laser vision correction surgery LASIK refractive surgery. For this and other great offers, login to member services, select discounts, then Vision, Hearing & Dental For this offer and more like it, login to member services, select discounts, then Vision, Hearing & Dental Save $20 on orders of $100 or more and get free shipping Discount per eye 1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier. 3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal. 5 Discount cannot be used in conjunction with your covered benefits. OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service. To Fax: To oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the member s policy. Laws in some states may prohibit network providers from discounting products and services that are not covered benefits under the plan. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package. 16

17 LiveHealth Online Easy, fast doctor visits. All from the comfort of your own computer or mobile device. Talk to a doctor today, tonight, anytime 365 days a year. Just sign up at livehealthonline.com or on the free mobile app MUMENABS VPOD 07/

18 Now you can get the health care you need without all the hassle Have a health question? Feeling under the weather? With LiveHealth Online, you don t have to deal with scheduling an appointment or long wait times at the urgent care center. In fact, you don t even have to leave your home or office. Using LiveHealth Online, you can see a doctor who can answer questions, make a diagnosis, and even prescribe basic medications, when needed.* With LiveHealth Online, you get: Immediate doctor visits through live video. Your choice of board-certified doctors. Help at a cost of only $49 per visit, subject to deductible and coinsurance. Private, secure and convenient online visits. What are the qualifi cations of the doctors you see using LiveHealth Online? Board-certified. Average 15 years practicing medicine. Mostly primary care physicians. Specially trained for online visits. When can you use LiveHealth Online? As always, you should call 911 with any emergency. Otherwise, you can use LiveHealth Online whenever you have a health concern and your own doctor isn t available. Doctors are available 24 hours a day, seven days a week, 365 days a year. Some of the most common uses include: Cold and flu symptoms such as a cough, fever and headaches Allergies Sinus infections and more! Sign up for LiveHealth Online today! It s quick and easy to sign up just go to livehealthonline.com or download the mobile app. apple.com play.google.com/store Start a conversation now Just enroll for free at livehealthonline.com or on the app, and you re ready to see a doctor. * As legally permitted in certain states. LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 18

19 From your computer From your mobile device Go to anthem.com and select Register Now Provide the personal information requested Create a username and password Search for Anthem Blue Cross and Blue Shield in your app store and select Install (It s free). Open the app and select Register Now Confirm your identity Create a username and password Set your preferences Set your preferences Select Submit Confirm and select Register Need help signing up? Call the Help Desk at * You must be 18 years or older to register your own account. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association ANMENABS VPOD Rev. 02/15 19

20 Take care of yourself. Use your preventive care benefits. Getting regular checkups and exams can help you stay well and catch problems early. It may even save your life. Our health plans offer the services listed in this preventive care flier at no cost to you. 1 When you get these services from doctors in your plan s network, you don t have to pay anything out of your own pocket. You may have to pay part of the costs if you use a doctor outside the network. Preventive versus diagnostic care What s the difference? Preventive care helps protect you from getting sick. Diagnostic care is used to find the cause of existing illnesses. For example, say your doctor suggests you have a colonoscopy because of your age when you have no symptoms. That s preventive care. On the other hand, say you have symptoms and your doctor suggests a colonoscopy to see what s causing them. That s diagnostic care. Child preventive care Preventive physical exams Screening tests: Behavioral counseling to promote a healthy diet Blood pressure Cervical dysplasia screening Cholesterol and lipid level Depression screening Development and behavior screening Type 2 diabetes screening Hearing screening Height, weight and body mass index (BMI) Hemoglobin or hematocrit (blood count) HPV screening (female) Lead testing Newborn screening Screening and counseling for obesity Counseling for those ages 10 24, with fair skin, about ways to lower their risk for skin cancer Oral (dental health) assessment when done as part of a preventive care visit Screening and counseling for sexually transmitted infections Tobacco use: related screening and behavioral counseling Vision screening 2 when done as part of a preventive care visit Immunizations: Diphtheria, tetanus and pertussis (whooping cough) Haemophilus influenza type b (Hib) Hepatitis A and Hepatitis B Human papillomavirus (HPV) Influenza (flu) Measles, mumps and rubella (MMR) Women s preventive care: Well-woman visits Breast cancer, including exam, mammogram, and, including genetic testing for BRCA 1 and BRCA 2 when certain criteria are met 3 Breast-feeding: primary care intervention to promote breast-feeding support, supplies and counseling (female) 4,5 Contraceptive (birth control) counseling FDA-approved contraceptive medical services provided by a doctor, including sterilization Counseling related to chemoprevention for women with a high risk of breast cancer Meningococcal (meningitis) Pneumococcal (pneumonia) Polio Rotavirus Varicella (chickenpox) Counseling related to genetic testing for women with a family history of ovarian or breast cancer HPV screening 5 Screening and counseling for interpersonal and domestic violence Pregnancy screenings: includes, but is not limited to, gestational diabetes, hepatitis, asymptomatic bacteriuria, Rh incompatibility, syphilis, iron deficiency anemia, gonorrhea, chlamydia and HIV 5 Pelvic exam and Pap test, including screening for cervical cancer The preventive care services listed are recommendations as a result of the Affordable Care Act (ACA, or health care reform law). The services listed may not be right for every person. Ask your doctor what s right for you, based on your age and health condition(s). This sheet is not a contract or policy with Anthem Blue Cross and Blue Shield. If there is any difference between this sheet and the group policy, the provisions of the group policy will govern. Please see your combined Evidence of Coverage and Disclosure Form or Certificate for Exclusions and Limitations MUMENABS Rev. 09/15 20

21 Adult preventive care Preventive physical exams Screening tests: Alcohol misuse: related screening and behavioral counseling Aortic aneurysm screening (men who have smoked) Behavioral counseling to promote a healthy diet Blood pressure Bone density test to screen for osteoporosis Cholesterol and lipid (fat) level Colorectal cancer, including fecal occult blood test, barium enema, flexible sigmoidoscopy, screening colonoscopy and related prep kit and CT colonography (as appropriate) Depression screening Hepatitis C virus (HCV) for people at high risk for infection and a one-time screening for adults born between 1945 and 1965 Type 2 diabetes screening Immunizations: Diphtheria, tetanus and pertussis (whooping cough) Hepatitis A and Hepatitis B HPV Influenza (flu) Meningococcal (meningitis) Eye chart test for vision 2 Hearing screening Height, weight and BMI HIV screening and counseling Lung cancer screening for those ages who have a history of smoking 30 packs per year and still smoke, or quit within the past 15 years 6 Obesity: related screening and counseling Prostate cancer, including digital rectal exam and PSA test Sexually transmitted infections: related screening and counseling Tobacco use: related screening and behavioral counseling Violence, interpersonal and domestic: related screening and counseling Measles, mumps and rubella (MMR) Pneumococcal (pneumonia) Varicella (chickenpox) Zoster (shingles) for those 60 years and older A word about pharmacy items For 10 coverage of over-the-counter (OTC) drugs and other pharmacy items listed below, the person receiving the item(s) must meet the age and other specified criteria. You need to work with your in-network doctor or other health care provider to get a prescription for the item(s) and take the prescription to an in-network pharmacy. Even if the item(s) do not need a prescription to purchase them, if you want the item(s) covered at 10, you have to have the prescription. Child preventive drugs and other pharmacy items age appropriate: Dental fluoride varnish to prevent tooth decay of primary teeth for children from birth to 5 years old Fluoride supplements for children from birth through 6 years old Iron supplements for children 6-12 months Adult preventive drugs and other pharmacy items age appropriate: Aspirin use for the prevention of cardiovascular disease including aspirin for men ages and women ages Colonoscopy prep kit (generic or OTC only) when prescribed for preventive colon screening Tobacco cessation products including select generic prescription drugs, select brand-name drugs with no generic alternative, and FDA-approved over-the-counter products, for those 18 and older Vitamin D for men and women over 65 Women s preventive drugs and other pharmacy items age appropriate: Contraceptives including generic prescription drugs, brand-name drugs with no generic alternative, and over-the-counter items like female condoms or spermicides 5,7 Low dose aspirin (81 mg) for pregnant women who are at increased risk of preeclampsia Folic acid for women 55 years old or younger Breast cancer risk-reducing medications following the U.S. Preventive Services Task Force criteria (such as tamoxifen and raloxifene) 6 1 The range of preventive care services covered at no cost share when provided in-network are designed to meet the requirements of federal and state law. The Department of Health and Human Services has defined the preventive services to be covered under federal law with no cost share as those services described in the U.S. Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents and women supported by the Health Resources and Services Administration (HRSA) Guidelines. You may have additional coverage under your insurance policy. To learn more about what your plan covers, see your Certificate of Coverage or call the Customer Service number on your ID card. 2 Some plans cover additional vision services. Please see your contract or Certificate of Coverage for details. 3 Check your medical policy for details. 4 Breast pumps and supplies must be purchased from an in-network medical provider for 10 coverage; we recommend using an in-network durable medical equipment (DME) supplier. 5 This benefit also applies to those younger than You may be required to get prior authorization for these services. 7 A cost share may apply for other prescription contraceptives, based on your drug benefits. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 21

22 Introducing Healthy Lifestyles! We value you, your work and your well-being. That s why we are offering Healthy Lifestyles to all employees and their dependents (age 18 and older) for FREE. With Healthy Lifestyles, you can: used to build a well-being plan. rewards and better health. Then, keep using Healthy Lifestyles to earn more rewards at 5,000 and 10,000 points. Complete your Well-Being Assessment Set up your well-being plan Track your weight weight 10 times every 90 days. Track activities of the following at least 10 times: servings and steps. Advance a focus area Make a journal entry Create an inspiration Use our resource center Sign up for Healthy Lifestyles and take your WBA and get started: 1. Visit anthem.com Register Now Health & Wellness tab. Get Started under the Healthy Lifestyles Terms & Conditions. Well-Being Assessment There are many simple ways to earn points in Healthy Lifestyles: 2,500 annually 500 annually 500 every 90 days 1,000 every 90 days 1,000 every 90 days 10 a day 250 every 90 days 10 a day The Healthy Lifestyles programs are administered by Healthways, Inc., an independent company Healthways, Inc. All rights reserved. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri 22

23 How to sign up for Healthy Lifestyles 1. Go to anthem.com and log in using your Anthem username and password. If this is your first visit to anthem.com, select Register to complete the registration screens. Once you ve registered, log in to get started. 2. Select the Health & Wellness tab. 3. To access Healthy Lifestyles, select Get started > under the Healthy Lifestyles section. 4. Accept the Healthy Lifestyles terms and conditions and click Submit. Congratulations, you re registered! 5. Select Well-Being Assessment to get a complete picture of your current health and what it will take to improve it. 6. Select Start and answer the questions on the following screens. 23

24 7. When you answer the last question and click Finish, you will see this screen while your answers are processed. 8. Click View Full Report or download a PDF. After you ve reviewed your results, select Create Your Well-Being Plan. 9. Healthy Lifestyles will show you the areas that the program can help you address. Use the radio buttons to indicate your interest in working on each area and click Next. 10. Based on the information you ve provided, Healthy Lifestyles will recommend a primary focus area and two connected focus areas. Use the recommended focus areas or swap them out with others. Click Next to continue. 11. You can choose to add the trackers that support your focus areas here, or you can add them at a later time. After you have chosen your trackers, click Finish to complete your well-being plan setup. 12. Congratulations! You are now ready to start using your well-being plan, trackers and all of the online resources and tools that Healthy Lifestyles has to offer. The Healthy Lifestyles programs are administered by Healthways, Inc., an independent company Healthways, Inc. All rights reserved. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 24

25 Surround yourself with better health Surround yourself with better health Want to be healthier? Just look around. Through our health and wellness programs, you re surrounded by tools, resources and programs that can help you and your family live healthier. Best of all, it doesn t cost you anything extra. If you re not sure where to start, try our Well-Being Assessment and setting up a well-being plan. You can quickly achieve your first milestone of 3,000 points by completing the Well-Being Assessment and setting up your Well-Being Plan. Get extra support to reach your health goals When it comes to tackling a health issue or reaching a goal, there s no reason to go it alone. With your health plan, you can get help from health experts who can give you the guidance you need when you need it most. 24/7 NurseLine Your health concerns don t keep normal business hours. That s why 24/7 NurseLine is here for you any time of the day or night. Call the toll-free number on your member ID card to talk with a nurse about general health questions or urgent health concerns. Depending on your health need, you may get a follow-up call to make sure you ve taken steps to get care. Future Mom s maternity management program Are you a mom-to-be? You re just a phone call away from a nurse who can help answer your pregnancy questions. The Future Moms program also offers prenatal goodies, including a book about pregnancy and a week-by-week pregnancy tracking tool. Dads-to-be can be part of the program, too! Healthy Lifestyles Online When you sign up for Healthy Lifestyles, you ll take a private Well-Being Assessment. Based on the results of your assessment, you ll be able to spot areas to focus on that will become the basis of your well-being plan. Your well-being plan uses the personal goals you set to keep you motivated, and it changes over time as you make progress toward them. Each adult family member can earn up to $150 each year. Members earn a $50 incentive at each 3,000-, 5,000- and 10,000-point milestone MUMENABS Rev. 10/14 25

26 Track your progress Take charge of your wellness with custom trackers that help you manage your physical and mental health including: } A food tracker that keeps track of how many calories you consume a day and offers articles on healthy food. } An exercise tracker that helps you monitor your routine, as well as calculate your steps and calories burned. } A medication tracker that keeps track of your medications and can send you daily reminders. } A stress tracker to help you keep your stress levels in check and can send personalized reminders and tips when and where you want them, via or text. Quit smoking } Create a personalized plan to quit tobacco. } Get unlimited social support from a community of quitters. } Find tips and expert advice to help you quit for good. Take control of a health condition with ConditionCare When you join the ConditionCare program, you ll be able to speak with a personal coach who ll give you tips, keep you on track and supply lots of encouragement to make a positive change in your health. If you enroll in ConditionCare, you will work with a nurse to help manage diabetes, asthma, coronary artery disease, heart failure and/or COPD. } Asthma } Diabetes } Heart failure } Coronary artery disease (CAD) } Chronic obstructive pulmonary disease (COPD) To learn more and sign up for one of our health and wellness programs, call Member Services at the phone number on your member ID card. Better health is your greatest reward. Of course, extra incentives help, too. You may be able to earn rewards when you take part in any of these programs: } Enroll in ConditionCare $100 } Graduate from ConditionCare $200 } Future Mom s maternity management program $200 } Healthy Lifestyles Online $150 To learn more about these programs and incentives, log in to anthem.com and select Health & Wellness, then in the Programs for Healthier Living section, select Get My Rewards. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 26

27 How we protect our members As a member, you have the right to expect the privacy of your personal health information to be protected, consistent with state and federal laws and our policies. And you also have certain rights and responsibilities when receiving your health care. To learn more about how we protect your privacy, your rights and responsibilities when receiving health care and your rights under the Women s Health and Cancer Rights Act, go to To request a printed copy, please contact your Benefi ts Administrator or Human Resources representative. learn about and manage your health conditions. They also help you better understand your health benefits. To learn more about how we help manage your care, visit To request a printed copy, please contact your Benefi ts Administrator or Human Resources representative. How we help manage your care To decide if we'll cover a treatment, procedure or hospital stay, we use a process called Utilization Management (UM). UM is a program that lets us make sure you re getting the right care at the right time. Licensed health care professionals review information your doctor has sent us to see if the requested care is medically needed. These reviews can be done before, during or after a member s treatment. UM also helps us decide if the services will be covered by your health plan. We also use case managers. They're licensed health care professionals who work with you and your doctor to help you 27

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