Large Group Benefits. Personal Choice PPO tiered network plans

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1 Large Group Benefits Personal Choice PPO tiered network plans

2 Tiered network plans offer more choice and savings Our PPO tiered network plans offer cost savings for you and your employees. These health plans are available at a lower premium than our standard PPO plans, plus they give members the option to save on out-of-pocket costs for hospital and outpatient surgical services. We grouped our Personal Choice PPO acute care hospitals and facility providers into two tiers, based on cost and quality measures. Members pay less when they use tier 1 providers and more when they choose tier 2. $ $$ $$$ In-network tier 1 In-network Tier 2 Out-of-network All the freedom of a PPO, plus more ways to save The PPO tiered network plans offer the same flexibility of a PPO, plus the extra option to save on care. And the option to save is always there members can choose tier 1 providers for some services, and tier 2 providers for others. 1

3 Members can save on hospital and outpatient surgical services The amount a member can save is based on the tier the provider is in. Members can easily search ibxpress.com to see what tiers their providers are in. Here s a look at the types of providers and services that are subject to tiering. Outpatient surgery at ambulatory surgical centers Hospital-based outpatient radiology centers Inpatient hospital admissions for medical and maternity care Hospital-based outpatient labs Search on ibxpress.com Members can easily search ibxpress.com to see what tiers their providers are in. All other provider types and services are not subject to tiering and member cost-sharing is the same across all in-network providers: Primary care and specialist office visits Emergency room Urgent care centers Outpatient labs (LabCorp, independent labs) Ambulance providers for emergency and non-emergency ambulance services Physical, occupational, speech therapists Injectable medications (including allergy injections) Chemotherapy/dialysis Skilled nursing facilities for skilled nursing care Hospice Home health care Durable medical equipment Mental health and substance abuse services 2

4 Tiered Network Health Plans Benefits per contract year Personal Choice PPO Tiered $30-$60/$500 1 Tier 1 Tier 2 Personal Choice PPO Tiered $40-$80/90% 1 Tier 1 Tier 2 Deductible individual/family $0 $2,500/$5,000 $0 $5,000/$10,000 Coinsurance 10% 20% 10% 30% Out-of-pocket maximum individual/family 2 $7,350/$14,700 $7,350/$14,700 $7,350/$14,700 $7,350/$14,700 Preventive services 3 Preventive care for adult and children 0% 0% 0% 0% Immunization 0% 0% 0% 0% Preventive colonoscopy for colorectal cancer screening preventive plus providers/hospital-based 0% 0% 0% 0% Physician services Primary care office visit/retail clinic $30 $30 no ded $40 $40 no ded Specialist office visit $60 $60 no ded $80 $80 no ded Urgent care $100 $100 no ded $100 $100 no ded Spinal manipulations (20 visits per year) 4 $60 $60 no ded $80 $80 no ded Physical/occupational therapy (30 visits per year) 4 $60 $60 no ded $80 $80 no ded Hospitalization/other medical services Inpatient hospital services (includes maternity) 5 $500 per day 6 20% after ded 10% 30% after ded Inpatient professional services (includes maternity) 10% 20% after ded 10% 30% after ded Emergency room (not waived if admitted) 7 $200 $200 no ded $300 $300 no ded Routine radiology/diagnostic $60 20% after ded $80 30% after ded MRI/MRA, CT/CTA scan, PET scan $200 20% after ded $300 30% after ded Durable medical equipment/prosthetics 10% 10% no ded 10% 10% no ded Mental health, serious mental illness and substance abuse outpatient $60 $60 no ded $80 $80 no ded Mental health, serious mental illness and substance $500 per day 6 $500 per day, 10% 10% no ded abuse inpatient 5 no ded 6 Outpatient surgery ambulatory surgical center/hospital-based $500 per day 20% after ded 10% 30% after ded Outpatient lab/path freestanding/hospital-based $60 $60/20% after ded $80 $80/30% after ded Out-of-network 8, 9 Deductible individual/family 10 $5,000/$10,000 $5,000/$10,000 $7,500/$15,000 $7,500/$15,000 Coinsurance 50% 50% 50% 50% Out-of-pocket maximum individual/family 11 $10,000/$20,000 $10,000/$20,000 $15,000/$30,000 $15,000/$30, Family deductible and out-of-pocket maximum apply when an individual and one or more dependents are enrolled. Once an individual meets the individual deductible amount, claims for that individual will pay. Once the family deductible is met, claims for all individuals will pay. Once an individual meets the individual out-of-pocket maximum, benefits for that individual are covered in full. Once the family out-of-pocket maximum is met, benefits for all family members are covered in full. Individual deductible and out-of-pocket maximum apply when an individual is enrolled without dependents. 2. In-network out-of-pocket maximum includes copayments, coinsurance and deductible. 3. Age and frequency schedules may apply. 4. Visit limits are combined in-and out-of-network day Inpatient hospital day limit combined for out-of-network inpatient medical, maternity, mental health, serious mental illness, substance abuse and detoxification services. 6. Amount shown reflects the copayment per day. There is a maximum of five copayments per admission. Copayment waived if readmitted within ten days of discharge for any condition. 7. Out-of-network emergency room benefits are covered at the in-network cost-sharing level. 8. To receive maximum benefits, services must be provided by a participating provider. This is a highlight of available benefits. The benefits and exclusions for in-network and out-of-network care are not the same. All benefits are provided in accordance with the group contract and out-of-network benefits booklet/certificate. 9. Non-participating preferred providers may bill you for differences between the Plan allowance, which is the amount paid by Independence Blue Cross, and the actual charge of the provider. This amount may be significant. Claims payments for non-preferred professional providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or Independence Blue Cross's fee schedule, the payment is based on 50 percent of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentage of the Plan allowance, not the actual charge of the provider. 10. Deductible does not apply to preventive services. 11. Out-of-network out-of-pocket maximum includes coinsurance only. 3

5 Members save with tier 1 hospitals Here's a listing of our tier 1 and tier 2 hospitals arranged by county. Tier assignments are accurate as of publication. Tier 1 and Tier 2 hospitals by county Tier 1 - ($) Tier 2 ($$) Bucks Aria Health Bucks County Campus Doylestown Hospital Grand View Hospital Lower Bucks Hospital St. Luke s Health Network Quakertown Campus Chester Brandywine Hospital Jennersville Hospital Phoenixville Hospital Delaware Crozer-Chester Medical Center Delaware County Memorial Hospital Springfield Hospital Taylor Hospital Montgomery Abington Memorial Hospital Holy Redeemer Hospital and Medical Center Lansdale Hospital Pottstown Memorial Medical Center Suburban Community Hospital Philadelphia Aria Health Frankford Campus Aria Health Torresdale Campus Chestnut Hill Hospital Methodist Hospital Roxborough Memorial Hospital Thomas Jefferson University Hospital Bucks St. Mary Medical Center Chester Chester County Hospital Main Line Health Paoli Hospital Delaware Main Line Health Riddle Hospital Montgomery Albert Einstein Medical Center Montgomery Campus Main Line Health Bryn Mawr Hospital Main Line Health Lankenau Medical Center Philadelphia Albert Einstein Medical Center Albert Einstein Medical Center Germantown Campus Children's Hospital of Philadelphia Fox Chase Cancer Center Hahnemann University Hospital Hospital of the University of Pennsylvania Jeanes Hospital Mercy Fitzgerald Hospital Mercy Philadelphia Hospital Nazareth Hospital Penn Presbyterian Medical Center Pennsylvania Hospital Shriner's Hospital for Children St. Christopher's Hospital for Children Temple Northeast Campus Temple University Hospital Tier assignments are accurate as of publication. They are reviewed annually and are subject to change. Members can visit ibxpress.com for the most up-to-date information. 4

6 ibx.com/largegroup Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association