Choice 100+ A defined contribution plan can help control your costs and offer your 100+ employees more options

Transcription

1 Choice 100+ A defined contribution plan can help control your costs and offer your 100+ employees more options

2 With Choice 100+, employees choose the plan that best meets their needs from the options you provide. Contact your Independence Blue Cross account executive to learn how Choice 100+ can work for you. Why Choice 100+? Choice 100+ makes managing your health care costs as easy as budgeting for your yearly office supplies. Choice 100+ defined contribution products help take the guesswork out of how much it will cost to provide comprehensive health coverage to your employees. And while you benefit from more predictable costs, your employees get the benefit of more health care coverage choices. How defined contribution works: Set your health care budget based on the fixed dollar amount you will provide your employees to spend on their health care coverage. Choose one of five benefit packages, labeled A-E, each of which includes up to 20 plans at various price points, and select your associated prescription drug coverage. Your employees use the fixed dollar amount to shop for a health care plan that makes sense for them. Your current health plan vs. Choice 100+ Your current health care plan is a one-size-fits-all approach. makes it hard to budget your health care dollars due to annual premium increases. could leave some employees less satisfied since you can only offer a few plans. Plus, employees don t know the cost of their health care, so they may not appreciate the value. Choice lets you offer a variety of health plans to your employees, who may have diverse needs. makes managing your annual budget easier because you set a fixed dollar amount to spend on each employee. increases employee satisfaction since employees choose their health care plan from a greater variety of options based on their needs. Plus, they see the true dollar value of the health care benefits you provide. You should care because your employees will be more satisfied. you will have more control over your budget. your employees will have more options and a better understanding of the value of their health care benefits. With Choice 100+, you save money on health care coverage costs while offering employees more options to meet their diverse health care needs. It s win-win! 1

3 Get started Step 1: Select your package With a range of prices and plan structures, there s a package that delivers the affordability and coverage you want. Some features to keep in mind: Hoping to avoid deductibles for your employees? Package A cost-sharing includes several copay options with no upfront deductibles. Cost important? Package E is the best option if you are looking to offer a combination of lower cost options, and includes a variety of PPO High Deductible options with integrated prescription drug coverage. Somewhere in the middle? Packages B, C, and D include plans that balance out-of-pocket costs with the level of coverage you provide. Find plan details on the following pages: A: 4 B: 5 C: 6 D: 7 E: 8 Vision: 9 10 Dental: Guardian: Step 2: Select your plan options Once you have selected a package, you can review the plan options included in the package and decide which plan options you will make available to your employees. You may choose up to five plans. Be sure you include a range of price points and benefit levels so all employees can find a good match. Types of plans available Personal Choice PPO plans provide the ultimate in flexibility. Your employees get in-network coverage across the country when using participating BlueCard PPO providers plus coverage out-of-network. Also, your employees won t need referrals to visit specialists. Keystone POS requires your employees to select a primary care physician (PCP) to coordinate all their care with network providers, but they also have the choice to seek care from out-of-network providers. Direct POS provides out-of-network coverage, but your employees select a PCP and need referrals for certain services, which helps keep costs down. Keystone HMO plans require employees to select a PCP to coordinate all of their care with network providers. Personal Choice HRAs provide employers and employees with flexibility. If you wish to fund HRAs, you determine what medical expenses and services are eligible for reimbursement. You receive tax advantages for providing your employees with a way to save on medical expenses, and you may retain any funds left in an HRA when an employee leaves the company. When you offer a Personal Choice HSA plan, your employees are eligible to open a tax-advantaged HSA. Contributions to HSAs may be made by employers, employees, or a combination of both. Either way there are tax advantages for both you and your employees. And since HSA savings can be used to pay for deductibles and coinsurance, they may help offset increased employee costs. 2

4 Take a look at how the plans compare Access to a network of more than 60,000 physicians and specialists Keystone HMO Keystone Direct POS Personal Choice Keystone POS X X X X Must choose a PCP X X X No referrals needed to visit in-network specialists In-network benefits coast-to-coast through BlueCard PPO Away from Home Care program for employees who temporarily reside outside the service area Emergency and urgent care access across the country and around the world through BlueCard PPO and BlueCard Worldwide X* X X X X X X X X X Step 3: Select your prescription drug coverage Prescription drug coverage is required for large groups. Many of the plans you can select from include integrated prescription drug coverage. If any plans do not, select an Rx coverage option from the choices associated with your package. Step 4: Select Specialty coverage Want to offer your employees even more? Choose from our suite of options for a comprehensive benefits package that includes IBC Vision Care plans, United Concordia dental plans, and Guardian Supplemental plans, including life, disability, critical illness, cancer, and accident insurance. Step 5: Promote to your employees Once you complete your selections, instruct your employees how to select and sign up for their health plan. Your employees use the fixed dollar amount to shop for a health care plan that makes sense for them from the options you have provided. *Direct POS employees need a referral from their PCP for spinal manipulations, routine X-rays, and physical/ occupational therapy. For lab work, employees should use the facility recommended by their PCP for the lowest outof-pocket costs. 3

5 Opt Option Name Deductible Individual/ Family Package A Member Cost-sharing Coinsurance Primary Care Physician Specialist Inpatient Hospital Outpatient Surgery Prescription Drug A1 DC PPO Copay Opt 1 $0 0% $10 $20 $0 $0 Select a Rider $6,600 Individual Out-ofpocket Max A2 DC DPOS Copay Opt 2 $0 0% $10 $20 $0 $0 Select a Rider $6,600 A3 DC PPO Copay Opt 3 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 A4 DC POS Copay Opt 4 $0 0% $10 $20 $0 $0 Select a Rider $6,600 A5 DC HMO Copay Opt 5 $0 0% $10 $20 $0 $0 Select a Rider $6,600 A6 DC DPOS Copay Opt 6 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 A7 DC PPO Copay Opt 7 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 A8 DC PPO Copay Opt 8 $0 0% $30 $50 $400 a day/5 days $200 Select a Rider $6,600 A9 DC PPO HSA Opt 1 aggregate* $1,500/$3,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 A10 DC POS Copay Opt 9 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 A11 DC DPOS Copay Opt 10 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 A12 DC HMO Copay Opt 11 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 A13 DC POS Copay Opt 12 $0 0% $20 $40 $150 a day/5 days $150 Select a Rider $6,600 A14 DC POS Copay Opt 13 $0 0% $30 $50 $400 a day/5 days $200 Select a Rider $6,600 A15 DC POS Copay Opt 14 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 A16 DC HMO Copay Opt 15 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 A17 DC PPO Coinsurance Opt 1 embedded** $1,000/$3,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 A18 DC PPO HRA Opt 1 embedded** $1,500/$3,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $20/$40/$60 Int $6,450 A19 DC PPO HSA Opt 2 aggregate* $2,000/$4,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 A20 DC PPO Coinsurance Opt 2 embedded** $2,000/$4,000 0% after Ded $25 $50 0% after Ded 0% after Ded Select a Rider $6,600 All options are on a Contract Year basis Ded = Deductible Int = Integrated Opt = Option Rx Options Option 1 Option 2 Option 3 Option 4 Deductible $0 $0 $0 $0 Generic $10 $15 $10 $20 Brand $40 $35 $45 $40 Non-Formulary $70 $50 $75 $60 *Aggregate Individual members: the individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. Families: The full family deductible must be met before any family member receives benefits available after deductible. Once the family out-of-pocket maximum is met, benefits are covered at 100% for the entire family for covered services received from an in-network provider. **Embedded The individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. 4

6 Opt Option Name Deductible Individual/ Family Package B Member Cost-sharing Coinsurance Primary Care Physician Specialist Inpatient Hospital Outpatient Surgery Prescription Drug B1 DC PPO Copay Opt 8 $0 0% $30 $50 $400 a day/5 days $200 Select a Rider $6,600 Individual Out-ofpocket Max B2 DC PPO HSA Opt 1 aggregate* $1,500/$3,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 B3 DC POS Copay Opt 9 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 B4 DC DPOS Copay Opt 10 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 B5 DC HMO Copay Opt 11 $0 0% $15 $30 $250 a day/5 days $125 Select a Rider $6,600 B6 DC POS Copay Opt 12 $0 0% $20 $40 $150 a day/5 days $150 Select a Rider $6,600 B7 DC POS Copay Opt 13 $0 0% $30 $50 $400 a day/5 days $200 Select a Rider $6,600 B8 DC POS Copay Opt 14 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 B9 DC HMO Copay Opt 15 $0 0% $20 $40 $400 a day/5 days $200 Select a Rider $6,600 B10 DC PPO Coinsurance Opt1 embedded** $1,000/$3,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 B11 DC PPO HRA Opt 1 embedded** $1,500/$3,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $20/$40/$60 Int $6,450 B12 DC PPO HSA Opt 2 aggregate* $2,000/$4,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 B13 DC PPO Coinsurance Opt 2 embedded** $2,000/ $4,000 0% after Ded $25 $50 0% after Ded 0% after Ded Select a Rider $6,600 B14 DC POS Coinsurance Opt 3 embedded** $1,000/$3,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 B15 DC PPO HSA Opt 3 aggregate* $1,500/$3,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 B16 DC PPO Coinsurance Opt 4 embedded** $2,000/$6,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 B17 DC POS Coinsurance Opt 5 embedded** $1,000/$3,000 20% after Ded $35 $60 20% after Ded 20% after Ded Select a Rider $6,600 B18 DC PPO HSA Opt 4 aggregate* $2,500/$5,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 B19 DC PPO HSA Opt 5 aggregate* $2,000/$4,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 B20 DC PPO HSA Opt 6 aggregate* $2,500/$5,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/60 Int $6,450 All options are on a Contract Year basis. Ded = Deductible Int = Integrated Opt = Option Rx Options Option 1 Option 2 Option 3 Option 4 Deductible $0 $0 $0 $0 Generic $10 $15 $10 $20 Brand $40 $35 $45 $40 Non-Formulary $70 $50 $75 $60 *Aggregate Individual members: the individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider.. Families: The full family deductible must be met before any family member receives benefits available after deductible. Once the family out-of-pocket maximum is met, benefits are covered at 100% for the entire family for covered services received from an in-network provider. **Embedded The individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. 5

7 Opt Option Name Deductible Individual/ Family Package C Member Cost-sharing Coinsurance Primary Care Physician Specialist Inpatient Hospital Outpatient Surgery Prescription Drug C1 DC POS Coinsurance Opt 3 embedded** $1,000/$3,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 Individual Out-ofpocket Max C2 DC PPO HSA Opt 3 aggregate* $1,500/$3,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 C3 DC PPO Coinsurance Opt 4 embedded** $2,000/$6,000 20% after Ded $20 $40 20% after Ded 20% after Ded Select a Rider $6,600 C4 DC POS Coinsurance Opt 5 embedded** $1,000/$3,000 20% after Ded $35 $60 20% after Ded 20% after Ded Select a Rider $6,600 C5 DC PPO HSA Opt 4 aggregate* $2,500/$5,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 C6 DC PPO HSA Opt 5 aggregate* $2,000/$4,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 C7 DC PPO HSA Opt 6 aggregate* $2,500/$5,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 C8 DC PPO HRA Opt 2 embedded** $2,000/$4,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $20/$40/$60 Int $6,450 C9 DC POS Coinsurance Opt 6 embedded** $2,000/$6,000 20% after Ded $40 $50 20% after Ded 20% after Ded Select a Rider $6,600 C10 DC PPO HSA Opt 7 aggregate* $2,500/$5,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 C11 DC DPOS Coinsurance Opt 7 embedded** $3,500/$10,500 30% after Ded $20 $40 30% after Ded 30% after Ded Select a Rider $6,600 C12 DC PPO HSA Opt 8 aggregate* $2,500/$5,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 C13 DC PPO HSA Opt 9 aggregate* $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 C14 DC PPO HRA Opt 3 embedded** $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 C15 DC PPO HSA Opt 10 aggregate* $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 All options are on a Contract Year basis Ded = Deductible Int = Integrated Opt = Option Rx Options Option 1 Option 2 Option 3 Option 4 Deductible $0 $0 $0 $0 Generic $10 $15 $10 $20 Brand $40 $35 $45 $40 Non-Formulary $70 $50 $75 $60 *Aggregate Individual members: the individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider.. Families: The full family deductible must be met before any family member receives benefits available after deductible. Once the family out-of-pocket maximum is met, benefits are covered at 100% for the entire family for covered services received from an in-network provider. **Embedded The individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. 6

8 Opt Option Name Deductible Individual/ Family Package D Member Cost-sharing Coinsurance Primary Care Physician Specialist Inpatient Hospital Outpatient Surgery Prescription Drug D1 DC PPO HRA Opt 2 embedded** $2,000/$4,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $20/$40/$60 Int $6,450 Individual Out-ofpocket Max D2 DC POS Coinsurance Opt 6 embedded** $2,000/$6,000 20% after Ded $40 $50 20% after Ded 20% after Ded Select a Rider $6,660 D3 DC PPO HSA Opt 7 aggregate* $2,500/$5,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 D4 DC DPOS Coinsurance Opt 7 embedded** $3,500/$10,500 30% after Ded $20 $40 30% after Ded 30% after Ded Select a Rider $6,660 D5 DC PPO HSA Opt 8 aggregate* $2,500/$5,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 D6 DC PPO HSA Opt 9 aggregate* $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $5/$20/$45 Int $6,450 D7 DC PPO HRA Opt 3 embedded** $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 D8 DC PPO HSA Opt 10 aggregate* $3,000/$6,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 D9 DC PPO Coinsurance Plus Opt 1 embedded** $2,000/$4,000 10% after Ded $40 after Ded $60 after Ded 10% after Ded 10% after Ded $20/$40/$70 Int $6,600 D10 DC PPO HSA Opt 11 aggregate* $3,000/$6,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 D11 DC PPO HSA Opt 12 aggregate* $2,500/$5,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $20/$40/$60 Int $6,450 D12 DC PPO HSA Opt 13 aggregate* $3,500/$7,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 D13 DC PPO HRA Opt 4 embedded** $4,500/$9,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 D14 DC PPO HSA Opt 14 aggregate* $3,000/$6,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 D15 DC PPO Coinsurance Plus Opt 2 embedded** $3,000/$6,000 0% after Ded $30 after Ded $50 after Ded $500 a day/5 days after Ded All options are on a Contract Year basis Ded = Deductible Int = Integrated Opt = Option $500 after Ded $20/$40/$70 Int $6,600 Rx Options Option 1 Option 2 Option 3 Option 4 Deductible $0 $0 $250 $250 Generic $10 $20 $10 $20 Brand $45 $40 $45 $40 Non-Formulary $75 $60 $75 $60 Deductible is waived for generic drugs *Aggregate Individual members: the individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider.. Families: The full family deductible must be met before any family member receives benefits available after deductible. Once the family out-of-pocket maximum is met, benefits are covered at 100% for the entire family for covered services received from an in-network provider. **Embedded The individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. 7

9 Opt Option Name Deductible Individual/ Family Package E Member Cost-sharing Coinsurance Primary Care Physician Specialist Inpatient Hospital Outpatient Surgery Prescription Drug E1 DC PPO Coinsurance Plus Opt 1 embedded ** $2,000/$4,000 10% after Ded $40 after Ded $60 after Ded 10% after Ded 10% after Ded $20/$40/$70 Int $6,600 Individual Out-ofpocket Max E2 DC PPO HSA Opt 11 aggregate* $3,000/$6,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 E3 DC PPO HSA Opt 12 aggregate* $2,500/$5,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $20/$40/$60 Int $6,450 E4 DC PPO HSA Opt 13 aggregate* $3,500/$7,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $5/$20/$45 Int $6,450 E5 DC PPO HRA Opt 4 embedded** $4,500/$9,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $20/$40/$60 Int $6,450 E6 DC PPO HSA Opt 14 aggregate* $3,000/$6,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $5/$20/$45 Int $6,450 E7 DC PPO Coinsurance Plus Opt 2 embedded** $3,000/$6,000 0% after Ded $30 after Ded $50 after Ded $500 a day/5 days after Ded $500 after Ded $20/$40/$70 Int $6,600 E8 DC PPO HSA Opt 15 aggregate* $3,000/$6,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $20/$40/$60 Int $6,450 E9 DC PPO HSA Opt 16 aggregate* $3,500/$7,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $15/$35/$50 Int $6,450 E10 DC PPO HSA Opt 17 aggregate* $4,000/$8,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $15/$35/$50 Int $6,450 E11 DC PPO HSA Opt 18 aggregate* $5,000/$10,000 0% after Ded 0% after Ded 0% after Ded 0% after Ded 0% after Ded $15/$35/$50 Int $6,450 E12 DC PPO HSA Opt 19 aggregate* $4,000/$8,000 20% after Ded 20% after Ded 20% after Ded 20% after Ded 20% after Ded $15/$35/$50 Int $6,450 E13 DC PPO HSA Opt 20 aggregate* $5,000/$10,000 10% after Ded 10% after Ded 10% after Ded 10% after Ded 10% after Ded $15/$35/$50 Int $6,450 E14 DC PPO Coinsurance Plus Opt 3 embedded** $3,000/$6,000 10% after Ded $40 after Ded $60 after Ded 10% after Ded 10% after Ded $20/$40/$70 Int $6,600 E15 DC PPO Coinsurance Plus Opt 4 embedded** $4,000/$8,000 10% after Ded $40 after Ded $60 after Ded 10% after Ded 10% after Ded $20/$40/$70 Int $6,600 All options are on a Contract Year basis Ded = Deductible Int = Integrated Opt = Option All Package E options include integrated prescription drug coverage. *Aggregate Individual members: the individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider.. Families: The full family deductible must be met before any family member receives benefits available after deductible. Once the family out-of-pocket maximum is met, benefits are covered at 100% for the entire family for covered services received from an in-network provider. **Embedded The individual deductible must be met before the member receives benefits available after deductible. Once the individual out-of-pocket maximum is met, benefits are covered 100% for that member for covered services received from an in-network provider. The summaries in this brochure represent only a partial listing of benefits and exclusions of the Keystone Health Plan East and Personal Choice programs. These managed care plans may not cover all of your health care expenses. Read your contract, member handbook and/or benefit booklet carefully to determine which health care expenses are covered. If you need more information please call your Independence Blue Cross account executive. 8

10 Add more value with IBC Vision Care Every health plan in the Choice 100+ product suite can be upgraded to include a comprehensive vision plan offered by IBC 3, which gives employees access to routine eye care, frames, and lenses. IBC Vision Care is administered by Davis Vision 1, an independent company. The network includes more than 37,000 ophthalmologists, optometrists, and regional and national retailers, including Visionworks 2 optical retail centers. IBC Vision Care Vision benefits help reduce your company s overall health care spending and increase employee productivity. When your employees visit their vision provider, they are getting more than just their eyes checked. Eye exams can help detect more serious medical conditions like diabetes, hypertension, or heart disease. A comprehensive plan can give employees access to timely treatment and covered services that will help paint a picture of their overall health. IBC Vision Care gives you: Affordability: low monthly premiums Outstanding customer service: available to answer your questions seven days a week Integrated care management: disease management and reporting capabilities help determine early detection of costly diseases like glaucoma, diabetes, and cataracts With IBC Vision Care plans, members can take advantage of: Unlimited frame selection Fully-covered designer frame brands One-year frame warranty Contact lens replacement through LENS123 Value-added vision correction discounts Online account management through ibxpress.com 1. IBC Vision is administered by Davis Vision, an independent company. 2. An affiliate of Independence Blue Cross has a financial interest in Visionworks. You may choose to include vision coverage as a voluntary or group-sponsored benefit. You can offer one, two, or all three vision coverage plans. Group-sponsored coverage requires the member to select a vision coverage. Voluntary coverage allows the member the option to choose whether or not to elect one of the vision coverages as an add-on provided with each medical plan you offer. 3. IBC vision benefits are underwritten by QCC Insurance Company. 9

11 Option I PPO Vision Care 100 Option II PPO Vision Care 150 Option III PPO Vision Care 180 Option IV PPO Vision Care 100 Option V PPO Vision Care 150 Funding Type Employer Paid Employer Paid Employer Paid Voluntary Voluntary Voluntary Frequency Eye examination 24 months 12 months 12 months 12 months 12 months 12 months Lenses 24 months 12 months 12 months 12 months 12 months 12 months Frame 24 months 12 months 24 months 24 months 12 months 24 months Copayments Eye examination $0 $0 $10 $10 $0 $10 Spectacle Lenses $0 $0 $25 $25 $0 $25 Hardware Benefits Option VI PPO Vision Care 180 Eyeglass Benefit - Frames Participating provider frame collection: $100 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: $15 copayment Premier Level: $40 copayment Participating provider frame collection: $150 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: Included Premier Level: Included Participating provider frame collection: $130 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: Included Premier Level: $25 copayment Participating provider frame collection: $100 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: $15 copayment Premier Level: $40 copayment Participating provider frame collection: $150 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: Included Premier Level: Included Participating provider frame collection: $130 allowance, plus a 20% discount Davis Vision Frame Collection: Fashion Level: Included Designer Level: Included Premier Level: $25 copayment Contact Lenses (in lieu of eyeglasses) Up to $100 allowance, plus a 15% discount Up to $150 allowance, plus a 15% discount Up to $130 allowance, plus a 15% discount Up to $100 allowance, plus a 15% discount Up to $150 allowance, plus a 15% discount Up to $130 allowance, plus a 15% discount Additional Visionworks frame option N/A N/A Up to $180 allowance at any Visionworks location nationwide, plus a 20% discount on any overage N/A N/A Up to $180 allowance at any Visionworks location nationwide, plus a 20% discount 10

12 United Concordia Dental Oral wellness is about more than just a smile it s about the connection between dental and overall wellness. United Concordia is focused on providing cost-effective, responsive dental products to meet the always-changing needs of members. As dental benefits and wellness specialists, United Concordia focuses on helping members cover expenses like preventive dental care, restoration, and dental emergencies. United Concordia research shows health care costs are significantly lower when patients with some chronic conditions receive ongoing treatment and maintenance for gum disease. By adding dental insurance to your package, you can help improve your employees health and reduce their overall medical costs. 1 Products available PPO plan highlights: Discounts available for non-covered services from participating network providers Members can visit any licensed dentist, but will get the greatest value when they use a dentist who participates in the network Supported by one of the nation s largest networks with more than 102,900 unique in-network dentists and more than 283,100 access points 2 DHMO plan highlights: Cost-effective alternative to PPO plans Members must select a Primary Dental Office 3 and visit a network dentist to have coverage Primary dentists coordinate all care, including specialty referrals Preventive services covered with little or no copayment You may choose to include dental coverage as a voluntary or group-sponsored benefit. Group-sponsored allows you to offer your employees just the DHMO, just one of the three PPO options, or both the DHMO and one of the PPO options. Group-sponsored coverage requires the member to select a dental coverage. If you are offering coverage as voluntary, you must offer the DHMO and one of the PPO options. Voluntary allows the member the option to choose whether or not to elect one of the dental coverages as an add-on. You may not offer different PPO plans with different medical plans. Dental plans are administered by United Concordia Companies, Inc., and underwritten by United Concordia Life and Health Insurance Company. Administrative and claims offices located at 4401 Deer Path Road, Harrisburg, PA ( ). Policies have exclusions and limitations which may affect any benefits payable. See policy or your account representative for specific provisions and eligibility details. United Concordia dental programs are underwritten by United Concordia, an independent company. UCD does not offer Blue Cross products or services. UCD is solely responsible 1 United Concordia, Oral Health Study (2014). 2 United Concordia internal data, Access points are sites where network dentists see patients. Some dentists may be available at more than one access point. 3 Limitations and exclusions apply. 11

13 Covered Services Concordia Flex PPO Plan Option One Concordia Flex PPO Plan Option Two Concordia Flex PPO Plan Option Three Concordia Plus DHMO In- & Out-of-Network In- & Out-of-Network In- & Out-of-Network In-Network only Member Cost-Sharing Preventive & Diagnostic Services (Exams, Cleanings, Fluoride treatments, X-rays, Palliative) Basic Services (Fillings, Oral Surgery, Endodontics, Periodontics) Major Services (Crowns, Inlays, Onlays, Bridges, Dentures) Orthodontic Services (up to age 19) Deductible (waived for Preventive & Diagnostic) Annual Maximum Benefit 0%*** 0%*** 0%*** $0 20% 20% 20% $0-$261** Not covered* 50% 50% $0-$392** Not covered* Not covered* 50% $343-$3,540** $50 individual/ $150 family $50 individual/ $150 family $50 individual/ $150 family none $1,000 $1,500 $1,500 none Learn more about how Choice 100+ can work for you. Contact your Independence Blue Cross account executive today. Orthodontic Lifetime Maximum Member Cost-Sharing n/a n/a $1,500 none Network Concordia Advantage Concordia Advantage Concordia Advantage Concordia Plus DHMO No matter what package you select, all plans include 24/7 access to the benefits management tools of ibxpress.com * Discounts are available for non-covered services from participating network dentists. ** Covered services and copayments are listed in the Schedule of Benefits. ***Reimbursements are based on United Concordia s maximum allowable charges (MAC). Network dentists agree to accept United Concordia s allowances as payment in full for covered services. Non-network dentists may balance bill members. 12

14 Guardian supplemental insurance Independence Blue Cross (Independence) has collaborated with The Guardian Life Insurance Company of America (Guardian ), one of the nation s largest mutual life insurers and an independent leading provider of employee benefits, to offer a wider range of supplemental plans. The combined strength and expertise of Independence and Guardian, both market leaders in their respective industries, provides you with brands you can trust and the insurance products employees need, including: Life/ADD. Group Term and Supplemental Term insurance Disability. Long-Term and Short-Term Disability coverage for employees Accident. Provides benefit payment for services or procedures due to a covered accident, such as X-rays and ambulance services, regardless of what is covered by the employee s medical policy. A key differentiator of this product is a special benefit: enhanced coverage for children injured in organized sports Critical illness. Cancer, heart attack, and stroke for example. Provides a lump sum benefit payment to help employees pay for out-of-pocket medical costs and non-medical costs Now you can complement your health benefits plan with life, disability, accident, and critical illness insurance to help you and your employees manage risks and contain costs when the unexpected happens. Life Insurance Employer Funded Voluntary Type Flat Amounts Multiples of salary Increments Choice You choose from options below You choose from options below Employee can choose from all options; Spouse and child options available Employee benefit $50,000 or $100,000 1 times salary to a maximum of $100,000 or 2 times salary to a maximum of $300,000 $10,000 - $500,000 in $10,000 increments Guarantee issue Employees under age 65 Employees under age 65 Employees under age 65 are eligible for $200,000 Accidental death & dismemberment 100% of life benefit 100% of life benefit 100% of life benefit LifeAssist Yes Yes Yes Guardian s Life and Accident and Disability programs are underwritten by Guardian, an independent company. Guardian does not offer Blue Cross products or services. Guardian is solely responsible. Products are underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Some products may not be available in all states. Policy limitations and exclusions apply. Optional riders and/ or features may incur additional costs. Documents are the final arbiter of coverage. Life Insurance Policy Form #GP-1-R-EPOPT-96 et al.; Critical Illness Policy Form #GC-CI-11 et al.; Long-Term Disability Policy Form #GP-1-LTD07-1.0, et al.; Short-term Disability Policy Form #GP-1-STD07-1.0, et al.; Accident Insurance Policy Form #GP-1-AC-IC-12 et al.; Cancer Insurance Policy Form #GP-1-CAN-IC-12 et al. # (exp. 11/17) Accelerated Life Yes Yes Yes Portable & Convertible Yes Yes Yes Short Term Disability Insurance Employer Funded Voluntary Coverage amount 66.67% of salary 60% of salary 60% of salary Maximum benefit $1,500 per week $1,500 per week $1,500 per week Elimination period 15 day accident/15 day illness 15 day accident/15 day illness Maximum duration 13 weeks 13 weeks 13 weeks Guarantee issue Yes Yes Yes Pre-existing condition exclusion 15 day accident/15 day illness No No 3 months look back; 12 months after 2 week limitation 13

15 Long Term Disability Insurance Employer Funded Voluntary Plan Standard Enhanced Standard Enhanced Choice Coverage amount You choose from options below 66.67% or 60% of salary You choose from options below 66.67% or 60% of salary You choose one option You choose one option 60% of salary 60% of salary Maximum benefit $7,500 or $10,000 $7,500 or $10,000 $7,500 $7,500 Elimination period 90 days 90 days 90 days 90 days Payment period Special limitations While unable to work in own occupation for first 2 years; unable to work in any occupation through Social Security non-retirement age 24 month benefit limit for mental health and substance abuse While unable to work in own occupation 24 month benefit limit for mental health and substance abuse While unable to work in own occupation for first 2 years; unable to work in any occupation through Social Security non-retirement age 24 month benefit limit for mental health and substance abuse Guarantee issue Yes Yes Yes Yes While unable to work in own occupation 24 month benefit limit for mental health and substance abuse Pre-existing condition exclusion 3 months look back; 12 months after exclusion 3 months look back; 12 months after exclusion 3 months look back; 12 months after exclusion 3 months look back; 12 months after exclusion Accident Voluntary Plan Value Advantage Premier Accident coverage type Off job Off job Off job ER/Urgent care $150/$50 $175/$75 $200/$100 Hospital/ICU admission $750/$1,500 $1,000/$2,000 $1,250/$2,500 Hospital/ICU stay $175/$350 per day $225/$450 per day $250/$500 per day Spouse and child coverage Accidental death and dismemberment Yes Yes Yes Employee - $10,000 Spouse - $5,000 Child - $5,000 Employee - $25,000 Spouse - $12,500 Child - $5,000 Employee - $50,000 Spouse - $25,000 Child - $5,000 Child organized sport 20% increase to child benefit 20% increase to child benefit Portable Yes Yes Yes 20% increase to child benefit Critical Illness Voluntary Type Flat Amounts Employee benefit $2,500, $5,000, $7,500, $10,000 or $15,000 Payout Upon diagnosis Guarantee issue Employees under age 65 Spouse and child coverage Portable 50% of employee election for spouse. 25% of employee election for child Yes 14

16 Manage your plan with ibxpress.com It s easy to stay to manage your accounts and payments with ibxpress.com. Your employer portal allows you to: Add or delete employees from your plan View coverage history or update information View current and prior invoices Receive and pay invoices online Get monthly billing reminders Your employees can also access ibxpress.com, which is loaded with wellness tools and information to help your employees stay healthy. Whether they want to research symptoms, complete a health assessment, engage in an online lifestyle improvement program, or record and track important health information, ibxpress.com can help. Important information Choice 100+ product guidelines You must choose a Select Drug plan option. If offering vision or dental, you must offer this coverage with all Choice 100+ plans you select. You may not offer the same medical plan with different drug plans. Choice 100+ products cannot be combined with non-choice 100+ products. Employer contribution requirement* For contributory plan offerings, you must contribute a minimum of 25 percent of the calculated gross monthly premium or 75 percent of the single tier rate of the lowest cost option offered. Off-anniversary benefit change Upgrades and downgrades will only be allowed on anniversary. Participation requirements A minimum of 75 percent participation is required. Billing You will receive a total monthly bill from each insurance carrier. It s your responsibility to collect the employee s portion and submit a full payment to Independence and any partners. High deductible health plan funding limitation Per the Affordable Care Act regulations, employers should not fund more or less than the federally mandated standards for funding employee deductibles. The high deductible plan design selected will specify the funding requirement; please refer to each plan design for specific funding requirements. * As permitted by the state and federal laws and regulations. Submission guidelines All offerings are subject to final underwriting review and acceptance. Additional guidelines and policies may apply. This document is for informational purposes only and is not intended to be all-inclusive. 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 (12/15)