2006 Health Insurance Brochure HMO. ARHealth PPO POS. A R Health

Transcription

1 Arkansas Public School Retirees 2006 Health Insurance Brochure ARHealth HMO PPO POS A R Health SM

2 COMMON QUESTIONS Need a Health Insurance Card How do I Add/Drop members from my contract? What do I do with Student Verification Forms? Need to change my address/telephone number My Social Security Number, name, or birthdate is wrong on my identification card Need to change my Primary Care Physician (PCP) Need to know if a provider is in your network How do I appeal a claim denial? Need to check claim status or have other claims related issue Need to know why a prescription took a higher copay or was not covered or need a new prescription card How do I get Prior-Approval for a prescription? WHO CAN HELP Contact EBD (877) X X X X X X Call Customer Service (800) ARBenefits Web site or X X X X X X X X X X X X X X X Customer Service customerservicepse@arkbluecross.com X X Call NMHC Rx (800) Table of Contents Welcome Letter Public School Retiree Rates Self Service Features ARHealth Senior Benefits About ARHealth Senior ARHealth Benefits About ARHealth About the Traditional HMO and POS HMO and POS Benefit Summary About the Traditional PPO Plan PPO Benefit Summary

3 A R Health SM Dear Arkansas Public School Retirees: Introducing ARHealth! Arkansas State and Public School Employee Benefits Division (EBD) and Health Advantage have partnered to offer two health plans explicitly for retirees ARHealth and ARHealth Senior. WHY? Retirees have different needs than active employees. Retirees have the freedom to travel, in-state and around the country; some retirees have special medical needs; other retirees have developed relationships with specialists and don t always need to consult a primary care physician. If Medicare is not your primary coverage, the ARHealth plan features are as follows: You do not have to select a primary care physician (PCP). This plan has lower copayments and coinsurance than the traditional HMO and POS plans. If you are on the ARHealth plan, you will have preventive services covered at 100% and a vision exam every 24 months for a $30 copay. If Medicare is not your primary coverage, you can use any physician in the Health Advantage network without a referral. If Medicare is not your primary coverage and you are traveling out of the state and need to see a physician, you can use any physician in the BlueCard traditional network. However, if you are scheduling services out of state, you will need to have an out-of-network referral approved by Health Advantage. Your prescription drug benefit, mental health benefit and other medical benefits will remain the same. To select this plan, you will have to enroll on-line or submit an application to Employee Benefits Division. If you do not enroll, you will remain in your current plan. Enrollment forms are available in your Enrollment Guide from Employee Benefits Division. If Medicare is your primary coverage, the ARHealth Senior plan features are as follows: You do not have to enroll in this plan, you will be automatically enrolled. You do not have to select a primary care physician (PCP). You can see any physician anywhere. You can get a vision exam every 24 months for only a $30 copayment. The premium for the ARHealth Senior plan is much lower than any other Medicare supplement. The ARHealth Senior plan will pay supplemental to your Medicare A and B. (See benefit chart on page 5.) You will not have a prescription drug card or separate mental health coverage as you have now. Your mental health benefits are covered under your Medicare policy and we encourage you to enroll with Medicare Part D for prescription drug coverage. (See benefit description on page 5.) If you have any questions about these plans, please call Health Advantage Customer Service at or Employee Benefits Customer Service at or Best regards, Barbara Melugin Manager, Arkansas State and Public School Accounts 1

4 Arkansas School Retirees Rates 2006 Retirees Not Medicare Eligible Total Monthly Cost Less State Contribution Total Monthly Employee Cost Retiree Not Medicare Eligible Only Health Advantage HMO $ ($ 78.57) $ Health Advantage POS $ ($ 78.57) $ ABCBS PPO $ ($ 78.57) $ ARHealth $ ($ 78.57) $ Retiree Not Medicare Eligible + Spouse Not Medicare Health Advantage HMO $1, ($ 78.57) $1, Health Advantage POS $1, ($ 78.57) $1, ABCBS PPO $1, ($ 78.57) $1, ARHealth $1, ($ 78.57) $1, Retiree Not Medicare Eligible + Child(ren) Health Advantage HMO $ ($ 78.57) $ Health Advantage POS $ ($ 78.57) $ ABCBS PPO $1, ($ 78.57) $ ARHealth $ ($ 78.57) $ Retiree & Spouse Not Medicare Eligible + Child(ren) Health Advantage HMO $1, ($ 78.57) $1, Health Advantage POS $1, ($ 78.57) $1, ABCBS PPO $1, ($ 78.57) $1, ARHealth $1, ($ 78.57) $1, Retiree Not Medicare Eligible + Spouse Medicare Health Advantage HMO $ ($ 78.57) $ Health Advantage POS $ ($ 78.57) $ ABCBS PPO $ ($ 78.57) $ ARHealth $ ($ 78.57) $ Retiree Not Medicare Eligible + Spouse Medicare Eligible + Child(ren) Health Advantage HMO $1, ($ 78.57) $ Health Advantage POS $1, ($ 78.57) $ ABCBS PPO $1, ($ 78.57) $1, ARHealth $1, ($ 78.57) $ ARHealth Retirees Medicare Eligible Without Rx Medical Prescription Drug Total Monthly Premium Less State Contribution Total Monthly Employee Cost Retiree Medicare Eligible Only $ Not Offered $ ($ 78.57) $ Retiree Medicare Eligible and Spouse not Medicare $ $ $ ($ 78.57) $ Retiree Medicare Eligible and Child(ren) $ $ $ ($ 78.57) $ Retiree Medicare Eligible and Spouse Not Medicare and Child(ren) $ $ $1, ($ 78.57) $ Retiree Medicare Eligible and Spouse Medicare $ Not Offered $ ($ 78.57) $ Retiree Medicare Eligible and Spouse Medicare and Child(ren) $ $ $ ($ 78.57) $ *Please note the Rates stated above are set by the Arkansas State and Public School Life and Health Insurance Board. 2

5 SELF-SERVICE FEATURES If your busy lifestyle demands all your time during the normal 8 to 5 customer service hours, we have two self-service features that are available 24 hours a day, seven days a week. My Blueprint is an online, self-service center for members of Health Advantage and Arkansas Blue Cross. We strive to meet customer expectations by providing members with this convenient self-help access to their health plan information 24 hours a day, seven days a week. For Health Advantage members, the self-service center is available on Arkansas Blue Cross members should go to Register today to access My Blueprint. Click on the First-Time User link and follow the instructions to create your own log-on and password, giving you immediate secure access to your information. What can I do by using My Blueprint? o Check member eligibility o Check status of claims and claim history o Update My Blueprint information o Medical Cost & Quality Calculator (New) o o o o Order replacement ID card View Explanation of Benefits Access HealthConnect Blue Generic Drug Calculator (New) My BlueLine, the interactive voice response system, recognizes speech patterns to answer questions when you call the customer service telephone number If you are calling during business hours, at any time you can press 1 to use My BlueLine or press 2 to immediately be routed to the next available customer service representative. If you choose to use My BlueLine, you simply respond to the questions asked by the system with no buttons to push getting your questions answered quickly and easily. What information is available by using My BlueLine? o Get answers to benefit questions o Order a new ID card o Check status of claims o Order a claim form With HealthConnect Blue, members who do not have Medicare as their primary insurance have access to a Health Coach day or night by calling or through the HealthConnect Blue link from My Blueprint at or When should you call? When you re looking for general health information When you re admitted to or discharged from the hospital When you want more information about your disease or illness A Health Coach can offer information, support and help you work with your doctor to make confident health decisions that are right for you. Being well informed is the first step in taking charge of your health. There s no better place to start than with a HealthConnect Blue Health Coach. Call today! 3

6 ARHealth Senior Benefit (For Medicare Primary members) Medicare Does Not Pay Part A Hospital Services Inpatient Hospital Deductible/Benefit Period Per Day Copayment days in Hospital Per Day Copayment days in Hospital (Lifetime Reserve) Percent of Medicare Allowable Expenses (Additional 365 days after hospital benefits stop) Blood Deductible First 3 pints (if deductible is not met by blood replacement) ARHealth Senior Benefit ARHealth will pick up the Part A deductible and copayment and 100% of Medicare-allowable expenses for an additional 365 days after Medicare hospital benefits stop. ARHealth will pick up the Blood Deductible Copayment Per Day Days in Skilled Nursing Facility Part B Physician and Medical Services Part B Deductible Medicare Approved amounts applied to Part B coinsurance (20% medical/50% mental health) Part B Excess Charges Additional Benefits Vision Care from Participating Health Advantage Physician ARHealth will pay the copayment for Skilled nursing for days ARHealth will pick up the Medicare Part B deductible and 20% Part B coinsurance. ARHealth will pay 100% of Part B excess charges 1 exam covered every 24 months with a $30 Copayment Public School Retirees with Medicare are advised to enroll in Medicare Part D when it becomes available. After January 1, 2006, Medicare Primary members will no longer have prescription benefits. Here s a brief description of the Medicare Part D Standard Drug Benefit If your 2006 drug costs are between: You Pay: Up to a maximum of: Total Costs (excluding monthly Part D Plan Premiums: $0 - $ % $250 $250 $251 - $2,250 25% $500 $750 $2,251 - $5, % $2,850 $3,600 Over $5,100 5% (or $2 generic / $5 brand-name) No limit $3, % (or $2/$5 copayments) of drug costs above $5,100 4

7 About ARHealth Senior (For Medicare Primary members) Health Advantage is excited to be the claims administrator for the new ARHealth and ARHealth Senior plans. These plans are available to all Arkansas State and Public School Retirees and their dependents. Who will be on ARHealth Senior? 1. Medicare Primary retirees will be automatically enrolled in ARHealth Senior. 2. Medicare Primary Spouses of Retirees without Medicare who select the ARHealth plan. 3. Retirees who become Medicare Primary mid-year will be automatically moved to ARHealth Senior at that time. What do I need to know about ARHealth Senior? 1. Medicare Primary members will no longer have prescription drug coverage. The start of the plan year has been changed to January 1 st to coincide with the new Medicare Part D prescription drug coverage that will be available to Medicare eligible members effective January 1, It is strongly recommended that Medicare primary retirees consider taking out Medicare Part D when it is available. 2. Non-Medicare spouses and dependents of Medicare Primary retirees will still have prescription drug benefits through NMHCRX, and will be enrolled in ARHealth. 3. Retirees and spouses who are eligible for Medicare must obtain Medicare Parts A and B to participate in any of the retirement plans. 4. The benefits for ARHealth Senior are comparable to Medigap Plan F, with lower monthly premiums. Since Health Advantage is the claims administrator for this plan, will I have to use Health Advantage Network physicians and facilities? No. Medicare Primary members may see any provider of their choice. There is no provider network to worry about. However, dependents that are on ARHealth will be using the Health Advantage network to receive in-network benefits. Will this plan cover medical expenses outside the United States? ARHealth Senior will cover medical care within the United States, but there is no medical coverage (even for medically necessary emergency care) in a foreign country. What about my life insurance? Retirees can continue their life insurance in retirement regardless of whether you enroll in COBRA, one of the state sponsored health plans, or have no health insurance at all. Please check with USAble Life at or refer to your Enrollment Guide from Employee Benefits Division (EBD) for complete details. Your enrollment period has been extended to November 15th. 5

8 A R Health SM For Retirees and their dependents Without Medicare In-Network Out-of-Network Deductible - Individual None None $500 Deductible - Family None None $1,000 Lifetime Maximum None None $1,000,000 Copayment Coinsurance Coinsurance Annual Coinsurance Limit - Unlimited $1,250 $4,000 Individual Annual Coinsurance Limit - Family Unlimited $2,500 $8,000 Preventive Care Services Physical Exams, Adults (visit only) $0 0% 30% after deductible Well Baby/Child Care $0 0% 30% after deductible Children's Immunizations $0 0% 30% after deductible Annual Gynecological Visit $0 0% 30% after deductible Routine Mammogram $0 0% 30% after deductible Vision screenings 1 every 24 mos. $30 copayment 0% Not covered Preventive Dental Services Not covered Not covered Not covered Physician Services PCP Visits $20 0% 30% after deductible Specialist Visits $30 0% 30% after deductible Inpatient Medical Care $0 15% 30% after deductible Outpatient Surgical Care $0 15% 30% after deductible Allergy Services Specialist Visits $30 0% 30% after deductible Injections $0 15% 30% after deductible Outpatient Services Diagnostic Testing (lab and X-ray) $0 15% 30% after deductible Surgical Services (facility charge) $100 15% 30% after deductible Emergency Room Visit $100 (waived if admitted to same hospital) 15% $100 copayment 15% coinsurance Urgent Care Center/ER After-hours $100 (waived if admitted to 15% $100 copayment 15% Clinic Visit Observation Services same hospital) $100 (waived if admitted to same hospital) coinsurance 15% $100 copayment 15% coinsurance Ambulance (Land or Air) ($1,000 maximum per year for $0 15% 30% after deductible transport services) Home Health Services (120 visits per year) $0 20% 30% after deductible Home Infusion IV, Drugs/Solutions $0 20% 30% after deductible Physical, Occupational, Speech Therapy, Cardiac Rehab and Chiropractic Services (60 visits per member per year combined) $0 20% 30% after deductible 6

9 A R Health Inpatient Hospital (unlimited days at semiprivate room rate) SM For Retirees and their dependents Without Medicare In-Network Copayment $400 copayment per admission (maximum: 3 copays per year, per person) In-Network coinsurance Out-of network coinsurance 15% 30% after deductible Inpatient Rehab (limited to 60 days per year) $400 copayment per admission (maximum: 3 copays per year, per person) 15% 30% after deductible Maternity Services * Initial Physician Visit $20 0% 30% after deductible OB Services $0 15% 30% after deductible Hospital Services (facility fee) $400 copayment per 15% 30% after deductible admission Inpatient Physician Services $0 15% 30% after deductible Outpatient Diagnostic Testing (lab $0 15% 30% after deductible and X-ray) Transplants (specific transplants covered subject to contract-year limits when authorized in advance by Health Advantage) $400 inpatient hospital copayment 0% not covered Durable Medical Equipment ($10,000 maximum per year) $0 20% 30% after deductible Prosthetics ($15,000 maximum per year) $0 20% 30% after deductible TMJ ($500 lifetime maximum) $25 15% 30% after deductible Ostomy Supplies $0 10% 30% after deductible The Summary Plan Description (SPD) can be viewed online at under the Benefits Library section, or you may contact Employee Benefits Division for a paper copy. *Treatment for infertility is not a covered benefit benefits cover testing and counseling only. NOTE: Out-of-Network Deductible, Copayment and Coinsurance amounts do not apply to the In-Network Annual Coinsurance Limit. Annual Coinsurance Limits are calculated on a fulfillment basis, not aggregate. Expenses incurred for services that exceed benefit limits are not applied to the Annual Coinsurance Limit. Your enrollment period has been extended to November 15th. 7

10 About ARHealth (For non-medicare retirees and their dependents) Health Advantage is excited to be the claims administrator for the new ARHealth and ARHealth Senior plans. These plans are available to all Arkansas State and Public School Retirees and their dependents. Who will be on the ARHealth? 1. Non-Medicare retirees and their non-medicare spouses may choose this plan. 2. Non-Medicare spouses of Medicare Primary retirees. 3. Dependent children of Medicare Primary retirees on ARHealth Senior, and dependents of non- Medicare retirees who choose ARHealth. What do I need to know about ARHealth? 1. If you are the policyholder and do not have Medicare as your primary insurance, you may stay on the plan you currently have, or you may change to another plan, including ARHealth. 2. Non-Medicare spouses and dependents of Medicare Primary retirees will still have prescription drug benefits through NMHCRX with $10, $25, and $50 prescription copayments. 3. With the ARHealth you will not need a Primary Care Physician (PCP) or referrals for specialty care, as long as you stay within the Health Advantage network. 4. When the retiree is eligible for Medicare, he/she will be automatically enrolled in ARHealth Senior, no matter what plan is chosen during Open Enrollment. Since Health Advantage is the claims administrator for this plan, will I have to use Health Advantage Network physicians and facilities? Yes, to receive in-network benefits, members will need to stay within the Health Advantage network of providers; however, referrals are not required for specialty care. If you choose to use a provider that is not in the Health Advantage network, there is an out-of-network benefit available. If I don t have to select a Primary Care Physician (PCP), why is there a separate PCP copayment? Claims from general practice, family practice, internal medicine, and pediatric physicians will all be considered PCP claims, and will take a $20 copayment. Will this plan cover medical expenses outside the United States? Yes, you will have coverage within the United States or for medically necessary emergency care in a foreign country. See ARHealth Senior for guidelines for Medicare Primary members. What about my life insurance? Retirees can continue their life insurance in retirement regardless of whether you enroll in COBRA, one of the state sponsored health plans, or have no health insurance at all. Please check with USAble Life at or refer to your Enrollment Guide from Employee Benefits Division (EBD) for complete details. Your enrollment period has been extended to November 15th. 8

11 About The Traditional HMO and POS Plans The traditional Health Advantage HMO and POS plans are available to public school retirees who are not eligible for Medicare. If one of the traditional plans is chosen, and the retiree becomes eligible for Medicare mid-year, the retiree will be changed to ARHealth at that time. Prescription benefits are only available to members who do not have Medicare as their primary insurance. Medicare primary spouses who are on the traditional plans will not have prescription benefits. Medicare primary members are strongly encouraged to take Medicare Part D, which will be available through various carriers effective January 1, Questions and Answers Q. What is BlueCard? A. BlueCard links participating health-care providers and the independent Blue Cross and Blue Shield Plans across the country. When you need urgent or emergency care out of the service area (including foreign travel), you can call (BLUE) located on the back of the identification card to locate a Blue Cross and Blue Shield provider. You should ask for the traditional network. The call center is open 24 hours a day, seven days a week. You can also access BlueCard providers online at Q. My child will be living out of state. How will he/she be covered? A. Contact Customer Service at and request an Out of Area application or go to to print a form. Your dependents will be listed as Out of Area dependents and your normal benefits will apply if they see Blue Cross participating providers in that state. Q. Do I need a referral for my annual gynecological visit and mammogram? A. No. Both are covered without a referral. No referral is ever required to an in-network gynecologist. Q. My Emergency Room (ER) claim was denied for not being an emergency. What is an emergency? A. An emergency is defined as traumatic bodily injury or sudden, unexpected onset of an illness which requires immediate care and attention from a qualified physician, or when the condition, if not treated immediately, could reasonably be expected by a prudent layperson to result in serious physical impairment. When emergency services are needed, the member is to proceed as follows: 1. Seek emergency care immediately at the nearest emergency facility. 2. As soon as possible, notify your PCP of your emergency care, so that follow-up care may be arranged. 3. All follow-up care must be authorized by the PCP and rendered by an in-network provider in order for in-network benefits to apply. Q. What is covered under the Enhanced Wellness Benefit? A. For a complete list of preventive services that are now covered 100%, visit and look under the Benefits Library for the Summary Plan Description, or you may call Customer Service at Q. Does Health Advantage require preauthorization for services? A. Preauthorization if only required for the following services: Breast reduction (not related to cancer) Enteral feeding IDET Out-of-network services Swing bed care (preauthorization from Case Management) Transplant (excluding kidney and cornea) 9

12 PUBLIC SCHOOL RETIREES TRADITI IN-NETWORK HMO & POS OUT-OF- NETWORK POS ONLY DEDUCTIBLE NOT APPLICABLE $500 Individual $1,000 Family ANNUAL COINSURANCE LIMIT Copays do not apply to coinsurance limit $1,500 Individual $3,000 Family $5,000 Individual $10,000 Family LIFETIME MAXIMUM Unlimited $1,000,000 PHYSICIAN SERVICES Primary Care Physician Office Visits $25 Copay 40% after Deductible Specialist Office Visits $35 Copay 40% after Deductible Inpatient and Outpatient Physician Services 40% after Deductible PREVENTIVE CARE SERVICES - *Please refer to SPD 0% NOT COVERED for a complete list of covered preventive services HOSPITAL SERVICES Inpatient Services (semi-private room) $500 Copay 40% after Deductible Maximum 3 Copays per Contract Year Outpatient Surgery $100 Copay + 40% after Deductible Outpatient diagnostic testing (lab, x-ray, tests performed 40% after Deductible outside the doctor s office) Emergency Room Visit or Urgent Care Center- Copay waived if admitted to the same hospital as in-patient ALLERGY SERVICES Office Visit $100 Copay + $25 Copay for PCP $35 Copay for Specialist $100 Copay + 40% after Deductible Allergy Injections 40% after Deductible Allergy Serum 40% after Deductible AMBULANCE SERVICES- $1,000 Maximum Per Member Per Contract Year REHABILITATIVE SERVICES Inpatient Rehabilitation Services- Limited to 60 days per Member per Contract Year Outpatient Rehabilitation Services: Physical, Occupational, and Speech Therapy Chiropractic Services and Cardiac Rehab Limit of 60 aggregate visits per Member per contract year $500 per admission + 40% after Deductible 40% after Deductible Your enrollment period has been extended to November 15th. 10

13 ONAL HMO/POS BENEFIT SUMMARY IN-NETWORK HMO & POS OUT-OF- NETWORK POS ONLY DURABLE MEDICAL EQUIPMENT- 40% after Deductible $10,000 MAX PER MEMBER PER CONTRACT PROSTHETICS- $15,000 ANNUAL MAXIMUM 40% after Deductible DIABETIC EQUIPMENT AND INSULIN PUMP 40% after Deductible SUPPLIES OSTOMY SUPPLIES 10% Coinsurance 40% after Deductible HOME HEALTH SERVICES-120 VISITS PER MEMBER 40% after Deductible PER CONTRACT YEAR HOME IV DRUGS/SOLUTIONS 40% after Deductible INJECTABLE MEDICATIONS-Medications when covered Office Visit Copay 40% after Deductible by Health Advantage-Subject to exclusions and limitations May Apply + INFERTILITY SERVICES** Infertility Counseling $35 Copay 40% after Deductible Infertility Testing (outpatient Surgery Copay may apply) 40% after Deductible SKILLED NURSING FACILITY- $500 Copay + 40% after Deductible Limited to 60 days Per Member Per Contract Year Hospice Care (must be approved by Health Advantage) 20% 40% after Deductible TMJ- Covered when diagnosed as medical condition Applicable Copay 40% after Deductible Limited to $500 Lifetime Maximum per Member Organ Transplant Services- must be approved by Health Advantage (2 transplants per Member per Lifetime) $500 per admission NOT COVERED *The Summary Plan Description (SPD) can be viewed online at under the Benefits Library section, or you may contact Employee Benefits Division for a paper copy. **Treatment for infertility is not a covered benefit benefits cover testing and counseling only. NOTE: Out-of-Network Deductible, Copayment and Coinsurance amounts do not apply to the In-Network Annual Coinsurance Limit. Annual Coinsurance Limits are calculated on a fulfillment basis, not aggregate. Expenses incurred for services that exceed benefit limits are not applied to the Annual Coinsurance Limit. For In-Network benefits, services must be performed, arranged or authorized by the Primary Care Physician, except for Emergency Care. The Member is responsible for the difference between Billed Charges and Allowable Charges for services covered at the Out-of-Network benefit level. 11

14 About The Traditional PPO Plan Arkansas Blue Cross and Blue Shield s PPO plan is available to Arkansas state retirees who are not eligible for Medicare. If one of the traditional plans is chosen, and the retiree becomes eligible for Medicare mid-year, the retiree will be changed to ARHealth at that time. Questions and Answers Q. What is a PPO plan? A. a PPO (Preferred Provider Organization) is an Indemnity Plan. The Arkansas Blue Cross and Blue Shield PPO plan offers the largest network of hospitals, physicians, and other health-care providers, which can be accessed without having to obtain a referral from a Primary Care Physician. Q. What if I receive care outside of the Blue Cross network? A. If you choose a hospital or physician who is a participating provider with any Blue Cross and Blue Shield nationwide, that provider has agreed to accept Blue Cross payment in full except for your deductible and appropriate coinsurance. If you use a hospital or physician who is not a participating provider with Blue Cross, that provider is free to bill you charges for covered services in excess of the company s payment. Q. What is BlueCard? A. BlueCard links participating health-care providers and the independent Blue Cross and Blue Shield Plans across the country. When you need urgent or emergency care out of the service area (including foreign travel), you can call (BLUE) located on the back of the identification card to locate a Blue Cross and Blue Shield provider. You should ask for the PPO network. The call center is open 24 hours a day, seven days a week. You can also access BlueCard providers online at Q. What do I need to do if I have a need for medical assistance and I m outside the United States? A. Members traveling abroad should contact the BlueCard helpline at (BLUE) and ask for BlueCard Worldwide. This is a provider locator service open 24 hours a day, 365 days a year. We also recommend that you visit the Web site at to locate providers in advance and take advantage of the valuable health and travel information listed there. Q. What is covered under the Enhanced Wellness Benefit? A. For a complete list of preventive services that are now covered 100%, visit and look under the Benefits Library for the Summary Plan Description, or you may call Customer Service at Q. Does the PPO cover preventive dental and vision exams? A. No. The PPO does not have coverage for these services. 12

15 Deductible (Annual) Individual Family In-Network $500 At least two family members must meet the $500 deductible. Public School Retirees Indemnity PPO Benefit Summary 2006 Out-of-Network $1,500 At least two family members must meet the $1,500 deductible. Coinsurance (what you pay) 20% 40% Annual Out-of-Pocket Limits Individual $3,000 $8,000 Family At least two family members must At least two family members must meet the meet the individual out-of pocket limit. individual out-of-pocket limit Lifetime Maximum None $1,000,000 Preventive Care Services for a complete list of services covered at 100%, please refer to your Summary Plan Description which can be accessed at Immunizations, Mammograms, Physical Exams-Adults, Gynecological Visits Well Baby Care Well Child Care No deductible, 0% coinsurance 40% coinsurance after deductible Physician Services 20% coinsurance after deductible 40% coinsurance after deductible Outpatient Services 20% coinsurance after deductible 40% coinsurance after deductible Inpatient Hospital 20% coinsurance after deductible 40% coinsurance after deductible Emergency Room Services 20% coinsurance after deductible 40% coinsurance after deductible Maternity Services Physician and Hospital Services 20% coinsurance after deductible 40% coinsurance after deductible Transplants Most transplants require 20% coinsurance after deductible 40% coinsurance after deductible prior approval Durable Medical Equipment $10,000 maximum per year 20% coinsurance after deductible 40% coinsurance after deductible Prosthetics 20% coinsurance after deductible $15,000 maximum per year 40% coinsurance after deductible TMJ $500 lifetime maximum 20% coinsurance after deductible 40% coinsurance after deductible Physical, Occupational, Speech Therapy, Cardiac Rehab, and Chiropractic Services 60 visits per member per year combined 20% coinsurance after deductible 40% coinsurance after deductible Ambulance (Land or Air) $1,000 maximum per year for 20% coinsurance after deductible 40% coinsurance after deductible transport services Home Nurse Visits 120 visits per year 20% coinsurance after deductible 40% coinsurance after deductible Home Infusion IV Drugs & Solutions 20% coinsurance after deductible 40% coinsurance after deductible Important Notice: If you use a hospital/physician who is a preferred provider, such hospital/physician has agreed to accept Arkansas Blue Cross and Blue Shield's payment for covered services as payment in full - except for your deductible and coinsurance, if applicable. If you use a hospital/physician who is a non-preferred provider, such hospital/physician is free to bill you charges for covered services in excess of Arkansas Blue Cross and Blue Shield's payment. Before receiving services from any hospital/physician, please check your directory of participating providers. Member may be responsible for charges in excess of any dollar maximum. This benefit summary provides a brief description of your state employee benefits for the Arkansas Blue Cross and Blue Shield Indemnity PPO Plan. Arkansas Blue Cross and Blue Shield is a Claims Administrator under the direction of the Employee Benefits Division. For a complete description of your benefits please refer to the Summary Plan Description (SPD) published by Employee Benefits, your Group Administrator. 13

16 Your enrollment period has been extended to November 15th. Call one of our Regional Offices Jonesboro Fayetteville Fort Smith Hot Springs Texarkana Pine Bluff Health Advantage USAble Corporate Center 320 W. Capitol, Suite 400 PO Box 8069 Little Rock, AR Arkansas Blue Cross and Blue Shield USAble Corporate Center 320 W. Capitol, Suite 400 PO Box 2181 Little Rock, AR To determine when and if providers have joined the Arkansas Blue Cross or Health Advantage network visit the provider directories (updated nightly) found at or By using the providers listed in the directory, members will receive the highest level of benefits from their health plan. P.O. Box 2181 Little Rock, AR PRSRT STD U.S. POSTAGE PAID LITTLE ROCK, AR PERMIT # 1913