Automotive Aftermarket Association Southeast Competitor Plan BlueCard PPO

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1 Automotive Aftermarket Association Southeast Competitor Plan BlueCard PPO Effective January 1, 2017

2 Hospital Choice Network The Blue Cross and Blue Shield of Alabama Hospital Choice Network is a local Alabama effort to evaluate cost, quality and patient experience in member hospitals. Hospitals are categorized into either Lower Member Cost Share or Higher Member Cost Share, based on their performance. Only Alabama general acute care hospitals are eligible for participation in the Hospital Choice Network. Rehabilitation hospitals, psychiatric hospitals, specialty facilities, out-of-state hospitals, VA hospitals and long-term care hospitals are exempt from Hospital Choice Network scoring. All hospitals are evaluated annually with changes made effective January 1. In addition, reviews are completed on a quarterly basis allowing hospitals to improve their status. To review the evaluation criteria for all hospitals and/or the level of Member Cost Share for a particular hospital, please use the Find a Doctor tool on our website at AlabamaBlue.com. The Member Cost Share level will be included in the information provided for each hospital that participates in the Hospital Choice Network. For more information on the evaluation criteria, click on the name of the hospital and then click on the Cost, Quality or Patient Experience tabs. If you have any questions, please call the Customer Service number on the back of your ID card. 1

3 Automotive Aftermarket Association Southeast Competitor Plan BENEFIT IN-NETWORK OUT-OF-NETWORK Benefit payments are based on the amount of the provider s charge that Blue Cross and Blue Shield recognizes for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a, coinsurance, calendar or for each admission, visit or service. SUMMARY OF COST SHARING PROVISIONS Calendar Year Deductible $500 per individual; $1,500 per family Calendar Year Out-of-Pocket Maximum $6,350 individual; $12,700 per family In-Network Services: Deductibles, s and coinsurance apply to the out-of-pocket maximum, including drugs. Out-of-Network Services: Deductibles, s and coinsurance apply to the out-of-pocket maximum. After you reach Calendar Year Out-of-Pocket Maximum, applicable expenses covered at 100% for remainder of calendar. INPATIENT HOSPITAL AND PHYSICIAN BENEFITS Preadmission Certification is required for inpatient admissions (except emergency hospital admissions and maternity); notification within 48 hours for emergencies. Call (toll free) for precertification. Inpatient Hospital Inpatient Physician Visits and Consultations 100% after $250 per day hospital days 1-6 for each admission 100% after $500 per day hospital days 1-6 for each admission Mental Health Disorders and substance abuse services covered at 100% not subject to calendar OUTPATIENT HOSPITAL BENEFITS Covered at 80% after $1,000 per admission Note: In Alabama, available only for accidental injury Mental Health Disorders and substance abuse services covered at 80% not subject to calendar Precertification is required for some outpatient hospital benefits and physician-administered drugs; please see your benefit booklet. Outpatient Surgery (Including Ambulatory Surgical Centers) 100% after $250 hospital ; in Alabama, not covered 100% after $500 hospital Emergency Room (Medical Emergency) Covered at 100% after $250 hospital Covered at 100% after $250 hospital Emergency Room (Accident) Note: If you have a medical emergency as defined by the plan after 72 hours of an accident, refer to Emergency Room (Medical Emergency) above. Covered at 100% after $250 hospital Covered at 100% after $250 hospital for services within 72 hours, 80% of the allowed amount, subject to the calendar when services are rendered after 72 hours of the accident and not a medical emergency as defined by the plan Emergency Room Physician Covered at 100% after $50 physician Covered at 100% after $50 physician Outpatient Diagnostic Lab, Pathology, & X-ray Laboratory testing performed in the physician s office, but sent to an outpatient hospital for processing subject to hospital Covered routine mammograms not subject to hospital Dialysis, IV Therapy, Chemotherapy & Radiation Therapy Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) 100% after $250 hospital 100% after $500 hospital Covered at 100%; no or Covered at 100% after $50 daily hospital ; in Alabama, not covered ; in Alabama, not covered BENEFIT IN-NETWORK OUT-OF-NETWORK 2

4 BENEFIT IN-NETWORK OUT-OF-NETWORK PHYSICIAN BENEFITS Precertification is required for some physician benefits and physician-administered drugs; please see your benefit booklet. IN-NETWORK SERVICES NOT SUBJECT TO THE $500 CALENDAR YEAR DEDUCTIBLE Precertification is required for some physician benefits and physician-administered drugs; please see your benefit booklet. Office Visits & Consultations Covered at 100% after $35 primary physician or $50 specialist physician Second Surgical Opinions Covered at 100% after $50 physician Diagnostic X-ray Covered at 100% after $10 per CAT Scan, MRI, PET/SPECT, ERCP, angiography/arteriography, cardiac cath/arteriography, colonoscopy, UGI endoscopy, muga-gated cardiac scan procedure Covered at 100% after $100 per procedure Diagnostic Lab & Pathology Covered at 100%; no or Dialysis, IV Therapy, Chemotherapy & Radiation Therapy Covered at 100%; no or IN-NETWORK SERVICES SUBJECT TO THE $500 CALENDAR YEAR DEDUCTIBLE Surgery & Anesthesia Maternity Care PREVENTIVE CARE BENEFITS Routine Immunizations and Preventive Services For a listing of the specific immunizations and preventive services, go to AlabamaBlue.com/preventiveservices or call customer servcie for a printed copy Certain immunizations may also be obtained through the Pharmacy Vaccine Network. See AlabamaBlue.com/pharmacy for more information. Covered at 100%; no or Not covered. Additional Routine Preventive Services Covered at 100%; no or Lipid panel Urinalysis Complete CBC Note: In some cases, office visit s or facility s may apply PRESCRIPTION DRUG BENEFITS Prescription Drug Card The pharmacy network for the plan is the Prime Participating Pharmacy Network Some drugs require prior authorization Prescription drugs other than Specialty Drugs - 90 day supply may be purchased but applies for each 30 day supply; some s combined for diabetic supplies Specialty drugs - up to a 30 day supply Oral Impotence drugs not covered View the most current Preferred Brand Drug List and Specialty Drug List on the web at AlabamaBlue.com Not covered. Tier 1 Drugs: You pay $15 per Not covered Tier 2 Drugs: You pay $50 per Tier 3 Drugs: You pay $75 per Tier 4 Drugs: You pay 50% per Generic Drugs are mandatory when available and can be classified as any tier Mail Order Pharmacy Benefits Up to 90 day supply Mail Order drugs are available by calling Prim at or visiting AlabamaBlue.com Covered at 100% after the following s: Tier 1 Drugs: You pay $37.50 per Tier 2 Drugs: You pay $125 per Tier 3 Drugs: You pay $ per Generic Drugs are mandatory when available and can be classified as any tier 3 No benefits available

5 BENEFIT IN-NETWORK OUT-OF-NETWORK BENEFITS FOR OTHER COVERED SERVICES Precertification is required for some other covered services; please see your benefit booklet. If no precertification is obtained, no benefits are available. Allergy Testing & Treatment Ambulance Service Participating Chiropractic Services Limited to 12 visits per member each calendar Durable Medical Equipment (DME) Rehabilitative Occupational, Speech and Physical Therapy Occupational, physical and speech therapy limited to combined maximum of 30 visits per Habilitative Occupational, Speech and Physical Therapy Occupational, physical and speech therapy limited to combined maximum of 30 visits per Home Health and Hospice HEALTH MANAGEMENT BENEFITS ; in Alabama, no benefits available ; in Alabama, covered at 50% subject to calendar Occupational and Physical Therapy: ; in Alabama, covered at 50% subject to calendar Speech therapy covered at 80% subject to calendar Occupational and Physical Therapy: ; in Alabama, covered at 50% subject to calendar Speech therapy covered at 80% subject to calendar ; in Alabama, not covered Individual Case Management Coordinates care in event of catastrophic or lengthy illness or injury Disease Management Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. Baby Yourself A maternity program; For more information, please call You can also enroll online at AlabamaBlue.com. Useful Information to Maximize Benefits To maximize your benefits, always use In-Network providers for services covered by your health benefit plan. To find In-Network providers, check a provider directory, provider finder website (AlabamaBlue.com) or call BLUE (2583). In-Network hospitals, physicians and other healthcare providers have a contract with Blue Cross and Blue Shield of Alabama or another Blue Cross and/or Blue Shield Plan for furnishing healthcare services at a reduced price (examples: BlueCard PPO, PMD, Preferred Care). In-Network Pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or Preferred Care Services, Inc. Out-of-Network providers generally do not contract with Blue Cross and Blue Shield of Alabama or another Blue Cross and/or Blue Shield Plan. If you use Out-of-Network providers, you may be responsible for filing your own claims and paying the difference between the provider s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to In-Network providers in the same area or the average charge for care in the area. Please be aware that providers/specialists may be listed in a PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information. Bariatric Surgery, Gastric Restrictive procedures and complications arising from these procedures are not covered under this plan. Please see your benefit booklet for more detail and for a complete listing of all plan exclusions. This is not a contract, benefit booklet or a Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the group contract. Check your benefit booklet for more detailed information. Statement of Nondiscrimination Blue Cross and Blue Shield of Alabama complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Foreign Language Assistance Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711) Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) 4