New Bedford PEC Q&A. For Active Employees or Non-Medicare Eligible Retirees

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1 New Bedford PEC Q&A For Active Employees or Non-Medicare Eligible Retirees Q: What are the new deductibles for the HMO, POS and PPO plans? A: $250 Individual, $500 for two people and $750 for family Q: What services do not require me to pay a copay or deductible? A: The following services are paid at 100% without a copay or deductible: Well child visits Routine adult physicals and tests Routine GYN and related lab tests Routine vision tests Q: When do I have to pay a copay but not the deductible? A: The following services are covered with a copay, but no deductible: PCP/OBGYN visits Pediatrician office visits for non-routine care Sick visits Office visits when provided by a specialist, including mental health providers Q: When do I just pay the deductible? A: The following services are subject to the deductible: Inpatient care, including maternity care Inpatient mental health care, drug or substance abuse facility Hospital outpatient department and day surgery Ambulance Skilled nursing care PT, OT, and speech/hearing therapy Diagnostic testing such as x-rays & lab tests CT scans, MRIs, PET scans and nuclear imaging tests* *$100 copay after deductible for members on the PPO plan

2 Q: How is emergency care covered? A: You are covered 100% after you pay your deductible and $75 copay for the HMO and POS and $100 copay on the PPO. The copay is waived if you are admitted or for an observation stay. Q: How are drug copays treated? A: Prescription drugs are covered with a copay and there is not a deductible. Prescription drug copays count towards your total annual out-of-pocket maximum. Q: Do I have to pay my deductible for blood glucose monitors, insulin pumps and infusion devices? A: No. These are covered without having to satisfy the deductible. Q: I have a daughter in college in South Carolina and she has asthma and sees a doctor on a regular basis. What plan should I be on? A: The PPO would be the recommended plan. Members seeking treatment on a regular basis outside the New England area should be on a PPO plan. With the PPO plan, members have access to a national network of providers more than 1,000,000 physicians and 6,100 hospitals throughout the U.S. and Puerto Rico through the BlueCard program. Q: I have a son in college in Florida, but he never goes to the doctor. What plan should I be on? A: The HMO and POS provide coverage for emergency services anywhere, anytime. So, in the situation above, members can choose one of the lower cost options (HMO or POS) and have the piece of mind that their dependent(s) is covered for emergency or urgent care while out of area. Q: If I only have two people on my plan, do I have to pay the full $750 per family in deductibles? A: No. The deductible is per member up to a maximum of $750. If you have two people, each person would have to satisfy $250, or $500 in total.

3 Q: I am in the HMO plan, travelling on vacation in California and have a stroke. Am I covered? What happens if I am unable to get home and need rehabilitation? A: The HMO provides coverage for Emergency and Urgent care anywhere while traveling. Services provided in Emergency room or inpatient care while hospitalized as medically necessary, and as authorized by the BCBSMA/and plan would be provide until member is medically allowed to return to the service area (New England) Q: John has an HMO and is traveling out of New England. He needs medical attention and decides to go to a walk-in or local Urgent Care facility instead of the Emergency Room. What are his charges or fees for service? A: If you travel outside the service area, you are covered for an urgent or emergency care visit and one follow-up visit. In the case of John, he would be responsible for a $25 (specialist) copay for the urgent care visit.in addition, John may also be responsible for the deductible, if such tests as x-rays, labs, Nuclear Imagining, CT, MRI and PET scans are preformed. Q: The out-of-pocket maximums are now $5,000/individual and $10,000/family. These seem very high. How could I hit that maximum? A: If you are in the HMO or are in the POS or PPO and use in-network doctors and hospitals it would be extremely unlikely for you to hit the out-of-pocket maximum. For example: Number of Service Cost Total Services T3 Inpatient Hospital Stays $250 Deductible $250 (Annual Deductible) 12 PCP visits $15 $ Specialist Visits $25 $1, Tier 1 Prescription Drugs $10 $ Tier 2 Prescription Drugs $25 $ Tier 3 Prescription Drugs $40 $800 Total Out-of-Pocket Expense Paid by Member $3,055 Total Out-of-Pocket Plan Maximum/Member $5,000 Important: If you use out-of-network providers you will pay 20% of the cost for many services, and could hit the out-of-pocket maximum.

4 Q: I am in the POS plan and might change to the HMO plan to save money. What happens if I don t like it and want to change? A: You can change your plan election each year at Open Enrollment. Q: What are the basic differences between the HMO, POS and PPO plans? A: Network Blue New England Deducible: The Health Maintenance Organization (HMO) plan offers in-network coverage only throughout New England and requires referrals from a primary care provider (PCP) in order to see specialists. Blue Choice New EnglandSM: The Point-of-Service (POS) plan combines the benefits of the HMO plan with the ability for members to self-refer for out-of-network coverage. Blue Care ElectSM Deductible: The Preferred Provider Organization (PPO) plan offers access to the Blue Cross Blue Shield national network with no referrals for a flexible coverage solution. BCBS HMO POS PPO Network Coverage BCBS New England BCBS New England BCBS New England In-Network Deductible $250 Individual $500 Two person $750 Family $250 Individual $500 Two person $750 Family $250 Individual $500 Two person $750 Family In-Network Coinsurance 100% coverage after deductible for most services 100% coverage after deductible for most services 100% coverage after deductible for most services Out-of-Network Care Only emergency care is You pay the deductible You pay the deductible (non-bcbs providers) covered out-of-network and 20% coinsurance and 20% coinsurance Out-of-Network Not applicable $250/$750 $250/$750 Deductible PCP Required Yes Yes No, but recommended PCP Referral Required Yes Yes, for in-network No to see Specialist specialists PCP Copay $15 per visit $15 per visit $30 per visit Specialist Copay $25 per visit $25 per visit $40 per visit What you Pay/Week $42.95 Individual $ Family $47.47 Individual $ Family $56.76 Individual $ Family What you Pay/Year* $2,062 Individual $4,880 Family $2,278 Individual $5,422 Family $2,724 Individual $6,533 Family *Note: The annual costs above are based on xx paychecks/year. (confirming with Angela)

5 Important Information for Active Employees During Open Enrollment take the time to study the differences between each plan option and select the plan that is best for you and your family. Currently, many of our members are paying extra premium dollars for the POS or PPO plans, but only use in-network doctors and hospitals. If you are using in-network providers, consider switching from the POS or PPO plan to the HMO option. If you move from the POS to HMO plan you will save $216/year for single coverage and $542/year for family coverage. There are even greater savings if you switch from the PPO plan to the HMO plan option. Q: What is the difference between our current HPHC drug plan and the BCBS drug plan? A: The copays are the same, but the list of drugs covered is different. Please go to to see if the drugs you are taking are covered on the BCBS drug plan. Q: What happens if the drug I am taking is not on the BCBS drug list (formulary)? A: Blue Cross Blue Shield of Massachusetts implemented a transition program to allow a new member with eligibility of less than 90 days a one time fill of a non-covered drug or a bypass of step therapy edits to avoid a disruption of care at the point of sale. Members with eligibility less than 90 days are allowed one fill of a non-covered medication during the transition process. That fill will trigger a letter to both the member and prescribing physician, advising them that the medication is non-covered and listing formulary alternatives. Members will need to switch to a formulary alternative or have their provider seek authorization for the non-covered medication. If the member and provider decide to seek authorization for the non-covered medication, the Blue Cross Blue Shield of Massachusetts Customer Service Associates can assist the member by obtaining the proper forms and educating the member on how the programs work, so the completed request forms can be reviewed in a timely manner for determination with respect to all pharmacy management programs. Providers can seek authorization via phone, web or fax. Members with eligibility less than 90 days will also be allowed a bypass of step therapy edits during the transition process. If the member fills a prescription for a formulary medication that is subject to step therapy edits, the claim will pay and will continue to pay as long as the member does not allow 130 days to elapse between refills.

6 Members will not be allowed a bypass of prior authorization or quantity limits during the transition process. For Medicare Eligible Retirees Q: What doctors can I see under the new BCBS Medicare supplement plans? A: Medex, you can seek care from any provider participating in Medicare. There's no need to choose a primary care provider or get a referral. Medicare PPO Blue uses a network of doctors, specialists, and hospitals. You can choose any doctor who is part of the network to be your provider of choice. To view a list of providers, please visit Your provider of choice can help you coordinate your care, however, you may also see any Medicareparticipating providers outside the network. If you choose to see a doctor who is not part of the network, you may have to pay more for those services. Q: Is the new coverage similar to what I am used to? A: Yes, the coverage is very similar, if not better, than today s coverage. Please refer to the summaries for more details. Q: Wonder if I go to Florida for a few months every year. What plan should I select? A: For Medicare eligible retirees the Medex plan will be a great option. With the Medex plan, you can seek care from any provider in the US participating in Medicare. There's no need to choose a primary care provider or get a referral. Q: I am in the middle of cancer treatment. Am I going to have any problems? A: No, Blue Cross Blue Shield of Massachusetts will work with you and your PCP to make sure coverage is uninterrupted. Q: Is the drug list different for the retiree plans? A: Yes.

7 Q: I am currently on the Tufts Medicare Preferred plan. Is that going to be continued? A: The Tufts Medicare Preferred plan will be replaced with Blue Cross Blue Shield of Massachusetts s Blue Medicare PPO plan. Q: How is the retiree prescription drug plan (PDP) different from the active plans? A: Please refer to the materials provided. This is a government regulated Medicare D plan. We use CVS/Caremark as the pharmacy drug plan provider. Members may use any pharmacy in the network (68,000) or the mail service through CVS/Caremark. All literature will be mailed to each subscriber. The formulary is different from the BCBSMA Express Scripts plan list. We will have formulary information and all materials available at Medicare Retiree meetings and at the Retirement Board to guide and answer questions. Q: If I am on the retiree medical plan, what do I do if my drug(s) aren t covered under the PDP formulary? A: There is a policy for seeking an exception and prior authorization. The physician would work with CVS/Caremark to provide necessary information for review, and approval. If denied, there is no coverage under this plan. Member would need to discuss any alternative medications with their physician.