Business BlueEssentials SM. Trust in Business BlueEssentials GROUP INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

Transcription

1 Business BlueEssentials SM Trust in Business BlueEssentials GROUP INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

2 Table of Contents Overview Networks Savings Services Tools Value Plan Benefits Exclusions

3 Exclusions 33 Other Services This Policy Does Not Cover Non-emergency services when received at or from out-of-network provider or hospitals, except true emergency services when received in emergency rooms of out-of-network hospitals. Hospital or skilled nursing facility charges when preauthorization is not received. Please see preauthorization in your policy found in My Health Toolkit. Services and supplies not medically necessary, investigational/experimental in nature, not needed for the diagnosis or treatment of an illness or injury, or not specifically listed in Covered Services. Any service or supply provided by a member of the patient s family or by the patient, including the dispensing of drugs. This means the spouse, parent, grandparent, brother, sister, child or spouse s parent. Charges for a missed appointment or for filling out claim forms. Any loss resulting from a member being legally intoxicated or impaired, by being under the influence of alcohol, any narcotic or drug, unless taken on the advice of a physician. The member or member s representative must provide any available test result, upon our request, showing blood alcohol or drug levels. If the member refuses to provide these test results, we will not provide benefits. Services or supplies related to chewing or bite problems, pain in the face, ears, jaws or neck resulting from problems of the jaw joint(s), also known as temporomandibular joint disorders (TMJ). This is a partial list of some of our exclusions. For a full list of excluded services and supplies, or for all limitations, please refer to your policy in My Health Toolkit. BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.

4 Have Questions? Contact your agent or broker today. BCBSSC BCBSSC business card die cut

5 WITH THE CARD THAT OPENS DOORS IN 50 STATES BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

6 Overview 3 Think Blue TRUST BlueCross BlueShield of South Carolina has earned the trust of South Carolinians for nearly 70 years, offering solutions for business owners throughout the state. Ensuring access to quality health coverage is vital to the health and well-being of every community in our state. We re more than a recognized member of the community we re a strong and stable partner you can count on. CHOICE Our goal is simple: to provide the highest quality coverage at a reasonable price. Since there s no such thing as one size fits all, we offer numerous choices to make sure you have the right plan for you and your business. Let us help you find the right Business BlueEssentials plan for your company. LARGE PROVIDER NETWORK You ll love Blue s extensive network of doctors, hospitals, specialists, pharmacies and other health care providers that work to keep your employees safe, healthy and on the job. COMMUNITY OUTREACH Supporting our local community your working families living in your community is important to us. That s why the BlueCross BlueShield of South Carolina Foundation supports workplace giving programs, health care-related research, education and service throughout the state. We also encourage our employees to volunteer their time and talents to non-profit organizations. By supporting projects that directly benefit South Carolina s most vulnerable populations, we are helping to create a strong community for everyone. AWARD-WINNING CUSTOMER SERVICE Year after year, independent companies recognize our Customer Service team for providing excellent service to our members. In 2014, in fact, 35 BlueCross customer service advocates (CSAs) were recognized for providing superior service to our members. The recognition came from a leading research firm called Service Quality Management Group for the CSAs ability to resolve member issues during the first call, as well as callers overall service experience. Our world-class Customer Service team is always here to help you and your employees! The BlueCross BlueShield of South Carolina Foundation is an independent licensee of the Blue Cross and Blue Shield Association

7 Overview 4 Think Basics BLUE CROSS HEALTH PLAN BASICS Here are some key things to know before you shop for a plan. Business BlueEssentials plans often are referred to as metallic plans (Gold, Silver and Bronze) to illustrate the value of benefits in each plan. DEFINING GOLD, SILVER AND BRONZE PLANS Each plan must cover the same set of minimum essential health benefits. While the range of benefits is the same among the plans, the value of the benefits will vary. This means the amounts members pay such as copayments, coinsurance or deductibles are different. These metal levels can help you compare plans, monthly premiums and costs for services, such as doctor or hospital visits. ESSENTIAL HEALTH BENEFITS All of our Affordable Care Act (ACA) health plans include these essential health benefits: Ambulatory patient services: services that can be completed during a single day and don t require a patient to be admitted to the hospital Emergency services: care that is given in a hospital emergency room Hospitalization: hospital stays Maternity and newborn care: care for pregnant women and newborn babies Mental health and substance dependency services Prescription drugs: medications your doctor prescribes Rehabilitative and habilitative services and devices: services that help you recover lost abilities or services that help you gain functions so you can participate in daily life Routine wellness and preventive services and chronic disease management services

8 Overview 5 SUSTAINED HEALTH BENEFIT Each of our Business BlueEssentials plans covers many important preventive benefits the ACA recommends. (Note: Some plans may have different levels of preventive benefits.) The PPACA doesn t cover some common procedures, however, including: Electrocardiograms (EKGs) Chest X-rays Blood work (except lipid screenings) Urinalysis Our Sustained Health Benefit is an optional program with all of our Business BlueEssentials plans. Sustained Health provides $300 toward allowable expenses for preventive services the member s plan may not cover. And Sustained Health offers BlueCross one-of-a-kind discounted pricing on these preventive services. Consider the benefits of Sustained Health for you and your employees. FREE credit monitoring for every member. HEALTH REIMBURSEMENT ARRANGEMENTS (HRA) An HRA from BlueCross is a smart solution for businesses striving to maximize cost savings while offering their employees quality benefits that are flexible and affordable. In combination with a Business BlueEssentials high deductible health plan (HDHP), HRAs can save your company and your employees a considerable amount on health care costs. By selecting your reimbursement model and plan structure, you can design a benefits plan that best meets your needs, then fund HRA accounts through monthly contributions. Employees apply those funds toward medical expenses you deem qualified, including deductibles, coinsurance and other out-of-pocket expenses. You have numerous other choices in the plan design, including how much money will be funded and at what levels to set deductibles, copayments and out-of-pocket maximums. QUALITY CARE WITH A VIRTUAL DOCTOR Why wait for the care you need now? You have 24/7/365 access to a board-certified physician through the convenience of video consults on your mobile phone or online. Virtual doctors can treat many of the most common medical conditions, including: Cold and flu symptoms Respiratory infections Allergies Sinus problems Bronchitis And more! Urinary tract infections They can also write prescriptions according to the regulatory guidelines of your state. We have a national network of doctors ready to answer your call.

9 Networks 6 Think Networks PROVIDER NETWORK Our group Business BlueEssentials plans come with access to our Preferred Blue Network. The Preferred Blue Network is the largest provider network in South Carolina. The Preferred Blue Network is a group of physicians, hospitals and other health care providers that agree to provide health care services to our members at a discounted rate, sometimes referred to as the allowed amount. IN NETWORK To make the most of plan benefits, members should always choose providers who are in network. This option gives discounted rates for health care services. OUT OF NETWORK Refers to health care providers we have not contracted with and who do not participate in the network. These providers may charge amounts above the in-network allowed amount. BlueCross will be responsible for only 50 percent of covered charges (the covered charge cannot exceed the allowed amount in-network providers charge). Members are responsible for the remaining 50 percent, plus any amount in excess of the covered charge. Out-of-network expenses do not go toward satisfying the maximum out of pocket. in BlueCross has an agreement with providers to provide services at a discounted rate In-network provider: Lower cost to member Member out Out-of-network provider: Benefits are paid up to 50 percent

10 Networks 7 BENEFITS WITHOUT BORDERS Members can rest easy knowing their BlueCross coverage travels beyond South Carolina s borders. The BlueCard and BlueCard Worldwide programs give members access to a network of participating doctors and hospitals across the country and around the world. There are various BlueCard networks outside the state of South Carolina. When searching for an out-of-state provider on our website, members should enter the prefix on their member ID cards. The prefix determines which BlueCard network is associated with which health plan. PREAUTHORIZATION A preauthorization is also known as a prior authorization, prior approval or precertification. A preauthorized service is one that BlueCross determines to be medically necessary for a patient s condition. Preauthorization does not guarantee, however, that we will pay benefits for the service. Contract limitations or exclusions may apply. Additionally, a preauthorization may only be for a specific period of time or number of visits or treatments. Members or their doctors must get a preauthorization for certain categories of benefits. Failure to get a preauthorization may result in a lower level of benefits or denial of benefits. We make our final benefit determination when we process member claims. In-network providers in South Carolina are familiar with this requirement, and they should request any necessary preauthorization on behalf of the member. The member is ultimately responsible, however, for making sure the provider gets the prior authorization. When traveling out of state using our BlueCard program, the member is responsible for getting any necessary prior authorization. And members may be balance billed for any additional charges higher than what is covered by insurance. URGENT CARE VISITS Sometimes illnesses or minor injuries happen after business hours or on weekends and require urgent care. We make urgent care visits easy, convenient and cost effective for our members! Members can visit any Doctors Care clinic in South Carolina. The visit is considered as a primary care physician visit. For locations, go to DoctorsCare.com

11 Savings 8 Think Savings SMALL BUSINESS TAX CREDIT The ACA, also known as the Health Care Reform law, provides a small business health care tax credit. If you have fewer than 25 full-time equivalent employees making an average of $50,000 a year or less and you pay at least 50 percent of their premiums, you may qualify for a tax credit. [Gold 1 and Silver 1 are the only qualified plans for the tax credit. They must be purchased through the Small Business Health Options Program (SHOP) marketplace.] Small Business Tax Credit Fewer than 25 full-time employees and making $50,000 or less Employer qualifies for Employer Pays 50% of premium Gold 1 and Silver 1 qualifying plans

12 Services 9 Think Services PREVENTIVE SERVICES Services such as preventive screenings for children, women and men, including prostate screenings and lab work according to American Cancer Society guidelines, are provided at 100 percent. For a complete list of covered preventive services, visit (This link leads to a third party website. That company is solely responsible for the contents and privacy policies on its site.) The American Cancer Society (ACS) is an independent organization that provides health information on behalf of BlueCross BlueShield of South Carolina. PHARMACY SERVICES RETAIL To receive the highest level of benefits for prescription drugs, you must get them through our network. You can find a list of pharmacies on our website at When you buy drugs from a network pharmacy, you must show your BlueCross ID card. Prescription drugs filled at an out-of-network pharmacy are covered at 50 percent, and the cost does not apply to your deductible or maximum out of pocket. Up to 31-day supply RETAIL 90 Retail 90 is a pharmacy program that allows Business BlueEssentials members to purchase up to a three-month supply of maintenance prescription medications at local retail pharmacies at the lower mail-order copayment amount. Retail 90 is a product of Caremark, an independent company that provides a pharmacy network on behalf of BlueCross. The Retail 90 Pharmacy Network includes more than 62,000 pharmacies across the country, including the largest retail chains. A complete list of the Retail 90 Pharmacy Network is available on the Prescription Drug Information page on our website. Up to 90-day supply MAIL ORDER Members also can get their medications at discounted rates with our mail-order program. Information about the mail-order program is located on our website under Prescription Drug Information. Up to 90-day supply SPECIALTY DRUGS Drugs designated as specialty medications must be filled at a Caremark Specialty Pharmacy. Caremark Specialty Pharmacy is an independent company that provides pharmacy services on behalf of BlueCross. You ll find the list of drugs that must be filled at Caremark on the Business BlueEssentials SM Covered Drug List. Up to 31-day supply TIERS Tier 1 Drugs: Usually generic and will generally cost you the least amount of money out of your pocket. Tier 2 Drugs: Most often brand drugs, sometimes referred to as Preferred Drugs, because they usually cost you less than other brand drugs. Tier 3 Drugs: Most often brand drugs, sometimes referred to as Non-Preferred Drugs, because they usually cost you more than other brand drugs. They may have generic equivalents. Tier 4 Drugs: Drugs that treat complex conditions and are usually very expensive. You will usually pay more for drugs in this tier.

13 Tools 10 Think Smart BLUES ENROLL SM AND BLUE E-BILL SM We offer two great online tools to manage your company s benefits. This means you will have more time to focus on YOUR business. With BluesEnroll, it s never been easier to add or delete employees and/or dependents, order new ID cards, pay your bill and much more. Blue e-bill is another online service that gives you the ability to access and manage your account 24 hours a day, seven days a week. MY HEALTH TOOLKIT We understand the importance of making the right health care decisions. My Health Toolkit helps you and your employees make smart decisions and manage your health plan. My Health Toolkit is the BlueCross information and customer service center. With My Health Toolkit, members can take control of their health care from the comfort of their own homes. Whether you need to locate an in-network doctor or want to research the cost of a specific surgery, My Health Toolkit has resources that can help you make sound decisions on future treatments. As more power is placed in your hands to manage your health care benefits, we are here to help you every step of the way. TO SET UP AN ACCOUNT: Go to On the home page, find the Member Login: My Health Toolkit box and click Register. Create your profile by entering your member information found on your insurance card. Follow the remaining steps to complete your profile.

14 Tools 11 Think Control MY HEALTH TOOLKIT OFFERS WAYS TO MAKE INFORMED HEALTH CARE DECISIONS: Claims Summary View claims status and an Explanation of Benefits (EOB). Eligibility and Benefits Read about your benefits and coverage information and check your eligibility. Ask Customer Service Send a secure message directly to the customer service area for fast answers to your questions. Authorization Status Verify your authorization status for inpatient and outpatient visits. and Out-of-Pocket Statuses See how close you are to meeting your deductible and maximum out of pocket. Request a New ID Card. Compare Hospital Quality Choose the hospital that is right for you by comparing up to 10 facilities on the number of patients treated, complication rates, average lengths of stay for certain conditions and procedures, and more. Plan Comparison Tool Compare which benefit plan is right for you and your family. Estimate Treatment Costs Research average costs and days of treatment for specific medical conditions or procedures. Compare Drug Costs Look up cost and consumer information about prescription drugs. Find a Doctor Find a network doctor or hospital across the country and around the world. IMPROVE YOUR WELLNESS Personal Health Record A confidential online tool providing a summary of all your health information, including doctors visits, prescriptions, lab results and much more. You also can keep track of upcoming medical appointments and print a copy of your medical history. Additional features are available, based on your benefit plan. Personal Health Assessment An online survey that helps identify risk factors and offers ways to improve your health based on your answers. Health Library This feature offers medical information, health calculators, self-care channels and nutrition guides to help improve and protect your health.

15 Value 12 Think Value DISCOUNT AND VALUE-ADDED PROGRAMS Sometimes all you need to feel great is a little sprucing up. And saving money in the process makes it even more rewarding. That s why our members enjoy our discounts and value-added programs. With no claims to file and no annual limits, members pay the discounted rate directly to participating providers. FITNESS AND WELLNESS Fitness Center Memberships Getting in shape is now more affordable than ever! We make it easy for our members to save on memberships to local fitness facilities and other exercise centers. Children s Fitness With My Gym Children s Fitness Center, choose from a variety of structured, ageappropriate classes that use music, dance, relays, games and more. Weight Management Enjoy discounts on weight-loss programs and services, including Jenny Craig. Plus, get one-on-one support to help you lead a healthy lifestyle. Allergy Relief You ll breathe easier thanks to special prices on products designed to reduce exposure to indoor allergens. Alternative Health Care Where does it hurt? With Natural Blue SM you can tap into an extensive network of credentialed acupuncturists, massage therapists, chiropractors, plus diet advisers all offering extensive discounts. Members also can get information about vitamins and natural supplements, as well as purchase items, such as home fitness equipment, at a discount. Healthy Reading Stay health conscious and informed with access to a wide variety of articles and information online. Members also can purchase books, DVDs and CDs at discounted rates. For more information, visit

16 Value 13 HEARING AND VISION Laser Vision Correction Our members receive exclusive discounts on Lasik vision correction services, including exams, surgery and preoperative and postoperative care. Eye Care Open your eyes to special savings from Vision One eye exams, designer frames, lenses and contacts. Hearing Care Hear that? With Blue, get great savings from TruHearing a leader in digital hearing aids and ranked No. 1 in customer service. Save on hearing exams and follow-up care, too. BLUE365 BlueCross members have access to Blue365, a daily deal website with discounts on everyday products that can help families live healthier, happier lives. Members can enjoy discounts on personal care products, fitness, wellness and lifestyle products and healthy eating, as well as financial services. Blue365 complements a member s health coverage by making it easier and more affordable to make healthy choices. COSMETIC Cosmetic Surgery Lift your spirits with preferred rates on face-lifts, breast lifts, breast augmentation and reduction, tummy tucks, nose reshaping, ear pinning, even cheek and chin augmentation. Save on nonsurgical procedures, too. Hair Restoration Suffering from hair loss? You have everything to gain. As a member, you ll save 20 percent on a hair transplantation procedure. Teeth Whitening Purchase professional teeth-whitening services at a special discounted rate. Dental Services Through Companion Global Dental, our members can receive dental work overseas at a fraction of what you would pay in the United States. Because Companion Global Dental is a separate company from BlueCross, Companion Global Dental will be responsible for all aspects of global dental services. Visit: for the deal of the day!

17 Value 14 Your Navigator SM for Health Management At BlueCross, we take extra steps toward improving the health of your workforce through our comprehensive health management programs. Using a 360 approach, we offer wellness, prevention and treatment programs to your employees dealing with an array of chronic conditions. All of these programs are offered under the name Your Navigator for Health Management. There are programs for all members that focus on the early detection of illness and the prevention of disease. Members with chronic conditions also receive more targeted educational information and contact with our highly trained health specialists. Our members with intensive needs receive care coordination and the support of our team of caring nurses. Members are automatically enrolled in the appropriate programs based on claims history, pharmacy spending and physician referral. Members can self-refer to any of these programs at any time. Through Your Navigator for Health Management, we offer programs that cover the spectrum of health and disease in four categories: PREVENTION AND WELLNESS CONDITION MANAGEMENT DISEASE MANAGEMENT CRITICAL HEALTH MANAGEMENT Children s Health Cholesterol Improvement Men s Health Before Baby (preconception) Pre-Hypertension Tobacco Cessation Weight Management Women s Health WalkingWorks SM for South Carolina Schools Alcohol Management Back Care Healthy and Active Kids (childhood obesity) High Cholesterol High Blood Pressure (hypertension) Irritable Bowel Syndrome Maternity Migraine (adult and pediatric) Metabolic Health (pre-diabetes) Neonatal Intensive Care Unit (NICU) Case Management Asthma Chronic Obstructive Pulmonary Disease (COPD) Depression Diabetes Heart Disease Heart Failure Care Calls (hospitalto-home transition) Case Management (for conditions including cancer, severe trauma, multiple chronic conditions, complex wounds, weight-loss surgery, Hepatitis C, traumatic brain injury, rheumatoid arthritis, transplants and neuro-muscular diseases) Care Guardian (emergency room diversion management) Chronic Kidney Disease

18 Benefits

19 Benefits 16 PREFERRED PROVIDER ORGANIZATION (PPO) GOLD 1 PPO GOLD 1 SHOP PPO GOLD 2 Individual: $1,200 Family: $2,400 Individual: $1,200 Family: $2,400 Individual: $800 Family: $1,600 Coinsurance 20% 20% 30% Out-of-Pocket Maximum Individual: $4,200 Family: $8,400 Individual: $4,200 Family: $8,400 Individual: $4,000 Family: $8,000 Primary Care Physician $15 Copayment $15 Copayment $15 Copayment Specialist $30 Copayment $30 Copayment $40 Copayment Urgent Care Centers or Facilities $50 Copayment $50 Copayment $50 Copayment Emergency Room Services $300 Copayment, then $300 Copayment, then $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $10 Preferred (Tier 2): $35 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $200 Generic (Tier 1): $10 Preferred (Tier 2): $35 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $200 Generic (Tier 1): $6 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $200 Mail Order (90 Day) Generic (Tier 1): $14 Preferred (Tier 2): $95 Non-Preferred (Tier 3): $270 Generic (Tier 1): $14 Preferred (Tier 2): $95 Non-Preferred (Tier 3): $270 Generic (Tier 1): $9 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $270

20 Benefits 17 HIGH DEDUCTIBLE (HD) GOLD 3 HRA GOLD 4 HRA GOLD 5 Individual: $2,000 Family: $4,000 Individual: $2,400 Family: $4,800 Individual: $3,000 Family: $6,000 Coinsurance 0% 0% 0% Out-of-Pocket Maximum Individual: $2,000 Family: $4,000 Individual: $2,400 Family: $4,800 Individual: $3,000 Family: $6,000 Primary Care Physician $35 Copayment $20 Copayment Specialist $60 Copayment $40 Copayment Urgent Care Centers or Facilities $60 Copayment $50 Copayment Emergency Room Services $300 Copayment, then $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $10 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): $200 Generic (Tier 1): $10 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): $200 Mail Order (90 Day) Generic (Tier 1): $14 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162 Generic (Tier 1): $14 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162

21 Benefits 18 HD GOLD 6 HRA GOLD 7 PPO GOLD 8 Individual: $1,350 Family: $2,700 Individual: $2,000 Family: $4,000 Individual: $2,000 Family: $4,000 Coinsurance 30% 0% 20% Out-of-Pocket Maximum Individual: $2,700 Family: $5,400 Individual: $2,000 Family: $4,000 Individual: $4,000 Family: $8,000 Primary Care Physician $15 Copayment Specialist $40 Copayment Urgent Care Centers or Facilities $50 Copayment Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $20 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Mail Order (90 Day) Generic (Tier 1): $28 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162

22 Benefits 19 PPO GOLD 9 PPO GOLD 10 Individual: $1,500 Family: $3,000 Individual: $1,250 Family: $2,500 Coinsurance 20% 20% Out-of-Pocket Maximum Individual: $4,500 Family: $9,000 Individual: $3,500 Family: $7,000 Primary Care Physician $20 Copayment $40 Copayment Specialist $40 Copayment $65 Copayment Urgent Care Centers or Facilities $50 Copayment $65 Copayment Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Mail Order (90 Day) Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162 $150 Copayment, then $300 Copayment, then Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162

23 Benefits 20 PPO SILVER 1 PPO SILVER 1 SHOP PPO SILVER 2 Individual: $2,250 Family: $4,500 Individual: $2,250 Family: $4,500 Individual: $200 Family: $400 Coinsurance 20% 20% 50% Out-of-Pocket Maximum Individual: $6,850 Family: $13,700 Individual: $6,850 Family: $13,700 Individual: $6,850 Family: $13,700 Primary Care Physician $30 Copayment $30 Copayment $30 Copayment Specialist $60 Copayment $60 Copayment $60 Copayment Urgent Care Centers or Facilities $60 Copayment $60 Copayment $60 Copayment Emergency Room Services $200 Copayment, then $200 Copayment, then $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $15 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $15 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $30 Preferred (Tier 2): $60 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $500 Mail Order (90 Day) Generic (Tier 1): $21 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $21 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $42 Preferred (Tier 2): $162 Non-Preferred (Tier 3): $270

24 Benefits 21 PPO SILVER 3 PPO SILVER 4 PPO SILVER 5 Individual: $1,000 Family: $2,000 Individual: $950 Family: $1,900 Individual: $2,200 Family: $4,400 Coinsurance 50% 50% 40% Out-of-Pocket Maximum Individual: $6,350 Family: $12,700 Individual: $6,250 Family: $12,500 Individual: $6,500 Family: $13,000 Primary Care Physician $25 Copayment $25 Copayment $25 Copayment Specialist $50 Copayment $50 Copayment $50 Copayment Urgent Care Centers or Facilities $50 Copayment $50 Copayment $50 Copayment Emergency Room Services $200 Copayment, then $200 Copayment, then $200 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $15 Preferred (Tier 2): $40 Non-Preferred (Tier 3): Specialty (Tier 4): and Coinsurance Generic (Tier 1): $12 Preferred (Tier 2): $35 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Mail Order (90 Day) Generic (Tier 1): $21 Preferred (Tier 2): $108 Non-Preferred (Tier 3): Generic (Tier 1): $17 Preferred (Tier 2): $95 Non-Preferred (Tier 3): $270

25 Benefits 22 PPO SILVER 6 HD SILVER 7 HD SILVER 8 Individual: $2,150 Family: $4,300 Individual: $1,500 Family: $3,000 Individual: $2,300 Family: $4,600 Coinsurance 30% 30% 20% Out-of-Pocket Maximum Individual: $6,850 Family: $13,700 Individual: $6,350 Family: $12,700 Individual: $5,000 Family: $10,000 Primary Care Physician $25 Copayment Specialist $50 Copayment Urgent Care Centers or Facilities $50 Copayment Emergency Room Services $200 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $15 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Mail Order (90 Day) Generic (Tier 1): $21 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270

26 Benefits 23 HD SILVER 9 HRA SILVER 10 HRA SILVER 11 Individual: $3,600 Family: $7,200 Individual: $5,000 Family: $10,000 Individual: $5,200 Family: $10,400 Coinsurance 0% 0% 40% Out-of-Pocket Maximum Individual: $3,600 Family: $7,200 Individual: $5,000 Family: $10,000 Individual: $6,850 Family: $13,700 Primary Care Physician $35 Copayment $0 for first four visits; thereafter $20 Specialist $60 Copayment $60 Copayment Urgent Care Centers or Facilities $60 Copayment $60 Copayment Emergency Room Services $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $20 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $200 Generic (Tier 1): $0 Preferred (Tier 2): $50 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $500 Mail Order (90 Day) Generic (Tier 1): $28 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $0 Preferred (Tier 2): $135 Non-Preferred (Tier 3): $270

27 Benefits 24 HRA SILVER 12 PPO SILVER 13 HD SILVER 14 Individual: $6,700 Family: $13,400 Individual: $5,500 Family: $11,000 Individual: $4,000 Family: $8,000 Coinsurance 0% 0% 0% Out-of-Pocket Maximum Individual: $6,700 Family: $13,400 Individual: $5,500 Family: $11,000 Individual: $4,000 Family: $8,000 Primary Care Physician $0 for first four visits; then $0 for first four visits; then Specialist Urgent Care Centers or Facilities Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $0 Preferred (Tier 2): $50 Non-Preferred (Tier 3): $100 Specialty (Tier 4): $500 Generic (Tier 1): $0 Preferred (Tier 2): $50 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 30% Mail Order (90 Day) Generic (Tier 1): $0 Preferred (Tier 2): $135 Non-Preferred (Tier 3): $270 Generic (Tier 1): $0 Preferred (Tier 2): $135 Non-Preferred (Tier 3): $270

28 Benefits 25 HD SILVER 15 HRA SILVER 16 HRA SILVER 17 Individual: $2,500 Family: $5,000 Individual: $3,400 Family: $6,800 Individual: $4,250 Family: $8,500 Coinsurance 30% 0% 0% Out-of-Pocket Maximum Individual: $5,000 Family: $10,000 Individual: $3,400 Family: $6,800 Individual: $4,250 Family: $8,500 Primary Care Physician Specialist Urgent Care Centers or Facilities Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $20 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $20 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Mail Order (90 Day) Generic (Tier 1): $28 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $28 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270

29 Benefits 26 HRA SILVER 18 PPO SILVER 19 PPO SILVER 20 Individual: $6,000 Family: $12,000 Individual: $3,000 Family: $6,000 Individual: $3,100 Family: $6,200 Coinsurance 0% 20% 30% Out-of-Pocket Maximum Individual: $6,000 Family: $12,000 Individual: $6,000 Family: $12,000 Individual: $6,200 Family: $12,400 Primary Care Physician $20 Copayment $35 Copayment $35 Copayment Specialist $40 Copayment $60 Copayment $60 Copayment Urgent Care Centers or Facilities $50 Copayment $60 Copayment $60 Copayment Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $20 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Mail Order (90 Day) Generic (Tier 1): $28 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162

30 Benefits 27 PPO SILVER 21 PPO SILVER 22 Individual: $2,900 Family: $5,800 Individual: $2,900 Family: $5,800 Coinsurance 40% 30% Out-of-Pocket Maximum Individual: $6,000 Family: $12,000 Individual: $6,850 Family: $13,700 Primary Care Physician $35 Copayment $40 Copayment Specialist $60 Copayment $65 Copayment Urgent Care Centers or Facilities $60 Copayment $65 Copayment Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Mail Order (90 Day) Generic (Tier 1): $8 Preferred (Tier 2): $30 Non-Preferred (Tier 3): $60 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $12 Preferred (Tier 2): $81 Non-Preferred (Tier 3): $162 $150 Copayment, then $300 Copayment, then Generic (Tier 1): $22 Preferred (Tier 2): $50 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 10 percent up to $200 Generic (Tier 1): $31 Preferred (Tier 2): $135 Non-Preferred (Tier 3): $270

31 Benefits 28 PPO BRONZE 1 HD BRONZE 2 HD BRONZE 3 Individual: $5,000 Family: $10,000 Individual: $3,700 Family: $7,400 Individual: $5,000 Family: $10,000 Coinsurance 50% 50% 20% Out-of-Pocket Maximum Individual: $6,850 Family: $13,700 Individual: $6,350 Family: $12,700 Individual: $6,350 Family: $12,700 Primary Care Physician $60 for first four visits; thereafter and Coinsurance Specialist $90 Copayment, then Urgent Care Centers or Facilities $90 Copayment Emergency Room Services $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $25 Preferred (Tier 2): and Coinsurance Non-Preferred (Tier 3): Specialty (Tier 4): and Coinsurance Mail Order (90 Day) Generic (Tier 1): $35 Preferred (Tier 2): Non-Preferred (Tier 3):

32 Benefits 29 HD BRONZE 4 HD BRONZE 5 HRA BRONZE 6 Individual: $5,200 Family: $10,400 Individual: $6,300 Family: $12,600 Individual: $6,850 Family: $13,700 Coinsurance 30% 0% 0% Out-of-Pocket Maximum Individual: $6,450 Family: $12,900 Individual: $6,300 Family: $12,600 Individual: $6,850 Family: $13,700 Primary Care Physician Specialist Urgent Care Centers or Facilities Emergency Room Services $300 Copayment, then Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $30 Preferred (Tier 2): $60 Non-Preferred (Tier 3): Specialty (Tier 4): Mail Order (90 Day) Generic (Tier 1): $42 Preferred (Tier 2): $162 Non-Preferred (Tier 3):

33 Benefits 30 HD BRONZE 7 HRA BRONZE 8 BRONZE 9 Individual: $6,500 Family: $13,000 Individual: $6,800 Family: $13,600 Individual: $6,000 Family: $12,000 Coinsurance 0% 0% 50% Out-of-Pocket Maximum Individual: $6,500 Family: $13,000 Individual: $6,800 Family: $13,600 Individual: $6,850 Family: $13,700 Primary Care Physician Copayment $40 for the first four visits; then Specialist Copayment Urgent Care Centers or Facilities Emergency Room Services Inpatient Hospitalization PHARMACY BENEFITS Prescription Drugs Generic (Tier 1): $22 Preferred (Tier 2): Non-Preferred (Tier 3): Specialty (Tier 4): $150 Copayment, then $300 Copayment, then Generic (Tier 1): $22 Preferred (Tier 2): and Coinsurance Non-Preferred (Tier 3): Specialty (Tier 4): and Coinsurance Mail Order (90 Day) Generic (Tier 1): $31 Preferred (Tier 2): Non-Preferred (Tier 3): Generic (Tier 1): $31 Preferred (Tier 2): Non-Preferred (Tier 3):

34

35 Exclusions 32 EXCLUDED SERVICES We Will Not Pay Benefits For: Any services or benefits not specifically covered under the terms of this policy, that were received before this policy went into effect or after it terminates, or claims submitted after the time limit for filing claims has been exceeded. Services or charges for which the member is entitled to payment or benefits from other sources (e.g., workers compensation), for which the provider does not charge, or for which the member is not legally obligated to pay, including treatment provided in a government hospital or benefits provided under Medicare or other government programs (except Medicaid). Cosmetic surgery, or surgery or treatment for the purpose of weight reduction, including any complications from or reversal of these procedures, or reconstructive procedures made necessary by weight loss. Refractive care, such as radial keratotomy, laser eye surgery or Lasik. Services for the detection and correction of structural imbalance, distortion or subluxation (spinal subluxation) to remove nerve interference. Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries, unless it results from a medical (physical or mental) condition, even if the condition is not diagnosed before the injury. Treatment resulting from war or acts of war (whether declared or undeclared), while participating in a riot or uprising, or while in the military service or its auxiliary units. An illness you get or injury you receive while committing or attempting to commit a crime, felony or misdemeanor or while engaging or attempting to engage in an illegal act or occupation.