BlueEssetials SM Idividual Plas
Are You Ready? While there have bee drastic chages i the world of health isurace, the oe costat is our commitmet to serve you. The jourey to fidig the best pla is oe that you do t have to travel aloe. Let BlueCross BlueShield of South Carolia be your guide to fidig the perfect health isurace solutio! The road to affordable coverage starts here. Now, more tha ever, you are i the driver s seat. The choices may seem overwhelmig, but remember, BlueCross has bee helpig people fid health care sice 1946. We are ready to help you fid your way to the coverage you eed. Times have chaged. Are you ready? How to Choose a Health Pla Whe headig somewhere you ve ever bee, it s always good to have directios ad recommedatios. Before we start, we wat you to uderstad some basic isurace words so you ca make a iformed decisio. Premium This is the amout you pay each moth for your coverage. I geeral, if you choose a lower premium, you ll have a higher deductible ad pay more of your health care costs. A pla with a higher premium usually has a lower deductible, so your out-of-pocket costs for health care services are less. Out-of-Pocket Maximum The most you pay for covered services durig a beefit period before your coverage begis to pay 100 percet of the allowed amout. This maximum ever icludes your premium, balace-billed charges or health care ot covered by your isurace. Deductible This is the amout you pay for your care before your isurace starts payig. For example, if your pla has a $2,000 deductible, you will eed to pay all of the bills for your medical care util you ve paid $2,000 of your ow moey. Oce you reach that amout, your health pla kicks i ad starts helpig to pay. So, if you ca afford to pay up frot for some of your health care, you should choose a pla with a higher deductible because that ca lower your mothly premium. 2
Now that you kow the basics, here are a few suggestios o how to pick the pla that is best for you. Whe you compare the plas i the BlueEssetials product lie, you will otice differeces i coisurace, copaymets, deductibles ad out-of-pocket maximum amouts. To choose the pla that s right for you, ask yourself these questios: How much coverage ca I afford? This is always the iterestig part! Several factors will impact your overall costs. Plas with higher deductibles ad coisurace ofte have lower premiums. The opposite is also true plas with lower deductibles ad coisurace ofte have higher premiums. It is up to you to decide whe ad how you pay toward your health care. If you prefer payig a higher premium up frot so you ca lower your future costs, you may wat to cosider buyig a pla with a low deductible ad coisurace, such as BlueEssetials SM Gold 1. If you prefer payig a lower premium while uderstadig you will pay more whe you receive medical treatmet, you may wat to cosider buyig a BlueEssetials SM Broze 1 pla. How ofte do I go (or expect to go) to the doctor? Whe you look at the chart comparig our plas, you ll see some boxes that have a set amout like $25. This is the copaymet. A copaymet is a fixed amout that you pay each time you go to the doctor. If you go to the doctor (or a specialist) several times a year, the you may wat to choose a pla with copaymets. You ll see that some of our plas have copaymets o matter how ofte you go to the doctor. Others offer limited visits, which mea you ll pay the copaymet the first few visits, the pay your deductible ad coisurace for ay visits beyod those. What is coisurace? Oce you ve met your deductible, you ad BlueCross share your medical costs util you reach your out-of-pocket maximum. Your part of the bill is your coisurace. For example: If your coisurace is 40 percet, the you pay 40 percet of the bill ad we pay 60 percet. The lower your coisurace, the less you pay for health care services. Just keep i mid that a lower coisurace amout could mea a higher premium. What about prescriptio drug beefits? If you eed to take several prescriptios or oes that cost a lot, you may wat to cosider a pla that offers low copaymets for prescriptio drugs. Ready to choose a pla? Oce you review your pla optios, all you eed to do is go to www.myscblueapp.com to apply. MySCBlueApp.com is available 24 hours a day, seve days a week. Tax Credit IforMATio The Affordable Care Act, also kow as the health care reform law, provides fiacial assistace to help you afford health coverage purchased through the marketplace. You ca use advace paymets of this fiacial assistace immediately to lower your mothly premium costs. If you qualify, you may also be able to get lower out-of-pocket costs. To lear more about the fiacial assistace, please visit www.hcreasyifo.com. To fid out if you qualify for fiacial assistace, please call 866-628-4282. 3
The Beefits Now that you kow what to cosider whe choosig a pla, it s time to review our plas. BlueEssetial plas are divided ito two categories: the metallic plas (Gold, Silver ad Broze) ad the catastrophic pla. Ayoe ca buy a metallic pla, but oly certai people qualify for BlueEssetials SM Catastrophic 1. What is the differece betwee the Gold, Silver ad Broze plas? Each pla must cover the same set of miimum essetial health beefits. While the rage of beefits is the same amog the plas, the value of the beefits will vary. This meas the amout that you pay, such as a copaymet, coisurace or deductible, is differet. These Essetial Health Beefits are covered uder the BlueEssetials SM Metal Plas: ambulatory patiet services; emergecy services; hospital services; materity ad ewbor care; metal health ad substace use services; prescriptio drugs; habilitatio ad rehabilitatio services; lab services; prevetive services; ad pediatric services. Beefits & Features Coisurace Deductible Out-of-Pocket Maximum Descriptio The portio of covered expeses that you pay before you reach your out-of-pocket maximum. The amout each perso must pay each beefit year before BlueCross pays beefits. The most you pay durig a beefit period (usually a caledar year) before BlueCross begis to pay 100% of allowed chages. BlueEssetials Gold 1 BlueEssetials Silver 1 20% 50% $1,200 $0 $4,200 $6,350 Lifetime Beefit Maximum The most BlueCross will pay while you re isured uder this pla. Ulimited lifetime Ulimited lifetime Physicias Services Primary Care Physicia A physicia who directly provides or coordiates a rage of health care services for a patiet. Icludes office charges for treatmet of a accidet or ijury; ijectios for allergy, tetaus ad atibiotics; diagostic lab ad diagostic X-ray services (such as chest X-rays ad stadard plai film X-rays) whe performed i the physicia s office ad billed by the physicia. Also icludes physicia visits for metal health & substace use disorders. $15 $20, the 50% coisurace 4
What is the BlueEssetials Catastrophic 1 Pla? Youg adults ad people for whom coverage is otherwise uaffordable ca purchase a catastrophic pla. Catastrophic plas are offered to people who: Are uder age 30 before the beefit year begis. Have received certificatio from the marketplace statig they are exempt from the idividual madate because they do ot have a affordable coverage optio or because they qualify for a hardship exemptio. To determie your qualificatio, please visit www.healthcare.gov or call 800-318-2596. BlueEssetials Silver 2 BlueEssetials Silver 3 BlueEssetials Broze 1 BlueEssetials Broze 2 BlueEssetials Catastrophic 40% 20% 40% 50% 0% $2,000 $3,000 $5,000 $5,000 $6,350 $6,350 $5,200 $6,250 $6,350 $6,350 Ulimited lifetime Uilimited lifetime Ulimited lifetime Ulimited lifetime Ulimited lifetime $25 $25 $60 for first 4 visits, the 40% coisurace 50% coisurace $25 for first 3 visits, the 0% coisurace 5
Beefits & Features Descriptio BlueEssetials Gold 1 BlueEssetials Silver 1 Physicias Services (co t) Specialist A physicia specialist focuses o a specific area of medicie or a group of patiets to diagose, maage, prevet or treat certai types of symptoms ad coditios. Icludes office charges for treatmet of a accidet or ijury; ijectios for allergy, tetaus ad atibiotics; diagostic lab ad diagostic X-ray services (such as chest X-rays ad stadard plai film X-rays) whe performed i the physicia s office ad billed by the physicia. $30 $50 the 50% coisurace All Other Physicias Services Ipatiet ad Outpatiet Hospital; Skilled Nursig Facility; Cliic Lab, X-ray, ad the readig/iterpretatio of diagostic lab ad X-ray services; surgery, male sterilizatio; secod surgical opiio; cosultatio; aesthesia; dialysis treatmet, chemotherapy ad radiatio therapy ad Specialty Drugs (icludig the admiistratio) 20% coisurace 50% coisurace Prevetive Services Prevetive Care/ Screeigs/ Immuizatios Services covered accordig to USPSTF, CDC ad HRSA 0% 0% Mammograms Services covered accordig to USPSTF 0% 0% Prostate Screeigs Services covered accordig to the America Cacer Society. 0% 0% Facility Services Ipatiet Hospital Outpatiet Hospital Icludig metal health & substace use disorders, materity, ewbors ad hospice Icludig metal health & substace use disorders 3 3 3 3 Emergecy Room 3 3 6
BlueEssetials Silver 2 BlueEssetials Silver 3 BlueEssetials Broze 1 BlueEssetials Broze 2 BlueEssetials Catastrophic $50 $50 $90 the deductible 50% 0% 40% 20% 40% 50% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 7
Beefits & Features Descriptio BlueEssetials Gold 1 BlueEssetials Silver 1 Materity/ Newbor Services Materity Newbor Preatal ad postpartum care icludig physicia ad hospital charges. A ewbor child is ot covered uder this beefit. Postatal care icludig physicia ad hospital charges. Policy must be purchased for the ewbor withi 60 days of his/her birth. 3 3 3 3 Prescriptio Drugs Retail 30-day supply or a 90-day supply with 3 copaymets if applicable Drug Card: Geeric $10 Preferred $35 No-Preferred $100 50% coisurace after deductible for Geeric, Preferred ad No-Preferred Mail order Up to 90-day supply Geeric $14 Preferred $95 No-Preferred $270 50% coisurace after deductible for Geeric, Preferred ad No-Preferred Specialty drug Specialty pharmacy oly $200 50% coisurace 8
BlueEssetials Silver 2 BlueEssetials Silver 3 BlueEssetials Broze 1 BlueEssetials Broze 2 BlueEssetials Catastrophic 3 3 3 3 3 3 3 3 3 3 Geeric $10 Preferred 40% coisurace after deductible No-Preferred 40% Drug Card: Geeric $12 Preferred $35 No-Preferred $100 Geeric $25 Preferred 40% after deductible No-Preferred 40% 50% 0% Geeric $14 Preferred 40% coisurace after deductible No-Preferred 40% Geeric $17 Preferred $95 No-Preferred $270 Geeric $35 Preferred 40% after deductible No-Preferred 40% 50% 0% 40% coisurace $200 40% 50% 0% 9
Prevetive Care You take your car i every few moths to get the oil chaged so it keeps ruig smoothly ad gets you where you eed to go. Why do t you do the same for yourself? Our BlueEssetials plas come with prevetive care beefits as recommeded by the Uited States Prevetive Services Task Force (USPSTF) grade A or B screeigs, the Ceters for Disease Cotrol ad Prevetio (CDC), the Health Resources ad Service Admiistratio (HRSA) ad the America Cacer Society (ACS). Immuizatios Screeigs recommeded for childre ad wome Prevetive prostate screeig ad associated lab work Prevetive mammography Lactatio support ad couselig (icludes breast pump purchased through a doctor s office, pharmacy or durable medical equipmet supplier ad is limited to oe pump every 12 moths) Female sterilizatio Idetified cotraceptio devices or services To see a list of all services recommeded by the USPSTF, please visit www.usprevetiveservicestaskforce.org. Provider Network Our idividual BlueEssetials plas come with access to our exclusive provider etwork, or EPN. We oly provide coverage for services provided by a i-etwork provider. We will ot cover services provided by a out-of-etwork provider, uless the services are due to a emergecy or the services are ot available at a i-etwork provider. Coverage without borders Members ca rest easy kowig their BlueCross coverage travels beyod the Exclusive Provider Network available withi South Carolia s borders. Members have access to a Exclusive Provider Network of participatig doctors ad hospitals across the coutry, ad access to a etwork of participatig doctors ad hospitals aroud the world. 10
Importat IforMATio Regardig PreAUTHorizATios A preauthorizatio is also kow as a prior authorizatio, prior approval or precertificatio. A preauthorized service has bee determied to be medically ecessary for a patiet s coditio. Preauthorizatio does ot guaratee, however, that we will pay beefits for the service. Cotract limitatios or exclusios may apply. Additioally, a preauthorizatio may oly be for a specific period of time or umber of visits or treatmets. We make our fial beefit determiatio whe we process your claims. You or your doctor must get a preauthorizatio for certai categories of beefits. Without a preauthorizatio, we must dey those beefits. I-etwork providers i South Carolia are familiar with this requiremet. They will hadle gettig a preauthorizatio. If a i-etwork provider i South Carolia does ot get a preauthorizatio, the provider caot bill you for the services. For some services to be covered, you are required to use a provider we choose, who may or may ot be a i-etwork provider. Whe that happes, we will treat the provider as a i-etwork provider. What is a SUMMAry of BeefiTS ad CoverAGe (SBC)? Have you always wished health isurace came with a easy-to-read user s guide? You re i luck! You have the right to get a easy-to-uderstad summary of a health pla s beefits ad coverage, otherwise kow as a SBC. A SBC allows you to make a apples to apples compariso of differet plas. All isurace compaies must use the same stadard form to help you compare plas. SBCs iclude details, called coverage examples, that let you see what the pla covers for diabetes care ad childbirth, two commo medical situatios. To request a copy of ay SBC for our BlueEssetials plas, just go to www.southcaroliablues.com/liks/metallic/sbc ad click o the Summary of Beefits ad Coverage lik. Plus My Health Toolkit My Health Toolkit is your olie BlueCross iformatio ad customer service ceter. With My Health Toolkit, you ca maage your health care from the comfort of your ow home. Services iclude: Go paperless with our olie bills ad Explaatio of Beefits. Estimate costs for certai prescriptio drugs ad treatmets. Pay your bill. Request a ew ID card. Take a Persoal Health Assessmet. Fid a i-etwork doctor, specialist or hospital ear you. Check the status of a claim. Rate your doctor. 11
Discout ad Added value ProgrAMS Sometimes all you eed to feel great is a little sprucig up. That s why our members ejoy discouts ad value-added programs such as: Cosmetic surgery Visio Hair restoratio Allergy relief LASIK Vitamis ad supplemets Digital hearig aids Members also ca use Blue365, a daily deal website exclusively for our members. Blue365 complemets your health coverage by makig it easier ad more affordable to make healthy choices. Blue365 icludes: Discouts o fitess ceter memberships Discouts o weight loss ad utritio programs 12
Excluded Services for Members Uder Age 65 We Will Not Pay Beefits for: Ay services or beefits ot specifically covered uder the terms of this policy, which were received before this policy wet ito effect or after it termiates, or claims submitted after the time limit for filig claims has bee exceeded. Services or charges for which the member is etitled to paymet or beefits from other sources (workers compesatio or auto isurace), for which the provider does ot charge, or for which the member is ot legally obligated to pay, icludig treatmet provided i a govermet hospital or beefits provided uder Medicare or other govermet programs (except Medicaid). Cosmetic surgery, or surgery or treatmet for the purpose of weight reductio, icludig ay complicatios from or reversal of these procedures, or recostructive procedures made ecessary by weight loss. Illess cotracted or ijury sustaied as the result of war or act of war (whether declared or udeclared), or participatio i a feloy, riot or isurrectio. Refractive care, such as radial keratotomy, laser eye surgery or LASIK. Spial subluxatio. Treatmet, services or supplies received because of suicide, attempted suicide or iteratioally self-iflicted ijuries uless it results from a medical (physical or metal) coditio. Excluded Services for Members Ages 65 or Older ad Eligible for Medicare We Will Not Pay Beefits for: If Medicare says a expese for medical service or supply is eligible uder the Medicare program, this policy will pay beefits show uder the Schedule of Beefits. But if a service or supply is ot a eligible Medicare expese, this policy will ot pay beefits uless specified i the Schedule of Beefits. No-emergecy services i hospitals that do t participate with Medicare. Outpatiet prescriptio drugs, except for Medicare Part B coisurace for immuosuppressive drugs durig the first year followig a Medicare-covered orga trasplat. Other Services This Policy Does Not Cover We Will Not Pay Beefits for: No-emergecy services whe received at or from out-of-etwork providers or hospitals. Hospital or skilled ursig facility charges whe preauthorizatio is ot obtaied. Please see Preauthorizatio i the policy. Services ad supplies that are ot medically ecessary, that are ivestigatioal/experimetal i ature, ot eeded for the diagoses or treatmet of a illess or ijury, or ot specifically listed i Covered Services. Ay service or supply provided by a member of the patiet s family or by the patiet, icludig the dispesig of drugs. This meas the spouse, paret, gradparet, brother, sister, child or spouse s paret. Charges for a missed appoitmet or for fillig out claim forms. Ay loss resultig from you beig legally itoxicated or impaired, by beig uder the ifluece or alcohol, ay arcotic or drug uless take o the advice of a physicia. You or your represetative must provide ay available test result, upo our request, showig blood alcohol or drug levels. If you refuse to provide these test results, o beefits will be provided. Services or supplies related to chewig or bite problems, pai i the face, ears, jaws or eck resultig from problems of the jaw joit(s), also kow as temporomadibular joit disorders (TMJ). Pediatric Detal Services Exclusios ad Limitatios We Will Not Pay Beefits for: Services ad supplies primarily for cosmetic or aesthetic purposes, icludig persoalizatio or characterizatio of detures. Services a detist provides beyod the scope of his or her licese or that do ot meet accepted stadards of detal practice. Detal services that cost more tha they would have if o coverage had existed. Charges for visits at home or i the hospital, except i coectio with emergecy care. Detal care ot specifically listed i the policy or schedule of beefits. Replacemet of a deture that could have bee repaired or exteded. This is a list of some of our exclusios. For a full list of excluded services ad supplies, or for all limitatios, please refer to your policy. 13
HAve QUeSTioNS? If you re a potetial member with a questio: Call us: 877-313-2583 Fax us: 803.264.0225 Mail us: P.O. Box 100118 Columbia, SC 29202-3209 www.facebook.com/bcbssc www.twitter.com/bcbssc HCRfacts.com visit a South Carolia BLUe retail ceter for: Face-to-face service Free classes ad semiars Bill paymet Expert advice Greeville 1025 Woodruff Road Suite A105 Greeville, SC 855-392-BLUE (2583) Mout Pleasat Towe Cetre Place 1795 Highway 17 North, Uit 7 Mout Pleasat, SC 843-216-7760 opeig october 21. www.facebook.com/scblueretail www.scblueretailceters.com 14 14908-8-2013