Thank You! [INSERT Name] [INSERT Address] [INSERT City, SC] [INSERT Date] Dear [Insert Name] Thank you for staying blue. We are happy you selected BlueCross BlueShield of South Carolina as your health insurance provider. Your [PLAN NAME] is scheduled to begin on [EFFECTIVE DATE]. Your monthly premium amount is [$xxx.xx]. In this package you will find: How Your Benefits Work This will help you better understand your plan coverage Member and Premium Schedule A summary of your specific benefits Value-Added Discounts Details on discounts you ll receive as a member Notice of Privacy Practices This lets you know what is considered to be Protected Health Information and the ways we can keep that information private How to Contact Us Important phone numbers, addresses and email addresses When visiting our website, www.southcarolinablues.com, be sure to log in to My Health Toolkit. This is the go-to place for all things BlueCross. Sincerely, Marketplace Operations BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. 1
PRESCRIPTION DRUG COVERAGE BlueEssentials SM Covered Drug List The BlueEssentials Covered Drug List is the list of drugs we cover under your plan. BlueCross BlueShield of South Carolina works with a team of health care providers to choose drugs that provide quality treatment. Find the BlueEssentials Covered Drug List on our website, www.southcarolinablues.com. Or for specific drug costs of your current plan and coverage rules, log in to My Health Toolkit. Saving you money while offering you choices We have many different ways to save you money and give you choices. When looking at the BlueEssentials Covered Drug List, be sure that you carefully review the tier of the drug. Tier 1 Tier 2 Tier 3 Tier 4 Drugs on this tier are usually generic and will generally cost you the least amount of money out of your pocket. Drugs on this tier are most often brand drugs, sometimes referred to as preferred drugs, because they usually cost you less than other brand drugs. Drugs on this tier are 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. These are usually expensive drugs that treat complex conditions. You will usually pay more for drugs in this tier. Take your prescription to one of our thousands of Retail Network pharmacies. Find a list of network pharmacies by going to www.southcarolinablues.com and logging in to My Health Toolkit. Where applicable, you could get a 90-day supply of covered maintenance medications from our mail-order pharmacy. Call the customer service number on the back of your ID card to get mail order started. If your drug is designated as a specialty drug on the Covered Drug List, it s available from our Specialty Pharmacy. You also can start this process by calling the Customer Service number on the back of your ID card. What if my drug is not on the BlueEssentials Covered Drug List? Usually, there are no benefits for drugs not covered on the BlueEssentials Covered Drug List. If your drug is not on this list, call Member Services to verify that your drug is not covered. If you learn that BlueCross does not cover your drug, you have two choices: 1 Use the BlueEssentials Covered Drug List to work with your health care professional to find another medication that is covered. 2 Ask BlueCross to make an exception and cover your drug. Usually, BlueCross will only approve your request for an exception if the medications on the BlueEssentials drug list are not as effective as the non-covered drug in treating your condition or if they cause adverse side effects. 2
BlueEssentials SM Member and Premium Schedule Member s Name: Member s ID Number: [John Smith] [ZCY123456789123] Type of Plan: SINGLE/FAMILY Effective Date: 1/01/15 Benefit Period: 1/1-12/31 Covered Dependents: [Jane Smith] [John Smith, Jr.] [Samantha Smith] Deductible Out-of-pocket Limit Coinsurance $1,200 per Member for single coverage and $2,350 per family for family coverage per Benefit Period. With family coverage, once one person meets his/her Deductible, benefits will be begin paying for that person. $4,200 per Member for single coverage and $8,250 per family for family coverage per Benefit Period 20% Policy Number Policy Description Premium BlueEssentials (Rev. 1/2015) BlueEssentials [$55.00] Total Monthly Premium [$115.00] Benefits are provided In-network only. No benefits are provided for services received Out-of-network, unless the service is due to an Emergency or the service is not available at a Network Provider. BlueEssentials Member Schedule (1/2015) Gold 1
Your BlueEssentials Benefits (Gold 1) Deductible (You Pay) $1,200 per Member for single coverage and $2,350 per family for family coverage per Benefit Period. With family coverage, once one person meets his/her Deductible, benefits will be begin paying for that person. Copayments (You Pay) $15 Primary Care Physician (PCP) Office Visit $30 Specialist Office Visit $300 Emergency Room Copayments do not apply to the Deductible. The Deductible applies to the Out-of-pocket Limit. Copayments do apply to the Out-of-pocket Limit. Out-of-Pocket Limit (You Pay) Other Limits (We Pay) $4,200 per Member for single coverage and $8,250 per family for family coverage per Benefit Period. Covered Services will be paid at 100% of the Allowable Charges when you reach your Out-of- Pocket Limit. The Out-of-Pocket Limit includes Copayments, Deductibles and Coinsurance. It doesn t include premiums; charges in excess of the Allowed Amount; amounts exceeding any Maximum Payments for benefits; or any expense not allowed according to any provisions of this coverage. (Per Member Benefit Period) 60 days for Skilled Nursing Facility Services 60 visits for Home Health Care 6 months per episode for Inpatient and Outpatient Hospice Care 30 visits for Physical, Speech and Occupational Therapy Services combined There is no annual or lifetime dollar limits on benefits provided. All benefits payable on Covered Services are based on our Allowed Amount. All Covered Services must be Medically Necessary. All admissions require Preauthorization. Certain other services also require Preauthorization. See the Preauthorization section of the Certificate for information concerning the Preauthorization requirement. For the most up-to-date information, visit www.southcarolinablues.com and log into your My Health Toolkit account.
FREQUENTLY ASKED QUESTIONS How can I pay my bill? Pay online through My Health Toolkit at SouthCarolinaBlues.com. When will I get my ID card? You will receive your ID card seven to 10 business days before your coverage begins. Visit a South Carolina BLUE SM retail center near you (see back cover for locations) Call 855-404-6752 to pay by phone I have a friend who has her prescriptions mailed to her. Is that an option for me? Do I have a grace period to make my payment? Your payment is due on the first of every month. If your payment is not received by the first, you will not be able to receive benefits. Who is covered on my policy? For specific member coverage information, refer to your BlueEssentials SM Member and Premium Schedule. How can I add my child or spouse? You can add your child or spouse to your policy during open enrollment. Or if one of you has a qualifying life event you can enroll in your same or new coverage as a special enrollment period (SEP). How do I change my address? You can contact us at 855-404-6752 or contact your agent. Yes. To find out more, call Caremark at 888-277-4144. Caremark is an independent company that manages prescription drug benefits on behalf of BlueCross. Why did my pharmacy say that a drug requires prior authorization? There are different reasons a drug might require prior authorization. Some of the reasons include ensuring the appropriate quantities are being used, that the drug is being used in accordance with FDA approved indications and that the most cost-effective therapy for you is being used. The pharmacy or your doctor will need to contact Caremark at 800-337-5022. What does it mean that my drug has a quantity limit? Based on the FDA guidelines, we will only cover a certain amount of the drug you are taking for a specific period of time. What happens if I am under the care of a physician who is not in your BlueEssentials Network? You can log in to your account by visiting www.healthcare.gov. Please call us at 855-404-6752 to request a Transition of Care Authorization form. Once you complete the form and return it to us, we can evaluate if your situation qualifies for transition of care benefits. 5
DISCOUNT AND VALUE-ADDED PROGRAMS Sometimes all you need to feel great is a little sprucing up. That s why our members enjoy discounts and value-added programs such as: 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. 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. Alternative Health Care Where does it hurt? With NaturalBlue ȘM you can tap into an extensive network of credentialed acupuncturists, massage therapists, chiropractors, plus diet advisers all offering extensive discounts. Allergy Relief You ll breathe easier thanks to special prices on products designed to reduce exposure to indoor allergies. Children s Fitness With My Gym Children s Fitness Center, choose from a variety of structured, age-appropriate classes that use music, dance, relays, games and more. HEARING AND VISION Laser Vision Correction You ll see exclusive discounts on Lasik surgery offered through QualSight, a national network of credentialed Lasik surgeons. 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. 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. BLUE365 Wellness Discounts As a BlueCross member, you have access to Blue365, a daily deal website with discounts on various wellness products and services. Blue365 complements your health coverage by making it easier and more affordable to make healthy choices. Visit Blue365deals.com/BCBSSC for the deal of the day! 6
NOTICE OF OUR PRIVACY POLICIES AND PRACTICES Dear Member: This Notice has been prepared to inform you that we do not disclose and we reserve no right to disclose to our affiliates or to nonaffiliated third parties, your nonpublic personal financial information, which we collect and maintain except with your permission or as permitted by law. We will not disclose your nonpublic personal financial information except as described in this Notice even if our customer relationship with you may end. If you are a plan sponsor or group policyholder, this Privacy Notice describes our practices for safeguarding nonpublic personal financial information about employee benefit plan participants and beneficiaries. Information we collect and maintain: We collect nonpublic personal financial information about you from the following sources: Information we receive from you on applications, at your request or otherwise; Information we obtain from your transactions with us, our affiliates or others; Information we receive from consumer-reporting agencies. How we protect information: Except as otherwise described in this Notice, we restrict access to your nonpublic personal financial information to our employees who need to know to provide our products and services to you and as permitted by law. We maintain physical, electronic, and procedural safeguards that comply with applicable legal requirements to guard your nonpublic personal financial information. We have installed usernames, passwords, and other safety features on our Web applications to help ensure that the information you provide remains safe and secure. Changes to this Notice: We may amend our privacy policies and practices at any time, and we will inform you of any material changes as required by law. YOU DO NOT NEED TO DO ANYTHING IN RESPONSE TO THIS NOTICE. THIS NOTICE IS MERELY TO INFORM YOU ABOUT OUR PRIVACY POLICIES AND PRACTICES. 7
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