2013 IBM Health Benefit Comparison Charts

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1 203 IBM Health Benefit Comparison Charts for IBM Active Employees These Health Benefit Comparison Charts provide a summary overview of the coverage available for medical services, mental health/substance abuse care, and prescription drugs under each IBM medical option, as well as the dental coverage available under each IBM dental option. For coverage information for the IBM-Vision Plan, log on to anthem.com/preenrollment (Employer ID = IBM) or refer to the Anthem Blue View Vision Chart available in the Reference Library on netbenefits.com/ibm. If you have questions about discounts available under the EyeMed Discount Card, contact EyeMed Vision Care at For more information about your IBM health benefit options, please refer to: Your Benefits Election page on NetBenefits at netbenefits.com/ibm for your available options and their costs. About Your Benefits, the IBM Summary Plan Description available in the Reference Library on NetBenefits, for detailed information on covered services and exclusions for all of your IBM benefit plans. These comparison charts provide a side-by-side view of general coverage information to help you see key plan features at a glance and choose the option that best matches your needs. If you want to know more about a specific provision, contact the administrator of your medical or dental option or call the IBM Employee Services Center for assistance. Under all IBM medical options, certain services may be subject to a medical necessity review to determine whether they are covered under the IBM health benefits program. Be aware that not every treatment is considered a covered health service under the IBM benefit plan, even though a physician or medical professional may perform or prescribe the procedure or treatment, and even if it is the only treatment available for a particular injury, sickness or mental illness.

2 Your Medical Options At-A-Glance The chart below shows what you pay for covered services under each IBM medical option. Your Medical Options At-A- Glance Annual Deductible (Individual/ Family). IBM PPO In-Network. $,04/ $3,3 Out-of-Network. $,930/ $5,996 IBM PPO Plus Annual Out-of-Pocket Maximum (Individual/ Family). $7,356/ $3,24 $3,496/ $24,289 In-Network None $4,898/ $7,346 Out-of-Network $,930/ $5,996 IBM Exclusive Provider Organization In-Network Only $3,496/ $24,289 None $6,748/ $2,46 Lifetime Benefit Maximum Per Person. Routine/ Preventive Services. Unlimited No charge No charge, PCP 2 / 25% SCP 2, no Unlimited 45%, no Other Office Hospitals Visits. Lab Services. and Surgery. Unlimited No charge No charge PCP 2 / 25% SCP 2, no Unlimited 45%, no Unlimited No charge No charge PCP 2 / 25% SCP 2, no no no no after no $674 copay per admission inpatient; 25% outpatient IBM High Deductible PPO with HSA (Note: Family and out-of-pocket maximums apply if two or more individuals are enrolled) In-Network $2,248/ $4,497 (in-and outof-network combined) $6,250/ $2,500 Out-of-Network $4,393/ $2,590 Unlimited No charge No charge, after PCP 2 / after SCP 2 Unlimited 45%, no Emergency Room. after in-network no $37 copay, (waived if admitted) Other Services 3. after no No charge for x-rays, DME and prosthetics; 20% for other imaging services Typical HMO In-Network Only Varies by HMO; from NetBenefits, select the Review/Update your Election link under Medical, then click the HMO plan option name to view coverage information. Annual applies to medical and mental health/substance abuse services combined Note: For Out-of-Area options, benefits for medical services will be paid at the in-network level for all IBM PPO options. Mental health/substance abuse care will be paid at the in-network level 2 PCP = Primary Care Physician; SCP = Specialty Care Physician if care is pre-certified and provided by an in-network provider (or other provider if there is no 3 Other Services include: imaging, x-rays, durable medical equipment (DME) and prosthetics in-network provider at your location).

3 Mental Health/Substance Abuse Coverage At-A-Glance The chart below shows what you pay for covered services under each IBM medical option. Mental Health Annual Deductible Annual Out-of-Pocket Maximum Inpatient Outpatient IBM PPO In-Network Shared with medical Shared with medical, 2 after ; precertification required 25%, no ; precertification required for 4 ; Out-of-Network Shared with medical Shared with medical, 2 ; precertification required 3 precertification required for IBM PPO Plus In-Network N/A Shared with medical, 2 20%; precertification required 25%; precertification required for Out-of-Network Shared with medical Shared with medical, 2 ; precertification required 3 4 ; precertification required for IBM Exclusive Provider Organization In-Network N/A Shared with medical, 2 $674 copay per admission; precertification required Emergency room: $37 copay, no (waived if admitted) IBM High Deductible PPO with HSA In-Network Shared with medical Shared with medical, 2 ; precertification required 25%; precertification required for 20% for office visits, after ; 30% for other services, after ; precertification required for Out-of-Network Shared with medical Shared with medical, 2 ; 4 ; precertification required 3 precertification required for Typical HMO In-Network Varies by HMO; from NetBenefits, select the Review/Update your Election link under Medical, then click the HMO plan option name to view coverage information See annual s and out-of-pocket maximums listed on the Medical Options At-A-Glance page; these amounts apply to medical and mental health/substance abuse services combined. 2 Mental health/substance abuse services will be covered at 00% once the participant reaches this amount in any eligible out-of-pocket expenses (medical, mental health/substance abuse or a combination of the two) or once the family out-of-pocket maximum is reached. 3 Precertification for inpatient services received out-of-network is required, otherwise you will be responsible for a $50 penalty plus costs of care not deemed medically necessary. 4 Outpatient treatment from an eligible out-of-network provider will be covered at 45% of the usual and prevailing rate, after the

4 Prescription Drug Coverage IBM Managed Pharmacy Program Provisions of the IBM Managed Pharmacy Program apply if your prescription drug coverage is administered by CVS Caremark. Coverage for short-term medication: You may obtain up to a 30-day supply (plus up to two refills) from a retail pharmacy; you ll save money if you use a CVS Caremark network pharmacy. Coverage for long-term medication: If you are taking medication for a chronic condition, you must order your medication through the CVS Caremark mail order service or through a CVS pharmacy under Maintenance Choice after you have filled a 30-day supply (plus up to two refills) through a retail pharmacy; otherwise, your medications will not be covered and you will pay the entire cost for the refill at a retail pharmacy. Note: Prescription drug charges apply to the annual and out-of-pocket maximum under the IBM High Deductible PPO with Health Savings Account plan option. Preventive drugs are not subject to the annual under this plan. If Your Medication Requires Special Handling If you need covered prescription medication that requires special handling or administration such as chemotherapy and are currently receiving it through your doctor s office or other treatment center, you can order it through the CVS Caremark Specialty Pharmacy. By ordering covered prescription medication this way, you may pay less for it overall. Additionally, you may be able to have it shipped directly to you or your doctor s office at no additional charge. Contact CVS Caremark for more details. Different per prescription maximums apply; refer to the table below. Under the IBM Managed Pharmacy Program, you pay a percentage of the cost for prescription drugs, as shown in the chart below. Prescription Drug Coverage Participating Pharmacies (up to 30-day supply) Traditional Medications No Special Handling Required Your Share of the Cost Retail and Mail Order Non-Participating Pharmacies (up to 30-day supply) Mail Order (up to 90-day supply) Generic 20% of discounted cost, up to $22 30% of actual cost 20% of discounted cost, up to $24 Formulary Brand Name 20% of discounted cost, up to $73 30% of actual cost 20% of discounted cost, up to $83 Non-Formulary Brand Name 45% of discounted cost, up to $47 55% of actual cost 45% of discounted cost, up to $368 Specialty Medications Special Handling Required Generic 20% of discounted cost, up to $28 30% of actual cost 20% of discounted cost, up to $30 Formulary Brand Name 20% of discounted cost, up to $88 30% of actual cost 20% of discounted cost, up to $222 Non-Formulary Brand Name 45% of discounted cost, up to $83 55% of actual cost 45% of discounted cost, up to $457 If a generic with the identical active ingredient is available and you choose the equivalent brand name drug instead, you will pay the generic coinsurance plus the difference between the generic and the applicable brand name drug; per prescription maximums will not apply. Note: Benefits may vary for prescription drug benefits administered directly by HMOs. For additional coverage details, go to NetBenefits, select the Review/Update Your Election link under Medical, then click the HMO plan option name to view coverage information.

5 IBM Dental Options The charts below show what you pay for covered services under each IBM dental option. Note: Frequency and treatment limits may apply; contact the plan directly for details. IBM Dental Basic Dental Basic In-Network Out-of-Network Annual Deductibles/Benefit Maximums Annual None None Annual benefit maximum $500 per person, in- and out-of network combined Lifetime benefit maximum None None Orthodontia lifetime benefit maximum Not covered Not covered Preventive Care Routine exams, cleanings, x-rays, fluoride treatment Minor Restorative Care Amalgam fillings, composite fillings Reimbursed at 00% of negotiated fee for all eligible charges You pay 20% of the negotiated fee for all eligible charges. Major Restorative Care Root canal therapy; gingivectomy; periodontic, scaling and Not covered Not covered root planning; crowns and bridges; dentures, extractions Orthodontia Orthodontia treatment Not covered Not covered IBM Dental Plus You pay 20% of the U&P rate, plus any amount over the U&P rate for all eligible charges. You pay 20% of the U&P rate, plus any amount over the U&P rate for all eligible charges. Dental Plus In-Network Out-of-Network Annual Deductibles/Benefit Maximums Annual (excludes orthodontia) None $50 per person, waived for preventive care Annual benefit maximum (excludes orthodontia) $2,000 per person, in- and out-of network combined Lifetime benefit maximum None None Orthodontia lifetime benefit maximum $2,500 per person, in- and out-of network combined Preventive Care Routine exams, cleanings, x-rays, fluoride treatment Minor Restorative Care Amalgam fillings, composite fillings Major Restorative Care Root canal therapy; gingivectomy; periodontic, scaling and root planning; crowns and bridges; dentures, extractions Orthodontia Orthodontia treatment Reimbursed at 00% of the negotiated fee for all eligible charges You pay 20% of the negotiated fee for all eligible charges. You pay 35% of the negotiated fee for all eligible charges. You pay 50% of the negotiated fee plus any amount that exceeds the lifetime maximum. You pay 20% of the U&P rate, plus any amount over the U&P rate for all eligible charges. You pay 20% of the U&P rate, plus any amount over the U&P rate for all eligible charges. You pay 35% of the U&P rate, plus any amount over the U&P rate for all eligible charges. You pay 50% of the U&P rate, plus any amount that exceeds the lifetime maximum. These are the most common major restorative care procedures; other procedures may be covered. Also, some procedures have varying levels of treatment. Contact the plan directly for details.

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