PPO Choice. It s Your Choice!

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1 Offered by Capital Advantage Insurance Company A Capital BlueCross Company PPO Choice It s Your Choice! Issued by Capital Advantage Insurance Company, a Capital BlueCross subsidiary. Independent licensees of the Blue Cross and Blue Shield Association.

2 It s Your Choice! Welcome to PPO Choice. Your employer has selected a plan that gives you the freedom to choose the Providers you want to see. PPO Choice features two levels of participating Providers. You will maximize your benefits and have the lowest out-ofpocket costs when using a PPO Choice 1 doctor, hospital, or other health care professional. You also have access to Providers outside our 21-county service area through our BlueCard network. BlueCard Providers are covered at the highest benefit level. Which Level is Right For Me? When using a PPO Choice 1 Provider, you will have no outof-pocket expenses for most covered services after meeting your plan deductible. You also have the freedom to use a PPO Choice 2 Provider. You will pay a separate deductible when using a PPO Choice 2 Provider and may share in more of the costs by paying a higher coinsurance and copayment. There is a separate deductible for each Choice Provider level. Your deductibles, coinsurance, or copayment may vary based on the Provider you choose. With PPO Choice, you can even see doctors or hospital providers who do not participate in the network and receive some level of coverage. You must first meet a separate annual deductible and then pay 50 percent of allowed charges for covered services. When you use a PPO Choice 1 or PPO Choice 2 Provider, there are no claims to file. Your Provider takes care of the paperwork for you. If you choose to see a nonparticipating provider, you may have to submit the bill and claim form to be reimbursed for eligible expenses. To find a participating Provider in the Capital BlueCross 21-county service area, search our online directory of health care professionals and ancillary Providers at capbluecross.com. 21-COUNTY SERVICE AREA To find a BlueCard participating Provider anywhere outside our service area, you can search the Blue Cross and Blue Shield Association s online directory at bcbs.com. You can also call BLUE, or, when traveling outside of the country, you can call collect to for assistance 24 hours a day, seven days a week.

3 If you re looking for more, you ve come to the right place! Your Benefits Your PPO Choice plan covers adult and pediatric preventive care and other important health care services. Services may be subject to copayments, coinsurances, and deductibles. You do not need a referral to see a specialist; however, some services require preauthorization. Please refer to your Certificate of Coverage and/or Benefit Highlight Sheet, or check your benefits online by logging in to mycapbluecross.com. Preventive care*: Routine physicals Annual gynecological exams Annual mammograms for women 40 and over Childhood immunizations Select screenings Other covered services*: Doctor office visits for illness or injury Maternity and newborn care Emergency care and emergency ambulance service Lab tests and X rays Inpatient and outpatient hospital services Disease management programs Physical, occupational, speech, and manipulation therapies Mental health care Substance abuse treatment Home health care Skilled nursing-facility care * The above listing is not a complete summary of benefi ts. Please refer to your Certificate of Coverage and Benefit Highlight Sheet for a detailed description of all benefits, limitations, definitions of terms, and exclusions that apply to your plan.

4 Your Share of the Cost The term cost-sharing refers to the amount of money you contributed towards the cost of your medical services. Your contribution typically includes deductibles, copayments, and coinsurance. For nonparticipating providers, after you have met your deductible, you may be responsible for coinsurance AND you may pay any difference between what the provider charges and what Capital BlueCross pays. Since cost-sharing amounts vary depending on your specific coverage, it is important that you refer to the Summary of Cost Sharing and Benefits section of your Certificate of Coverage. Terms to Know: Annual deductible: A specified dollar amount that you or your entire family must incur each benefit period before benefits are paid under your coverage. PPO Choice Members must meet a separate annual deductible for each Choice Level Provider. Coinsurance: The percentage you are required to pay based on the total amount allowed by Capital BlueCross. Copayment: The specified dollar amount that you are required to pay directly to your Provider at the time a service is rendered. Out-of-pocket maximum: The maximum amount of coinsurance that you or your entire family must pay during a benefit period. Participating Provider: A health care facility Provider or a professional Provider who is properly licensed, where required, and has a contract with Capital BlueCross to provide benefits under your coverage.

5 Your Member Identification Card (ID card) Preauthorization Your ID card is the key to accessing the benefits provided under PPO Choice. Show this card each time you seek medical services. The following is important information about the ID card: ID # YWP PROVIDER PRACTICE RxBIN RxPCN ADV RxGrp RXCAP Rx Plan Information Preauthorization Group # Plan 361 C1 OV $20 SP $20 UC $100 ER $100 C2 OV $40 SP $ 40 UC $100 ER $100 MEMBER NAME PPO Choice Suitcase Symbol Your Copayments Preauthorization: A clinical program in which our nurses work with physicians to approve and monitor certain health care services prior to the delivery of services. The purpose of preauthorization is to ensure that all Members receive medically appropriate treatment to meet their individual needs. Certain medical and therapy services and all nonemergency inpatient hospital admissions require preauthorization. Please refer to the Preauthorization Program attachment to your Certificate of Coverage for more information. Copayment: The specified dollar amount that you are required to pay directly to your Provider at the time a service is rendered. Your ID card will indicate two levels of copayments Choice 1 and Choice 2. C1 OV $$ PPO Choice 1 office visit copayment C2 OV $$ PPO Choice 2 office visit copayment SP $$ Specialty office visit copayment UC $$ Urgent care copayment ER $$ Emergency room visit copayment Suitcase Symbol: This symbol lets you know that your coverage includes BlueCard and BlueCard Worldwide. With both programs, you have access to BlueCard participating Providers nationwide and worldwide. The back of the ID card has important information such as: Toll-free phone numbers. General instructions for filing claims. Emergency care information. Remember to destroy old ID cards and use only your most recent ID card. Please contact Customer Service at the phone number that appears on your ID card if any information on your card is incorrect or if you have questions.

6 When you take the time to become a better health care consumer, you are doing your part to help keep health care affordable. And as a Member of the Capital BlueCross family of companies, you will have access to the information and tools to assist you in making better decisions about your health and well-being. Great ways to become a better health care consumer Register for a secure personal account at mycapbluecross.com. If you haven t already set up a mycapbluecross.com secure personal account, register on our Web site to establish a user ID and password. Your secure account is a valuable tool that can help you make the most of your health care benefits. Here s how: When you login to mycapbluecross.com you can Check the status of a claim. Compare hospital quality and treatment costs. Print a temporary proof of coverage. SM Access the Simply Well Member newsletter. View your Explanation of Benefits (EOB) for the past two years. And much more! Take your FREE Better Health Works SM Personal Profile. The Better Health Works Personal Profile starts by asking you questions about yourself and the way you live. Based on the answers you provide, you ll receive customized recommendations for your health situation. And to help you follow through on those recommendations, we provide you with the support you need to make positive health changes. For more information, go to capbluecross.com/bhw or call (TTY: ). Research your prescription drug options. Review the formulary information and prescription drug program guidelines on our Web site. Compare the costs of retail pharmacy medications before you buy. Try using Mail Service to save more on the medications you take regularly.

7 Call Nurse Line 24 hours a day, 7 days a week. When your doctor is out, Nurse Line is always in. Nurse Line is staffed by experienced Registered Nurses who provide information and support for any health-related concern, at no cost to you. Call BLUE (TTY: ). Get moving! Living healthy 365 days a year means making healthy choices in every area of your life; that s why you ll enjoy Healthy Family Fun SM with Blue365, your online resource for living healthier. Search directly from our Web site for recreational activities, health consumer information, special offers, and discounts for Members only. Practice preventive care. Use your preventive care benefits: physical exams, screenings, and immunizations to detect potential health problems early. You ll find our adult and pediatric Preventive Health Guidelines on our Web site. Take control of the quality and cost of your health care. Use MyCare Advisor SM to research and compare average cost and quality information for many of the most common elective surgical and treatment procedures to maximize your health care dollar. Log in to mycapbluecross.com to access this valuable tool before deciding where and how much you spend on your procedure.

8 Contact Us (TTY: ) Monday through Friday 8 a.m. to 6 p.m. Look for more ways to become a better health care consumer. Be sure to come back often to see what s new. capbluecross.com Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-769 (9/2010)

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