2015 IBM Health Benefit Comparison Charts for IBM Active Employees

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1 2015 IBM Health Benefit Comparison Charts for IBM Active Employees These Health Benefit Comparison Charts provide a summary overview of the coverage available for medical, mental health/substance 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 IBM health benefit options, please refer to your Benefits Enrollment page on netbenefits.com/ibm for your available options and costs About Your Benefits, the IBM Summary Plan Description available in the Reference Library on netbenefits.com/ibm, for detailed information on covered 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 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 under each IBM medical option. Information for HMOs is available from your Benefits Election page on netbenefits.com/ibm. There is no lifetime benefit maximum for eligible received in-network; a $1 million lifetime benefit maximum applies for out-of-network care. IBM PPO with HSA Annual Deductible 1 (Individual/Family) $2,550 / $5,500 5 Annual Out-of- Pocket Maximum 2 (Individual/Family) Routine Preventive Services Other Office Visits and Outpatient Surgery PCP 3 : $0, after Urgent Care and Walk-in Clinics Inpatient Hospital and Surgery Emergency Room Other Services IBM will contribute $500 to your HSA and you can earn between $300 and $1,100 in tax-free incentives to be deposited in your HSA $6,50 / $12,900 $0, no 25% after Out-of-Network $15,600 / $23,500 5%, no IBM PPO Plus with HSA $6,50 / $12,900 $0, no $2,000 / $,000 5 PCP 3 : $0, after plus $150 copay (copay waived if admitted) IBM will contribute $500 to your HSA and you can earn between $300 and $1,100 in tax-free incentives to be deposited in your HSA 25% after Out-of-Network $15,600 / $23,500 5%, no IBM PPO $1,350 / $,000 $6,600 / $13,200 $0, no Out-of-Network $2,350 / $7,200 $15,000 / $27,000 5%, no IBM PPO Plus $300 / $600 $6,100 / $9,100 $0, no Out-of-Network $2,350 / $7,200 $15,000 / $27,000 5%, no IBM EPO PCP 3 : $0, no SCP 3 : 25%, no PCP 3 : $0, no SCP 3 : 25%, no $0 / $0 $6,600 / $13,200 $0 PCP 3 : 0% SCP 3 : 25% 25% after Facility: 20%, after PCP 3 : 20%, after 25% after Facility: 20%, after PCP 3 : 20%, after plus $150 copay (copay waived if admitted) 20%, after innetwork plus $150 copay (copay waived if admitted) 20%, after innetwork plus $150 copay (copay waived if admitted) 25% $903 copay $18 copay plus $150 copay ($150 copay waived if admitted) 20%, after 20%, after $0 for X-rays, DME and prosthetics; 20% for other imaging 1 Annual applies to medical and mental health/substance abuse combined. 2 Prescription drug coinsurance and copayments apply to the annual out-of-pocket maximum. 3 PCP = Primary Care Physician; SCP = Specialty Care Physician Other Services include: imaging, X-rays, durable medical equipment (DME), prosthetics and lab (no for lab); precertification is required for CT scans, MRIs, sleep studies, and cardiac studies. 5 If you enroll in Family coverage under an HSA-eligible health plan option, you must meet the Family before the plan begins to pay benefits. Individual s do not apply. Note: For Out-of-Area options, benefits for medical 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 if care is pre- certified and provided by an in-network provider (or other provider if there is no in-network provider at your location).

3 Mental Health/Substance Abuse Coverage The chart below shows what you pay for covered under each medical option. Information for HMOs is available from your Benefits Election page on netbenefits.com/ibm. IBM PPO with HSA Annual Deductible Annual Out-of-Pocket Maximum Inpatient Outpatient 1 1,2 ; precertification required Out-of-Network 1 1,2 ; IBM PPO Plus with HSA 1 1,2 ; precertification required Out-of-Network 1 1,2 ; IBM PPO 1 1,2 20%, after ; Precertification required Out-of-Network 1 1,2 ; IBM PPO Plus 1 1,2 20%, after ; Precertification required Out-of-Network 1 1,2 ; IBM EPO 1,2 $903 copay per admission; N/A precertification required Office visits: 25%, after Other : ; precertification required for non-routine. ; Office visits: 25%, after Other : ; precertification required for non-routine. ; 20%, no ; precertification required for non-routine ; 20%, no ; precertification required for non-routine ; 25%; precertification required for non-routine 1 See annual s and out-of-pocket maximums listed on the Medical Options At-A-Glance page; these amounts apply to medical, mental health/substance abuse and prescription drugs combined. 2 Mental health/substance abuse will be covered at 100% once an individual s eligible out-of-pocket expenses (medical, mental health/substance abuse, prescription drugs or a combination of these) reaches the out-of-pocket maximum or once the family out-of-pocket maximum is reached. 3 Precertification is required for inpatient received out-of-network; otherwise, a $150 penalty will apply and you will be responsible for all costs of care not deemed medically necessary. Outpatient treatment from an eligible out-of-network provider will be covered at 55% of the usual and prevailing rate, after the.

4 Prescription Drug Coverage under the IBM Managed Pharmacy Program Provisions of the IBM Managed Pharmacy Program apply if your prescription drug coverage is administered by CVS/caremark. Short-term medications: 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. Long-term medications: If you are taking medication for a chronic condition, you must order it through the CVS/caremark mail order service or through a CVS/caremark pharmacy under Maintenance Choice, after you have filled a 30-day supply (plus up to two refills) through a retail pharmacy; otherwise, your longterm medication will not be covered, and you will pay the entire cost for the refill at a retail pharmacy. Specialty medications: 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. Ordering it this way may save you money, and you may be able to have it shipped directly to you or your doctor s office at no additional charge. Under the IBM PPO, IBM PPO Plus and IBM EPO, different per prescription provisions apply for specialty medications, as shown in the chart below. IBM PPO with HSA, IBM PPO Plus with HSA Under both HSA-eligible health plan options, preventive prescription drugs are not subject to the annual. Keep in mind that benefits for other prescription drugs under these options are not payable until the applicable annual is met. Your costs for prescription drugs will count toward the annual out-of-pocket maximum. Once you meet the out-of-pocket maximum, the plan pays 100% of the cost for eligible prescription drugs. The chart below shows what you pay per prescription. Participating pharmacies Non-participating pharmacies Mail order (up to 90-day supply) Traditional medications Generic 10% of discounted cost after, up to $150 30% of actual cost after 10% of discounted cost after, up to $50 Brand name formulary 30% of discounted cost after, up to $ % of actual cost after 30% of discounted cost after, up to $50 1 Brand name non-formulary 50% of discounted cost after, up to $ % of actual cost after 50% of discounted cost after, up to $50 1 Specialty medications Generic 10% of discounted cost after, up to $150 30% of actual cost after 10% of discounted cost after, up to $50 Brand name formulary 30% of discounted cost after, up to $ % of actual cost after 30% of discounted cost after, up to $50 1 Brand name non-formulary 50% of discounted cost after, up to $ % of actual cost after 50% of discounted cost after, up to $50 1 IBM PPO, IBM PPO Plus, IBM EPO Your costs for prescription drugs will count toward the annual out-of-pocket maximum. Once you meet the out-of-pocket maximum, the plan pays 100% of the cost for eligible prescription drugs. The chart below shows what you pay per prescription. Participating pharmacies Non-participating pharmacies Mail order (up to 90-day supply) Traditional medications Generic 20% of discounted cost, up to $2 30% of actual cost 20% of discounted cost, up to $26 Brand name formulary 20% of discounted cost, up to $ % of actual cost 20% of discounted cost, up to $225 1 Brand name non-formulary 50% of discounted cost, up to $ % of actual cost 50% of discounted cost, up to $50 1 Specialty medications Generic 20% of discounted cost, up to $31 30% of actual cost 20% of discounted cost, up to $33 Brand name formulary 20% of discounted cost, up to $ % of actual cost 20% of discounted cost, up to $2 1 Brand name non-formulary 50% of discounted cost, up to $ % of actual cost 50% of discounted cost, up to $ 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.

5 IBM Dental Options The charts below show what you pay for covered under each IBM dental option. Note: Frequency and treatment limits may apply; contact the administrator of your dental option directly for details. IBM Dental Basic 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 Out-of-Network Routine exams, cleanings, X-rays, fluoride treatment Reimbursed at 100% of negotiated fee for all eligible charges You pay 20% of the usual and prevailing (U&P) rate, plus any amount over the U&P rate Minor Restorative Care Amalgam fillings, composite fillings You pay 20% of the negotiated fee You pay 20% of the U&P rate, plus any amount over the U&P rate Major Restorative Care 1 Root canal therapy; gingivectomy; periodontic, scaling and root Not covered Not covered planing; crowns and bridges; dentures; extractions Orthodontia Orthodontia treatment Not covered Not covered IBM Dental Plus Out-of-Network Annual Deductibles/Benefit Maximums Annual None $50 per person, waived for preventive care Annual benefit maximum $2,000 per person, in- and out-of-network Lifetime benefit maximum None None Orthodontia lifetime benefit maximum $2,500 per person, in- and out-of-network Preventive Care Routine exams, cleanings, X-rays, fluoride treatment Reimbursed at 100% of the negotiated fee for all eligible charges You pay 20% of the U&P rate, plus any amount over the U&P rate Minor Restorative Care Amalgam fillings, composite fillings You pay 20% of the negotiated fee You pay 20% of the U&P rate, plus any amount over the U&P rate Major Restorative Care 1 Root canal therapy; gingivectomy; periodontic, scaling and root planing; crowns and bridges; dentures; extractions Orthodontia Orthodontia treatment You pay 35% of the negotiated fee You pay 50% of the negotiated fee plus any amount that exceeds the lifetime maximum. You pay 35% of the U&P rate, plus any amount over the U&P rate You pay 50% of the U&P rate, plus any amount over the U&P rate 1 These are the most common major restorative care procedures; other procedures may be covered. Also, some procedures have varying levels of treatment. Contact the administrator of your dental option for details.

6 3.IM-H-515N.108_NB2

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