This guide is information only. You must enroll to be covered ANMENABS MUMENMUB REV 01/14

Transcription

1 A guide to choosing your Anthem Blue Cross and Blue Shield health plan University of Southern Indiana Blue Access PPO and Lumenos HSA Effective January 1, MUMENMUB REV 01/14 This guide is information only. You must enroll to be covered ANMENABS 3 14

2 An Anthem Blue Cross and Blue Shield ID card means something It means you have access to quality care from quality doctors. It means you can always get your questions answered. It means you have our support before you ever need health care. And that s what this guide is for. We want you to have everything you need to make a good decision.

3 Getting started with health insurance Let's start with how health insurance works in general How most health plans work Deductible Out-of-pocket limit What you pay What we pay 1. You pay your deductible. This is a set amount that you pay before your plan starts paying for covered services. 2. After you meet your deductible, you and your plan share the cost of covered services. You pay coinsurance (a percentage of the cost) each time you get care. Your insurance covers the rest. 3. You re protected by your plan s out-of pocket limit. That s the most you pay for covered health services each year. With some plans, you still have copays even after you reach your out-of-pocket limit. What about the money for health insurance that gets deducted from your paycheck? That s your premium. Think of it like a membership fee. It s separate from what you pay when you get care. Remember, this chart is only an example. Your actual costs will depend on the type of plan you choose, the service you get and the doctor. To see your actual costs, please refer to your plan information. 3

4 Choose a health plan that works for you Invest in your health with the right health plan. The doctors, hospitals and other health care providers in our network have agreed to charge lower rates for our members. PPO Preferred Provider Organization. This type of plan covers services from almost any doctor or hospital, but you get a discount if you use a provider from the PPO network. You pay more if you go to a doctor who s not in the PPO network. You don t usually need a referral from your main doctor, also called a primary care doctor, to see a specialist. Visit anthem.com/ppobasics to watch a video explaining the basics of a PPO. Some PPO plans may have different rules. So be sure to check your plan details. HSA Health Savings Account. This is an account where you put money in and use the funds to pay for future health care like your deductible and coinsurance. If you use up the funds before you reach your deductible, you pay for care until you reach the deductible. After that, your plan works much like a PPO you pay a percentage of the cost for care until you reach your out-of-pocket maximum. People who don t have a lot of health problems often end up not using all the money in their account. So they end up not paying anything out of pocket. Visit anthem.com/hsabasics to watch a video explaining the basics of an HSA. Our Anthem ID card means I can choose my child's doctor. 4

5 Frequently asked questions (FAQs) You can register at anthem.com your simple and convenient solution to managing your health Can I keep my current doctor? Yes, you can. But keep in mind that you get the most out of your plan if your doctor is part of the network. Some plans cover only services from network doctors, which means you pay for the full cost if you see a doctor outside the network. Other plans cover services from doctors outside the network but your plan pays more of the cost when you see a network doctor. Be sure to check the details of your plan. To fi nd out if your doctor is in our network, or to find a new doctor or pharmacy in our network, go to our Find a Doctor tool on anthem.com. You can search by specialty and check a doctor s training, certifi cations and member reviews. Be ready to enter your plan name to view the network that serves your plan. You can also use Find a Doctor on your smartphone. What prescription drugs are covered? If you have complex or long-term conditions, you may need specialty drugs. Your coverage includes these types of drugs and the support you may need when you take them. To learn more about pharmaceutical programs that may apply to your coverage, check out the Customer Support section on anthem.com. Then go to FAQs > Pharmacy. How do I use my health plan when I need care? After you enroll, your member ID card will come in the mail. Be sure to bring it with you to the doctor. Is preventive care covered? Yes, preventive care from a network provider is covered at 100%. It s very important to take care of your health with regular checkups even when you feel fi ne. So talk to your doctor about screenings and immunizations that you may need to protect your health. Can I manage my health care on the Web? Yes. As soon as you become a member, you ll be able to register at anthem.com. It s designed to help you manage your health care and your coverage simply and conveniently. Many of our members find these self-service tools helpful: Check on your claims. Find a doctor or pharmacy. Check the price of a drug and refill a prescription. Track your health care spending. Compare quality and costs at hospitals and other facilities. Go paperless. Take your Health Assessment to learn about your health risks so you can address them. Visit anthem.com/guidedtour to watch a video explaining how our website can help you. Do I have health and wellness benefits with my plan? Yes. In fact, we have a set of tools and resources that can help you reach your health goals. They can also save you money on products and services for your health. Just go to anthem.com and click the Health & Wellness tab. Once you re a member, you can log in and see more. Check out these health and wellness programs your employer is providing in addition to your health insurance benefits. 24/7 NurseLine Our registered nurses can answer your health questions wherever you are any time, day or night. Future Moms Moms-to-be get personalized support and guidance from registered nurses to help them have a healthy pregnancy, a safe delivery and a healthy baby. ConditionCare Get the added support you may need if you have asthma, diabetes, heart disease, chronic obstructive pulmonary disease or heart failure. A nurse coach can answer questions about your health and help you reach your health goals based on your doctor s care plan. You can work with dietitians, health educators, pharmacists and social workers to reach those goals and feel your best. ComplexCare If you have a serious health condition or a number of health issues that need extra care, a nurse coach will help answer your questions, work to coordinate your care, and help you effectively use your health benefits. Healthy Lifestyles Take charge of your total wellness through 5

6 Frequently asked questions (FAQs) a personalized Well-Being Plan and custom trackers that help you manage your physical and mental health. MyHealth Advantage Avoid health problems, stay healthy and save money. This program tracks your health information to see if there s anything you can do to improve your health. If so, you ll get a personalized and confidential MyHealth Note in the mail. How can my plan help me save money? You'll save money every time you go to a doctor in network they've agreed to charge lower rates for Anthem members. But we'll also help save you money before you go to the doctor. At anthem.com, you can compare how much a medical procedure will cost at different locations. Plus, all members get discounts on health-related products. Home Delivery Pharmacy You can save money and time by having your prescriptions delivered to your home. Learn how to get started with Home Delivery. Cost and Quality If you re getting an imaging test (like an X- ray), a sleep test, colonoscopy orendoscopy, we ll work with you and your doctor to give you choices so you can fi nd quality facilities at low prices. 6

7 Your health plan details In this next section, you ll fi nd out what s covered by your plan, how much you ll pay when going to different types of doctors, and more.

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9 Your Summary of Benefits University of Southern Indiana - Buy-Up Plan Blue Access (PPO) Effective January 1, 2015 Covered Benefits Network Non-Network Deductible (Single/Family) $500/$1,000 $1,000/$2,000 Out-of-Pocket Limit (Single/Family) $2,500/$5,000 $5,000/$10,000 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: $20/$20 allergy injections (PCP and SCP) Covered in full allergy testing Covered in full MRAs, MRIs, PETS, C-Scans, Nuclear Covered in full Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic No copayment/coinsurance Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Hearing screenings and Vision screenings which are limited to Screening tests (i.e. Snellen eye chart) and Ocular Photo screening Emergency and Urgent Care Emergency Room Services $250 $250 facility/other covered services (copayment waived if admitted) Urgent Care Center Services MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Allergy injections Allergy testing Inpatient and Outpatient Professional Services Include, but are not limited to: Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Blue 8.0 $50 Covered in full Covered in full University of Southern Indiana 8 0 PPO SOB Buy-Up Plan.doc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 9

10 Your Summary of Benefits Covered Benefits Network Non-Network Inpatient Facility Services (Network/Non-Network combined) days except for: days Network/Non-Network combined for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) days for skilled nursing facility Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-Network combined) visits (excludes IV Therapy) Durable Medical Equipment and Orthotics Prosthetic Devices Prosthetic Limbs Physical Medicine Therapy Day Rehabilitation programs Hospice Care No copayment/coinsurance No copayment/coinsurance Ambulance Services No copayment/coinsurance No copayment/coinsurance Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits (PCP/SCP) $20/$20 Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical/Occupational therapy: 90 visits combined $20/$20 Manipulation therapy: 12 visits Speech therapy: 40 visits $20/$20 Cardiac/Pulmonary Rehabilitation: visits $20/$20 Copayments/Coinsurance based on setting where covered services are received Accidental Dental: Copayments/Coinsurance based on setting where covered services are received 10

11 Your Summary of Benefits Covered Benefits Network Non-Network Behavioral Health Services Mental Illness and Substance Abuse 1 : Inpatient Facility Services Inpatient Professional Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services, Outpatient Hospital/Alternative Care Facility, Outpatient Professional Human Organ and Tissue Transplants 2 Acquisition and transplant procedures, harvest and storage Prescription Drug Options: Network Tier structure equals 1/2/3/4 $20/$20 No copayment/coinsurance 50% Network Retail Pharmacies: (30-day supply) Diabetic test strips $10/$24/$40 NCS 50% 3 50% 3 Home Delivery Service: (90-day supply) Diabetic test strips $20/$48/$80 NCS Not covered Not covered Specialty Medications (limited to a 30 day supply retail and mail) Network Retail & Mail: $150 Not covered Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits Specialty medications are limited to 30 day supply regardless of whether they are retail or mail order. Lifetime Maximum Medical Surgical Treatment of Morbid Obesity Notes: All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non-Network Human Organ and Tissue Transplant (HOTT) Services) Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. Network and non-network deductibles, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. Dependent Age: to end of the month which the child attains age 26 Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other Network Provider as allowed by the plan. When allergy injections are rendered with a Physicians Home and Office Visit, only the Office Visit cost share applies. When the Office Visit cost share is a % coinsurance, deductible and coinsurance apply to allergy injections. NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount. PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. Benefit period = calendar year Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings. 11

12 Your Summary of Benefits Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing limited to 82 visits/calendar Year and 164 visits/lifetime. 1 We encourage you to review the Schedule of Benefits for limitations. 2 Kidney and Cornea are treated the same as any other illness and subject to the medical benefits. 3Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Precertification: Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not medically necessary. Pre-existing Exclusion Period: None This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail 12

13 Your Summary of Benefits University of Southern Indiana - Core Plan Blue Access (PPO) Effective January 1, 2015 Covered Benefits Network Non-Network Deductible (Single/Family) $750/$1,500 $1,500/$3,000 Out-of-Pocket Limit (Single/Family) $4,500/$9,000 $9,000/$18,000 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: $30/$30 allergy injections (PCP and SCP) Covered in full allergy testing Covered in full MRAs, MRIs, PETS, C-Scans, Nuclear Covered in full Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic No copayment/coinsurance Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Hearing screenings and Vision screenings which are limited to Screening tests (i.e. Snellen eye chart) and Ocular Photo screening Emergency and Urgent Care Emergency Room Services $250 $250 facility/other covered services (copayment waived if admitted) Urgent Care Center Services MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Allergy injections Allergy testing Inpatient and Outpatient Professional Services Include, but are not limited to: Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Blue 8.0 $75 Covered in full Covered in full University of Southern Indiana 8 0 PPO SOB Core Plan.doc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 13

14 Your Summary of Benefits Covered Benefits Network Non-Network Inpatient Facility Services (Network/Non-Network combined) days except for: days Network/Non-Network combined for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) days for skilled nursing facility Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia Other Outpatient Services (including but not limited to): Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-Network combined) visits (excludes IV Therapy) Durable Medical Equipment and Orthotics Prosthetic Devices Prosthetic Limbs Physical Medicine Therapy Day Rehabilitation programs Hospice Care No copayment/coinsurance No copayment/coinsurance Ambulance Services No copayment/coinsurance No copayment/coinsurance Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits (PCP/SCP) $30/$30 Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: 60 visits Occupational therapy: 60 visits Manipulation therapy: 12 visits Speech therapy: 40 visits Cardiac/Pulmonary Rehabilitation: Accidental Dental: $30/$30 $30/$30 $30/$30 $30/$30 Copayments/Coinsurance based on setting where covered services are received Copayments/Coinsurance based on setting where covered services are received 14

15 Your Summary of Benefits Covered Benefits Network Non-Network Behavioral Health Services Mental Illness and Substance Abuse 1 : Inpatient Facility Services Inpatient Professional Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services, Outpatient Hospital/Alternative Care Facility, Outpatient Professional Human Organ and Tissue Transplants 2 Acquisition and transplant procedures, harvest and storage Prescription Drug Options: Network Tier structure equals 1/2/3/4 $30/$30 No copayment/coinsurance 50% Network Retail Pharmacies: (30-day supply) Diabetic test strips $10/$40/$60 NCS 50% 3 50% 3 Home Delivery Service: (90-day supply) Diabetic test strips $20/$80/$120 NCS Not covered Not covered Specialty Medication (limited to a 30 day supply Retail and Mail Network Retail & Mail: $150 Not covered Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits Specialty medications are limited to 30 day supply regardless of whether they are retail or mail order. Lifetime Maximum Medical Surgical Treatment of Morbid Obesity Notes: All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non-Network Human Organ and Tissue Transplant (HOTT) Services) Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance. Network and non-network deductibles, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. Dependent Age: to end of the month which the child attains age 26 Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other Network Provider as allowed by the plan. When allergy injections are rendered with a Physicians Home and Office Visit, only the Office Visit cost share applies. When the Office Visit cost share is a % coinsurance, deductible and coinsurance apply to allergy injections. NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount. PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. Benefit period = calendar year Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings. 15

16 Your Summary of Benefits Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing limited to 82 visits/calendar Year and 164 visits/lifetime. 1 We encourage you to review the Schedule of Benefits for limitations. 2 Kidney and Cornea are treated the same as any other illness and subject to the medical benefits. 3Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Precertification: Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not medically necessary. Pre-existing Exclusion Period: None This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail 16

17 Your Summary of Benefits University of Southern Indiana CDHP/HSA 1 Lumenos Health Savings Accounts Effective January 1, 2015 Please note: As we receive additional guidance and clarification from the U.S. Department of Health and Human Services, we may be required to make additional changes to your benefits. Covered Benefits Network Non-Network Deductible Family coverage requires the family deductible to be met before coinsurance applies. The single deductible Single: $1,500 Family: $3,000 does not apply to family coverage. Network and Non-Network deductibles are combined. Out-of-Pocket Limit Single: $5,000 Family: $10,000 Single: $10,000 Family: $20,000 Physician Home and Office Services (PCP/SCP) 10% 30% Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries, allergy serum, allergy injections and allergy testing Preventive Care Services No copayment/coinsurance 30% Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Routine Vision and Hearing exams Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Emergency and Urgent Care Emergency Room Hospital (facility/other covered services) 10% 10% Urgent Care Center Services 10% 30% Inpatient and Outpatient Professional Services 10% 30% Include but are not limited to: Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services (Network/Non-Network 10% 30% combined) days except for: 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 100 days for skilled nursing facility Outpatient Surgery Hospital/Alternative Care Facility 10% 30% Surgery and administration of general anesthesia Blue 8.0 University of Southern Indiana 8.0 LHSA SOB 1.doc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 17

18 Your Summary of Benefits Covered Benefits Network Non-Network Other Outpatient Services (including but not limited to): 10% 30% Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment and Orthotics (excluding Prosthetic Devices and Medical Supplies) Prosthetic Devices Physical Medicine Therapy Day Rehabilitation programs Hospice Care 10% 10% Ambulance Services 10% 10% Accidental Dental Services $3,000 limit per occurrence 10% 30% (network and non-network combined) Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits (PCP/SCP) 10% 30% Other Outpatient Hospital/Alternative 10% 30% Care Facility Limits apply to: Cardiac Rehabilitation: 36 visits Pulmonary Rehabilitation: 20 visits Physical therapy: 20 visits Occupational therapy: 20 visits Manipulation therapy: 12 visits Speech therapy: 20 visits Behavioral Health Services 1 : 10% 30% Inpatient Facility Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Hospital/Alternative Care Facility. Human Organ and Tissue Transplants 10% 30% Acquisition and transplant procedures, harvest and storage. 18

19 Your Summary of Benefits Covered Benefits Prescription Drugs Network Retail Pharmacies: (30-day supply) Includes diabetic test strip Anthem Rx Direct Mail Service: (90-day supply) Includes diabetic test strip Network Non-Network 10% 30%2 10% Not covered Lifetime Maximum Surgical Treatment of Morbid Obesity Notes: All medical and prescription drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding NonNetwork Human Organ and Tissue Transplant (HOTT) Services. Deductible(s) apply to covered services listed with a percentage (%) coinsurance. Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copayment/ coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional cost share applies. Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be required before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans. Network and Non-network Deductible are combined. Network and Non-network coinsurance and out-of-pocket maximums are separate and do not accumulate to each other. Dependent Age: to end of the month which the child attains age 26 No cost share (NCS) means no deductible/coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment. Benefit period = calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing limited to 82 visits/calendar Year and 164 visits/lifetime. 1 We encourage you to contact Our Mental Health Subcontractor to assure the use of appropriate procedures, setting and medical necessity. Refer to Schedule of Benefits for limitations. 2 Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Precertification: Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: None This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. The benefits reflected in this quotation have been adjusted to comply with changes required by the Affordable Care Act beginning in This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval. 19

20 Your Summary of Benefits University of Southern Indiana CDHP/HSA 2 Lumenos Health Savings Accounts Effective January 1, 2015 Please note: As we receive additional guidance and clarification from the U.S. Department of Health and Human Services, we may be required to make additional changes to your benefits. Covered Benefits Network Non-Network Deductible Family coverage requires the family deductible to be met before coinsurance applies. The single deductible Single: $2,500 Family: $5,000 does not apply to family coverage. Network and Non-Network deductibles are combined. Out-of-Pocket Limit Single: $6,000 Family: $12,000 Single: $12,000 Family: $24,000 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries, allergy serum, allergy injections and allergy testing Preventive Care Services No copayment/coinsurance Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam, Routine Vision and Hearing exams Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Emergency and Urgent Care Emergency Room Hospital (facility/other covered services) Urgent Care Center Services Inpatient and Outpatient Professional Services Include but are not limited to: Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams Inpatient Facility Services (Network/Non-Network combined) days except for: 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 100 days for skilled nursing facility Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia Blue 8.0 University of Southern Indiana 8.0 LHSA SOB 2.doc Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 20

21 Your Summary of Benefits Covered Benefits Network Non-Network Other Outpatient Services (including but not limited to): Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services (Network/Non-network combined) 100 visits (excludes IV Therapy) Durable Medical Equipment and Orthotics (excluding Prosthetic Devices and Medical Supplies) Prosthetic Devices Physical Medicine Therapy Day Rehabilitation programs Hospice Care Ambulance Services Accidental Dental Services $3,000 limit per occurrence (network and non-network combined) Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits (PCP/SCP) Other Outpatient Hospital/Alternative Care Facility Limits apply to: Cardiac Rehabilitation: 36 visits Pulmonary Rehabilitation: 20 visits Physical therapy: 20 visits Occupational therapy: 20 visits Manipulation therapy: 12 visits Speech therapy: 20 visits Behavioral Health Services 1 : Inpatient Facility Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Hospital/Alternative Care Facility. Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage. 21

22 Your Summary of Benefits Covered Benefits Prescription Drugs Network Retail Pharmacies: (30-day supply) Includes diabetic test strip Anthem Rx Direct Mail Service: (90-day supply) Includes diabetic test strip Network Non-Network 2 Not covered Lifetime Maximum Surgical Treatment of Morbid Obesity Notes: All medical and prescription drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding NonNetwork Human Organ and Tissue Transplant (HOTT) Services. Deductible(s) apply to covered services listed with a percentage (%) coinsurance. Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copayment/ coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional cost share applies. Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be required before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans. Network and Non-network Deductible are combined. Network and Non-network coinsurance and out-of-pocket maximums are separate and do not accumulate to each other. Dependent Age: to end of the month which the child attains age 26 No cost share (NCS) means no deductible/coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment. Benefit period = calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered. Private Duty Nursing limited to 82 visits/calendar Year and 164 visits/lifetime. 1 We encourage you to contact Our Mental Health Subcontractor to assure the use of appropriate procedures, setting and medical necessity. Refer to Schedule of Benefits for limitations. 2 Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips. Precertification: Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: None This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. The benefits reflected in this quotation have been adjusted to comply with changes required by the Affordable Care Act beginning in This benefit overview is for illustrative purposes and some content may be pending Indiana Department of Insurance approval. 22

23 WELCOME TO BLUE VIEW VISION! Good news your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what s covered, your discounts, and much more! University of Southern Indiana Effective Date: Janaury 1, 2015 Voluntary Blue View Vision SM Your Blue View Vision network Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced ophthalmologists, optometrists, and opticians. Blue View Vision s network also includes convenient retail locations, many with evening and weekend hours, including CONTACTS, LensCrafters, Sears Optical SM, Target Optical, JCPenney Optical and most Pearle Vision locations. Best of all when you receive care from a Blue View Vision participating provider, you can maximize your benefits and money-saving discounts. Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply. YOUR BLUE VIEW VISION PLAN AT-A-GLANCE VISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORK Routine eye exam once every 12 months $10 copay, then covered in full $40 allowance Eyeglass frames Once every 24 months you may select an eyeglass frame and receive an allowance toward the purchase price Eyeglass lenses (Standard) Once every 12 months you may receive any one of the following lens options: Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair) Standard plastic lenticular lenses (1 pair) Eyeglass lens enhancements When obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost. Lenses (for a child under age 19) Standard Polycarbonate (for a child under age 19) Factory Scratch Coating $130 allowance, then off any remaining balance $10 copay, then covered in full $10 copay, then covered in full $10 copay, then covered in full $10 copay, then covered in full $0 after eyeglass lens copay $0 after eyeglass lens copay $0 after eyeglass lens copay $45 allowance $40 allowance $60 allowance $80 allowance $80 allowance No allowance on lens enhancements when obtained out-of-network Contact lenses once every 12 months Prefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses. Elective Conventional Lenses; or Elective Disposable Lenses; or Non-Elective Contact Lenses Your contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period. $150 allowance, then 15% off any remaining balance $150 allowance (no additional discount) Covered in full $105 allowance $105 allowance $210 allowance EXCLUSIONS & LIMITATIONS (not a complete list) Combined Offers. Not combined with any offer, coupon, or in-store advertisement. Excess Amounts. Amounts in excess of covered vision expense. Sunglasses. Sunglasses and accompanying frames. Safety Glasses. Safety glasses and accompanying frames. Not Specifically Listed. Services not specifically listed in this plan as covered services. Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power. Orthoptics. Orthoptics or vision training and any associated supplemental testing. 23

24 OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay) Retinal Imaging - at member s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies. lenses (Adults) Standard Polycarbonate (Adults) Tint (Solid and Gradient) UV Coating Progressive Lenses 1 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Anti-Reflective Coating 2 Standard Premium Tier 1 Premium Tier 2 Other Add-ons and Services Additional Pairs of Eyeglasses Complete Pair Anytime from any Blue View Vision network provider Eyeglass materials purchased separately Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc. Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are Standard contact lens fitting 3 available to you once a comprehensive eye exam has Premium contact lens fitting 4 been completed. $75 $40 $15 $15 $65 $85 $95 $110 $45 $57 $68 off retail price off retail price off retail price off retail price Up to $55 10% off retail price Conventional Contact Lenses Discount applies to materials only 15% off retail price Laser vision correction surgery LASIK refractive surgery Discount per eye For more information, go to anthem.com/specialoffers and select vision care. Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, more. * and much 1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier. 3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal. OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service. To Fax: To oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision Attn: OON Claims P.O. Box 8504 Mason, OH Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the member s policy. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package. Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 7/12 24

25 Getting started with Home Delivery Pharmacy If you take prescribed medicine on a regular basis, you can get up to a 90-day supply mailed right to your door.* Here s how to start: Step one Create your account and print your order form There are two ways to do this: }} Log on to your health plan s website. Register at your health plan website if you haven t done so. Click Prescription Benefits in the Useful Tools box. Click Start a New Prescription. This takes you to the Express Scripts website. You can find out how to: Print an order form to mail in with your prescription. Print a fax form to take to your doctor to fax in your prescription. See how much your medicine will cost. Step two See your doctor for a prescription for a 90-day supply of your medicine You ll need a 90-day supply prescription for your first Home Delivery Pharmacy order. But you should also ask your doctor to write you another prescription for a 30-day supply. This is so you can get the 30-day supply filled at your local pharmacy while your first Home Delivery order is being processed. }} Your doctor can give you a prescription to mail in with your order form. }} Or, the doctor can fill out the physician fax form and fax it to the phone number on the form. If your doctor prescribes a brand-name drug, your plan design may require the Home Delivery Pharmacy to substitute the generic version instead. Step three Paying for your prescription You can pay by e-check, check, money order or credit card. Make checks and money orders payable to Express Scripts, and write your member ID number on the front. You can enroll in e-check payments, have credit cards on file through the website or call the number on your member ID card. Step four Send us your prescription You can send us your prescription in two ways: }} Mail: Fill out the order form and mail it with the prescription and payment (if you re using a check/money order) to the address listed on the form. Please fill out payment information on the form if you re not using a check/money order. }} Fax: Your doctor can complete the physician fax form and fax it to the phone number on the form. All prescriptions and refills, including those sent in by your doctor, are processed as soon as they are received. Please don t send in your prescription unless you are ready to have it filled. Important to know Your medicine will be sent to your home within two weeks from the time the Home Delivery Pharmacy gets your order. If you need your medicine sooner, call the number on your ID card to ask for your order to be sent overnight. Please allow three to five days for processing plus the shipping time. You will be charged an additional fee. Your order will be sent through the post office, UPS or FedEx. Please note, with some medicines, you may have to sign to accept delivery. Need help getting started? Call the phone number on your ID card. You will be transferred to Express Scripts. They can help you get started. *Based on drug benefit plan design. anthem.com Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association MUMENABS 1/14 25