This guide is information only. You must enroll to be covered ANMENABS 02/ MUMENMUB REV 01/14

Transcription

1 A guide to choosing your Anthem Blue Cross and Blue Shield health plan Indianapolis Public Schools Blue Access (PPO) and High Deductible Plans Effective January 1, MUMENMUB REV 01/14 This guide is information only. You must enroll to be covered ANMENABS 02/15

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. We re also giving you a personalized Enrollment Resource webpage where you can: Watch an interactive video with helpful tips on selecting a plan. View and save a digital version of this guide. Find a doctor in your network. View your full plan details. View your enrollment resources at

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. If your plan has copays (fl at fees like $30 for each visit) along with a deductible, you only need to pay the copay for most doctor visits. 2. After you meet your deductible, you and your plan share the cost of covered services. You pay a copay or 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. Blue Access (PPO) Option 1 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. High Deductible Plans 2 & 3 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. 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? 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 enroll? You enroll by filling out a paper form. 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. 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. Download the free anthem.com mobile app so you can manage your health care on the go! Visit anthem.com/guidedtour to watch a video explaining how our website can help you. 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. 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 5

6 Your plan details In this next section, you ll find more information about your plan.

7 Your Summary of Benefits IPS Blue Access (PPO) Option 1 Effective January 1, 2016 Covered Benefits Network Non-Network Deductible (Single/Family) $1,000/$2,000 $2,000/$4,000 Out-of-Pocket Limit (Single/Family) $5,000/$10,000 $10,000/$20,000 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: $40/$45 allergy injections (PCP and SCP) $5 allergy testing 30% MRAs, MRIs, PETS, C-Scans, Nuclear 30% Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic NCS 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 $200 $200 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 $40 30% $5 30% 30% Indianapolis Public Schools 8.0 PPO SOB 7

8 Your Summary of Benefits Covered Benefits Network Non-Network Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 60 days Network/Non-Network combined 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 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 Prosthetic Devices Prosthetic Limbs Physical Medicine Therapy Day Rehabilitation programs Hospice Care Ambulance Services 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: Physical therapy: Unlimited Occupational therapy: Unlimited Manipulation therapy: 60 visits Speech therapy: Unlimited Cardiac Rehabilitation: Unlimited Pulmonary Rehabilitation: Unlimited Accidental Dental: $3,000 limit per occurrence (Network and Non-network combined) Behavioral Health Services Mental Illness and Substance Abuse 2 : Inpatient Facility Services Inpatient Professional Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services, Outpatient Hospital/Alternative Care Facility, Outpatient Professional 30% 30% 30% NCS 30% $40/$45 30% Copayments/Coinsurance based on setting where covered services are received 30% 30% $40/$40 30% NCS 30% Indianapolis Public Schools 8.0 PPO SOB 8

9 Your Summary of Benefits Covered Benefits Network Non-Network Human Organ and Tissue Transplants 3 Acquisition and transplant procedures, harvest and storage Prescription Drug Options: Network Tier structure equals 1/2/3 (and 4, if applicable) Network Retail Pharmacies: (30-day supply) Includes diabetic test strip NCS Separate Pharmacy Out of pocket: $1,850 single/$3,700 family Generic formulary/non-formulary $10 Brand formulary min. $20 max $70 Brand Non Formulary 40% min. $40 max $90 Separate Pharmacy Out of pocket: N/A, min $40 5 Home Delivery Service: (90-day supply) Includes diabetic test strip Member may be responsible for additional cost when not selecting the available generic drug. Generic formulary /non formulary $25 Brand formulary min. $50 max $175 Brand non formulary 40% min $100 max $225 Not covered Medicare Rx - Wrap 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 Unlimited Not covered Unlimited Not covered 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, including 0%. However, the deductible does not apply to Emergency Room Services where a copayment and coinsurance applies and may not apply to some Behavioral Health services where coinsurance applies. 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. Certain diabetic and asthmatic supplies have no deductible/copayment/coinsurance up to the maximum allowable amount at network pharmacies except diabetic test strips. Benefit period = calendar year Prosthetic limbs are unlimited and do not apply to the Plan Lifetime Maximum. Mammograms (Diagnostic) are no copayment/coinsurance in Network office and outpatient facility settings. Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. Indianapolis Public Schools 8.0 PPO SOB 9

10 Your Summary of Benefits 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. Abortion coverage is limited to coverage in cases of rape or incest, or if it is necessary to avert the pregnant women s death or irreversible impairment of a major bodily function. 1 These covered services are not subject to the deductible/copayment if you have a flat dollar copayment and if rendered without an office visit. 2 We encourage you to review the Schedule of Benefits for limitations. 3 Kidney and Cornea are treated the same as any other illness and subject to the medical benefits. 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 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. 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. Indianapolis Public Schools 8.0 PPO SOB 10

11 Your Summary of Benefits IPS Blue Access for Health Savings Accounts (with Copays) Option 2 (High Deductible Plan) Effective: January 1, 2016 Covered Benefits Network Non-Network Embedded Deductible The single deductible does apply to family coverage. Deductible applies to all services Single: $2,600 Family: $5,200 Single: $5,200 Family: $10,400 Out-of-Pocket Limit Single: $4,200 Family: $8,400 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: allergy injections (PCP and SCP) allergy testing MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic 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 (facility/other covered services) (copayment waived if admitted) 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) Unlimited days except for: 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 90 days for skilled nursing facility Blue 8.0 Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia $15/$30 $5 0% 0% Single: $8,400 Family: $16,800 NCS $100 $100 $50 0% 0% 0% Indianapolis Public Schools 8.0 BAHSA SOB #2 11

12 Your Summary of Benefits Covered Benefits Network Non-Network Other Outpatient Services including but not limited to: 0% Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services. Home Care Services 100 visits (excludes IV Therapy) (Network/Non-network combined) Durable Medical Equipment, Orthotics and Prosthetics Physical Medicine Therapy Day Rehabilitation programs Hospice Care 0% 0% Ambulance Services 0% 0% Accidental Dental Services $3,000 limit per occurrence (Network and Non-network combined) 0% Outpatient Therapy Services (Combined Network & Non-Network limits apply) Physician Home and Office Visits Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: Unlimited Occupational therapy: Unlimited Manipulation therapy: 60 visits Speech therapy: Unlimited Cardiac Rehabilitation: Unlimited Pulmonary Rehabilitation: Unlimited Behavioral Health Service Mental Illness and Substance Abuse 1 : Inpatient Facility Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services, Outpatient Hospital/Alternative Care Facility, Outpatient Professional. Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage. $15/$30 0% Benefits provided in accordance with Federal Mental Health Parity 0% Indianapolis Public Schools 8.0 BAHSA SOB #2 12

13 Your Summary of Benefits Covered Benefits Network Non-Network Prescription Drugs Medical deductible applies before copayments Network Retail Pharmacies: (30-day supply) Includes diabetic test strip Generic formulary/nonformulary $10 Brand formulary $25 Brand Non Formulary $50, max $50 2 Home Delivery Service: (90-day supply) Includes diabetic test strip Specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail service. Medicare Rx - Wrap Generic formulary /non formulary $20 Brand formulary $50 Brand non formulary $100 Not covered Notes: All medical and prescription drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non- Network Human Organ and Tissue Transplant (HOTT) Services) Deductible(s) apply to covered services listed with a percentage (%) coinsurance including 0%. Deductible applies to all prescription drug expenses. Once the deductible is met the appropriate copayment/coinsurance applies. 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 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. No cost share (NCS) means no deductible/copayment/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. 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 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. Elective abortions not covered unless otherwise noted in your Certificate of Coverage. 1 We encourage you to review the 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 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 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. Indianapolis Public Schools 8.0 BAHSA SOB #2 13

14 Your Summary of Benefits IPS Blue Access for Health Savings Accounts Option 3 (High Deductible Plan) Effective: January 1, 2016 Covered Benefits Network Non-Network Embedded Deductible The single deductible does apply to family coverage. Single: $4,500 Family: $9,000 Single: $9,000 Family: $18,000 Out-of-Pocket Limit Single: $6,450 Family: $12,900 Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: allergy injections (PCP and SCP) allergy testing MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, non-maternity related Ultrasounds, and pharmaceutical products Preventive Care Services Services included but not limited to: Routine medical exams, Mammograms, Pelvic 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 (facility/other covered services) (copayment waived if admitted) 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) Unlimited days except for: 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 90 days for skilled nursing facility Blue 8.0 Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia Single: $9,000 Family: $18,000 NCS Indianapolis Public Schools 8.0 BAHSA SOB #3 14

15 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 100 visits (excludes IV Therapy) (Network/Non-network combined) Durable Medical Equipment, Orthotics and Prosthetics 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 Other Outpatient Hospital/Alternative Care Facility Limits apply to: Physical therapy: Unlimited Occupational therapy: Unlimited Manipulation therapy: 60 visits Speech therapy: Unlimited Cardiac Rehabilitation: Unlimited Pulmonary Rehabilitation: Unlimited Behavioral Health Service Mental Illness and Substance Abuse 1 : Inpatient Facility Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services, Outpatient Hospital/Alternative Care Facility, Outpatient Professional. Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage. Benefits provided in accordance with Federal Mental Health Parity Indianapolis Public Schools 8.0 BAHSA SOB #3 15

16 Your Summary of Benefits Covered Benefits Network Non-Network Prescription Drugs Network Retail Pharmacies: (30-day supply) Includes diabetic test strip Home Delivery Service: (90-day supply) Includes diabetic test strip Specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail service. Medicare Rx - Wrap 2 Not covered Notes: All medical and prescription drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non- Network Human Organ and Tissue Transplant (HOTT) Services) Deductible(s) apply to covered services listed with a percentage (%) coinsurance including 0%. Deductible applies to all prescription drug expenses. Once the deductible is met the appropriate copayment/coinsurance applies. 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 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. No cost share (NCS) means no deductible/copayment/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. 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 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. Elective abortions not covered unless otherwise noted in your Certificate of Coverage. 1 We encourage you to review the 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 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 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. Indianapolis Public Schools 8.0 BAHSA SOB #3 16

17 Indianapolis Public Schools Effective Date:01/01/2016 Blue View VisionSM WELCOME TO BLUE VIEW VISION! Good new s y our v ision plan is flex ible and easy to use. This benefit summary outlines the basic components of y our plan, including quick answ ers about w hat s cov ered, y our discounts, and much more! 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 1-800CONTACTS, LensCrafters, Sears OpticalSM, 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 Routine eye exam once every 24 months 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 24 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) 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 Contact lenses once every 24 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 IN-NETWORK $0 copay, then covered in full OUT-OF-NETWORK $50 allowance $150 allowance, then off any remaining balance $70 allowance $0 copay, then covered in full $0 copay, then covered in full $0 copay, then covered in full $50 allowance $75 allowance $100 allowance $0 after eyeglass lens copay $0 after eyeglass lens copay $0 after eyeglass lens copay No allowance on lens enhancements when obtained out-of-network $150 allowance, then 15% off any remaining balance $105 allowance $150 allowance (no additional discount) $105 allowance Covered in full $210 allowance Your contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit perio d. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit perio d, nor can any unused amount be carried over to the following benefit period. EXCLUSIONS & LIMITATIONS (not a complete list) Combined Offers. Not combined w ith any offer, coupon, or in-store adv ertisement. Excess Amounts. Amounts in ex cess of cov ered v ision ex pense. Sunglasses. Sunglasses and accompany ing frames. Safety Glasses. Safety glasses and accompany ing frames. Not Specifically Listed. Serv ices not specifically listed in this plan as cov ered serv ices. 17 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 serv ice interv al as indicated in the plan design. Non-Prescription Lenses. Any non-prescription lenses, ey eglasses or contacts. Plano lenses or lenses that hav e no refractiv e pow er. Orthoptics. Orthoptics or v ision training and any associated supplemental testing.

18 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 ey e ex am Not more than $39 Eyeglass lens upgrades When obtaining ey ew ear from a Blue View Vision prov ider, y ou may choose to upgrade y our new ey eglass lenses at a discounted cost. Ey eglass lens copay ment applies. Additional Pairs of Eyeglasses Any time from any Blue View Vision netw ork prov ider lenses (Adults) Standard Poly carbonate (Adults) Tint (Solid and Gradient) UV Coating Progressiv e Lenses 1 Standard Premium Tier 1 Premium Tier 2 Premium Tier 3 Anti-Reflectiv e Coating 2 Standard Premium Tier 1 Premium Tier 2 Other Add-ons and Serv ices Complete Pair Ey eglass materials purchased separately Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, ey eglass cases, etc. Contact lens fit and follow-up A contact lens fitting and up to tw o follow -up v isits are av ailable to y ou once a comprehensiv e ey e ex am has been completed. Standard contact lens fitting3 Premium contact lens fitting 4 $75 $40 $15 $15 $65 $85 $95 $110 $45 $57 $68 off retail price 40% 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 refractiv e surgery Discount per ey e For more information, go to anthem.com/specialoffers and select v ision care. Members can take adv antage of sav ings opportunities from dozens of v endors on a v ariety of products and serv ices, including LASIK v ision surgery, hearing serv ices and aids, w ellness products, w eight loss programs, fitness memberships, elder care serv ices, 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. Exampl es 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 y ou choose an out-of-netw ork prov ider, please complete an out-of-netw ork claim form and submit it along w ith y our itemized receipt to the fax number, address, or mailing address below. When v isiting an out-of-netw ork prov ider, discounts do not apply and y ou are responsible for pay ment of serv ices and/or ey ew ear materials at the time of serv ice. To Fax: To oonclaims@ey ew earspecialoffers.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 memb er s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits unde r 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): R ightchoice 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 Insu rance 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 18

19 Better health is right before your eyes. It s true, with Blue View VisionSM. Eye care that s off the charts! Eye exams. Do you really need them if you re seeing just fine? Absolutely. Here s why: Eye doctors can detect eye diseases like macular degeneration and glaucoma early on, and they re often the first ones to find health problems like high blood pressure, high cholesterol and diabetes. We think that s a pretty good reason to get regular exams. That s why we make getting eye care easy and affordable. See all the benefits you get with Blue View Vision! Plenty of choices. You can get your eye care and eyewear just about anywhere! More doctors and locations. With over 30,000 eye doctors at more than 25,000 locations, you re sure to find an eye care professional that s close to home or work. And you can even buy eyewear at a location that s different from your eye doctor for an even greater selection. More freedom. Choose the style that works best for you! Incredible convenience! With Blue View Vision, you have access to one of the nation s largest vision networks. You can call or click online at CONTACTS, visit a private practice eye doctor, or go in-store one of these popular retail stores: Many of these stores have hours at night and on the weekends, so you can go whenever it s best for you. Just go to anthem.com to find an in-network provider near you. Serious savings on just about everything. With Blue View Vision, you get a retail allowance. That s the amount of money that goes toward your glasses or contacts that you buy from an in-network provider. After that, you get discounts on the remaining balance: off for eyeglass frames* and 15% for conventional contact lenses (not disposables). And, there s still more: Standard/basic eyeglass lenses include a factory scratch coating at no extra cost. High-quality progressive lenses and anti-reflective coatings at different price levels so you can control how much you spend. UV-blocking Transitions lenses ($110 value) and impact resistant polycarbonate lenses ($55 value) available for covered dependents under age 19 at no additional cost. Negotiated savings on popular lens options and treatments. 40% off extra pairs of glasses anytime, from any network provider. off other upgrades, accessories and nonprescription sunglasses. 19

20 Better health is right before your eyes. It s true, with Blue View Vision SM. Eye care that s off the charts! Using your Blue View Vision benefits couldn t be easier! We want you to be able to get your eye care and eyewear when you need it at the price you can afford. Just remember, you ll save time and money by using an eye doctor or retail store that s in the network. Take a look: When you use an in-network provider, it s a breeze. All you have to do is: Find an in-network provider at anthem.com. Make an appointment. Show the staff your member ID card. If you don t have it, don t worry. They can look up your ID number online if they re part of the Blue View Vision network. Pay your copay or any remaining balance if you have one. When you use an out-of-network provider you re still covered. But here s how it works: Pay the full cost of the services you receive at your visit. Get a claim form at anthem.com. Mail your receipt and your claim form to us and we ll pay you back the amount your plan covers. We re all about your total health. That means keeping all your docs in the loop. If you have our health and vision plans, your doctors can work together to keep you at your healthy best. Here s how: Let s say that during your regular eye exam, your eye doctor finds that you have a high-risk condition like diabetes or high blood pressure. Your eye doctor shares that information with your primary care doctor. The information is tracked in an electronic health record so you get the important follow-up care and support you need. We re here when you need us including nights and weekends! If you have a question you can reach us at , Monday-Saturday, 7:30 a.m. to 11:00 p.m. EST and Sunday, 11:00 a.m. to 8:00 p.m. EST. Get information 21 hours every day from our automated telephone system (early morning hours are used to refresh the system). Log in at anthem.com anytime to check your benefits. Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cro s 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 20 marks of the Blue Cross and Blue Shield Association.

21 Register with anthem.com to access your benefits* From your computer From your mobile device Go to anthem.com and select Register Now Provide the personal information requested Create a username and password Search for Anthem Blue Cross and Blue Shield in your app store and select Install (It s free). Open the app and select Register Now Confirm your identity Create a username and password Set your preferences Set your preferences Select Submit Confirm and select Register Need help signing up? Call the Help Desk at * You must be 18 years or older to register your own account. 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 affi liates 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 ANMENABS VPOD Rev. 02/15 21

22 Looking for a doctor? Finding one online is fast and easy Use our online Find a Doctor tool to look for doctors, hospitals, pharmacies, labs and other health care providers in your Anthem Blue Cross and Blue Shield network. Check if your favorite doctor is in the network, or look for one near you. Avoid getting out-of-network care if you can it will cost you more or your plan may not cover it all. Here s all you need to do: If you re a member Go to anthem.com and log in. Or use your ID number or the first three letters to search without logging in. Under Useful Tools on the right, select Find a Doctor. 1 If you re not a member yet Go to anthem.com. Under Useful Tools on the right, select Find a Doctor. Next, select a type of provider, place or name. Select Search. 2 3 Under Search by selecting a plan/network, choose a state, and enter or pick the plan/network*. Next, select a type of provider, place or name. Select Search. Select a provider to see more information, such as: }} Training }} Specialties }} Languages spoken }} Address (including a map) }} Phone number Going mobile Use your mobile device to search for doctors, hospitals and more with our free app from the App Store SM or Google Play TM. Just search for Anthem Blue Cross and Blue Shield and download the app. You can even get turn-by-turn directions to find a doctor s office. *If you don t know the name of the plan or network, check with your human resources department or benefits administrator. 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 benefi ts 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 ANMENABS VPOD 08/15 22

23 Compare quality and costs at hospitals and other facilities on anthem.com Did you know that different facilities may charge different amounts for the same service? Estimate your share of the costs before you get your care. Higher prices don t always mean better care. Compare facilities based on their quality measures for certain procedures length of stay, patient experience, complications and more: Just go to anthem.com and log in (located in the top right corner). Select Estimate Your Cost. Simply search or browse for the procedure you are looking for and the tool will help guide you. You can easily compare facilities in your area. Estimate Your Cost is just one of the many tools we have to help you manage your health care, simply and conveniently. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, 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 benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, 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 ANMENABS VPOD Rev. 09/15 23