2015 Small Group Guide

Transcription

1 CALIFORNIA Effective January 1, Small Group Guide EmployeeElect for medical groups with 1-50 employees Plans that offer choices and meet Affordable Care Act requirements 37046CABENABC Rev. 04/15

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3 Access to the latest range of plans Built from the ground up with the strengths you ve come to expect from the Anthem product portfolio We re here to help you understand Anthem Blue Cross (Anthem) plans and offer any support you may need. This guide is one important way we do that, because it gives you a good picture of what s offered through EmployeeElect. The newest Anthem plans are well-positioned for the changing market. You ll find they offer all the essential health benefits (EHB) such as emergency care, hospital stays, maternity and newborn care, prescription drugs and preventive care, as well as other features needed to comply with the Affordable Care Act (ACA). They deliver on our longstanding portfolio strengths, including network value, plan variety, pharmacy coverage and comprehensive care. This guide can answer many of your questions about: Changes to look for in 2015, such as the updated and simplified plan naming structure plans and features including medical, pharmacy and specialty. The latest on our health and wellness offerings... and much more. This provides an overview of plans available. This is intended to be a brief overview of benefits and is not intended to be a legal contract. The entire provisions of benefits, limitations and exclusions can be found in the Combined Evidence of Coverage/Certificate. In the event of a conflict between the Combined Evidence of Coverage/Certificate and this overview, the terms of the Combined Evidence of Coverage/Certificate will prevail. 1

4 The Anthem product portfolio Every plan in our portfolio is ACA-compliant, covering everything from emergencies to counseling services to preventive care, and more, including: Preventive, wellness and chronic disease management services Outpatient (ambulatory) care Emergency services, including emergency room or urgent care Inpatient care (hospital stays) Laboratory services Prescription drugs Mental health and substance abuse Maternity (pregnancy) and newborn care Pediatric services, including dental and vision care Rehabilitative and habilitative services and devices (habilitative services help a person learn, keep or improve skills they may not be developing normally) Gender discrimination prevention Oral chemotherapy Our plans all provide for in-network benefits. Some have additional out-of-network benefits as well. Different plans feature different degrees of in-network access, and some plans have larger networks than others. In-network (i.e., participating) doctors, hospitals and pharmacies have agreed to accept lower costs for their covered services. These agreed-upon rates can help lower the cost of covered health care services, including employer s and employee s share of the costs. Out-of-network (or nonparticipating) doctors, hospitals and pharmacies do not provide services at a negotiated (agreed-upon) rate. To find a network doctor, hospital or pharmacy, use our online Provider Directory at anthem.com/ca. 2

5 Changes to look for in 2015 Updated naming structure is clearer and more complete The plan names include the following elements: Anthem + metal tier + network name + product type + copay or deductible/coinsurance/out-of-pocket maximum Example: Anthem Gold Select HMO 35/20%/6600 Our plans meet ACA metal level requirements: platinum, gold, silver and bronze. The difference between these levels is the actuarial value. In other words, a plan, on average, must cover a defined percentage of medical costs in order to meet the metal level requirements. Here s what it means when you see the Plus in the plan name When the Plus is added to a plan name (as in Anthem Platinum Priority Select HMO 10/10%/2500 Plus ), it means the plan contains one or all of the following: 1. Healthy Support Package A a robust health and wellness offering with online resources and webinars, plus fitness reimbursements and health incentives of up to $600/year. 2. Focused network offered on only one of these networks: SELECT PPO Network. SELECT HMO Network. Priority SELECT HMO Network. 3. Select Drug List a focused list of drugs that include a select number of medications in all therapeutic categories and classes. Pediatric dental is embedded within all plans The ACA is written so all children have access to affordable dental care to keep their teeth and gums healthy. It s part of the essential health benefits (EHB) included in all medical plans. Other required EHBs that are embedded in member medical plans include emergency care, hospital stays, maternity and newborn care, prescription drugs and preventive care. New Consumer-Driven Health Plans (CDHP) Deductible First Health Reimbursement Account (HRA) To meet the in-network deductible, a member s plan will work as follows. Step 1: Upfront in-network deductible members must pay a certain part of the in-network deductible, per member/ per family, before using their HRA account. Amounts paid toward the upfront deductible will apply towards the annual in-network deductible. Step 2: Health Reimbursement Account after meeting the upfront deductible, members can use money in their HRA to help meet the rest of the annual in-network deductible. Step 3: Traditional health coverage once the annual in-network deductible has been met, coverage under this plan begins. 3

6 Products and features for 2015 On the following pages, you ll find product grids that give you a top-line description of the complete range of Anthem plans for The explanations below correspond to column headers found on those grids. Metal structure Actuarial Values (AV) can be used to compare different plan designs to determine how overall cost sharing differs across plans with different cost-sharing provisions. Minimum AV Platinum 88% 92% Gold 78% 82% Silver 68% 72% Bronze 58% 62% Maximum AV Product type PPO Allows members to go directly to any in-network provider. There is no need to choose a primary care physician (PCP) or get a referral to see other doctors. HMO Requires members to choose a PCP; a referral is required to see other doctors. Health Savings Account (HSA) A savings account for certain plans that members can fund with pre-tax dollars and use to pay for qualified health care expenses, including prescriptions. This is often used with a Consumer-Driven Health Plan. Health Reimbursement Account (HRA) Employer-funded plan to help pay for covered costs. This is used with a CDHP and requires the deductible first. This means members must pay a certain part of the in-network deductible the upfront deductible before using their HRA account. HRA funds cannot be used for the upfront deductible. Once the yearly in-network deductible is met, coverage under this plan begins. Note: The HSA employer contribution, or the amount newly made available by the employer under an integrated HRA that may only be used for cost sharing, may be considered part of the AV calculation when the contribution is available and known to the issuer at the time the plan is purchased. Network(s) Note: At enrollment, the group will be required to choose only one PPO network option. Note: At enrollment, the group will be required to choose only one HMO network option. PPO network options Prudent Buyer PPO Network Access to nearly 60,000 California doctors and specialists, and more than 330 hospitals. SELECT PPO Network Access to nearly 41,000 California doctors and specialists, and more than 300 hospitals. HMO network options (Please refer to the rate guide for detailed network availability.) CaliforniaCare HMO Network Access to more than 41,000 California doctors and specialists, and more than 330 hospitals. SELECT HMO Network Access to more than 25,000 California doctors and specialists, and over 250 hospitals. Priority SELECT HMO Network Access to more than 7,200 California doctors and specialists, and more than 150 hospitals. 4

7 Pharmacy The Anthem drug list contains the names of FDA-approved generic and brand-name medications. The list is divided into four tiers. Tier 1 drugs have the lowest cost share; Tiers 2 and 3 drugs have a progressively higher cost share. Tier 4 may have a coinsurance up to a maximum dollar amount per prescription. In evaluating a plan, it s important to look at the drug list to understand which drugs are covered. Each of our products includes one of two different drug lists. Anthem National Drug List is a broad list of our covered drugs. Anthem Select Drug List is a list of drugs that includes a select number of medications in all therapeutic categories and classes, while meeting the requirements of the ACA. View our drug lists online: The Select Drug List: anthem.com/ca/selectdrugtier4 The National Drug List: anthem.com/ca/national4tier Download our mobile app to access prescription information and pharmacy tools on the go. This app helps you find a pharmacy, price a drug, switch from retail to home delivery, order a refill, check order status and more. To download the Anthem Blue Cross mobile app, visit Google Play TM (Android) or the Apple Store SM (ios). After logging in the first time and choosing Prescription Benefits, a prompt appears to download the Express Scripts app, which powers the Pharmacy tools. But you only need to visit the Anthem Blue Cross mobile app to manage your pharmacy benefits, all in one place! Pediatric dental EHB * Dental benefits that are part of a PPO medical plan include in and out-of-network benefits. Dental benefits that are part of an HMO medical plan include in-network benefits only. All of our Small Group health plans include pediatric dental EHBs, which provide important coverage for kids up to age 19. Benefits include preventive care, fillings and more extensive services like medically necessary orthodontia. Members can see any provider in the Dental Prime network. Diagnostic and preventive services (cleanings, exams and X-rays) not subject to deductible In and out-of-network coinsurance* 100% Basic services (fillings) 50% Endodontic, periodontal, oral surgery and major services 50% Medically necessary orthodontia 50% Because these benefits are part of a medical plan, they share a combined out-of-pocket maximum. Diagnostic and preventive services like cleanings, exams and X-rays are not subject to the deductible, so members can take advantage of them right away. These benefits have no annual maximum. 5

8 Pediatric vision EHB * Vision benefits that are part of a PPO medical plan include in and out-of-network benefits. Vision benefits that are part of an HMO medical plan include in-network benefits only. All of our Small Group health plans include pediatric vision EHBs, which provide coverage for vision exams and glasses or contacts for kids up to age 19. Members can see any provider in the Blue View Vision SM network, which includes retailers such as CONTACTS, LensCrafters, Sears Optical SM, Target Optical and JCPenney Optical. Anthem Vision Pediatric Blue View Vision Network Routine eye exam (once every calendar year) Lenses single, bifocal, trifocal (once every calendar year) Lens treatments In network $0 copay $0 copay UV coating Covered in full N/A Standard factory scratch coating Covered in full Out of network* $0 copay up to plan s maximum allowed amount (MAA) (of $30) $0 copay up to plan s MAA (of $25, $40, $55) N/A Standard polycarbonate Covered in full N/A Standard Transitions Covered in full N/A Standard progressive lenses Covered in full $0 copay up to plan s MAA (of $40) Frames (once every calendar year) $0 copay, Formulary $0 copay up to plan s MAA (of $45) Elective contact lenses (once every calendar year in lieu of eyeglasses) Nonelective contact lenses (once every calendar year in lieu of eyeglasses) Low vision (once every five calendar years) $0 copay, Formulary $0 copay up to plan s MAA (of $80) Covered in full $0 copay up to plan s MAA (of $210) Covered in full N/A Because these benefits are part of a medical plan, they share a combined deductible and out-of-pocket maximum. Covered children can choose from a selection of frames and contact lenses. Glasses with Transitions lenses (to protect eyes from UV rays) and polycarbonate lenses and/or scratch coating (to protect lenses from damage) are available through in-network providers at no extra charge. We also offer family stand-alone vision plans. For more information, please view the vision section. 6

9 Anthem plans for

10 The updated naming structure includes these elements: Anthem + metal tier + network name + product type + copay or deductible/coinsurance/out-of-pocket maximum In-network benefits are represented below. For out-of-network benefits, please refer to the Combined Evidence of Coverage/Certificate. Product type HMO plan name Deductible Anthem Platinum Priority Select HMO 20/0%/4000 Plus Anthem Platinum Select HMO 20/0%/4000 Plus Anthem Platinum Priority Select HMO 10/10%/2500 Plus Anthem Platinum Select HMO 10/10%/2500 Plus Office visits (primary care physician) Specialist office visits Urgent care Coinsurance $0 $20 $40 $40 0% $0 $10 $10 $10 10% Anthem Gold Priority Select HMO 30/0%/6250 Plus Anthem Gold Select HMO 30/0%/6250 Plus Anthem Gold Priority Select HMO 500/20%/4500 Plus Anthem Gold Select HMO 500/20%/4500 Plus $0 $30 $50 $60 0% $500 (facility) (3x fam) $30 $60 $60 20% Anthem Gold Priority Select HMO 35/20%/6600 HMO Anthem Gold Select HMO 35/20%/6600 Anthem Gold HMO 35/20%/6600 Anthem Gold Priority Select HMO 35/25%/6600 Anthem Gold Select HMO 35/25%/6600 Anthem Gold HMO 35/25%/6600 $0 $35 $60 $60 20% $0 $35 $60 $60 25% Anthem Silver Priority Select HMO 1500/20%/6250 Plus Anthem Silver Select HMO 1500/20%/6250 Plus Anthem Silver Priority Select HMO 1500/30%/6550 Plus Anthem Silver Select HMO 1500/30%/6550 Plus Anthem Silver Priority Select HMO 1500/30%/6550 Anthem Silver Select HMO 1500/30%/6550 Anthem Silver HMO 1500/30%/6550 $1,500 (facility) $45 $65 $90 20% $1,500 (facility) $50 $75 $75 30% $1,500 (facility) $50 $75 $75 30% This provides an overview of plans available. This is intended to be a brief overview of benefits and is not intended to be a legal contract. The entire provisions of benefits, limitations and exclusions can be found in the Combined Evidence of Coverage/Certificate. In the event of a conflict between the Combined Evidence of Coverage/Certificate and this overview, the terms of the Combined Evidence of Coverage/Certificate will prevail. All product offerings are subject to regulatory review and approval. Family deductibles are two times the in-network single member amount, except as otherwise noted. Family out-of-pocket maximums are two times the in-network single network amount. 8

11 Emergency room 1 Outpatient surgery Hospital inpatient Out-of-pocket maximum Pharmacy deductible (if any) Tier 1/Tier 2/Tier 3/Tier 4 Drug list Healthy Support $150 $250 $250 per day up to 5 days max $4,000 (medical and Retail: $5/$15/$25/10% (up to $500) Select A $150 $250 $500 per day up to 3 days max $2,500 (medical and Retail: $5/$30/$60/30% (up to $500) Select A $250 $600 $600 per day up to 5 days max $6,250 (medical and Retail: $15/$50/$70/20% (up to $500) Select A $ % 20% 20% $4,500 (medical and Retail: $15/$35/$70/30% (up to $500) Select A $250 $250 $750 per day up to 3 days max $6,600 (medical and Retail: $250 deductible (waived tier 1) $15/$35/$70/25% (up to $250) National N/A $250 $250 $1,000 per day up to 3 days max $6,600 (medical and Retail: $500 deductible (waived tier 1) $10/$30/$60/25% (up to $250) National N/A $250 20% 20% $6,250 (medical and Retail: $500 deductible (waived tier 1) $15/$50/$70/20% (up to $500) Select A $ % 30% 30% $6,550 (medical and Retail: $500 deductible (waived tier 1) $15/$35/$70/30% (up to $500) Select A $250+30% 30% 30% $6,550 (medical and Retail: $500 deductible (waived tier 1) $15/$35/$70/25% (up to $250) National N/A 1 Deductible is waived only for the outpatient hospital emergency room charge. A member may receive other services while being treated in the emergency room; for these services, the member will be responsible for the applicable deductible and coinsurance. 9

12 The updated naming structure includes these elements: Anthem + metal tier + network name + product type + copay or deductible/coinsurance/out-of-pocket maximum In-network benefits are represented below. For out-of-network benefits, please refer to the Combined Evidence of Coverage/Certificate. Product type PPO plan name Deductible Office visits (primary care physician) Specialist office visits Urgent care Coinsurance Anthem Platinum Select PPO 20/10%/4000 Plus $0 $20 $40 $40 10% Anthem Gold Select PPO 30/20%/6250 Plus $0 $30 $50 $60 20% Anthem Gold Select PPO 1000/20%/4000 Plus $1,000 (3x fam) $20 $40 $40 20% Anthem Gold Select PPO 500/20%/4500 Anthem Gold PPO 500/20%/4500 Anthem Gold Select PPO 1000/20%/4000 Anthem Gold PPO 1000/20%/4000 $500 (3x fam) $30 $60 $60 20% $1,000 (3x fam) $20 $40 $40 20% Anthem Silver Select PPO 1500/20%/6250 Plus $1,500 $45 $65 $90 20% PPO 2 Anthem Silver Select PPO 2000/35%/6600 Plus $2,000 $25 $45 35% 35% Anthem Silver Select PPO 1500/20%/6250 $1,500 $45 $65 $90 20% Anthem Silver PPO 1500/20%/6250 Anthem Silver Select PPO 2000/35%/6600 Anthem Silver PPO 2000/35%/6600 $2,000 $25 $45 $45 35% Anthem Bronze Select PPO 5000/30%/6250 Plus $5,000 (medical and $60 (3 visits before deductible) $70 $120 30% Anthem Bronze Select PPO 5750/35%/6450 Plus $5,750 $50 (3 visits before deductible) $50 (3 visits before deductible) 35% 35% Anthem Bronze Select PPO 5000/30%/6250 Anthem Bronze PPO 5000/30%/6250 $5,000 (medical and $60 (3 visits before deductible) $70 $120 30% Anthem Bronze Select PPO 6000/35%/6600 Anthem Bronze PPO 6000/35%/6600 $6,000 $70 (3 visits before deductible) $70 (3 visits before deductible) 35% 35% This provides an overview of plans available. This is intended to be a brief overview of benefits and is not intended to be a legal contract. The entire provisions of benefits, limitations and exclusions can be found in the Combined Evidence of Coverage/Certificate. In the event of a conflict between the Combined Evidence of Coverage/Certificate and this overview, the terms of the Combined Evidence of Coverage/Certificate will prevail. All product offerings are subject to regulatory review and approval. Family deductibles are two times the in-network single member amount, except as otherwise noted. Family out-of-pocket maximums are two times the in-network single network amount. 10

13 Emergency room 1 Outpatient surgery $150 10% 10% Hospital inpatient Out-of-pocket maximum $4,000 (medical and Pharmacy deductible (if any) Tier 1/Tier 2/Tier 3/Tier 4 Drug list Healthy Support Retail: $5/$15/$25/10% (up to $500) Select A $250 20% 20% $6,250 (medical and Retail: $15/$50/$70/20% (up to $500) Select A $ % 20% 20% $4,000 (medical and Retail: $250 deductible (waived tier 1) $15/$35/$70/30% (up to $500) Select A $ % 20% 20% $4,500 (medical and Retail: $250 deductible (waived tier 1) $15/$35/$70/25% (up to $250) National N/A $ % 20% 20% $4,000 (medical and Retail: $250 deductible (waived tier 1) $15/$35/$70/25% (up to $250) National N/A $250 20% 20% $6,250 (medical and Retail: $500 deductible (waived tier 1) $15/$50/$70/20% (up to $500) Select A $ % 35% 35% $6,600 (medical and Retail: $15/$35/$70/30% (up to $500) Select A $250 20% 20% $6,250 (medical and Retail: $500 deductible (waived tier 1) $15/$50/$70/20% (up to $250) National N/A $ % 35% 35% $6,600 (medical and Retail: $15/$35/$70/25% (up to $250) National N/A $300 30% 30% $6,250 (medical and Retail: Deductible/$15/$50/$75/30% (up to $500) Select A $ % $ % $1, % $6,450 (medical and Retail: $250 deductible (waived tier 1) $15/$50/$90/30% (up to $500) Select A $300 30% 30% $6,250 (medical and Retail: Deductible/$15/$50/$75/25% (up to $250) National N/A 35% 35% 35% $6,600 (medical and Retail: $250 deductible (waived tier 1) $15/$50/$90/25% (up to $250) National N/A 1 Deductible is waived only for the outpatient hospital emergency room charge. A member may receive other services while being treated in the emergency room; for these services, the member will be responsible for the applicable deductible and coinsurance. 2 PPO plans include an aggregate embedded accumulation for the family deductible and out-of-pocket maximum. This means that the family amounts can be met by any combination of amounts from any family member; however, deductible can be met for one member of the family as soon as that one member satisfies the individual deductible or out-of-pocket amounts. 11

14 The updated naming structure includes these elements: Anthem + metal tier + network name + product type + copay or deductible/coinsurance/out-of-pocket maximum In-network benefits are represented below. For out-of-network benefits, please refer to the Combined Evidence of Coverage/Certificate. Product type CDHP plan name Employer contribution Deductible Office visits (primary care physician) Specialist office visits Urgent care Coinsurance CDHP 1 Anthem Gold Select PPO 2000/20%/4000 w/ HRA Anthem Gold PPO 2000/20%/4000 w/ HRA Anthem Silver Select PPO 2000/30%/6350 w/ HSA Anthem Silver PPO 2000/30%/6350 w/ HSA $1,000 $250 $2,000 (medical and pharmacy combined) Upfront deductible: $1,000 for individual and $2,000 for family $2,000 (medical and pharmacy combined) 20% 20% 20% 20% 30% 30% 30% 30% Anthem Bronze Select PPO 5500/30%/6450 w/ HSA Anthem Bronze PPO 5500/30%/6450 w/ HSA $250 $5,500 (medical and pharmacy combined) 30% 30% 30% 30% Anthem Bronze Select PPO 6350/0%/6350 w/ HSA Anthem Bronze PPO 6350/0%/6350 w/ HSA $250 $6,350 (medical and pharmacy combined) 0% 0% 0% 0% This provides an overview of plans available. This is intended to be a brief overview of benefits and is not intended to be a legal contract. The entire provisions of benefits, limitations and exclusions can be found in the Combined Evidence of Coverage/Certificate. In the event of a conflict between the Combined Evidence of Coverage/Certificate and this overview, the terms of the Combined Evidence of Coverage/Certificate will prevail. All product offerings are subject to regulatory review and approval. Family deductibles are two times the in-network single member amount, except as otherwise noted. Family out-of-pocket maximums are two times the in-network single network amount. 12

15 Emergency room Outpatient surgery Hospital inpatient Out-of-pocket maximum Pharmacy deductible (if any) Tier 1/Tier 2/Tier 3/Tier 4 Drug list Healthy Support 20% 20% 20% $4,000 (medical and pharmacy combined) Retail and home delivery: Deductible/20% National N/A 30% 30% 30% 30% 30% 30% 0% 0% 0% $6,350 (medical and pharmacy combined) $6,450 (medical and pharmacy combined) $6,350 (medical and pharmacy combined) Retail and home delivery: Deductible/30% National N/A Retail and home delivery: Deductible/30% National N/A Retail and home delivery: Deductible/0% National N/A 1 HRA/HSA plans include aggregate nonembedded accumulation for the family deductible and out-of-pocket maximum. This means the family amounts can be met by any combination of amounts from any family member, and one member can meet the entire amount for the family. The individual deductible and out-of-pocket amounts do not apply to family contracts. 13

16 Small Group eligibility For plan year beginning on or after January 1, 2015, eligible groups consist of actively-engaged businesses or services with 1-50 employees. These groups must have the majority of their 1-50 employees working in the state of California. Participation requirements The participation requirements for an Anthem Blue Cross Small Group EmployeeElect health plan are: 70% for groups with 1-14 eligible employees. 50% for groups with 15 or more eligible employees. The minimum participation is 100% if noncontributory. Anthem Blue Cross may conduct periodic audits to confirm participation levels. Note: During the annual open enrollment period of November 2015 to December 2015, participation requirements will not be enforced. Waiting periods Pursuant to SB 1034 (2014), Anthem will not impose a waiting period. Groups are responsible for providing Anthem accurate member eligibility dates, taking into account any group imposed waiting period. In accordance with SB 1034, groups are responsible for ensuring that any group imposed waiting period is consistent with Section 2708 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-7). These are the waiting period options: First of the month, following date of hire. First of the month, following one month from date of hire. First of the month, following two months from the date of hire, not to exceed 90 days. Clarification on self-funded arrangements Anthem Blue Cross Small Group plans cannot be sold or utilized in conjunction with any product, whether insured or self-funded, that funds any annual deductible, copay, coinsurance, or out-of-pocket expense of the health benefit plan (i.e., wrapping ). Small businesses considerations How rating will change in 2015 Before 2015, the rate was determined by the employee s age and the ZIP code where the employee lived. Beginning in 2015, the rate will now be calculated based on the employee s age and the employer s ZIP code. Rating rule change: Rates will adjust for age at contract anniversary. New hires will be rated based on their age on the effective date of their contract, not their age on the group s effective or anniversary date. How medical rates are calculated member-level rating 2014 rate structure Based on each family member s age and employee s ZIP code ACA-compliant rate structure Based on each family member s age and employer s ZIP code. Note: You have the option to waive the waiting period for all new hires at the initial group enrollment only. Also, your group s waiting period is applied to all employees in the group, with no exceptions for any eligible employee. 14

17 A full ofering of health and wellness programs to help keep members healthier. 15

18 Health and wellness At Anthem Blue Cross, we understand that the health of your employees has a great impact on the health of your business. That s why we provide a unique blend of health and wellness programs to help keep all of your employees living their best, no matter how healthy they are or need to be. New! LiveHealth Online LiveHealth Online is faster than a visit to the urgent care center. It s a tool that lets members interact with doctors through their computers or mobile devices. No sitting in traffic, no waiting in a crowded waiting room, and no appointments needed. Members just need the LiveHealth Online app or a computer with a webcam. To get started, go to livehealthonline.com. LiveHealth Online is part of your health plan. This means your visit may cost the same as a regular office visit copay, or it may cost $49, depending on your health plan benefits.* LiveHealth Online applies only to ACA-compliant plans. It does not apply to legacy plans. * Integrated into health plan benefits as a regular office visit copay with all PPO and CDHP (HSA) plans. HMO and CDHP (HRA) plans are not included. Please note that online visits are part of the office visit limit that your health plan may have. 24/7 NurseLine Members can call anytime to speak to a registered nurse who s trained to answer general health questions, help them understand symptoms and help them determine the right care at the right time. Employee Assistance Program (EAP) Provides employees and household members with up to three counseling sessions with a licensed social worker, counselor or psychologist to help with issues ranging from stress management to family and work-related concerns. Other services include limited financial and legal consultations at no cost. Members can simply call or visit anthemeap.com, a specialized website for program information and personal assistance resources such as an online child care/elder care locator. Employers can also easily download promotional material on the website. Utilization Management Includes precertification of medical procedures, imaging services and hospitalization to authorize care and align medical services with the member s benefits. Imaging Cost and Quality A member outreach program designed to lower the costs of expensive imaging procedures. If the member qualifies, they are contacted about equal-quality, lower-cost imaging alternatives in their area. At that point, members can choose the lower-cost option or stick with their original appointment. Case Management Offers telephonic and video chat nursing support following a major hospitalization or procedure due to illness or injury. Cancer, NICU and transplant services included. Case Management also provides members with multiple health issues or those who may require more frequent medical care with a personal nurse care manager to receive individualized care. Case Management helps members maximize health benefits, arrange post-discharge care, find community health services and improve self-management of conditions. Quick Care Options An initiative to educate members about nonemergency/avoidable ER visits and steer them to lower-cost settings with shorter wait times, including urgent care centers, walk-in doctors offices and retail health clinics. The Quick Care Options program includes targeted education opportunities after members have an avoidable ER visit. ConditionCare For members with chronic conditions like asthma, diabetes or heart disease, the ConditionCare disease management program provides targeted information, guidance and support. With 24/7 access to health professionals, members are equipped to better understand and manage their condition, and make healthier choices for optimal wellness. } } Future Moms Provides mothers-to-be with personalized support and guidance, helping them achieve healthier pregnancies and deliveries. With their own team of obstetric specialists, expectant members get access to expert information and direction throughout their pregnancy and postpartum period. 16

19 MyHealth Advantage Communicates gaps in care and health savings opportunities to targeted members (via mailed MyHealth Notes) and gaps in care to their treating providers (via mailed notices). MyHealth Advantage analyzes comprehensive health information and suggests ways members can be healthier and reduce out-of-pocket expenses. The program aims to reduce health care costs by increasing member compliance with medical best practices and improving health care quality. Behavioral Health UM/CM/DM Offers immediate and longer-term mental health management and information to eligible members. Infertility buy-up option Offers infertility benefits for an additional charge that will be added to the member s premium. } } Healthy Lifestyles online If members are ready to improve their health, Healthy Lifestyles can be the guide to their success. Healthy Lifestyles creates a well-being plan, helps track success, and connects members to wellness resources and other people going through similar experiences. To enroll in Healthy Lifestyles, log on to anthem.com/ca, select the Health and Wellness tab and get started under the Healthy Lifestyles section. 17

20 Provide your employees with a well-rounded benefts package from Anthem. 18