2015 ANNUAL ENROLLMENT GUIDE

Transcription

1 2015 ANNUAL ENROLLMENT GUIDE State of Louisiana Employees and Retirees Administered by Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and is an independent licensee of the Blue Cross and Blue Shield Association. 01MK4360 R05/15

2 TABLE OF CONTENTS Introduction... 1 PELICAN HRA PELICAN HSA MAGNOLIA LOCAL MAGNOLIA LOCAL PLUS MAGNOLIA OPEN ACCESS Applies to ALL Plans Mental Health and Substance Abuse Benefits Provider Network Care Management Programs General Information Online Tools Wellness Programs Healthy Discounts Balance Billing Disclosure This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

3 Blue Cross and Blue Shield of Louisiana is proud to serve your healthcare needs. Your Blue Cross plan offers many benefits and features, including: a large network of doctors and hospitals physician office visits direct access to specialty care without a referral member discounts and savings through Blue365 a comprehensive new wellness and prevention program online tools to help you get the most from your health plan an ID card recognized around the world local customer service Service Blue Cross is committed to meeting the challenging demands of healthcare in the 21st century. As part of this commitment, we constantly strive for excellence in customer service. Our goal is to bring Blue Cross plan members the high level of service they expect and deserve. Survey results from polling the state of Louisiana employees and retirees reveal that 89 percent of those members were satisfied overall with their Blue Cross experience. CUSTOMER SERVICE online: by phone: by ogbhelp@bcbsla.com To view the Summary of Benefits and Coverage (SBC), go to Ready to Enroll? Visit the OGB online enrollment portal at or Complete the paper annual enrollment form, or Contact human resources if you are an active employee or OGB if you are a retiree. 1

4 2 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

5 PELICAN HRA

6 PELICAN HRA 1000 SCHEDULE OF BENEFITS Nationwide Network Coverage Preferred Care Providers and BCBS National Providers OGB BENEFIT PLAN PELICAN FORM NUMBER HRA HR /15 SCHEDULE OF BENEFITS: Actives, Retirees without Medicare, Retirees With Medicare COMPREHENSIVE CDHP MEDICAL BENEFIT PLAN PLAN NAME SCHEDULE OF BENEFITS PLAN NUMBER State of Louisiana Office of Group Benefits ST222ERC Nationwide Network Coverage PLAN'S ORIGINAL EFFECTIVE Preferred DATECare Providers and BCBS National Providers PLAN'S ANNIVERSARY DATE January 1, 2013 January 1 BENEFIT PLAN FORM NUMBER 40HR /15 Lifetime Maximum Benefit:..Unlimited PLAN Benefit NAME Period:...03/01/15 PLAN NUMBER 12/31/15 State of Louisiana Office of Group Benefits ST222ERC PLAN'S ORIGINAL EFFECTIVE DATE PLAN'S ANNIVERSARY DATE January Deductible 1, 2013 Amount per Benefit Period: Network January 1 Non-Network Individual: $2, $4, Lifetime Maximum Benefit:..Unlimited Family: $4, $8, Benefit Period:...03/01/15 12/31/15 SPECIAL NOTES Deductible Amount Deductible Amount per Benefit Period: Network Non-Network Eligible Expenses for services of a Network Provider that apply to the Deductible Amount for Network Individual: Providers will not count toward to the Deductible Amount for Non-Network $2, Providers. $4, Family: Eligible Expenses for services of Non-Network Providers that apply $4, to the Deductible Amounts $8, for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. SPECIAL NOTES Deductible Coinsurance: Amount Plan Plan Participant Eligible Network Expenses Providers... for services of a Network that apply to the 80% Deductible Amount 20% for Network Providers will not count toward to the Deductible Amount for Non-Network Providers. Non-Network Providers... 60% 40% Eligible Expenses for services of Non-Network Providers that apply to the Deductible Amounts for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. Out-of-Pocket Maximum per Benefit Period: Coinsurance: Plan Plan Participant Includes all all eligible Coinsurance Amounts, Deductibles and Network Providers... Prescription Drug Copayments 80% 20% 40HR /15 Network 1 Non-Network Non-Network Individual Providers... $5, $10, % 40% Family $10, $20, SPECIAL NOTES 40HR /15 1 Out-of-Pocket Maximum Eligible Expenses for for services of of a a Network Provider that apply to to the the Deductible and Out-of-Pocket Maximum for for Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Non-Network Providers. 4 Eligible Expenses for for services of of Non-Network Providers that apply to to the the Out-of-Pocket Maximum for for Non- Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Network Providers.

7 Includes all eligible Coinsurance Amounts, Deductibles and Prescription Drug Copayments Network Non-Network Individual $5, $10, PELICAN HRA 1000 Family $10, $20, SPECIAL NOTES Out-of-Pocket Maximum Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will not count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will not count toward to the Out-of-Pocket Maximum for Network Providers. When the maximum Out-of-Pocket amounts, as shown above have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. There may be a significant Out-of-Pocket expense to the Plan Participant when using a Non-Network Provider. Eligible Expenses Eligible Expenses are reimbursed in accordance with a fee schedule of maximum Allowable Charges; not billed charges. All Eligible Expenses are determined in accordance with plan Limitations and Exclusions. Eligibility The Plan Administrator assigns Eligibility to all Plan Participants. 40HR /15 2 5

8 PELICAN HRA 1000 COINSURANCE Physician s Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1 60% - 40% 1 Allied Health/Other Office Visits Chiropractors Retail Health Clinics Nurse Practitioner Physician s Assistant 80% - 20% 1 60% - 40% 1 Specialist Office Visits including surgery performed in an office setting. Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic Ambulance Services (For Emergency Medical Transportation Only) Ground Transportation Air Ambulance 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 80% - 20% 1,2 Ambulatory Surgical Center and Outpatient Surgical Facility 80% - 20% 1,2 60% - 40% 1,2 Autism Spectrum Disorders (ASD) Office Visits 80% - 20% 1,3 60% - 40% 1,3 Autism Spectrum Disorders(ASD) Inpatient Hospital Birth Control Devices - Insertion and Removal (As listed in the Preventive and Wellness Article in the Benefit Plan.) Cardiac Rehabilitation (Must begin within six months of qualifying event; Limit of 26 Visits per Plan Year ) 80% - 20% 1,2 60% - 40% 1,2 100% - 0% 60% - 40% 1 80% - 20% 1,2,3 60% - 40% 1,2,3 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 6 40HR /15 3

9 PELICAN HRA 1000 COINSURANCE Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician s office.) NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1,2 60% - 40% 1,2 Diabetes Treatment 80% - 20% 1 60% - 40% 1 Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities 80% - 20% 1 Not Covered Dialysis 80% - 20% 1,2 60% - 40% 1,2 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices 80% - 20% 1,2 60% - 40% 1,2 Emergency Room (Facility Charge) 80% - 20% 1 80% - 20% 1 Emergency Medical Services (Non-Facility Charge) Flu Shots and H1N1 vaccines (Administered at Network Providers, Non- Network Providers, Pharmacy, Job Site or Health Fair) Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) High-Tech Imaging Outpatient (CT Scans, MRI/MRA, Nuclear Cardiology, PET Scans) Home Health Care (Limit of 60 Visits per Plan Year, combination of Network and Non-Network) (One Visit = 4 hours) Hospice Care (Limit of 180 Days per Plan Year, combination of Network and Non-Network) 80% - 20% 1 80% - 20% 1 100% - 0% 100% - 0% 80% - 20% 1,3 Not Covered 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 Injections Received in a Physician s Office (When no other health services is received) 80% - 20% 1 per injection 60% - 40% 1 per injection Inpatient Hospital Admission (All Inpatient Hospital services included) Inpatient and Outpatient Professional Services 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR /15 4 7

10 PELICAN HRA 1000 COINSURANCE Mastectomy Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) Mental Health/Substance Abuse - Inpatient Treatment Mental Health/Substance Abuse - Outpatient Treatment NETWORK PROVIDERS NON-NETWORK PROVIDERS 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 Pregnancy Care Physician Services 80% - 20% 1 60% - 40% 1 Preventive Care Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness/Routine Care Article in the Benefit Plan.) Rehabilitation Services Outpatient: Speech Physical/Occupational 2 (Limit of 50 Visits combined PT/OT per Plan Year. Authorization required for visits over the combined limit of 50.) Pulmonary Therapies (Limit 30 Visits per Plan Year) (Visit limits are combination of Network and Non-Network Benefits; Visit limits do not apply when services are provided for Autism Spectrum Disorders.) Skilled Nursing Facility (Limit of 90 days per Plan Year) 3 100% - 0%3 100% - 0% 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 60% - 40% 1,2 Sonograms and Ultrasounds - Outpatient 80% - 20% 1 60% - 40% 1 Urgent Care Center 80% - 20% 1 60% - 40% 1 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 8 40HR /15 5

11 PELICAN HRA 1000 COINSURANCE COINSURANCE NETWORK PROVIDERS NETWORK PROVIDERS NON-NETWORK NON-NETWORK PROVIDERS PROVIDERS Vision Care (Non-Routine) Exam Vision Care (Non-Routine) Exam 80% - 20% 1 80% - 20% 1 60% - 40% 1 60% - 40% 1 X-Ray and Laboratory Services X-Ray and Laboratory Services 80% - 20% 1 80% - 20% 1 60% - 40% 1 60% - 40% Subject to Plan Year Deductible Subject 2 to Plan Year Deductible 2 Pre-Authorization Required Pre-Authorization 3 Required 3 Age and/or time restrictions apply Age and/or time restrictions apply ORGAN, TISSUE AND BONE MARROW TRANSPLANTS ORGAN, TISSUE AND BONE MARROW TRANSPLANTS Authorization is Required Prior to Services Being Performed Authorization is Required Prior to Services Being Performed Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Organ, Tissue and Bone Marrow Transplants and evaluation for a Plan Participant s suitability for Organ, Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization Tissue Bone Marrow transplants will not be covered unless a Plan Participant obtains written authorization from the Claims Administrator, prior to services being rendered. from the Claims Administrator, prior to services being rendered. Network Benefits..80% - 20% Network Benefits..80% - 20% Non-Network Benefits.Not Covered Non-Network Benefits.Not Covered CARE MANAGEMENT CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling supplies must be made to Blue Cross and Blue Shield of Louisiana by calling If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Benefits. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. Participant remains responsible for his applicable Deductible and Coinsurance percentage. 40HR / HR /15 6 9

12 PELICAN HRA 1000 If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all covered Inpatient charges. The Plan Participant is responsible for all charges not covered and for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Network Provider Hospital: FIFTY PERCENT (50%) reduction of the Allowable Charges. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all services and supplies requiring an Authorization. The Plan Participant is responsible for all charges not covered and remains responsible for his Deductible and applicable Coinsurance percentage. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling Air Ambulance Non-Emergency Applied Behavior Analysis Bone growth stimulator Cardiac Rehabilitation CT Scans Day Rehabilitation Programs Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $ , such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs Low Protein Food Products MRI/MRA Nuclear Cardiology 40HR /15 7

13 Dialysis Durable Medical Equipment (Greater than $300.00) Electric & Custom Wheelchairs Home Health Care Hospice Hyperbarics Implantable Medical Devices over $ , such as Implantable Defibrillator and Insulin Pump Infusion Therapy (Exception: Infusion Therapy performed in a Physician s office does not require prior Authorization. The Drug to be infused may require prior Authorization). Intensive Outpatient Programs Low Protein Food Products MRI/MRA Nuclear Cardiology 40HR2032 Oral Surgery 03/15 (not required when performed in a Physician s 7 office) Organ Transplant Evaluation Orthotic Devices (Greater than $300.00) Outpatient surgical procedures not performed in a Physician s office Outpatient non-surgical procedures (Exceptions: X-rays, lab work, Speech Therapy and Chiropractic Services do not require prior Authorization. Non-surgical procedures performed in a Physician's office do not require prior Authorization). Outpatient pain rehabilitation or pain control programs Partial Hospitalization Programs PET Scans Physical/Occupational Therapy (Greater than 50 visits) Prosthetic Appliances (Greater than $300.00) Residential Treatment Centers Sleep Studies Specialty Pharmacy (Complete list of drugs available online at I m a Provider>Pharmacy Management>Specialty Pharmacy Program Drug List.pdf) Stereotactic Radiosurgery, including but not limited to gamma knife and cyberknife procedures Vacuum Assisted Wound Closure Therapy PELICAN HRA 1000 Population Health In Health: Blue Health The Population Health program targets populations with one or more of these five(5) chronic health conditions diabetes, coronary artery disease, heart failure, asthma and chronic obstructive pulmonary disease (COPD). (The In Health: Blue Health Services program is not available to Plan Participants with Medicare primary.) Through the In Health: Blue Health Services program, OGB offers an incentive to Plan Participants on Prescription Drugs used to treat the five chronic conditions listed above. a. OGB Plan Participants participating in the program qualify for $0 Copayment for certain Generic Prescription Drugs approved by the U. S. Food and Drug Administration (FDA) for any of the 5 chronic health conditions. b. OGB Plan Participants participating in the program qualify for $15 Copayment for certain Brand-Name Prescription Drugs for which an FDA-approved Generic version is not available. c. If a Generic is available and the OGB Plan Participant chooses the Brand-Name Drug, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost plus the $15 Brand-Name Copayment. The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 11

14 The In Health: Blue Health Services prescription incentive does not apply to any Prescription Drugs not used to treat one of these five health conditions with which you have been diagnosed. Please refer to the Care Management article, Population Health In Health: Blue Health section of the Benefit Plan for complete information on how to qualify for this incentive. PELICAN HRA Medically necessary/non-investigational Prescription Drugs requiring parenteral administration in in a 40HR2032 Physician s 03/15 Office are payable under the Medical 8 and Surgical Benefits Prescription Drugs that can be self-administered and are providedto to a Plan Participantinin a Physician s office are payable under the Medical and Surgical Benefits. Authorizations The following Prescription Drug categories require Prior Authorization. The Plan Participant s Physician must call to to obtain Authorization. The Plan Participant or or his Physician should call the Customer Service number on the back of of the ID ID card, or or go to to the Claims Administrator s website at at for the most current list of of Prescription Drugs that require Prior Authorization: Growth hormones* Anti-tumor necrosis factor drugs* Intravenous immune globulins* Interferons Monoclonal antibodies Hyaluronic acid derivatives for joint injection* ** Shall include all drugs that are in in this category. Therapeutic/Treatment Vaccines Examples include, but are not limited to to vaccines to to treat the following conditions: Allergic Rhinitis Alzheimer s Disease Cancers Multiple Sclerosis Therapeutic/Treatment Vaccines Network Provider: % -- 0% Non-Network Provider:... 70% -- 30% (After Deductible is is Met) OGB S Pharmacy Benefits Manager MedImpact Formulary: 3-Tier Plan Design* PRESCRIPTION DRUGS Prescription Drug Benefits are provided under the Hospital Benefits and Medical and Surgical Benefits Articles of the medical plan, and under the Pharmacy Plan provided by OGB s Pharmacy Benefits Manager (sometimes PBM ). Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana provides Claims Administration services only for Prescription Drugs dispensed as follows: Prescription Drugs Covered Under Hospital Benefits and Medical and Surgical Benefits 1. Prescription Drugs dispensed during an Inpatient or Outpatient Hospital stay, or in an Ambulatory Surgical Center are payable under the Hospital Benefits. 12 OGB will begin using the MedImpact Formulary to to help Plan Participants select the most appropriate, lowest-cost options. The formulary is is reviewed on a quarterly basis to to reassess drug tiers based on the current prescription drug market. Plan Participants will continue to to pay a portion of of the cost of of their prescriptions in in the form of of a copayment or or coinsurance. The amount Plan Participants pay toward their prescription depends on whether they receive a generic, preferred brand or or non-preferred brand name drug.

15 Therapeutic/Treatment Vaccines PELICAN HRA 1000 Network Provider: % - - 0% Non-Network Provider:... 70% % (After Deductible is is Met) OGB S Pharmacy Benefits Manager MedImpact Formulary: 3-Tier Plan Design* OGB will begin using the MedImpact Formulary to to help Plan Participants select the most appropriate, lowest-cost options. The formulary is is reviewed on on a a quarterly basis to to reassess drug tiers based on on the current prescription drug market. Plan Participants will continue to to pay a a portion of of the cost of of their prescriptions in in the form of of a a copayment or or coinsurance. The amount Plan Participants pay toward their prescription depends on on whether they receive a a generic, preferred brand or or non-preferred brand name drug. *These changes do do not affect Plan Participants with Medicare as as their primary coverage. PRESCRIPTION DRUG PLAN PARTICIPANT PAYS Generic 50% up up to to $30 Preferred 50% up up to to $55 Non-Preferred 65% up up to to $80 Specialty 50% up up to to $80 The pharmacy out-of-pocket maximum has been changed from $1,200 to to $1,500. Once met: Generic $0 $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay There 40HR2032 may 03/15 be more than one drug available to treat 99 your condition. We encourage you to speak with your Physician regularly about which drugs meet your needs at the lowest cost to you. Compound Drugs Compound Drugs over $400 require prior Authorization from MedImpact. 90-day fill option at retail or mail order network pharmacies For maintenance medications, 90-day prescriptions fills may be filled for the applicable coinsurance with a maximum that is two and a half times the maximum copayment. For example, if your share of the cost of a generic drug is $30, you can fill your 30-day prescription for $30 or a 90-day prescription for $75. Over-the-counter drugs Medications available over-the-counter in the same prescribed strength will no longer be covered under the pharmacy plan. What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time 13

16 PELICAN HRA 1000 Over-the-counter drugs Medications available over-the-counter in the same prescribed strength will no longer be covered under the pharmacy plan. What is a formulary? A formulary is a list of medications available to Plan Participants under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, non-preferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. 1. In the event the Plan Participant does not present his identification card to the Network pharmacy at the time of purchase, the Plan Participant will be responsible for full payment for the drug and must then file a claim with the Pharmacy Benefits Manager for reimbursement. Reimbursement is limited to the rates established for Non-Network pharmacies. If a Plan Participant chooses a Brand-Name Drug for which an FDA-approved Generic version is available, the OGB Plan Participant pays the difference between the Brand-Name and Generic cost, plus a $40 Copayment for a 31 day supply. 2. Regardless of where the Prescription Drug is obtained, Eligible Expenses for Brand Name Drugs will be limited to: a. The Pharmacy Benefits Manager's maximum Allowable Charge for the Generic, when available; or b. The Pharmacy Benefits Manager's maximum Allowable Charge for the Brand Drug dispensed, when a Generic is not available. c. There is no per prescription maximum on the Plan Participant's responsibility for payment of costs in excess of the Eligible Expense. Plan Participant payments for such excess costs are not applied toward satisfaction of the annual Out-of-Pocket threshold (above) HR2032 This 03/15 Plan allows Benefits for drugs and medicines 10 approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $ per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: 14 Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia

17 successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by the PBM. 4. Retirees with Medicare will be automatically enrolled in OGB s Medicare Part D coverage with a commercial wrap benefit. 5. In addition, this Plan allows Benefits limited to $ per month for expenses incurred for the purchase of low protein food products for the treatment of inherited metabolic diseases if the low protein food products are Medically Necessary and are obtained from a source approved by the OGB. Such expenses shall be subject to Coinsurance and Copayments relating to Prescription Drug Benefits. In connection with this Benefit, the following words shall have the following meanings: a. Inherited metabolic disease shall mean a disease caused by an inherited abnormality of body chemistry and shall be limited to: Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Methylmalonic Acidemia (MMA) Isovaleric Adicemia (IVA) Propionic Acidemia Glutaric Acidemia Urea Cycle Defects Tyrosinemia b. Low protein food products mean food products that are especially formulated to have less than one gram of protein per serving and are intended to be used under the direction of a Physician for the dietary treatment of an inherited metabolic disease. Low protein food products shall not include natural foods that are naturally low in protein. 6. Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are not subject to the Prescription Drug deductible and are covered at 100%. Smoking cessation screening and counseling are covered under the Preventive or Wellness Care article of the Benefit Plan. 7. The following drugs, medicines, and related services and supplies are not covered: Drugs used to treat anorexia, weight loss or weight gain Drugs used to promote fertility Dietary supplements; Medical Foods Bulk Chemicals Drugs for cosmetic purposes or to promote hair growth Nutritional or parenteral therapy; Vitamins and minerals; Drugs available over the counter (OTC) (unless expressly covered by this Plan) Prescription drugs (federal legend) with an OTC equivalent PELICAN HRA 1000 For more information on the pharmacy benefit, visit the MedImpact website at or call MedImpact member services at HR /

18 16 This Annual Enrollment Guide is presented for general information only. It is not a benefit plan, nor intended to be construed as the Blue Cross benefit plan document. If there is any discrepancy between this Annual Enrollment Guide and the Blue Cross benefit plan document and Schedule of Benefits, the FINAL Blue Cross benefit plan document and Schedule of Benefits will govern the benefits and plan payments.

19 PELICAN HSA

20 PELICAN HSA 775 SCHEDULE OF BENEFITS: Actives SCHEDULE OF BENEFITS Nationwide Network Coverage Preferred Care Providers and BCBS National Providers OGB BENEFIT PLAN PELICAN FORM NUMBER HSA HR1697 R03/15 COMPREHENSIVE CDHP MEDICAL BENEFIT PLAN PLAN NAME SCHEDULE OF BENEFITS PLAN NUMBER State of Louisiana Office of Group Benefits ST222ERC Nationwide Network Coverage PLAN'S ORIGINAL EFFECTIVE Preferred DATECare Providers and BCBS National Providers PLAN'S ANNIVERSARY DATE January 1, 2013 January 1 BENEFIT PLAN FORM NUMBER 40HR1697 R03/15 Lifetime Maximum Benefit:... Unlimited PLAN Benefit NAME Period:...03/01/15 PLAN NUMBER 12/31/15 State of Louisiana Office of Group Benefits ST222ERC PLAN'S Deductible ORIGINAL Amount EFFECTIVE per Benefit DATE Period: Network PLAN'S ANNIVERSARY Non-Network DATE January 1, 2013 January 1 Individual: $2, $4, Lifetime Family: Maximum Benefit:... $4, $8, Unlimited Benefit SPECIAL Period: NOTES...03/01/15 12/31/15 Deductible Amounts Deductible Amount per Benefit Period: Network Non-Network Eligible Expenses for services of a Network Provider that apply to the Deductible Amount for Network Individual: Providers will not count toward to the Deductible Amount for Non-Network $2, Providers. $4, Family: Eligible Expenses for services of Non-Network Providers that apply $4, to the Deductible Amounts $8, for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. SPECIAL NOTES Deductible Coinsurance: Amounts Plan Plan Participant Eligible Network Expenses Providers... for services of a Network that apply to the 80% Deductible Amount 20% for Network Providers will not count toward to the Deductible Amount for Non-Network Providers. Non-Network Providers... 60% 40% Eligible Expenses for services of Non-Network Providers that apply to the Deductible Amounts for Non-Network Providers will not count toward to the Deductible Amount for Network Providers. Out-of-Pocket Maximum per Benefit Period: Coinsurance: Plan Plan Participant Includes all all eligible Coinsurance Amounts, Deductibles and Network Providers... Prescription Drug Copayments 80% 20% Network Providers Non-Network Providers Non-Network 40HR1698 R03/15 Providers % 40% Individual $5, $10, Family $10, $20, SPECIAL NOTES 40HR1698 Out-of-Pocket R03/15 Maximum 1 Eligible Expenses for for services of of a a Network Provider that apply to to the the Deductible and Out-of-Pocket Maximum for for Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Non-Network Providers. Eligible Expenses for for services of of Non-Network Providers that apply to to the the Out-of-Pocket Maximum for for Non- Network Providers will not count toward to to the the Out-of-Pocket Maximum for for Network Providers. 18 When the the maximum Out-of-Pocket amounts, as as shown above have been satisfied, this Plan will will pay 100% of of

21 Includes all eligible Coinsurance Amounts, Deductibles and Prescription Drug Copayments Network Providers Non-Network Providers PELICAN HSA 775 Individual $5, $10, Family $10, $20, SPECIAL NOTES Out-of-Pocket Maximum Eligible Expenses for services of a Network Provider that apply to the Deductible and Out-of-Pocket Maximum for Network Providers will not count toward to the Out-of-Pocket Maximum for Non-Network Providers. Eligible Expenses for services of Non-Network Providers that apply to the Out-of-Pocket Maximum for Non- Network Providers will not count toward to the Out-of-Pocket Maximum for Network Providers. When the maximum Out-of-Pocket amounts, as shown above have been satisfied, this Plan will pay 100% of the Allowable Charge toward Eligible Expenses for the remainder of the Plan Year. There may be a significant Out-of-Pocket expense to the Plan Participant when using a Non-Network Provider. Eligible Expenses Eligible Expenses are reimbursed in accordance with a fee schedule of maximum Allowable Charges; not billed charges. All Eligible Expenses are determined in accordance with plan Limitations and Exclusions. Eligibility The Plan Administrator assigns Eligibility to all Plan Participants. 40HR1698 R03/

22 PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Physician s Office Visits including surgery performed in an office setting: General Practice Family Practice Internal Medicine OB/GYN Pediatrics 80% - 20% 1 60% - 40% 1 Allied Health/Other Office Visits Chiropractors Retail Health Clinics Nurse Practitioner Physician s Assistant 80% - 20% 1 60% - 40% 1 Specialist Office Visits including surgery performed in an office setting. Physician Podiatrist Optometrist Midwife Audiologist Registered Dietician Sleep Disorder Clinic Ambulance Services (For Emergency Medical Transportation Only) Ground Transportation Air Ambulance Ambulatory Surgical Center and Outpatient Surgical Facility 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 80% - 20% 1,2 80% - 20% 1,2 60% - 40% 1,2 Autism Spectrum Disorders (ASD) Office Visits 80% - 20% 1,3 60% - 40% 1,3 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR1698 R03/

23 PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Autism Spectrum Disorders(ASD) Inpatient Hospital Birth Control Devices - Insertion and Removal (As listed in the Preventive and Wellness Article in the Benefit Plan.) Cardiac Rehabilitation (Must begin within six months of qualifying event; Limited to 26 visits per Plan Year ) Chemotherapy/Radiation Therapy (Authorization not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 100% - 0% 60% - 40% 1 80% - 20% 1,2,3 60% - 40% 1,2,3 80% - 20% 1,2 60% - 40% 1,2 Diabetes Treatment 80% - 20% 1 60% - 40% 1 Diabetic/Nutritional Counseling - Clinics and Outpatient Facilities 80% - 20% 1 Not Covered Dialysis 80% - 20% 1,2 60% - 40% 1,2 Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices 80% - 20% 1,2 60% - 40% 1,2 Emergency Room (Facility Charge) 80% - 20% 1 80% - 20% 1 Emergency Medical Services (Non-Facility Charge) Flu Shots and H1N1 vaccines (Administered at Network Providers, Non- Network Providers, Pharmacy, Job Site or Health Fair) Hearing Aids (Hearing Aids are not covered for individuals age eighteen (18) and older.) 80% - 20% 1 80% - 20% 1 100% - 0% 100% - 0% 80% - 20% 1,3 Not Covered High-Tech Imaging Outpatient (CT Scans, MRI/MRA, Nuclear Cardiology, PET Scans) Home Health Care (Limit of 60 Visits per Plan Year, Combination of Network and Non-Network) (One Visit = 4 hours) 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 40HR1698 R03/

24 PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care (Limit of 180 Days per Plan Year, combination of Network and Non-Network) 80% - 20% 1,2 60% - 40% 1,2 Injections Received in a Physician s Office (When no other health services is received) Inpatient Hospital Admission (All Inpatient Hospital services included) Inpatient and Outpatient Professional Services Mastectomy Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) Mental Health/Substance Abuse - Inpatient Treatment Mental Health/Substance Abuse - Outpatient Treatment 80% - 20% 1 per injection 60% - 40% 1 per injection 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1,2 60% - 40% 1,2 80% - 20% 1 60% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s office.) 80% - 20% 1,2 60% - 40% 1,2 Pregnancy Care Physician Services 80% - 20% 1 60% - 40% 1 Preventive Care Services include screening to detect illness or health risks during a Physician office visit. The Covered Services are based on prevailing medical standards and may vary according to age and family history. (For a complete list of benefits, refer to the Preventive and Wellness/ Routine Care Article in the Benefit Plan.) 3 100% - 0%3 100% - 0% 1 Subject to Plan Year Deductible 2 Pre-Authorization Required 3 Age and/or time restrictions apply 22 40HR1698 R03/15 5

25 PELICAN HSA 775 COINSURANCE NETWORK PROVIDERS NON-NETWORK PROVIDERS Hospice Care Rehabilitation Services Outpatient: (Limit of 180 Days per Plan Year, Speech combination of Network and Non-Network) Physical/Occupational 2 80% - 20% 1,2 60% - 40% 1,2 (Limit (Limit of of Visits Visits combined PT/OT per per Plan Plan Year. Year. Authorization required for for Injections visits visits Received over over the the in combined a Physician s limit limit of Office of 50.) 50.) 80% - 20% 1 60% - 40% 1 (When no Pulmonary other health Therapies services (Limit (Limit is 30 received) 30 Visits Visits per per per injection per injection Inpatient Plan Plan Hospital Year) Year) Admission 80% - 20% 1,2 60% - 40% 1,2 (All Inpatient Hospital services included) 80% 80% - 20% - 20% 1,2 60% 60% - 40% - 40% 1,2 (Visit (Visit limits limits are are combination of of Network and and Inpatient Non-Network and Outpatient Benefits; Visit Professional Visit limits limits do do not not apply apply 80% - 20% 1 60% - 40% 1 Services when when services are are provided for for Autism Mastectomy Spectrum Disorders.) Bras - Ortho-Mammary Surgical (Limited to two (2) per Plan Year) 80% - 20% 1,2 60% - 40% 1,2 Mental Health/Substance Abuse - Inpatient 80% - 20% 1,2 60% - 40% 1,2 Treatment Skilled Nursing Facility (Limit (Limit of of days days per per 80% 80% - 20% - 20% 1,2 60% 60% - 40% - 40% 1,2 Mental Plan Plan Year) Health/Substance Year) Abuse - Outpatient 80% - 20% 1 60% - 40% 1 Treatment Sonograms and and Ultrasounds - - Outpatient 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 Newborn Sick, Services excluding Facility 80% - 20% 1 60% - 40% 1 Urgent Care Care Center 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 Newborn Sick, Facility 80% - 20% 1,2 60% - 40% 1,2 Vision Vision Care Care (Non-Routine) Exam Exam Oral Surgery for Impacted Teeth (Authorization is not required when performed in Physician s X-Ray and and Laboratory office.) Services 80% 80% - 20% - 20% 1 80% 20% 1,2 80% 80% - 20% - 20% 1 60% 60% - 40% - 40% 1 60% - 40% 1,2 60% 60% - 40% - 40% 1 Pregnancy 1 1 Subject to Care to Plan Plan Year Physician Year Deductible Services 80% - 20% 1 60% - 40% 1 Preventive 2 2 Pre-Authorization Care Services Required include screening to 3 Age 3 detect Age and/or illness time time or health restrictions risks apply during apply a Physician office visit. The Covered Services are based on prevailing medical 3 100% - 0%3 standards and may vary according to age 100% - 0% and family history. (For a complete ORGAN, list TISSUE of AND AND BONE MARROW TRANSPLANTS benefits, refer to the Preventive and Wellness/ Routine Care Article Authorization in the is is required prior prior to to services being being rendered. Benefit Plan.) Organ, Tissue and and Bone Bone Marrow Transplants and and evaluation for for a Plan a Plan Participant s suitability for for Organ, 1 Tissue Subject Bone Bone to Plan Marrow Year Deductible transplants will will not not be be covered unless a Plan a Plan Participant obtains written authorization from 2 from Pre-Authorization the the Claims Administrator, Required prior prior to to services being being rendered. 3 Age and/or time restrictions apply Network Benefits %- 20% - 20% Non-Network Benefits..... Not Not Covered CARE MANAGEMENT If a If a required Authorization is not is not requested prior prior to to Admission or or receiving other other Covered Services and and supplies, the the Plan Plan will will have have the the right right to to determine if the if the Admission or or other other Covered Services or or supplies were were Medically Necessary. If the If the Admission or or other other Covered Services and and supplies were were not not Medically Necessary, the the Admission or or other other Covered Services and and supplies will will not not be be covered and and the the Plan Plan Participant must must pay pay all all charges incurred. If the If the Admission or or other other Covered Services and and supplies were were Medically Necessary, Benefits will will be be provided 40HR1698 R03/15 5 based based on on the the Network status status of of the the Provider rendering the the services. 23

26 from the Claims Administrator, prior to services being rendered. PELICAN HSA 775 Network Benefits % - 20% Non-Network Benefits..... Not Covered 40HR1698 R03/15 6 CARE MANAGEMENT If a required Authorization is not requested prior to Admission or receiving other Covered Services and supplies, the Plan will have the right to determine if the Admission or other Covered Services or supplies were Medically Necessary. If the Admission or other Covered Services and supplies were not Medically Necessary, the Admission or other Covered Services and supplies will not be covered and the Plan Participant must pay all charges incurred. If the Admission or other Covered Services and supplies were Medically Necessary, Benefits will be provided based on the Network status of the Provider rendering the services. Authorization of Inpatient and Emergency Admissions Inpatient Admissions must be Authorized. Refer to Care Management and if applicable Pregnancy Care and Newborn Care Benefits sections of the Benefit Plan for complete information. Requests for Authorization of Inpatient Admissions and for Concurrent Review of an Admission in progress, or other Covered Services and supplies must be made to Blue Cross and Blue Shield of Louisiana by calling If a Blue Cross and Blue Shield of Louisiana Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the penalty amount stipulated in the Provider s contract with the other Blue Cross and Blue Shield plan. This penalty applies to all covered Inpatient charges. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. If a Non-Network Provider fails to obtain a required Authorization, the Claims Administrator will reduce Allowable Charges by the amount shown below. This penalty applies to all covered Inpatient charges. The Plan Participant is responsible for all charges not covered and for any applicable Deductible Amount and Coinsurance percentage shown in the Schedule of Benefits. Additional Plan Participant responsibility if Authorization is not requested for an Inpatient Admission to a Non- Network Provider Hospital: FIFTY PERCENT (50%) reduction of the Allowable Charges. The following services and supplies require Authorization prior to the services being rendered or supplies being received. Requests for Authorization must be made to Blue Cross and Blue Shield of Louisiana by calling Inpatient Hospital Admissions (Except routine maternity stays) Inpatient Mental Health and Substance Abuse Admissions Inpatient Organ, Tissue and Bone Marrow Transplant Services Inpatient Skilled Nursing Facility Services NOTE: Emergency services (life and limb threatening emergencies) received outside of the United States (out of country) are covered at the Network Benefit level. Non-emergency services received outside of the United States (out of country) are covered at the Non-Network Benefit level. Authorization of Outpatient Services, Including Other Services and Supplies If a Network Provider fails to obtain a required Authorization, no Benefits are payable. The Network Provider is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance percentage. 24 If a Network Provider in another Blue Cross and Blue Shield plan fails to obtain a required Authorization, no Benefits are payable. The Network Provider of the other Blue Cross and Blue Shield plan is responsible for all charges not covered. The Plan Participant remains responsible for his applicable Deductible and Coinsurance