POS. Point-of-Service. Coverage You Can Trust

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1 POS Point-of-Service Coverage You Can Trust Issued by Capital Advantage Insurance Company, a Capital BlueCross subsidiary. Independent licensees of the Blue Cross and Blue Shield Association.

2 Coverage You Can Trust Welcome to POS POS is a very flexible plan with one of the largest managed care networks in Central Pennsylvania and the Lehigh Valley with more than 11,000 physicians, hospitals, and other professional Providers. You also have access to Providers outside our 21-county service area through the BlueCard network. BlueCard Providers are also covered at the highest benefit level when your care is coordinated through your Primary Care Physician (PCP). Your Primary Care Physician One of the ways that your POS benefits work to keep you healthy is through easy, affordable access to preventive care administered by a Primary Care Physician (PCP). With POS, you get to choose your PCP from our extensive network. In fact, each Member of your family can choose his or her own PCP. You can select your PCP by reviewing our Provider directory available in print or on our Web site. Simply indicate your Provider selection on your enrollment form. It s that easy! Most likely, you already have a family physician that treats you for most of your care. With over 11,000 Providers in Central Pennsylvania and Lehigh Valley in our network, there is a good chance your current doctor already participates with Capital BlueCross. Your PCP coordinates most of the medical services you need either treating you directly or referring you to a specialist or hospital. When you are referred to a specialist, you can have confidence that your PCP will usually receive treatment updates from the specialist. And, you have the security in knowing that your PCP knows your health and family history. 21-COUNTY SERVICE AREA When you use a POS participating Provider, there are no claims to file. Your Provider takes care of the paperwork for you. If you choose to see a nonparticipating Provider, you may have to submit the bill and claim form to be reimbursed for eligible expenses.* *Reimbursement to Member based on allowed charges after meeting a deductible and other cost-sharing amounts.

3 BlueCard Program With POS, you have access to thousands of BlueCard participating doctors and hospitals outside our 21-county service area, across the country, and around the world. Please refer to your Certificate of Coverage for a detailed description of this benefit. BlueCard Emergency/Urgent Care When you travel outside the 21-county service area and need emergency medical attention, you should seek care from the nearest hospital. In the event of an urgent situation, you should first contact your PCP. If you are unable to contact your PCP in advance of receiving urgent care services, you should notify your PCP by the next business day. BlueCard Follow-Up Care If you require follow-up care after receiving care under the BlueCard benefit, you must first contact your PCP prior to receiving follow-up services. Your PCP will coordinate and authorize all necessary services. If you do not contact your PCP before receiving follow-up care, the services may not be covered under your benefit. To find a BlueCard participating Provider anywhere outside the service area, you can search the Blue Cross and Blue Shield Association s online directory at bcbs.com. You can also call BLUE, or, when traveling outside of the country, you can call collect at for assistance 24 hours a day, seven days a week.

4 If You re Looking For More, You ve Come To The Right Place! While many plans cover you in the event of an illness or emergency, POS benefits are designed to help you and your family to stay healthy. That s why POS covers preventive, adult and pediatric care, doctor office visits, well-baby checks, and other important health care services. 1 Your Benefits Your POS plan may cover medically necessary health care services when performed or referred by your PCP. Services may be subject to copayments, coinsurance, and deductibles. Some services require a preauthorization and you do need a referral when your PCP coordinates care with another physician. Please refer to your Certificate of Coverage and/or Benefit Highlight Sheet, or check your benefits online by logging into mycapbluecross.com. 2 Preventive Care*: Routine physicals Annual gynecological exams Annual mammograms for women 40 and over Childhood immunizations Select screenings Other Covered Services*: Doctor office visits for illness or injury Maternity and newborn care Emergency care and emergency ambulance service Lab tests and X rays Inpatient and outpatient hospital services Disease management programs Physical, occupational, speech, and manipulation therapies Mental health care Substance abuse treatment Home health care Skilled nursing-facility care 1 After any applicable deductibles, copayments or coinsurance amounts. 2 Some company benefit plans request Members to complete reimbursement forms for select services and some require copayments or coinsurances for hospitalization and surgeries. Depending on your company s benefit plan, there is a standard emergency room visit copayment which is waived if you are admitted to a hospital. See your Certificate of Coverage for details. *The above listing is not a complete summary of benefits. Please refer to your Certificate of Coverage and Benefit Highlight Sheets for a detailed description of all benefits, limitations, definitions of terms, and exclusions that apply to your plan.

5 Referrals In most cases, your PCP arranges your medical care, including services by a specialist. POS does not require you to get a referral from your PCP, but you will maximize your benefits and have the lowest out-of-pocket costs if your care is coordinated through your PCP. You should always check with your PCP before receiving medical care from another physician. If you need to see a specialist, your PCP will complete the referral paperwork for you. Ask your PCP for a copy of the referral form so you know what medical services are being requested. When your doctor s office is closed When you need medical services after normal office hours, contact your PCP. You may need to leave a message with your PCP s answering service who will contact your PCP or the physician on call. After hours calls should be limited to medical problems requiring immediate attention. However, do not postpone calling your PCP if you believe you need medical attention. If your condition qualifies as an emergency, you have coverage for transportation and related emergency care provided by a licensed ambulance service. In a true emergency, the first concern is to obtain necessary medical treatment seek care from the nearest appropriate facility Provider or call 911 for immediate assistance.

6 Your Share of the Cost The term cost-sharing refers to the amount of money you contribute towards the cost of your medical services. Your contribution typically includes deductible, copayments, and coinsurance. For nonparticipating Providers, after you have met your deductible, you may be responsible for coinsurance AND you may pay any difference between what the Provider charges and what Capital BlueCross pays. You are responsible for payment of any services for which benefits are not provided under your coverage, regardless of the Provider s participation status. Since cost-sharing amounts vary depending on your specific coverage, it is important that you refer to the Summary of Cost Sharing and Benefits section of your Certificate of Coverage for information on cost-sharing and the applicable cost-sharing amounts that are required under your coverage. Terms to Know: Annual Deductible: A specified dollar amount that you or your entire family must incur each benefit period before benefits are paid under your coverage. Coinsurance: The percentage you are required to pay based on the total amount allowed by Capital BlueCross for specific services. Out-of-Pocket Maximum: The maximum amount of coinsurance that you or your entire family must pay during a benefit period. Participating Provider: A health care facility Provider or a professional Provider who is properly licensed, where required, and has a contract with Capital BlueCross to provide benefits under your coverage. Please refer to your Certificate of Coverage for a detailed description of all benefits, limitations, definition of terms, and exclusions that apply to your plan.

7 Your Member Identification Card (ID card) Preauthorization Your ID card is the key to accessing the benefits provided under POS. Show this card each time you seek medical services. The following is important information about the ID card: Your PCP MEMBER NAME ID # YWG PROVIDER PRACTICE Preauthorization RxBIN RxPCN ADV RxGrp RXCAP Group # PCP $10 SP $20 UC $50 ER $100 Plan 361 Suitcase Symbol Your Copayments Preauthorization: A clinical program in which our nurses work with physicians to approve and monitor certain health care services prior to the Rx Plan Information delivery of services. The purpose of preauthorization is to ensure that all Members receive medically appropriate treatment to meet their individual needs. Certain medical and therapy services and all nonemergency inpatient hospital admissions require preauthorization. Refer to the Preauthorization Program attachment of your Certificate of Coverage for more information. Copayments: The specified dollar amount that you are required to pay directly to your Provider at the time a service is rendered. Your Providers will use this information to charge you the appropriate amount. The abbreviations stand for: PCP $$ PCP office visit copayment UC $$ urgent care copayment SP $$ specialist office visit copayment ER $$ emergency room visit copayment Suitcase Symbol: This symbol lets you know that your coverage includes BlueCard and BlueCard Worldwide. With both programs, you have access to BlueCard participating Providers anywhere in the nation outside of our 21 counties and around the world. The back of the ID card has important information such as: Toll-free telephone numbers. General instructions for filing claims. Emergency care information. Remember to destroy old ID cards and use only your current ID card. Please contact Customer Service at the phone number that appears on your ID card if any information on your card is incorrect or if you have questions.

8 When you take the time to become a better health care consumer, you are doing your part to help keep health care affordable. And as a Member of the Capital BlueCross family of companies, you will have access to the information and tools to assist you in making better decisions about your health and well-being. Great ways to become a better health care consumer... Register for a secure personal account at mycapbluecross.com. If you haven t already set up a mycapbluecross.com secure personal account, register on our Web site to establish a user ID and password. Your secure account is a valuable tool that can help you make the most of your health care benefits. Here s how: When you login to mycapbluecross.com you can Check the status of a claim. Compare hospital quality and treatment costs. Print a temporary proof of coverage. SM Access the Simply Well Member newsletter. View your Explanation of Benefits (EOB) for the past two years. And much more! Take your FREE Better Health Works SM Personal Profile. The Better Health Works Personal Profile starts by asking you questions about yourself and the way you live. Based on the answers you provide, you ll receive customized recommendations for your health situation. And to help you follow through on those recommendations, we provide you with the support you need to make positive health changes. For more information, go to capbluecross.com/bhw or call (TTY: ). Research your prescription drug options. Review the formulary information and prescription drug program guidelines on our Web site. Compare the costs of retail pharmacy medications before you buy. Try using Mail Service to save more on the medications you take regularly.

9 Call Nurse Line 24 hours a day, 7 days a week. When your doctor is out, Nurse Line is always in. Nurse Line is staffed by experienced Registered Nurses who provide information and support for any health-related concern, at no cost to you. Call BLUE (TTY: ). Get moving! Living healthy 365 days a year means making healthy choices in every area of your life; that s why you ll enjoy Healthy Family Fun SM with Blue365, your online resource for living healthier. Search directly from our Web site for recreational activities, health consumer information, special offers, and discounts for Members only. Practice preventive care. Use your preventive care benefits: physical exams, screenings, and immunizations to detect potential health problems early. You ll find our adult and pediatric Preventive Health Guidelines on our Web site. Take control of the quality and cost of your health care. Use MyCare Advisor SM to research and compare average cost and quality information for many of the most common elective surgical and treatment procedures to maximize your health care dollar. Log in to mycapbluecross.com to access this valuable tool before deciding where and how much you spend on your procedure.

10 Confidentiality Policies Capital BlueCross complies with federal Health Insurance Portability and Accountability Act (HIPAA) regulations protecting the privacy of our Member s personal health information. To learn more about our privacy practices, please refer to the Notice of Privacy Practices brochure included with your enrollment packet. You may also Contact our Customer Service Department at Additional Plan Information You may submit a written request for any of the following written information: A list of names, business addresses, and offi cial positions of the membership of the board of directors or offi cers of Capital BlueCross. The procedures adopted by Capital BlueCross to protect the confi dentiality of medical records and other Member information. A description of the credential process for participating Providers. A list of the participating Providers affi liated with participating hospitals. 5. If prescription drugs are provided as a benefi t under this coverage, whether a specifi cally identifi ed drug is included or excluded from this coverage. 6. A description of the process by which a participating provider can prescribe specifi c drugs, drugs used for an off-label purpose, biologicals and medications not included in the Capital BlueCross drug formulary for prescription drugs or biologicals when the formulary s equivalent has been ineffective in the treatment of the Member s disease or if the drug causes or is reasonably expected to cause adverse or harmful reactions in the Member s case, if prescription drugs are provided as a benefi t under the Member s coverage. 7. A description of the procedures followed by Capital BlueCross to make decisions about the nature of individual drugs, medical devices, or treatments. 8. A summary of the methodologies used by Capital BlueCross to reimburse providers for covered services. Please note that we will not disclose the terms of individual contracts or the specifi c details of any fi nancial arrangement between Capital BlueCross and a participating provider. 9. A description of the procedures used in the Capital BlueCross Quality Management program as well as progress towards meeting goals. Requests must specifi cally identify what information is being requested and should be sent to: Utilization Management Procedures Capital BlueCross is proud to employ licensed health care professionals in our Clinical Management Department. Through preauthorization activities, inpatient case management, and outpatient case management our licensed health care professionals strive to make an impact on our Members health. Please check your Certifi cate of Coverage to fi nd out which benefi ts are covered (and which are not). It is your responsibility as a Member to know the covered benefi ts to your specifi c benefi t package. In addition, we ask that you check with Customer Service or review the Provider directory to make sure that any specialist to whom you have been referred is part of the Capital BlueCross provider network. Preauthorization is a process for evaluating requests for coverage of services prior to the delivery of care. The general purpose of the preauthorization program is to facilitate the receipt by Members of: Medically appropriate treatment to meet individual needs Care provided by participating Providers delivered in an effi cient and effective manner Maximum available benefi ts, resources, and coverage Participating Providers are responsible for obtaining required preauthorization. However, if a nonparticipating provider is used, the Member is responsible for obtaining the required preauthorization. Members may be subject to a preauthorization penalty for failure to comply with preauthorization requirements. Members should refer to the Schedule of Cost-Sharing and Benefi ts section of their Certifi cate of Coverage to determine whether a preauthorization penalty applies to their coverage. A preauthorization decision is generally issued within two (2) business days of receiving all necessary information for non-urgent requests. The Case Management program is a service for Members with complex medical needs or who may be at risk for future adverse health events due to an existing medical condition or who may require a wide variety of resources, information, and specialized assistance to health them manage their health and improve their quality of life. The program assigns an experienced Capital BlueCross case management nurse or coordinator to a Member or family caretaker to help make arrangements for needed care or to provide assistance in locating available community resources. Case management services provided to Members are numerous and are always tailored to the individual needs of a Member. Participation in the Capital BlueCross Case Management program is voluntary and involves no additional cost to our Members. Capital BlueCross PO Box Harrisburg PA Members may also fax their requests to or by accessing capbluecross.com, an can be sent to the Customer Service Department. Members may also inform Capital BlueCross of their dissatisfaction with care or service by writing to the address above or by faxing Capital BlueCross at the number above. Health Plan Central at the number above.

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12 Contact Us (TTY: ) Monday through Friday 8 a.m. to 6 p.m. Look for more ways to become a better health care consumer. Be sure to come back often to see what s new. capbluecross.com This managed care plan may not cover all your health care expenses. Read your Certificate of Coverage Carefully to determine which health care services are covered. For more information, contact our Customer Service Department at (TTY: ), or visit our Web site. This brochure contains only a summary of general benefits. Please refer to your Certificate of Coverage or contact our Customer Service Department with any questions you may have. Some companies benefit plans may vary. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. NF-270 (9/2010)