Canon Anthem/GeoBlue U.S.A. Plan

Canon Anthem/GeoBlue U.S.A. Plan

Welcome to GeoBlue The Anthem/GeoBlue U.S.A. Plan includes access to the Blue Cross and Blue Shield provider network within the U.S. Your coverage features a full range of personal solutions, including concierge-level services and convenient online and mobile self-service tools available on www.geo-blue.com. To get the most from your GeoBlue plan, please take a few moments to become familiar with the benefits and services available to you. In addition to the information within this welcome kit, there is a video member tutorial on how-to.geo-blue.com. Visit the Member Hub section of www.geo-blue.com to download a copy of your ID card, check claims information and access additional benefits information. Please check your GeoBlue ID card carefully. You will need to use your ID card each time you visit a doctor, specialist, hospital or other health care provider as well as filling prescriptions and visiting a dental or vision provider. If you have questions or need additional information, contact GeoBlue Customer Service; we are available to assist you 24/7. Thank you, GeoBlue Table of Contents Online Registration... 2 Medical Care Inside the U.S.... 4 Retail Pharmacy & Mail Order Prescription Benefits... 5 Claim Submission and Information... 6 Claim Review... 7 Member Self-service Tools... 8 Travel Resources... 8 Wellness... 9 FAQs... 10 Important Contact Information... 12 1

www.geo-blue.com Register Online Register online to learn more about your benefits Visit www.geo-blue.com and click on Register in the upper right-hand corner to register and access important plan information: Print off a temporary ID card Review plan benefits Locate Blue Cross and Blue Shield providers and hospitals within the U.S. Locate trusted providers and hospitals outside of the U.S. You can also register through the GeoBlue app. Your ID Card USA Plan Jonathan Smith QHO0000000000 Group No. BIN Effective Date Dependent One Dependent Two Dependent Three Dependent Four Copay In Network, Inside U.S. Copay Out of Network, Inside U.S. 99990483 Copay Outside U.S. 610020 Rx Copay 01-Jan-2015 Canon Your GeoBlue ID card(s) will be mailed to you at the home address on file with your employer. Your Certificate Number is located under the Participant s name on the front your the ID card. Your Certificate Number begins with QHO. $0 $0 $0 $0 Complete Registration Step #1: You will need your GeoBlue ID card to register Enter the Certificate Number (e.g., QHO500000000H) located on the front of your ID card. Step #2: Enter your personal information Enter your First Name, Last Name (as it appears on your ID card) and your Date of Birth. Create Username and Password for future access to the site. Need help with registration? Visit how-to.geo-blue.com to watch the member tutorial video, or contact us: Inside the U.S.: 1.855.282.3517 customerservice@geo-blue.com 2

www.geo-blue.com Online Member Hub Once registered, the Member Hub is where you will find important information on: Coverage and benefits information Temporary ID card(s) Explanation of Benefits (EOB) Claim forms, filing instructions and status Doctors and hospitals inside and outside the U.S. Self-service member tools Get your GeoBlue ID card. It is important to have your GeoBlue ID card to access healthcare services. You will need to present your ID card whenever you receive medical care. This card can be accessed from multiple sources: GeoBlue ID card(s) will be mailed to you at your home address on file with Canon A temporary ID card is available in the Member Hub Your mobile ID card is available through the GeoBlue Mobile app Customer Service can provide replacement ID cards When you receive your card, please check the information on your ID card for accuracy. Call your International Affairs HR representative if you find an error on your card. Download the GeoBlue app. Download the GeoBlue app and login with the email address and password you created when you registered on the website. If you have not previously registered, you can register directly through the app. The GeoBlue app provides you with the most convenient access to your ID card and GeoBlue s self-service tools. Choose Eligibility to view your ID card on the GeoBlue App. 3

www.geo-blue.com Medical Care Inside the U.S. Finding Care Inside the U.S. GeoBlue members have access to the Blue Cross and Blue Shield network within the U.S., Puerto Rico, and U.S. Virgin Islands. To find a doctor or facility, click on the Find Doctors & Hospitals Inside the U.S. section in the Member Hub on www.geo-blue.com or in the GeoBlue app. Launch Search Click on Launch U.S. Provider Search Website. You will be redirected to the Blue Cross and Blue Shield Association National Doctor and Hospital Finder. Find a Doctor or Hospital QHO will automatically appear in the first field of the Find and Doctor or Hospital search box. You do not need to select a Network. Please fill in the Search by and Location fields to proceed. Contact us for assistance: Toll free within the U.S.: 1.855.282.3517 customerservice@geo-blue.com Scheduling an Appointment with a Blue Cross and Blue Shield provider Simply call the doctor and schedule an appointment. Be sure to present your GeoBlue ID card to the provider. In the event of a medical emergency Members should go immediately to the nearest physician or hospital and then call GeoBlue at the phone number for 24/7 Medical Assistance located on the back of your ID card. Using an Out-of-Network provider If you receive care from an Out-of-Network provider, you may need to pay out of pocket and submit a claim for reimbursement. View claim filing instructions in the Member Hub at www.geo-blue.com. 4

www.geo-blue.com Prescriptions Retail Pharmacy & Mail Order Prescription Benefits Prescription benefit coverage provided under the plan includes benefits for retail pharmacies as well as a mail order prescription drug programs. For a full list of covered and non-covered services, see your Benefit Booklet. Retail Pharmacies: Members have access to over 65,000 participating pharmacies within the U.S. Simply present your GeoBlue ID card at the pharmacy. Locate a participating pharmacy in the Member Hub at www.geo-blue.com under Coverage and Benefits and then Prescription Benefits. If you need assistance in locating a pharmacy call GeoBlue; toll-free in the U.S. 1.855.282.3517; or email customerservice@geo-blue.com. Mail Order Program if residing in the U.S.: Provided by Drug Source. Online: Visit the website at www.drugsourceinc.com Email: Send email to refills@drugsourceinc.com Phone: Call DrugSource to order: 1.800.854.8764 Hours: 8:30am - 7:00pm CST Mail: Complete the Drug Source Rx order form located in the Member Hub at geo-blue.com under Coverage and Benefits and then Prescription Benefits. Attach your prescription(s) to the order form and mail to: DrugSource, P.O. Box 1366, Elk Grove Village, Illinois 60009-1366 Physical Location: DrugSource Inc., 2020 Lunt Avenue, Elk Grove, IL 60007 Certain limitations and exclusions apply to your coverage under this plan and may affect your coverage. Your Benefit Booklet is available in the Member Hub on www.geo-blue.com. 5

www.geo-blue.com Claims Submitting a Claim Normally, providers of health care will bill us directly for services to you and your enrolled dependents. This is the preferred procedure. When your health care provider bills us, you do not need to send us a claim form unless we ask you to. Claims can be submitted directly online through eclaims, via email, fax or regular mail. However, if a physician, ambulance company or other provider sends their bill directly to you, or you pay the medical provider at the time of service, you will need to complete and submit a Claim Form. The Claim Form was developed for you to notify us of any covered health services for which we have not already been billed. eclaims If you are seeking reimbursement for covered services, you can quickly and conveniently submit claims electronically, using the GeoBlue app or the File an eclaim link on the Member Hub at www.geo-blue.com. Scanned paper documents are delivered directly to our Claims Department, and your eclaims are saved in your Member Profile. For detailed instructions, please see below. Paper Claims Claim forms can be downloaded from the Member Hub on www.geo-blue.com. Completed forms can be submitted via email, fax or postal mail. Email: claims@geo-blue.com Fax: +1.610.482.9623 Postal Mail: GeoBlue, Attn: Claims, 100 Matsonford Road, One Radnor Corporate Center, Suite 100, Radnor, PA 19087 Please read the following instructions about how to file a claim. Following these instructions will expedite the payment of your claim. 1. Complete and sign the claim form each time you incur a claim expense. Answer all questions, even if the answer is none or N/A. Be certain that the name on the bill you are submitting is the same as that which is indicated on your ID card. If not, please enclose a short note of explanation. 2. Attach the provider bill/documentation to the claim form and follow the instructions on the back of the form for submission to GeoBlue. Bills must be itemized: Canceled checks, cash register receipts and non-itemized balance due statements cannot be processed. Each itemized bill must include: name and address of provider (doctor, hospital, laboratory, ambulance service, etc.), name of patient, date(s) of service, amount charged for each service, total charge, diagnosis or reason for treatment 3. Additional Information If submitting expenses for more than one family member, please use a SEPARATE claim form for each person. All claims should be filed with our office within a two year period from the date of the incurred expense. If you have questions regarding the completion of this claim form, please contact Customer Service. 6

www.geo-blue.com Check Claim Status Visit Claims in the Member Hub To check your claim status, visit Claims in the Member Hub on www.geo-blue.com. From the Member hub you can view Summary of the Existing Claims, Claims in Process, Processed Claims and Finialized Claims. Contact us for assistance: Toll free within the U.S.: 1.855.282.3517 customerservice@geo-blue.com Summary of Existing Claims Claims in Process The Summary of Existing Claims page will give you an overview of Claims in Process, Processed Claims and Finalized Claims. Claims in process are claims that have been received but GeoBlue has not yet finalized processing the claim or made a determination of the amount due to the member or provider. Processed Claims Finalized Claims Processed claims have been completely processed. An explanation of benefits and payment (for paid claims) will be issued. Finalized Claims have been completely processed and an explanation of benefits and payment (for paid claims) has either already been mailed or will be mailed within the next 48 hours. 7

www.geo-blue.com Self-Service Tools and Travel Resources Translate Medical Terms and Phrases Convert symptoms, diagnoses and treatment plans into the thirteen most common languages. Translate Medications Find country-specific equivalents for prescriptions and over-the-counter medications. Global Counseling for Personal Issues For confidential assistance with any work, life, personal or family issue, you can talk to professional counselors for in-the-moment support and information about local resources all around the world. Available any day, any time, contact: Inside the U.S.: 1.877.249.4765 Outside the U.S.: +44.208.987.6228 Email us at: support@worldwideassist.co.uk 8

www.geo-blue.com GeoBlue Global Wellness GeoBlue is pleased to help expat members create a personal program to: Understand health risks worldwide Focus on prevention Change behaviors Manage current medical conditions Find reliable answers to health questions Trust the Healthy Living online resources from the Mayo Clinic, in addition to other authoritative sources, and 24/7 global wellness coaching. It all starts at www.geo-blue.com. Set a baseline by taking the Health Assessment and then work to increase wellness via a one-on-one relationship with a health coach or use one of the online programs specific to addressing issues related to fitness, weight, smoking and stress. Telephone counseling for any work, life, personal or family issues is also available 24/7. Stay up-to-date with international trends and news and expert advice with carefully curated information presented in magazine form as Travel Well or available as part of the broad and deep resources assembled by the Mayo Clinic. 9

FAQs www.geo-blue.com A. GENERAL INFORMATION A-1. How do I register online and gain access to GeoBlue s tools and services? Visit www.geo-blue.com, locate and click the Register link in the upper right-hand corner Enter Certificate Number (i.e., QHO500000000H), First Name, Last Name (as it appears on your ID card) and Date of Birth Create Username and Password for future access to the site A-2. Am I covered anywhere in the world? Yes. Coverage is provided on a worldwide basis. In order to maximize your covered benefit while in the U.S., you should seek care from a Blue Cross and Blue Shield network provider. Outside of the U.S. you can see any provider without a reduction of benefits. A-3. How can I obtain a new ID card? Download a PDF ID card online from www.geo-blue.com. Once logged in, visit the Member Hub and locate Print ID Card. To obtain a replacement hard plastic ID card, contact GeoBlue Customer Service toll free within the U.S.: 1.855.282.3517. A-4. Whom do I contact if I have questions about my benefits? View and download a copy of your benefits summary from www.geo-blue.com. Once logged in, visit the Member Hub and locate the Coverage & Benefits section. Available PDF Certificates will be listed. For more detailed questions, contact GeoBlue Customer Service: Toll free within the U.S.: 1.855.282.3517 customerservice@geo-blue.com B. ACCESS TO COVERAGE Inside the U.S. the first three letters of your ID card (ex. QHO). When a member shows their ID card at the time of service in the U.S., participating providers will only bill the member for any applicable deductible or copayment. B-2. How do I access participating pharmacies? Inside the U.S., present your ID card at any participating pharmacy and you will be charged the copayment/coinsurance applicable to your plan benefits. Locate a participating pharmacy online at www.geo-blue.com, in the Member Hub, select Coverage and Benefits and then Prescription Benefits. B-3. Do I need to choose a Primary Care Provider (PCP) or get referrals? No, GeoBlue does not require you to select a PCP or get referrals prior to receiving treatment. B-4. Is pre-certification required? Yes, pre-certification is required if you go to an out-of-network Provider. If you go to an in-network Provider it is their responsibility to coordinate pre-certification. B-5. How do I handle transition of care if I am currently in the middle of treatment with a provider in the U.S. that is not part of the Blue Cross and Blue Shield network? You will need to apply using the Continuation of Care form. Please call customer service for assistance. B-6. Is there a waiting period to be covered for my pre-existing conditions? No, the GeoBlue plan does not have a waiting period for pre-existing conditions. B-1. How do I access participating providers inside the U.S.? GeoBlue Members have access to the Blue Cross and Blue Shield network in the U.S., Puerto Rico, and the Virgin Islands. Members can find a doctor or hospital in the U.S. on www.geo-blue.com, by visiting the Member Hub and then selecting Find Doctors and Hospitals Inside the U.S. Before searching, you may be asked to enter an alpha prefix. This is 10

FAQs www.geo-blue.com C. CLAIMS C-1. How do I submit a claim for medical and/or prescription claims? Claim forms may be downloaded from the Member Hub on www.geo-blue.com. Select How to File Claims and Download Medical Claim Form. Send a legible, itemized bill from the provider, along with the completed member claim form to GeoBlue. eclaims: Located on the Member Hub or in the GeoBlue mobile app Email: claims@geo-blue.com Fax: +1.610.482.9623 Postal Mail: GeoBlue, Attn: Claims 100 Matsonford Road One Radnor Corporate Center, Suite 100 Radnor, PA 19087 C-2. Where do I get a claim form? Download a claim form online from the Member Hub on www.geo-blue.com. Locate How to File Claims and Download Medical Claim Form. C-4. How can I expedite my claim reimbursement? Submitting complete claim information, including a GeoBlue claim form and supporting documentation such as receipts and other medical documentation, will expedite the reimbursement of your claim. Submitting a claim in a language other than English or a currency other than U.S. dollars will not delay reimbursement. Please note that if you mail your claim, it takes mailing time to reach the claim office in Pennsylvania. Reimbursement checks can also take time to return to your location. Explanations of Benefits (EOB) can be viewed online in the Member Hub. GeoBlue encourages you to provide your phone number, fax number and e-mail address on the claim form so that questions can be resolved quickly. C-5. Can I have my claim reimbursements paid directly to my bank account? GeoBlue offers a variety of claim reimbursement options to suit your needs. You can select your preferred reimbursement method via the GeoBlue claim form. Complete banking information must be supplied if wire or electronic transfer is requested; see claim form for instructions. You may also elect to have claims reimbursed via a check in U.S. dollars. Be sure to indicate the appropriate mailing address on the claim form. When GeoBlue deposits claim payments to a member s bank account, GeoBlue will mail an Explanation of Benefit (EOB) to the member as confirmation of payment. C-6. Can I view my Claims Status online? You may view the status of your claims in the Member Hub on www.geo-blue.com in the section for Claims. D. Prescription Drugs D-1. Are prescription drugs covered? Yes, your GeoBlue plan provides coverage for prescription drugs. See your Benefit Booklet for full benefit details. D-2. Do I have a separate prescription drug ID card? No, you will receive one ID card that covers GeoBlue Medical, Prescription Drug, Vision and Dental benefits. D-3. Do my benefits include mail-order service? Yes, GeoBlue offers a mail order prescription drug program, provided by Drug Source. Visit the Member Hub at www.geo-blue.com and locate Coverage and Benefits and choose Prescription Benefits. E. Dental Coverage and Benefits E-1. Do I have dental coverage through GeoBlue? Yes, you have dental coverage with your medical plan. See Benefit Booklet for Details. Members can find an in-network dentist in the U.S. on www.geo-blue.com, by visiting the Member Hub and then selecting Find Doctors and Hospitals Inside the U.S. Out-of-network dentists may submit claims electronically to GeoBlue using payer ID #54763. You may need to pay out-of-pocket for dental services and submit a claim for reimbursement. E-2. Will I have a separate dental ID card? No, your Medical ID card contains your dental info. 11

FAQs www.geo-blue.com F. Vision Coverage and Benefits F-1. Do I have vision coverage through GeoBlue? Yes, you have vision coverage with your medical plan. See Benefit Booklet for details. Members can find in-network vision providers in the U.S. on www.geo-blue.com, by visiting the Member Hub and then selecting Find Doctors and Hospitals Inside the U.S. Out-of-network vision providers may submit claims electronically to GeoBlue using payer ID #54763. You may need to pay out-of-pocket for vision services and submit a claim for reimbursement. G-2. How can I access the GeoBlue app? Download the free app from the App Store, Google Play or Amazon. After downloading the free app, login with the email address and password you created when you registered on www.geo-blue. com. If you have not previously registered, you can register directly through the app. F-2. Will I have a separate vision ID card? No, your Medical ID card contains your vision info. G. Services Available to You and Your Family G-1. In general, what type of assistance does GeoBlue provide members? GeoBlue provides the following services to participants: 24-hour customer service Japanese translation services The ability to pay claims in major currencies Mobile and online resources Through GeoBlue s multiple Customer Service access points (phone and internet), members have 24/7/365 access to: Pre-departure planning Benefit and eligibility information Chronic conditions management Claim inquiries Important Contact Information Medical, Dental, Vision and Prescription Drug Contact Information For questions about your medical, dental, vision and prescription drug plan contact: Toll free within the U.S.: 1.855.282.3517 customerservice@geo-blue.com 100 Matsonford Road, One Radnor Corporate Center Suite 100, Radnor PA 19087 2015 GeoBlue 12

Medical Expense Claim Form and Instructions 1. Patient Information Member ID Please enter Member ID as shown on card Patient s Name (Given Name, Family Name) Patient s date of birth Patient s Gender Name of Primary Participant (Given Name, Family Name) employer of Primary Participant Primary Participant s date of birth Primary Participant s current mailing address Male GeoBlueSM GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licence of the Blue Cross and Blue Shield Association. Female Patient s Relationship to Primary Participant Self Spouse Child Member Email Phone 2. Other Health Insurance Is the patient covered under other health insurance? Yes No If YES, please complete this section Name and address of other insurance company Name of the Primary Participant Participant s Date of Birth Policy or identification number of other coverage Effective Date Termination Date 3. Diagnosis describe illness, injury or symptoms requiring treatment Was patient s treatment due to an accident? Yes No If YES, please describe the accident below including the date it occurred Was this a work related accident? Yes No If the accident was caused by someone else, attach a statement describing the accident 4. Charges use a separate line to list each type of service or provider and attach itemized bills for all services Name, City & Country of provider making charge Diagnosis Description of service Dates of Service Charges 5. Payment Details Make payment to the provider If payment is to be paid to the provider, please ensure bank information is on the provider invoice Make payment to Primary Participant Reimbursement Method: US Dollar Check Bank Wire Transfer (complete below) When possible, utilizing US bank accounts is recommended to avoid unnecessary fees by the receiving bank. U.S. bank accounts (only) wires will be completed via ACH which generally eliminates or reduces wire transaction fees. Account Holder s Name Must be: Primary Participant Bank Name Bank Address, City, Country Currency of Reimbursement Bank 9 digit ABA Number - US Banks Bank 8 or 11 digit SWIFT Code - NON-US Banks Bank Account Number SORT Code Bank IBAN Intermediary Bank Details (If Applicable) Name of Intermediary Bank Intermediary Bank SWIFT Code Intermediary Bank Account Number 6. Signature I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is hereby given to any provider of service, that participated in any way in the patient s care, to release to GeoBlue and its business associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that applicable law concerning personal information may differ among countries. Please see the back of this form for important information. Signature of Primary Participant or patient Page 1 of 2 Date GeoBlue ASO Med Claim Rev. 08/14

Complete the claim form(s) in its entirety Important information Claims should be submitted no later than 180 days after the date of service. Please submit a separate claim form for each patient Complete sections 1 & 2, answering all the questions Diagnosis and Charges Section Please be as descriptive as possible Submitted bills must be itemized canceled check, cash register receipts and non-itemized balance due statements cannot be processed. Itemized bill is a full description of all actual charges and each itemized bill must include: - Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.) - Name of patient - Date(s) of service - Amount charged for each service described - Total Charge - Diagnosis or reason for treatment Submitted bills for Prescriptions should include the name of the drug, the quantity dispensed and the dosage. Payment Details Section Correct banking information is critical to ensure timely and accurate reimbursement. Submitting electronic payment information without the all required information can delay payment, or the receiving bank may return the payment. Please contact your bank to ensure all account information is correct. Payments are made to the Primary Participant on the plan. Normally this means the member with the 00 suffix after this ID number. Payments cannot be made directly to a dependent or to a third party (other than the medical provider). For payments made via wire transfer/ach, the Primary Participant must be listed as an account holder on the bank account receiving funds. See notes below about specifics regarding international wire transfers. If paying international provider, invoice must include provider s full bank information. US Domestic ACH Payments The ACH (Automated Clearing House) enables you to electronically receive payments directly into your checking or savings account. All ACH payments require an ABA number and account number and will be paid in US Dollars. ABA: 9 digit identification number assigned to financial institutions by the American Bankers Association (ABA). Routing numbers are sometimes referred to as check routing numbers, ABA numbers, or routing transit numbers (RTN). Routing numbers may differ depending on where your account was opened and the type of transaction made. Account Number: The number that identifies your account within the bank. International Wires Wires going to foreign countries require different numbers depending on the receiving foreign country. All wire transfer payments should include SWIFT Bank Identifier Code (SWIFT BIC), either the account number or International Bank Account Number (IBAN), International Routing Code (IRC) as applicable and requested currency. SWIFT Bank Identifier CODE (SWIFT BIC): The 8 or 11 character SWIFT BIC is a unique series of alpha numeric characters that help to identify a specific financial institution. The SWIFT BIC should be obtained and verified with the beneficiary bank. International Routing Code (IRC): Some countries throughout the international banking community have created international routing codes, which are used in combination with the SWIFT BIC to aid in routing the payment through a main office to a branch. Each country has a specific name for their routing code (e.g. Sort Code in the United Kingdom, Canadian Payments Association Routing Numbers in Canada, BLZ Code in Germany, BSB Code in Australia, CLABE in Mexico). If required, you must provide the international routing code to facilitate receipt of an international payment. International Bank Account Number (IBAN): The IBAN is a standardized format of your account number used specifically for wire transfers with banks in other countries. The IBAN begins with a 2 letter country code and will include your personal account number as part of the code. The IBAN varies by country and financial institution. Contact your bank to verify your IBAN. Account Currency: For successful reimbursement, you are required to provide the currency of your bank account. Due to U.S. sanctions some currencies may be reviewed prior to reimbursement. For Parts 1 4 of the claim form: m m m m m Please submit a separate claim form for each patient Please be as descriptive as possible Submitted bills must be itemized canceled check, cash register receipts and non-itemized balance due statements cannot be processed. INSTRUCTIONS FOR FILING A CLAIM An Itemized bill is a full description of all actual charges and each itemized bill must include: m Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.), name of patient, date(s) of service, amount charged for each service described, diagnosis or reason for treatment Submitted bills for Prescriptions should include the name of the drug, the quantity dispensed and the dosage. Please note that submitting an incomplete form will result in the delay of processing your claim. To accurately complete Part 5., Payment Details: m Payments are made to the Primary Participant on the plan. Payments cannot be made directly to a dependent or to a third party (other than the medical provider). m For payments made via wire transfer/ach, the Primary Participant must be listed as an account holder on the bank account receiving funds. m If paying international provider, invoice must include bank information SEND COMPLETE CLAIM FORMS, WRITTEN INQUIRIES AND ADDRESS CHANGES TO ADDRESS BELOW One Radnor Corporate Center, Ste 100, Radnor, PA 19087 Member Services: +1.610.254.5304 1.855.282.3517 (U.S. Toll Free) Claims Submission Fax: 1.610.482.9623 Claims Submission Email: claims@geo-blue.com Page 2 of 2 GeoBlue ASO Med Claim Rev. 08/14