Individual and Family Plans...rates on face-lifts, breast lifts, breast augmentation and reduction,...

Individual and Family PlansNEW INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

BlueEssentialsSM

Table of Contents

Important Enrollment Dates

Overview

Value-Added Benefits

Plan Essentials

Member Tools

Plan Networks

Financial Assistance

Enrollment

Plan Benefits

Exclusions

Glossary

5

6

7

8-9

10-11

12-14

15-16

18-49

50-51

52-53

ENROLLMENT DATE EFFECTIVE DATE

November 15 through December 15, 2014 January 1, 2015

December 16, 2014 through January 15, 2015 February 1, 2015

January 16 through February 15, 2015 March 1, 2015

5

Overview

TRUST IN BLUE®BlueCross BlueShield of South Carolina is a company you trust. Ensuring access to quality health coverage is vital to the health and well-being of every community in our state. Having served South Carolina for almost 70 years, we’re more than a recognized member of the community — we’re a strong and stable partner you know you can count on.

Our goal is simple: provide the highest quality coverage at a reasonable price. Since there’s no such thing as one size fits all, we now offer more options than ever before. The choices are numerous to make sure you have the right plan for your needs. And you’ll love BLUE’s large network of doctors, hospitals, specialists, pharmacies and other health care providers. Let us help you find the right health insurance.

The BasicsESSENTIAL HEALTH BENEFITS

All of the new Affordable Care Act (ACA) health plans must include these Essential Health Benefits:

■ Ambulatory patient services: services that can be completed during a single day and don’t require a patient to be admitted to the hospital

■ Emergency services: care that is given in a hospital emergency room

■ Hospitalization: hospital stays

■ Maternity and newborn care: care for pregnant women and newborn babies

■ Mental health and substance dependency services

■ Prescription drugs: medications prescribed by your doctor

■ Rehabilitative and habilitative services and devices: services that help you recover lost abilities or services that help you gain functions so you can participate in daily life

■ Routine wellness and preventive services and chronic disease management services

6

Value

FITNESS AND WELLNESS

Fitness Center Memberships Getting in shape is now more affordable than ever! We make it easy for our members to save on memberships to local fitness facilities and other exercise centers.

Children’s Fitness With My Gym Children’s Fitness Center, choose from a variety of structured, age-appropriate classes that use music, dance, relays, games and more.

Weight Management Enjoy discounts on weight-loss programs and services, including Jenny Craig. Plus, get one-on-one support to help you lead a healthy lifestyle.

Allergy Relief You’ll breathe easier thanks to special prices on products designed to reduce exposure to indoor allergies.

Alternative Health Care Where does it hurt? With Natural BlueSM you can tap into an extensive network of credentialed acupuncturists, massage therapists, chiropractors, plus diet advisers — all offering extensive discounts.

BLUE365®

As a BlueCross member, you have access to Blue365, a daily deal website with discounts on various wellness products and services. Blue365 complements your health coverage by making it easier and more affordable to make healthy choices.

Visit: Blue365deals.com/BCBSSC for the deal of the day!

SpecialsDISCOUNT AND VALUE-ADDED PROGRAMS

Sometimes all you need to feel great is a little sprucing up. That’s why our members enjoy discounts and value-added programs, such as:

HEARING AND VISION

Laser Vision Correction You’ll see exclusive discounts on Lasik surgery offered through QualSight, a national network of credentialed Lasik surgeons.

Eye Care Open your eyes to special savings from Vision One — eye exams, designer frames, lenses and contacts.

Hearing Care Hear that? With Blue, get great savings from TruHearing — a leader in digital hearing aids and ranked No. 1 in customer service. Save on hearing exams and follow-up care, too.

COSMETIC

Cosmetic Surgery Lift your spirits with preferred rates on face-lifts, breast lifts, breast augmentation and reduction, tummy tucks, nose reshaping, ear pinning, even cheek and chin augmentation. Save on nonsurgical proce-dures, too.

Hair Restoration Suffering from hair loss? You have everything to gain. As a member, you’ll save 20 percent on a hair transplantation procedure.

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Essentials

BenefitsWITHOUT BORDERS

Members can rest easy knowing their BlueCross coverage travels beyond South Carolina’s borders. The BlueCard® and BlueCard Worldwide® programs give members access to a network of participating doctors and hospitals across the country and around the world.

PREVENTIVE SERVICES

Services such as preventive screenings for children, women and men, including prostate screenings and lab work according to the American Cancer Society (ACS) guidelines, are provided at 100 percent when provided by a network provider. The American Cancer Society is an independent company that provides some health information on behalf of BlueCross BlueShield of South Carolina.

We cover:■ U.S. Preventive Services Task Force (USPSTF) recommended Grade A or B screenings■ Immunizations as recommended by the Centers for Disease Control and Prevention (CDC)■ Screenings recommended for women and children by the Health Resources and

Services Administration (HRSA)■ Prostate screenings according to the ACS.

The USPSTF, CDC and HRSA are independent companies that provide some health information on behalf of BlueCross.

For more information, visit www.uspreventiveservicestaskforce.org. (This link leads to a thrid party website. That company is solely responsible for the content and privacy policy on its site.)

PHARMACY SERVICES

RETAIL To receive benefits for prescrip-tion drugs, you must get them through our network. A network pharmacy has contracted with our pharmacy benefit manager to provide prescription drugs. When you buy drugs from a network pharmacy, you must show your BlueCross ID card. You can find a list of network pharmacies at www.SouthCarolinaBlues.com under the pharmacy directory.

Up to 31-day supply.

MAIL ORDER Our mail-order pharmacy is one we have contracted with to provide prescription drugs. Our mail-order pharmacy information is located on our website under Prescription Drug Information.


SPECIALTY DRUG Some drugs are designated as specialty medications and must be filled at Caremark Specialty Pharmacy. Caremark Specialty Pharmacy is an independent company that provides pharmacy services on behalf of BlueCross. You’ll find the list of drugs that you must fill at Caremark on the BlueEssentials Covered Drug List.


88

Tools

Services

MANAGE YOUR BENEFITS

■ Claims Summary — View claims status and an Explanation of Benefits (EOB).

■ Eligibility and Benefits — Read about your benefits and coverage information and check your eligibility.

■ Ask Customer Service — Send a secure message directly to the customer service area that handles your coverage for faster answers to your questions.

■ Authorization Status — Verify your authorization status for inpatient and outpatient visits.

■ Deductible and Out-of-Pocket Statuses — See how close you are to meeting your deductible and out-of-pocket maximum.

■ Request a New ID Card.

MAKE INFORMED HEALTH CARE DECISIONS

■ Compare Hospital Quality — Choose the hospital that is right for you by comparing up to 10 facilities on the number of patients treated, complication rates, average lengths of stay for certain conditions and procedures, and more.

■ Plan Comparison Tool — Compare which benefit plan is right for you and your family.

■ Estimate Treatment Costs — Research average costs and days of treatment for specific medical conditions or procedures.

■ Compare Drug Costs — Look up cost and consumer information about prescription drugs.

■ Find a Doctor — Find a network doctor or hospital across the country and around the world.

MY HEALTH TOOLKIT®

We understand the importance of making the right health care decisions. These decisions affect the health of you and your family, and they impact your finances. That is why we created My Health Toolkit.

My Health Toolkit is an online resource for tools and information to help you manage your benefits, treatments and financial decisions. Whether you need to locate an in-network doctor or want to research the cost of a specific surgery, My Health Toolkit has resources that can assist you.

As more power is placed in your hands to manage your health care benefits, we are here to help you every step of the way.

99

Tools

TO SET UP AN ACCOUNT:

Go to www.SouthCarolinaBlues.com.

On the home page, find the “Member Login: My Health Toolkit” box and click “Register Now!”

Create your profile by entering your member information found on your insurance card. Follow the remaining steps to complete your profile.

IMPROVE YOUR WELLNESS

■ Personal Health Record — A confidential online tool providing a summary of all your health information, including doctors’ visits, prescriptions, lab results and much more. You also can keep track of upcoming medical appointments and print a copy of your medical history. Additional features are available, based on your benefit plan.

■ Personal Health Assessment — An online survey that helps identify risk factors and offers ways to improve your health based on your answers.

■ Health Library — This feature offers medical information, health calculators, self-care channels and nutrition guides to help improve and protect your health status.

10

Providers

IN NETWORK

To make the most out of your benefits, always choose providers who are in the BlueEssentials network, also known as an exclusive provider organization (EPO). Through this network, you’ll receive a discounted rate for health care services.

OUT OF NETWORK

Refers to health care providers we have not contracted with and who do not participate in the BlueEssentials network. These providers may charge full price for medical care and you will be responsible for all charges, including those above the in-network allowed amount. We do not provide benefits when you visit providers outside the network, except in cases of emergency.

Networks

ALLOWED AMOUNT

What you pay for medical

care is based on an

“allowed amount.” This

is a lower amount that

BlueCross BlueShield

of South Carolina has

negotiated with

in-network providers.

See page 11 for more

information.

BlueEssentials NETWORK

The BlueEssentials network provides access to a group of physicians, hospitals and other health care providers that agree to provide health care services to our members at a discounted rate, sometimes referred to as the allowed amount.

in

out

Member

BlueCross makes an agreement with providers to provide services at a discounted rate

In-network provider Lower cost to member

Out-of-network provider: benefits are not paid

11

Networks

PROVIDER NETWORK

Our individual BlueEssentials plans come with access to our BlueEssentials Network, also known as an EPO. We only cover services provided by an in-network provider. We will not cover services given by an out-of-network provider unless a service is due to an emergency or is not available at an in-network provider. In this instance, we will cover the services an out-of-network provider offers at the in-network coinsurance amount. These providers can bill you for the difference in the allowed amount and their actual changes.

IMPORTANT INFORMATION ABOUT PREAUTHORIZATION

A preauthorization is also known as a prior authorization, prior approval or precertification. A preauthorized service is one that

BlueCross determines to be medically necessary for a patient’s condition. Preauthorization, however, does not guarantee we will

pay benefits for the service. Contract limitations or exclusions may apply. Additionally, a preauthorization may only be for a specific period of time or number of visits or treatments.

You or your doctor must get a preauthorization for certain categories of benefits. Failure to get a preauthorization will result in a denial of your benefits. We make our final benefit determination when we process your claims.

In-network providers in South Carolina are familiar with this requirement and they will request any necessary preauthorization for you. If an in-network provider in South Carolina does not get a preauthorization, the provider cannot bill you for the services.

1212

Financials

EXAMPLE OF HOW A TAX CREDIT WORKS WITH A HEALTH PLAN:

The monthly cost for a health plan (cost depends on which health plan you choose)

Subtract the government tax credit (money paid to the insurance company)

YOU WOULD PAY

$432.67 per month

— $185.39 per month

$247.28 per month

EligibilityADVANCED PREMIUM TAX CREDIT (APTC)

The APTC is a federal subsidy that assists qualifying individuals and families by reducing the monthly premium amount to make health insurance affordable.

The amount of APTC an individual or family receives is based on the individual’s or family’s annual income compared to the Federal Poverty Level (FPL) and the cost of the second cheapest Silver plan available to that individual or family, in their service area. The individual or family can still choose any of our Gold, Silver or Bronze plans, however, and receive the APTC. EXAMPLE: A family of four has a household income of $47,100 a year. That places the family at 200 percent of the FPL. Per ACA guidelines, the percentage the family is responsible for is 6.3 percent of their income ($247.28 per month). If the second cheapest Silver plan in the family’s service area is $432.67 per month, the APTC amount is the difference ($432.67 - 247.28) = $185.39.

COST-SHARING REDUCTIONS

Members who qualify for the APTC may also be eligible for lower out-of-pocket costs, or cost-sharing reductions (CSR). To receive CSR, the individual or family must choose a Silver plan. EXAMPLE: An individual selects BlueEssentials Silver 2. Normally, the Silver 2 plan’s coinsurance is 40 percent, deductible is $2,000 and the out-of-pocket maximum is $6,350. Based on the individual’s APTC eligibility and household income, the member also qualifies for CSR resulting in a reduced coinsurance of 20 percent, deductible of $200 and out-of-pocket maximum of $2,250. The same Silver plan’s CSR may be higher or lower, depending on the individual’s income. Copayments for office visits and drugs may also be reduced.

POVERTY LEVELS

The FPL is a measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.

The amounts on the next page are 2014 numbers and used for calculating eligibility for APTC, Medicaid and the Children’s Health Insurance Program (CHIP).

1313

Financials

Family Size 100% 138% 150% 200% 250% 300% 350% 400%

1 $11,670 $16,105 $17,505 $23,340 $29,175 $35,010 $40,845 $46,680

2 15,730 21,707 23,595 31,460 39,325 47,190 55,055 62,920

3 19,790 27,310 29,685 39,580 49,475 59,370 69,265 79,160

4 23,850 32,913 35,775 47,700 59,625 71,550 83,475 95,400

5 27,910 38,516 41,865 55,820 69,775 83,730 97,685 111,640

6 31,970 44,119 47,955 63,940 79,925 95,910 111,895 127,880

7 36,030 49,821 54,045 72,060 90,075 108,090 126,105 144,120

8 40,090 55,324 60,135 80,180 100,225 120,270 140,315 160,360

Family Size 100% 138% 150% 200% 250% 300% 350% 400%

1 $972 $1,342 $1,458 $1,945 $2,431 $2,917 $3,404 $3,890

2 1,310 1,809 1,966 2,621 3,277 3,932 4,588 5,243

3 1,649 2,276 2,473 3,298 4,122 4,947 5,772 6,596

4 1,987 2,743 2,981 3,975 4,968 5,962 6,956 7,950

5 2,325 3,210 3,488 4,651 5,814 6,977 8,140 9,303

6 2,664 3,677 3,996 5,328 6,660 7,992 9,325 10,656

7 3,002 4,143 4,503 6,005 7,506 9,007 10,509 12,010

8 3,340 4,610 5,011 6,681 8,352 10,022 11,693 13,363

2014 POVERTY GUIDELINES

These figures are the 2014 HHS poverty guidelines which were published in the Federal Register on January 22, 2014.

ANNUAL GUIDELINES

MONTHLY GUIDELINES

For a family of more than eight members, add $4,060 for each additional member.

Produced by: CMCS/CAHPG/DEEO

1414

Financials

Cost Sharing PlansCOST SHARING PLANS

See the FPL chart to determine your cost sharing level

PLAN NAME BASE PLAN COST SHARE 1 200 – 250 percent FPL

COST SHARE 2 150 – 200 percent FPL

COST SHARE 3 100 – 150 percent FPL

Silver 1 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family)

50 percent

$0/$0 $6,000/$9,200

50 percent

$0/$0 $5,200/$8,150

15 percent

$0/$0 $2,250/$3,500

5 percent

$0/$0 $2,250/$3,050


40 percent

$2,000/$3,650 $6,350/$11,600

40 percent

$1,300/$2,400 $5,200/$9,600

20 percent $200/$350

$2,250/$4,100

5 percent

$0/$0 $2,250/$2,950


20 percent

$3,000/$5,700 $5,200/$9,850

20 percent

$1,600/$3,050 $5,200/$9,850

20 percent

$0/$0 $2,250/$3,700

5 percent

$0/$0 $2,250/$3,250


30 percent

$1,900/$3,450 $6,600/$12,050

30 percent

$1,900/$3,450 $5,200/$9,700

20 percent $50/$50

$2,250/$3,750

5 percent

$0/$0 $2,250/$3,100

HD Silver 5 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family)

20 percent

$2,300/$4,300 $5,000/$9,400

20 percent

$1,600/$3,050 $5,000/$9,400

20 percent $250/$450

$2,250/$4,150

5 percent

$200/$400 $2,250/$4,150

HD Silver 6 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family)

0 percent

$3,600/$6,900 $3,600/$6,900

0 percent

$2,900/$5,800 $2,900/$5,800

0 percent

$1,150/$2,600 $1,150/$2,600

0 percent

$500/$1,250 $500/$1,250


10 percent

$6,000/$11,000 $6,500/$11,900

10 percent

$3,250/$6,550 $5,200/$10,400

10 percent

$500/$1,000 $2,000/$4,150

10 percent $200/$450

$500/$1,200

15

Enrollment

SPECIAL ENROLLMENT PERIOD (SEP)

This is the time outside of the OEP during which you’re allowed to buy health insurance, provided you have a qualifying life event (QLE). In most cases, you qualify for a SEP within 60 days following the QLE.

WHAT IS A QUALIFYING LIFE EVENT?

A QLE is a significant change in a person’s circumstances. Here are some examples of QLEs:

NOTE: It’s important to remember that a tax penalty may be charged to individuals who are uninsured for any period during the year.

ENROLLMENT DATE EFFECTIVE DATE

November 15 through December 15, 2014 January 1, 2015

December 16, 2014 through January 15, 2015 February 1, 2015

January 16 through February 15, 2015 March 1, 2015

QUALIFYING EVENT ENROLLMENT PERIOD EVENT DATEAPPLICATION SUBMISSION DATE

EFFECTIVE DATE

Marriage Within 60 days after marriage July 4 July 28 August 1

Birth Within 60 days after birth April 20 May 6 April 20

Loss of Minimum Essential Coverage

Within 60 days before or after termination of other coverage

November 1 November 21 December 1

Sign UpWHEN CAN I ENROLL?

BlueCross is here to help you understand how the health care reform law will impact you and your family. Once a year, individuals can apply for health insurance during the Open Enrollment Period (OEP). This year, OEP will be from November 15, 2014, to February 15, 2015. These dates are especially important as they indicate when your new policy will become effective:

16

Enrollment

EPO

An EPO plan offers comprehensive health services from participating health care providers.

HIGH DEDUCTIBLE HEALTH PLAN (HDHP)

This health care coverage puts you in control of your health care expenses by keeping your costs down while providing great benefits and options to make your dollar go farther. All of the HDHP plans have access to the EPO network.

The PlansGold, Silver and Bronze aren’t just the metals used for Olympic medalists. Along with Platinum, these metals denote the different levels of coverage mandated by the ACA.

BLUE CROSS PLANS

Here are some key things to know before you start to shop for a plan. BlueEssentials plans are divided into two categories: the metallic plans (Gold, Silver and Bronze) and the Catastrophic Plan. Anyone can buy a metallic plan, but only certain people qualify for a Catastrophic plan.

The Gold, Silver and Bronze plans Each plan must cover the same set of minimum essential health benefits. While the range of benefits is the same among the plans, the value of the benefits will vary. This means the amount you pay yourself, such as a copayment, coinsurance or deductible, is different. These metal levels can help you compare plans, the monthly premiums and costs for services for things like doctors or hospital visits.

The Catastrophic Plan Young adults and people for whom coverage is otherwise unaffordable can purchase a Catastrophic plan.

A Catastrophic plan can be offered to an individual who:• Is under age 30 before the plan

year begins.• Has received certification from the

Marketplace stating he or she is exempt from the individual mandate because he or she does not have an affordable coverage option or qualifies for a hardship exemption.

Benefits

18

Benefits

18

BENEFIT GOLD 1 (In Network Only)

Deductible* Single Coverage: $1,200 per member per benefit period Family Coverage: $1,200 per member and $2,350 per family per benefit period.

The deductible applies to the out-of-pocket limit.

Maximum Out of Pocket $4,200 per benefit period for single coverage and $8,250 per family per benefit period.

Covered services will be paid at 100% of the allowable charges when you reach your single or family (whichever is applicable) maximum out of pocket.

Primary Care Physician Services $15 copayment per visit

The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging.

Preventive Services – Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes prostate screening and lab work according to ACS.

$0

Specialist Visit $30 copayment per visit


Inpatient Hospital Services 20% after deductible

Outpatient Hospital Services 20% after deductible

Urgent Care $15 copayment per visit

Emergency Room $300 copayment per visit, then 20% after deductible

Ambulance 20% after deductible

* This plan has an embedded family deductible. Once a family member meets the plan’s individual deductible, the plan begins paying benefits for that member. Benefits are not payable for other family members until each member meets his or her own deductible individually, or until the members collectively satisfy the family deductible. Once the deductible and coinsurance combined reach the out-of-pocket maximum, allowable charges then are payable at 100 percent for all family members.

19

Benefits

19


Mental Health and Substance Abuse:

Office Services Inpatient Hospital Services Outpatient Services Residential Treatment Center

$15 copayment per visit 20% after deductible 20% after deductible 20% after deductible

Prescription Drugs – Covers up to a 31-day supply at retail pharmacy and 90-day supply at mail-order pharmacy

Retail: Tier 1: $10

Tier 2: $35

Tier 3: $100

Mail Order: Tier 1: $14

Tier 2: $95

Tier 3: $270

Specialty Drugs (Tier 4) – Covers up to a 31-day supply

30%

Pediatric Vision Care

• Eye Exam – limited to one exam per benefit period

• Eyeglasses – frames limited to once every two years and lenses every benefit period. Contacts only when medically necessary.

$25 copayment

$50 copayment

Durable Medical Equipment 20% after deductible

Physical, Speech and Occupational Therapy and Habilitation

20% after deductible – limited to 30 visits per member per benefit period for physical, speech and occupational therapy

Home Health 20% after deductible – limited to 60 visits per member per benefit period

Skilled Nursing Facility 20% after deductible – limited to 60 days per member per benefit period

Hospice 20% after deductible – limited to six months per episode per member per benefit period

Transplants 20% after deductible

Lifetime Benefit Maximum Unlimited

20

Benefits

20


Deductible* Single Coverage: $800 per member per benefit period Family Coverage: $800 per member and $1,450 per family per benefit period.







$0









21

Benefits

21






Retail: Tier 1: $6

Tier 2: $30

Tier 3: $100


Tier 2: $81

Tier 3: $270


30%




$25 copayment

$50 copayment









22

Benefits

22

BENEFIT HD GOLD 3 (In Network Only)

Deductible** Single Coverage: $2,000 per member per benefit period Family Coverage: $4,250 per family per benefit period.




Primary Care Physician Services 0% after deductible


$0

Specialist Visit 0% after deductible



Urgent Care 0% after deductible

Emergency Room 0% after deductible


** This plan has an aggregate family deductible. Benefits are not payable for any family member until one member satisfies the family deductible, or until all family members collectively satisfy the family deductible – whichever occurs first. If one or more family members satisfies the family maximum out of pocket, allowable charges are payable at 100 percent for all family members.

23

Benefits

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BENEFIT HD GOLD 3 (In Network Only)



0% after deductible 0% after deductible 0% after deductible 0% after deductible


Retail and mail order Tier 1, Tier 2 and Tier 3: 0% after deductible


0% after deductible




$25 copayment

$50 copayment









24

Benefits

24

BENEFIT SILVER 1 (In Network Only)

Deductible Single coverage: $0 per member per benefit period. Family coverage: $0 per member and $0 per family per benefit period.






$0








25

Benefits

25






Retail: Tier 1: $30

Tier 2: $60

Tier 3: 50% after deductible


Tier 2: $162



50% after deductible




$25 copayment

$50 copayment









26

Benefits

26


Deductible* Single coverage: $2,000 per member per benefit period. Family coverage: $2,000 per member and $3,650 per family per benefit period.







$0









27

Benefits

27






Retail: Tier 1: $10











$25 copayment

$50 copayment









28

Benefits

28









$0



Inpatient Hospital Services $300 copayment per visit, then 20% after deductible






29

Benefits

29




$25 copayment per visit $300 copayment per visit, then 20% after deductible 20% after deductible $300 copayment per visit, then 20% after deductible


Retail: Tier 1: $12

Tier 2: $35

Tier 3: $100


Tier 2: $95

Tier 3: $270


30%




$25 copayment

$50 copayment



$300 copayment per visit, then 20% after deductible – limited to 30 visits per member per benefit period for physical, speech and occupational therapy


Skilled Nursing Facility $300 copayment per visit, then 20% after deductible – limited to 60 days per member per benefit period




30

Benefits

30









$0









31

Benefits

31






Retail: Tier 1: $12

Tier 2: $35

Tier 3: $100


Tier 2: $95

Tier 3: $270


30%




$25 copayment

$50 copayment









32

Benefits

32

BENEFIT HD SILVER 5 (In Network Only)

Deductible** Single coverage: $2,300 per member per benefit period. Family coverage: $4,300 per family per benefit period.






$0








33

Benefits

33












$25 copayment

$50 copayment









34

Benefits

34


Deductible** Single coverage: $3,600 per member per benefit period. Family coverage: $6,900 per family per benefit period.





Preventive Services – Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes pros-tate screening and lab work according to ACS.

$0








35

Benefits

35








0% after deductible




$25 copayment

$50 copayment









36

Benefits

36








Preventive Services – Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes pros-tate screening and lab work according to ACS.

$0









37

Benefits

37






Retail: Tier 1: $6

Tier 2: $30

Tier 3: $100


Tier 2: $81

Tier 3: $270


30%




$25 copayment

$50 copayment









38

Benefits

38

BENEFIT BRONZE 1 (In Network Only)

Deductible* Single Coverage: $5,000 per member per benefit period Family Coverage: $5,000 per member and $9,050 per family per benefit period.




Primary Care Physician Services $60 copayment per visit for first four visits, thereafter, deductible and coinsurance apply (combined with urgent care and mental health).



$0





Urgent Care $60 copayment per visit for first four visits, thereafter, deductible and coinsurance apply (combined with primary care services and mental health).



* This plan has an embedded family deductible. Once a family member

meets the plan’s individual deductible, the plan begins paying

benefits for that member. Benefits are not payable for other family members

until each member meets his or her own deductible individually, or until the members collectively satisfy the family

deductible. Once the deductible and coinsurance combined reach the

out-of-pocket maximum, allowable charges then are payable at 100

percent for all family members.

39

Benefits

39

BENEFIT BRONZE 1 (In Network Only)



$60 copayment per visit for first four visits, thereafter, deductible and coinsurance apply (combined with primary care and urgent care). 40% after deductible 40% after deductible 40% after deductible


Retail: Tier 1: $25











$25 copayment

$50 copayment









40

Benefits

40

BENEFIT HD BRONZE 2 (In Network Only)







$0








41

Benefits

41












$25 copayment

$50 copayment









42

Benefits

42








$0








43

Benefits

43












$25 copayment

$50 copayment









44

Benefits

44








$0








45

Benefits

45












$25 copayment

$50 copayment









46

Benefits

46








$0








47

Benefits

47








0% after deductible




$25 copayment

$50 copayment









48

Benefits

48

BENEFIT CATASTROPHIC (In Network Only)





Primary Care Physician Services $25 copayment per visit for first three visits, thereafter, deductible and coinsurance apply (combined with urgent care and mental health).



$0




Urgent Care $25 copayment per visit for first three visits, thereafter, deductible and coinsurance apply (combined with primary care service and mental health).




49

Benefits

49

BENEFIT CATASTROPHIC (In Network Only)



$25 copayment per visit for first three visits, thereafter, deductible and coinsurance apply (combined with urgent care and primary care services). 0% after deductible 0% after deductible 0% after deductible




0% after deductible




$25 copayment

$50 copayment









50

Exclusions

EXCLUDED SERVICES

Benefits We Don’t Cover

■ Any services or benefits not specifically covered under the terms of this policy, which were received before this policy went into effect or after it terminates, or claims submitted after the time limit for filing claims has been exceeded.

■ Services or charges for which the member is entitled to payment or benefits from other sources (ie, workers’ compensation), for which the provider does not charge, or for which the member is not legally obligated to pay, including treatment provided in a government hospital or benefits provided under Medicare or other government programs (except Medicaid).

■ Cosmetic surgery, or surgery or treatment for the purpose of weight reduction, including any complications from or reversal of these procedures, or reconstructive procedures made necessary by weight loss.

■ Illness contracted or injury sustained as the result of war or act of war (whether declared or undeclared), or participation in a felony, riot or insurrection.

■ Refractive care, such as radial keratotomy, laser eye surgery or Lasik.

■ Services for the detection and correction of structural imbalance, distortion or subluxation (spinal subluxation) to remove nerve interference.

■ Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries unless it results from a medical (physical or mental) condition, even if the condition is not diagnosed prior to the injury.

51

Exclusions

SERVICES, FEES AND CHARGES YOU PAY

You Must Pay for These

■ Non-emergency services when received at or from out-of-network providers or hospitals.

■ Hospital or skilled nursing facility charges when preauthorization is not received. Please see Preauthorization in the policy.

■ Services and supplies not medically necessary, investigational/experimental in nature, not needed for the diagnoses or treatment of an illness or injury, or not specifically listed in Covered Services.

■ Any service or supply provided by a member of the patient’s family or by the patient, including the dispensing of drugs. This means the spouse, parent, grandparent, brother, sister, child or spouse’s parent.

■ Charges for a missed appointment or for filling out claim forms.

■ Any loss resulting from you being legally intoxicated or impaired, by being under the influence or alcohol, any narcotic or drug, unless taken on the advice of a physician. You or your representative must provide any available test result, upon our request, showing blood alcohol or drug levels. If you refuse to provide these test results, no benefits will be provided.

■ Services or supplies related to chewing or bite problems, pain in the face, ears, jaws or neck resulting from problems of the jaw joint(s), also known as temporomandibular joint disorders (TMJ).

This is a partial list of some of our exclusions. For a full list of excluded services and supplies, or for all limitations, please refer to your policy.

5252

Health Care Glossary

AAFFORDABLE CARE ACT (ACA):The health care reform law was signed on March 23, 2010, and brings a lot of health care changes to consumers, providers and insurance companies. It dictates who must buy insurance, how insurance will be sold and what health benefits have to be included in a health plan.

ALLOWED AMOUNT:What you pay for medical care is based on an “allowed amount.” This is a lower amount that BlueCross BlueShield of South Carolina has negotiated with in-network providers. A provider who is not in your health plan’s network may charge more than the allowed amount and you may have to pay the entire amount.

BBENEFIT:The services that are covered by your insurance. For example, depending on your plan, benefits can include physi-cian visits, hospital stays, prescription drug coverage and more.

CCOINSURANCE:This is the percentage that you may pay for covered health services after you meet the plan deductible. It is also called “cost sharing.” You usually pay the plan deductible first, and then coinsurance may apply.

COPAYMENT:A flat fee (for example, $15) that you may pay for covered health care services.

DDEDUCTIBLE:This is the dollar amount that you must pay each year before insurance begins to pay for certain health care services. You pay the plan deductible first, and then coinsurance may apply.

EEFFECTIVE DATE:Refers to the date your insurance coverage actually begins. You are not covered and cannot begin to use your health plan benefits, until the effective date.

MMARKETPLACE:This is the government’s health insur-ance Marketplace where individuals can shop and compare health plans online or in person. Your agent can guide you through BlueCross BlueShield of South Carolina health plans available through the Marketplace.

MAXIMUM OUT OF POCKET:This is the most you will have to pay for covered services during your plan year. Once you’ve spent this amount – which includes your deductible, copayments (for doctor’s visits and prescription drugs) and your coinsur-ance amounts – BlueCross will pay for all your covered medical expenses.

METAL PLANS:The Marketplace will offer five different levels of health insurance plans (called “metal” plans because their names are Bronze, Silver, Gold, Platinum and Catastrophic). They will offer similar health benefits, with different out-of-pocket costs and premiums.

The health care reform law brings a lot of changes and it can be confusing. BlueCross BlueShield of South Carolina is here to help you understand what it means and to help you make the right health care decisions. Part of what makes this law seem so confusing is all of the new terminology. Here’s our health care reform glossary of the key words you may have heard and what they mean.

5353

Health Care Glossary

OOPEN ENROLLMENT:The period of time set up to allow you to choose from available individual health plans (November 15 through February 15). There are, however, Special Enrollment Periods for certain life events. (See Special Enrollment.)

PPREMIUM:This is the amount you pay each month for your coverage. In general, if you choose a lower premium, you’ll have a higher deductible and pay more for your health care costs. A plan with a higher premium usually has a lower deductible and pays more of your health care costs.

SSPECIAL ENROLLMENT:A period of time when individuals with special qualifying events (e.g., marriage, birth of a child, loss of employment) are allowed to enroll in or modify a health plan. The qualifying event will dictate the actual enrollment period, which is usually 60 days from the date of event.

SUBSIDY OR PREMIUM TAX CREDIT:

If an individual or family qualifies, the government may pay part of their monthly health insurance premium, in the form of an Advanced Premium Tax Credit (APTC). The amount of the APTC depends on things like taxable household income and family size. The APTC cannot be used to pay for doctor visits, prescriptions, etc. — but an individual or family that qualifies for APTC may also qualify for Cost Share Reductions (CSR) which can reduce their deductible, coinsurance, out-of-pocket maximum and/or any

copayment amounts.

SUMMARY OF BENEFITS AND COVERAGE (SBC):The SBC is a document that all insurance companies are required to provide consumers as a result of health care reform. It is a standardized summary of health plan benefits and coverage, including covered benefits, cost sharing examples, coverage limitations and exceptions. The purpose of the SBC is to help you understand similar features of each plan, make it easier to compare your options, and ultimately, choose a plan that is right for you or your family.

16633-11-2014

BCBSSC BCBSSC www.SouthCarolinaBlues.com

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