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www.ibx.com 1901 MARKET STREET PHILADELPHIA, PA 19103-1480

Dear prospective member: Thank you for your interest in Personal Choice®, which is our popular Preferred Provider Organization (PPO) health plan. YOUR PERSONAL CHOICE OPTIONS

We would like to provide you with information to help you choose the plan that’s right for you. We offer three types of plans with a choice of six Personal Choice options. All plans provide coverage in and out of network and give you the freedom to see specialists directly, without referrals.   

Basic I and II. These plans offer comprehensive coverage, including prescription drug coverage,

physician office visits, X-ray/lab testing, and hospitalization. Value HSA. This is an HSA-qualified, high-deductible health plan that offers prescription drug coverage, physician office visits, X-ray/lab testing, and hospitalization. This plan also allows you to use it in combination with a health savings account (HSA). HospitalCare I, II, and III. These plans provide coverage for inpatient/outpatient hospital services, along with X-ray/lab testing. They also include limited office visit coverage.

This chart compares what you would pay with each option for doctor’s visits and hospitalizations. For a more detailed description of each of these programs, please review the enclosed information. Plan Basic I

Deductible Individual/family $500/$1,000

Basic II

$1,000/$2,000

Value HSA

$5,000/$10,000

HospitalCare I

None

HospitalCare II

$1,000/$2,000

HospitalCare III

$2,000/$4,000

1 2

Doctor’s visit $30 copay, no deductible $35 copay, no deductible $0, after deductible 2 $40 copay 2

$40 copay , no deductible 2 $40 copay , no deductible

Specialist’s visit $50 copay, no deductible $60 copay, no deductible $0, after deductible 2 $75 copay 2

$75 copay , no deductible 2 $75 copay , no deductible

Hospital

Emergency room

20%, after deductible 20%, after deductible $0, after deductible $1,000 per admission 20%, after deductible 40%, after deductible

20%, after 1 deductible 20%, after 1 deductible $0, after deductible 1 $150 20%, after 1 deductible 40%, after 1 deductible

Not waived if admitted. Limited to three office visits per year for a primary care physician and specialist (combined in- and out-of-network).

HOW TO APPLY

To enroll in Personal Choice coverage, complete the enclosed application, sign it, and return it in the envelope provided. You do not need to send any money at this time. We will bill you after your application is processed. If you have any questions as you are completing your application, call Customer Service at 1-800-ASK-BLUE (1-800-275-2583). We will make sure you get the answers you need to make an informed decision about your health care coverage. Sincerely,

Paula Sunshine Vice President, Product Services

PC CVR LTR (1/11)

Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield – independent licensees of the Blue Cross and Blue Shield Association.


GG FlexibleGbenefits GG ReliableGhealthGinformation GG ValuableGrewardsGandGdiscounts


Personal Choice® It’s always your choice With Personal Choice you don’t need to select a primary care physician, and you never need a referral to see a specialist. Our network includes more than 58,000 physicians and specialists and more than 100 hospitals, including the area’s premier teaching hospitals. You also have access to BlueCard® PPO, which means you have in-network coverage from coast to coast with more than 676,000 PPO physicians and more than 5,500 participating hospitals in the United States.1 You’re covered in-network or out-of-network when you need: • primary care

• preventive care

• hospitalization

• specialist care

• emergency care

• X-rays and blood tests

Receiving care

Costs

Ease of use

In network locally or through a BlueCard® PPO provider

Visit any preferred provider directly without selecting a primary care physician (PCP)

Lower out-of-pocket costs and no balance-billing

- No PCP - No referrals - No claim forms to complete

Out of network

Visit any nonparticipating provider directly

Higher out-of-pocket costs with potential for balancebilling by nonparticipating providers

May require claim filing

Get rewarded for healthy living2 We offer cash rewards, discounts, and more to help you and your family lead a healthier life, including: Cash rewards • Up to $150 reimbursement on fitness center fees. • Up to $200 reimbursement for completing a tobacco cessation program. • Up to $200 reimbursement on weight management programs like

Weight Watchers®. Discounts3 • Receive discounts on products and services to help you lose weight, get fit,

reduce stress, and more from retailers like Reebok®, eDiets®, Snap Fitness, and Willow Stream Spas. Support and information • 24/7 access to a Health Coach, who can help with everyday health concerns

or significant treatment decisions. • Health encyclopedia, audio library, and decision-support tools.

Visit ibx.com or call us at 1-800-ASK-BLUE (1-800-275-2583).


#1 PPO in the region*

Select the plan that’s right for you Choose from our six Personal Choice plans to best meet your health insurance needs. The chart below shows what you pay when you get treatment from a participating doctor or hospital.

Plan

Deductible

Doctor’s visit

Specialist’s visit

Hospital/days4

Emergency room

Basic I

$500/$1,000

$30 copay, no deductible

$50 copay, no deductible

20%, after deductible/ 20%, after deductible6 unlimited days

Basic II

$1,000/$2,000

$35 copay, no deductible

$60 copay, no deductible

20%, after deductible/ 20%, after deductible6 unlimited days

Value HSA

$5,000/$10,000

$0, after deductible

$0, after deductible

$0, after deductible/ unlimited days

$0, after deductible

HospitalCare I

None

$40 copay5

$75 copay5

$1,000 per admission/ unlimited days

$1506

HospitalCare II

$1,000/$2,000

$40 copay, no deductible5

$75 copay, no deductible5

20%, after deductible/ 20%, after deductible6 unlimited days

HospitalCare III

$2,000/$4,000

$40 copay, no deductible5

$75 copay, no deductible5

40%, after deductible/ 40%, after deductible6 unlimited days

One of the additional benefits of the Personal Choice Value HSA plan is that you may pair it with a Health Savings Account (HSA). HSAs are tax-advantaged, personal bank accounts that you can set up and fund to reimburse covered medical expenses or to supplement your retirement savings. You can use any bank you like, or you can open an HSA with IBC’s preferred HSA vendor, The Bancorp Bank. For more information about Bancorp HSAs, visit www.mybancorpHSA.com.

Manage your benefits online You have access to your benefits 24/7 on ibxpress.com, our member website. We’ve partnered with WebMD®, one of the most widely recognized names in health information, to provide you with reliable, up-to-date information to make medical decisions that are right for you. At ibxpress.com you can: • take the Personal Health Profile and get a personalized action plan; • get in-depth information on doctors and hospitals; • use the Symptom Checker to get information on your health concerns; • use Lifestyle Improvement Programs to help you stop smoking, lose weight,

eat better, reduce stress, start exercising, and more; • request a new ID card; • check the status of a claim; • estimate treatment costs.

To learn more about our plans and to find rate information, please review the enclosed rates and benefits information. * According to a leading independent consumer magazine.


Why Choose Blue? • You will join 2.4 million members in the Philadelphia five-county region who carry a Blue Cross® card. • You get access to the tools to help you make informed health care decisions. • You can be confident that you’re covered by one of the leading health insurers in southeastern

Pennsylvania, with more than 70 years of experience.

1

Through the BlueCard PPO program, Personal Choice members can access all Blue plans’ BlueCard PPO networks anywhere in the United States.

2

Healthy Lifestyles programs are value-added programs and services—they are not benefits under the health care that you purchased and are therefore subject to change without notice.

3

This benefit is part of the Blue365 program. There is no fee to use the Blue365 program. However, for access to certain vendors offering discounts, members may be required to pay an annual fee to get the vendor discount.

4

Some benefits require precertification. If you use an out-of-network provider and do not obtain a precertification, the penalty is a 50% reduction in benefit.

5

Limited to 3 per year for specialist and primary care physician visits; combined in- and out-of-network.

6

Not waived if admitted.

® WebMD is an independent company offering health information and wellness education to Independence Blue Cross members. ® Weight Watchers is a registered mark of Weight Watchers International, Inc. This summary represents only a partial listing of the benefits of the Personal Choice program. Benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract carefully for a complete listing of the terms, limitations, and exclusions of the program. If you need more information, please call 1-800-ASK-BLUE (1-800-275-2583).

Personal Choice is available to individuals living in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties.

We’re here for you every step of the way.

www.ibx.com Benefits underwritten and administered by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. INDIVIDUAL 2010-0453 (1/11)


Individual guaranteed enrollment plans Rates effective March 1, 2012

Below are monthly premium rates for Individual Personal Choice guaranteed enrollment plans. Rates are based on the age of the oldest family member covered under the policy. To determine your rate, find the age category of the oldest member covered under the policy, select the plan you would like, and then locate the rate that corresponds with your current coverage type (Individual, Individual and child, etc.)

Single

Age 18 to 29

Husband/Wife Parent/Child Parent/Children Family

Age 30 to 39

Age 40 to 49

Value HSA

HospitalCare I

HospitalCare II

HospitalCare III

$199.29 $398.57 $299.53 $399.78 $599.06

$186.83 $373.66 $280.25 $373.66 $560.49

$154.17 $308.34 $231.25 $308.34 $462.50

$129.66 $259.32 $194.49 $259.32 $388.98

Basic I

Basic II

Value HSA

HospitalCare I

HospitalCare II

HospitalCare III

$444.47

$372.71

$262.09

$229.39

$186.45

$154.23

Husband/Wife

$888.94

$745.43

$524.19

$458.79

$372.89

$308.47

Parent/Child

$607.53

$508.94

$362.34

$322.81

$263.53

$219.06

Parent/Children

$770.57

$645.16

$462.59

$416.22

$340.61

$283.89

Family

$1,215.04

$1,017.87

$724.68

$645.62

$527.06

$438.13

Basic I

Basic II

Value HSA

HospitalCare I

HospitalCare II

HospitalCare III

Single

$562.83 $1,125.67 $725.89 $888.94 $1,451.78

$471.97 $943.93 $608.19 $744.41 $1,216.37

$363.55 $727.10 $463.80 $564.04 $927.59

$298.15 $596.30 $391.56 $484.98 $783.13

$238.60 $477.21 $315.69 $392.77 $631.38

$193.93 $387.86 $258.76 $323.59 $517.52

Basic I

Basic II

Value HSA

HospitalCare I

HospitalCare II

HospitalCare III

Husband/Wife Parent/Child Family

Age 60 and over

Basic II $272.44 $544.88 $408.66 $544.88 $817.33

Single

Parent/Children

Age 50 to 59

Basic I $324.90 $649.79 $487.96 $651.00 $975.90

Single Husband/Wife

$783.86

$657.31

$532.64

$412.75

$325.52

$260.08

$1,567.72

$1,314.62

$1,065.28

$825.50

$651.05

$520.16

$946.92

$793.53

$632.89

$506.17

$402.61

$324.91

Parent/Children

$1,109.97

$929.75

$733.13

$599.58

$479.69

$389.74

Family

$1,893.83

$1,587.07

$1,265.77

$1,012.33

$805.22

$649.82

Basic I

Basic II

Value HSA

HospitalCare I

HospitalCare II

HospitalCare III

Single

$946.92 $1,951.80 $1,138.96 $1,302.01 $2,277.91

$818.35 $1,636.70 $954.57 $1,090.79 $1,909.14

$702.94 $1,405.88 $803.19 $903.43 $1,606.38

$528.17 $1,056.34 $621.58 $715.00 $1,243.17

$413.07 $826.14 $490.15 $567.24 $980.31

$326.71 $653.42 $391.54 $456.37 $783.08

Parent/Child

Husband/Wife Parent/Child Parent/Children Family

Please be advised that benefits and rates are subject to change upon approval of the Pennsylvania Insurance Department.

We’re here for you every step of the way.

www.ibx.com

2011-0489 (01/12)

Personal Choice PPO products are underwritten and administered by QCC Insurance Company, a subsidiary of Independence Blue Cross, independent licensees of the Blue Cross and Blue Shield Association.


INDIVIDUAL COVERAGE PERSONAL CHOICE APPLICATION FORM PLEASE TYPE OR PRINT 1. ENROLLMENT INFORMATION (Please complete your name and address if information below is missing or incorrect.) Any person eligible for Medicare or Medicare disability benefits is not eligible to enroll in this coverage. Requested Effective Date of Coverage*: _____ _____ / _____ _____ / _____ _____ _____ _____ *The requested effective date cannot be guaranteed and cannot be more than 30 days prior to the receipt of the application. |

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Email:__________________________________________

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Home phone: (______)______________________________

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Last name

First name

MI

Street address

City

State

ZIP

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If you are a current member, please provide your identification number: ______________________________________________________

2. COVERAGE INFORMATION Coverage underwritten by QCC Insurance Company. Please check the coverage you want: o PPO Value HSA o Yes, I’d like an HSA account set up through Bancorp. Please send Bancorp my information. o PPO Basic I o PPO Basic II o PPO HospitalCare I o PPO HospitalCare II o PPO HospitalCare III

3. PERSONS TO BE COVERED Please complete the following information regarding yourself and dependents to be covered. Dependents include your spouse, dependent children (under age 26), and eligible handicapped children over age 26. Attach a separate list for additional dependents, if needed. NAME (included last name if different from applicant) Last First MI

SEX

Self

oM oF

Spouse

oM oF

DATE OF BIRTH MM DD YY

SOCIAL SECURITY NUMBER

HANDICAPPED CHILDREN (Over Age 26)

N/A N/A

oM oF oM oF oM oF Please answer the questions below: A. Do any of the persons listed above have health insurance with a Blue Cross® and/or Blue Shield® Plan or any other insurance company? o Yes o No B. Do you have any other accident and health insurance in force? o Yes o No C. If yes, do you intend to replace your current accident and health insurance with this insurance? o Yes o No (Please see Section 1 on the reverse.)

4. PRIOR INSURANCE Was your prior insurance through: o Employer/group o Individual plan Who was your prior Insurer? o No prior insurance o Blue Cross/Blue Shield o Aetna o Assurant o Celtic o Coventry o CIGNA o Health America o United HealthCare o Other ______________________________________ How long has it been since you were insured? o Currently insured o 1 – 3 months o 3 – 6 months o 7 – 11 months o 1 – 2 yrs o 2+ yrs o Never What is your primary reason for applying for health care coverage? o No longer covered under employer plan o Dependent, no longer covered under parent’s plan o Unemployed o Employer doesn’t offer health insurance o Not satisfied with current plan o Self-employed o New job, waiting for benefit eligibility o Other

5. IMPORTANT! READ THE REVERSE SIDE OF THIS FORM, BEFORE SIGNING AND DATING BELOW The information supplied on the application is accurate and complete to the best of my knowledge, and I have read and agree to the terms set forth on the reverse side of this form. SIGNATURE OF APPLICANT: ___________________________________________ DATE: _______/________/______

08488 1/11


IMPORTANT — PLEASE READ CAREFULLY 1. NOTICE OF PRE-EXISTING CONDITION(S) EXCLUSION QCC Insurance Company (“Company”) will not pay benefits during the first 12 months of the policy for charges related to any medical condition or illness for which medical advice or treatment was recommended or received within a 12-month period preceding the effective date of coverage. This preexisting condition exclusion does not apply to you or to any of your dependents (a) previously enrolled in any Blue Cross or Blue Shield policy, or in a policy of an affiliate of the Company, for a period of 12 months and are transferring directly without a break in coverage and (b) to an enrollee under the age of 19.

2. DECLARATION I elect coverage under the plan specified on this application for the persons listed on the reverse side and agree to abide by the conditions of the policy and pay required premiums for the plan as selected. I and my listed eligible dependent(s) authorize any hospital, physician, or health care provider to furnish the Company, its assignee of designee, with such medical information about the applicant and dependent(s) listed on the application as the Company may require for claims payment, utilization review, quality assurance, or fulfillment of obligations imposed by applicable state or federal law. I understand that my coverage will become effective upon the approval of my Application. I understand and agree that: (1) the policy contains a pre-existing condition exclusion; (2) the policy shall be binding on the Company only if all of statement(s) are complete and true.

3. NOTICE REGARDING FRAUDULENT INFORMATION Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

4. CONDITIONS OF ENROLLMENT I understand that if I and my dependents receive care from Non-Network Providers (Non-Participating Health Care Facilities and NonParticipating Professional Providers), except for emergencies, I will be responsible for higher Non-Network deductibles and coinsurance, and in some cases, the entire cost of the care.

5. SUBSCRIBER INFORMATION PLEASE NOTE: Most elective admissions require Pre-Admission Certification. Services that are rendered by Non-Network Providers are subject to deductible and coinsurance provisions. See your contract for details about your coverage, its limitations and exclusions, or call Personal Choice Customer Service at 1-800-ASK-BLUE (1-800-275-2583). Inquiries about your coverage should include your name, identification number, group number, and home address.

6. PLEASE NOTE If you must provide coverage for a child not living with you due to a court order, please contact us for the appropriate paperwork.

Please return this application in the enclosed postage-paid envelope! Send no money now — we will bill you later.

1901 Market Street, Philadelphia, PA 19103-1480 Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association. WIPMK2158A 2010-0330 (1/11)


Important information about Individual health plans Important notice to persons on Medicare This insurance duplicates some Medicare benefits. This is not Medicare Supplement Insurance. This insurance pays limited reimbursement for expenses if you meet the conditions listed in the policy. It also pays a fixed amount, regardless of your expenses, if you meet other policy conditions. It does not pay your Medicare deductibles or coinsurance and is not a substitute for Medicare Supplement Insurance. This insurance duplicates Medicare benefits: Any expenses or services covered by the policy are also covered by Medicare; It pays the fixed dollar amount stated in the policy and Medicare covers the same event. Medicare generally pays for most of all these expenses. Medicare pays benefits for medically necessary services regardless of the reason you need them. These include: hospitalization physician services hospice care other approved items and services Before you buy this insurance: Check the coverage in all health insurance policies you already have. For more information about Medicare and Medicare Supplement Insurance, review the “Guide to Health Insurance for People with Medicare,” available from the insurance company. For help in understanding your health insurance, contact your state insurance department or state senior insurance counseling program.

We do not use or share your PHI without your permission unless the law allows us to do so. Before using or disclosing your PHI for other purposes, we’ll obtain your written permission, also called an authorization. You may also direct us to share your PHI with someone you chose by giving us your written authorization. However, this authorization must include certain specific information in order to be valid. You may print a copy of our Authorization to Release Information form from our website www.ibx.com or request a copy by calling our Privacy Office at 215-241-4735. We are permitted to use or disclose your PHI for our payment and health care operations. Examples of these activities include paying claims for services you’ve received, coordinating the delivery of health care services, and monitoring the performance of our network providers to improve health care outcomes. We may also share your PHI in certain other circumstances, such as disclosures to health care oversight agencies for legally authorized health oversight activities like audits and investigations, or when we are required to do so by law. We may also share certain information with the sponsor of your group health plan so that they may perform their plan administration functions. The laws that protect your privacy also give you certain rights related to your PHI. For example, you may request a copy of your PHI that we have in our “Designated Record Set.” Please remember that IBC does not typically have copies of your medical records. Your health care provider should be contacted for copies of your medical records.

Please review our Notice of Privacy Practices for more detailed information about your privacy rights and how we may use and Emergency services share your PHI. You may view or print a copy of our notice An emergency is defined as the sudden and unexpected onset of from our website www.ibx.com by clicking on Privacy Policy, a medical or psychiatric condition manifesting or you may call our Privacy Office at 215-241-4735 to request itself in acute symptoms of sufficient severity or severe pain — that a copy of the notice be mailed to you. such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably Creditable coverage FAQs expect the absence of immediate medical attention Preexisting condition exclusions for Individual plans to result in placing the member’s health, or in the case of a (Personal Choice®, Keystone Health Plan East) and pregnant member, the health of the unborn child, in jeopardy; creditable coverage. serious impairment to bodily functions; or dysfunction of any bodily organ or part. Q: What is a preexisting condition exclusion? A: A preexisting condition exclusion is a denial of coverage Emergency care includes covered services provided to a for services provided in connection with health member in an emergency, including emergency conditions that existed before your health insurance transportation and related emergency services provided by a policy became effective. If you had a medical condition licensed ambulance service. or illness for which medical advice or treatment was recommended or received within a stated “look-back” Utilization review period, all claims for this medical condition or illness To assist Independence Blue Cross (IBC) in making coverage will be denied by IBC for a certain period of time. determinations regarding the medical necessity and Typically, a preexisting condition exclusion period is 12 appropriateness of requested services, IBC uses medical months. You should review the contract or member guidelines based on clinically credible evidence. This is called materials for your health plan to determine whether your utilization review. Utilization review can be done before a health plan has a preexisting condition exclusion and to service is performed (prenotification/precertification/ identify the related preexisting condition “look-back” preservice); during a hospital stay (concurrent review); or after period. This preexisting condition exclusion does not services have been performed (retrospective/post-service apply to enrollees under age 19. review). IBC follows applicable state/federal standards pertaining to how and when these reviews are performed. Q: What is creditable coverage? A: Creditable coverage is the previous health insurance Complaints and grievances coverage you had that may be used to reduce a You have a right to appeal any adverse decision through the preexisting exclusion period for your current coverage. complaint and grievance process. Instructions for the appeal You should review the contract or member materials for will be described in the denial notifications issued to you and in your health plan to determine whether your health plan your benefits booklet. has a preexisting condition exclusion period and to identify the related preexisting condition “look-back” A word about privacy period. This preexisting condition exclusion does not At IBC, protecting your privacy is very important to us. That is apply to enrollees under age 19. why we have taken numerous steps to see that your protected health information (PHI) is kept confidential. Protected health Q: Do the Individual plans have preexisting condition information is individually identifiable health information about exclusions? you. This information may be in oral, written, or electronic A: Yes. Like most individual plans, IBC’s Individual plans form. IBC may obtain or create your PHI while conducting its have preexisting condition exclusions. However, the business of providing you with health care benefits. preexisting condition exclusion may not apply if you have enough creditable coverage to waive the exclusion. IBC has implemented extensive policies and procedures regarding the collection, use, and release or disclosure of PHI Q: When would a preexisting condition exclusion not by and within our organization. We continually review our apply or be reduced for an Individual plan? policies and monitor our business processes to make sure that A: The preexisting condition exclusion in an Individual plan your information is protected, while assuring that the may be reduced if either: information is available as needed for the provision of health You had at least one month of coverage from a Blue care services. For example, our procedures include steps to Cross® and/or Blue Shield® plan and transfer directly assist us in verifying the identity of someone calling to request into an Individual plan without a break in coverage. PHI, procedures to limit who on our staff has access to your You had at least one month of coverage from a plan PHI, and to share only the minimum amount of information that is an affiliate of Independence Blue Cross and when PHI must be disclosed. We also protect any PHI transfer directly into an Individual plan without a transmitted electronically outside our organization by using break in coverage. only secure networks or by using encryption technology if the For this “Blue-to-Blue transfer” you will receive credit information is sent by email. towards your preexisting condition waiting period for

Personal Choice® member disclosure

up to 12 months for the time you were enrolled in the other Blue plan.Your preexisting condition exclusion period will be waived if you enroll in one of two designated Individual Personal Choice plans and you satisfy all of the eligibility requirements of the Health Insurance Portability and Accountability Act (HIPAA): You had health care coverage for the past 18 months without a break in coverage. Your most recent coverage is group coverage, which can be a governmental plan or church plan. (Note: COBRA coverage is considered group coverage.). Your most recent coverage was not terminated because of nonpayment of premium or fraud. You no longer qualify for any other group health coverage, Medicare or Medicaid, or coverage under a spouse’s policy and have exhausted your COBRA coverage, if available. You are not enrolled in an Individual (nongroup) plan or other health care coverage. You are applying for continued coverage in one of two designated HIPAA plans within 63 days of the termination date from your group plan. You are providing evidence of creditable coverage with a previous insurer. Evidence of creditable coverage may be through documentation (e.g., a Certificate of Continuous Coverage from your previous employer or health insurance identification card) or nondocumentary means (e.g., having your previous insurer call IBC or having IBC call your former employer or prior insurer to verify coverage). To discuss how best to provide non-documentary evidence of creditable coverage, call Customer Service at 1-800-453-2566. Q: May dependents enroll in the Individual plans even if their parents do not enroll? A: Yes. Dependents may enroll separately from their parents if all other conditions are met. Please note that this is different from most other insurance plans that permit a dependent to enroll only if a parent enrolls. The dependent must meet the conditions for a “Blue-to-Blue transfer” or the conditions under HIPAA in order to reduce or waive the preexisting condition exclusion. Q: Are there other individual plans that allow an individual to continue coverage without exclusions for preexisting conditions? A: The adultBasicSM and the Children’s Health Insurance Program (CHIP) allow enrollment without exclusions for preexisting conditions. This preexisting condition exclusion does not apply to enrollees under age 19. For information about the Individual plans, call Customer Service at 1-800-453-2566.

Procedures that support safe prescribing IBC utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers. Prior authorization Prior authorization is a requirement that your physician obtain approval from your health plan for coverage of, or payment for, your medication. IBC requires prior authorization of certain covered drugs to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to the Food and Drug Administration (FDA) guidelines. The approval criteria were developed and endorsed by the FutureSrcipts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical data, information submitted by the member’s prescribing physician, and the member’s available prescription drug therapy history. Their review includes a determination that there are no drug interactions or contraindications, that dosing and length of therapy are appropriate, and that other drug therapies, if necessary, were utilized. Without prior authorization, the member’s prescription will not be covered at the retail or mail order pharmacy (see 96Hour Temporary Supply Program). The prior authorization process may take up to two working days once complete information from the prescribing physician has been

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received. Incomplete information will result in a delayed decision. Prior authorization approvals for some drugs may be limited to 6 to 12 months. If the prior authorization for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy after the expiration date, a new prior authorization request will need to be submitted and approved in order for coverage to continue. Currently, the drugs listed below are a part of the prior authorization program. Prior authorization applies to all formulations of these specific drugs, including, but not limited to, tablet, capsule, and oral suspension. AcipHex®, Actiq®, AdcircaTM, Afinitor®, AlodoxTM, AltabaxTM, Ambien CR®, Amerge®, AmpyraTM, AMRIX®, Apidra®, Apidra® SoloSTAR®, AplenzinTM, Atacand®/Atacand HCT®, Avapro®/ Avalide®, AvidoxyTMDK, Axert®, AZOR®, BanzelTM, Benicar®/Benicar HCT®, BepreveTM, BiDil®, Byetta®, Caduet®, Caverject®, CaystonTM, Celebrex®, Cesamet®, Cialis®, Cimzia®, ColcrysTM, Cozaar®/Hyzaar®, Crestor®, DaytranaTM, Diabetic Test Strips (except Autodisc®, Breeze® 2, Contour®, FreeStyle Lite® and Precision Xtra®), Diovan®/ Diovan HCT®, Edex®, EdluarTM, EffientTM, Enbrel®, ExalgoTM, Exforge®, EXFORGE HCT®, Exjade®, FanaptTM, Fentora®, Flector® Patch, ForteoTM, Frova®, Genotropin®, Gleevec®, GlumetzaTM, Humalog®, Humatrope®, Humira®, Humulin®, HYCAMTIN® Capsules, Imitrex®, Intuniv®, InvegaTM, Iressa®, KapidexTM, Keppra XRTM, Kineret®, Lantus®, Levitra®, Lipitor®, Livalo®, Lunesta®, Lyrica®, MagnacetTM, Maxalt®, Micardis®/Micardis HCT®, Mobic®, MUSE®, Myobloc®, Nexavar®, Nexium®, Norditropin®, Noxafil®, NucyntaTM, NutriDoxTM, Nutropin®, Nutropin AQ®, Nuvigil®, OfortaTM, Omnitrope®, OnglyzaTM, OnsolisTM, Opana®/Opana®ER, Oracea®, PatadayTM, Pennsaid®, PrandiMetTM, Prevacid®, Prevacid/NapraPAC®, Prilosec® Suspension, PristiqTM, Protonix®, Provigil®, PyleraTM, Qualaquin®, Ranexa®, ReliON®/Novalin®, Relpax®, Renvela®, Requip® XLTM, RevatioTM, Revlimid®, RozeremTM, RyzoltTM, Sabril®, Saizen®, SamscaTM, Saphris®, SavellaTM, Seroquel XR®, Serostim®, Silenor®, Simcor®, SimponiTM, Singulair®, Sprycel®, Suboxone®, Subutex®, SumavelTM, Sutent®, Symlin®, Taclonex®, Taclonex Scalp® Suspension, Tarceva®, Tasigna®, Tekturna®/Tekturna HCT®, Temodar® Oral, Teveten®/Teveten HCT®, Tev-Tropin®, Thalomid®, ToviazTM, TreximetTM, Twynsta®, Tykerb®, Uloric®, Ultram® ER, Valturna®, VecticalTM, VeramystTM, Viagra®, Victoza®, Vimovo®, VimpatTM, Voltaren® Gel, VotrientTM, Vytorin®, VyvanseTM, XenazineTM, Xyzal®, Zelapar®, ZipsorTM, ZmaxTM, Zolinza®, Zorbtive® and Zyvox®. This list is subject to change. Age and gender limits The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals 14 and older, such as Ciprofloxacin®, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If the member’s prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. The prescribing physician may request preapproval of restricted medications when medically necessary. The approval criteria for this review were developed and endorsed by the FutureScripts Pharmacy and Therapeutics Committee, which is an established group of medical directors and practicing area physicians and pharmacists. The member should contact the prescribing physician to request that he or she initiate the preapproval process. To determine if a covered prescription drug prescribed for you has an age or gender limit, call FutureScripts at 1-888-678-7012. Quantity level limits Quantity level limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. We have several different types of quantity level limits, which are explained in detail below. Rolling 30-day period. This quantity limit is based on dosing guidelines over a rolling 30-day period. Examples of quantity level limits per rolling 30-day period are Emend®

(four 125mg capsules + eight 80mg capsules or four trifold packs [one 125mg capsule + two 80mg capsules]); Boniva® (two 150mg tablets); Avonex® (one kit, four injections); Betaseron® (15 vials); Copaxone® (32 vials); Fosamax Plus DTM (five tablets); Rebif® (12 injections); migraine drugs such as Amerge® (nine 2.5mg tablets), Imitrex® (36 50mg tablets), Maxalt® (12 10mg tablets), Migranal® (eight 4mg nasal spray units), Stadol NS® (four 10mg units), and Zomig® (nine 5mg tablets); sedative hypnotic drugs, such as Sonata® (14 capsules) and Ambien® (14 tablets); and oral narcotic drugs such as OxyContin® (90 units), Percocet® (180 units), and Percodan® (180 units). For example, if a member went to the pharmacy on October 1, 2009, for one of these medications, the computer sytem would have looked back 30 days to September 1, 2009, to see how much medication was dispensed. The purpose of these limits is to make certain that these drugs are being used appropriately and to guard against overuse or stockpiling. Refill too soon. With this quantity level limit, if a member used less than 75 percent of the total day supply dispensed, the claim will be rejected at the pharmacy. This will ensure that the medication is being taken in accordance with the prescribed dose and frequency of administration. Therapeutic drug class. This quantity level limit applies to some classes of drugs, such as narcotics (i.e., short-andlong-acting). If a member uses more than one drug within the same class, he or she may be unsafely duplicating medications and would be affected by the total quantity limits for a therapeutic drug class. Members will be able to obtain only a 30-day total supply of any combination of drugs in the same therapeutic drug class each month. If a physician requires that a member needs a medication therapy that exceeds any of the quantity level limits described above, the physician must request a quantity limit override. The member is required to contact the prescribing physician to initiate a preapproval request for an override. Some drugs may have a time period for quantity limit exceptions of 6 to 12 months. If the exception for a drug is limited to a certain time frame, an expiration date will be given at the time the approval is made. If the physician wants a member to continue the drug therapy that exceeds a quantity limit after the expiration date, a new request for a quantity limit exception will need to be submitted and approved in order for coverage to continue. To determine if a covered prescription drug prescribed for you has a quantity level limit, call FutureScripts at 1-888-678-7012. 96-Hour Temporary Supply Program The 96-Hour Temporary Supply Program applies to the following covered medications: most medications that require prior authorization; medications that are subject to age limits (preapproval required for ages outside of recommended ranges); migraine medications with quantity level limits, such as Amerge®, Imitrex®, Maxalt®, Migranal®, Stadol NS®, and Zomig® (preapproval of quantity override required for amounts over the quantity level limits). Under the 96-Hour Temporary Supply Program, if a member’s doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization/ preapproval has not been obtained by the doctor, the following steps will occur: 1. The participating retail pharmacy will be instructed to release a 96-hour supply of the drug to the member with no out-of-pocket cost-sharing at that time.* 2. By the next business day, our PBM will contact the member’s doctor to request that he or she submit the necessary documentation of medical necessity or medical appropriateness for review. 3. Once the completed medical documentation is received by our PBM, the review will be completed and the medication will be approved or denied. 4. If approved, the remainder of the prescription order will be filled, and the appropriate prescription drug out-ofpocket cost-sharing will be applied.* 5. If denied, notification will be sent to the doctor and the member.

Obtaining a 96-hour temporary supply does not guarantee that the prior authorization/preapproval request will be approved. Some medications are not eligible for the 96-Hour Temporary Supply Program due to packaging or other limitations, such as Retin-A® (tube), Enbrel® (2-week injection kit), medroxyprogesterone acetate (monthly injectable), and erectile dysfunction drugs. Additionally, certain drugs to treat hemophilia (antihemophilic factors) are not usually purchased at the pharmacy and must be special-ordered; therefore, they are not eligible for the 96hour temporary supply. The process for requesting a prior authorization/preapproval or override is as follows: The physician prescribing the medication completes a prior authorization form or writes a letter of medical necessity and submits it to our PBM by fax at 215-2413073 or 1-888-671-5285. A member’s physician may request the form by calling 1-888-678-7012. Members may request the form through Customer Service on behalf of their physician, but it must be completed and submitted by the doctor. The PBM will review the prior authorization request or letter of medical necessity. If a clinical pharmacist can not approve the request based on established criteria, a medical director will review the document. A decision is made regarding the request. If approved, the prescribing physician will be notified of approval via fax or telephone, and the Rx Claim System will be coded with the approval. The member may call the Customer Service phone number on his or her identification card to determine if the prescription is approved. If denied, the prescribing physician will be notified via letter, fax, or telephone. The member is also notified of all denied requests via letter. The appeals process will be detailed on the denial letters sent to the member and physician. Coverage for medications not on the formulary (specific to Select Drug Program® members only) Providers may request formulary coverage of a covered non-formulary medication when all formulary alternatives have been exhausted or there are contraindications to using the formulary alternatives. The provider should complete the covered non-formulary appeal form providing detail to support use of the covered non-formulary medication and fax the request to 215-241-3073 or 1-888-671-5285. If the nonformulary request is approved, the drug will be paid at the appropriate formulary benefit level. If the request is denied, the member and provider will receive a denial letter with the appropriate appeals language. Whether or not an appeal is filed, the member may always obtain benefits for the covered non-formulary drug at the appropriate non-formulary benefit level. Out-of-pocket expenses for non-formulary drugs are higher than for formulary drugs. Appealing a decision If a request for prior authorization/preapproval or override results in a denial, the member, or the physician on the member’s behalf, may file an appeal. Both the member and his or her provider will receive written notification of a denial, which will include the appropriate telephone number and address to direct an appeal. In all cases, the physician needs to be involved in the appeal process to provide the required medical information for the basis of the appeal. Prescription drug program provider payment information A PBM administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. IBC anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment. *Members with an integrated drug benefit (e.g., CMM and Major Medical) will pay the discounted cost of the 96-hour supply as well as the remainder of the prescription order (if approved at the time of purchase, and the medical claim for reimbursement will be processed through standard procedures.

1-800-ASK-BLUE (1-800-275-2583) www.ibx.com Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association. IBC Disclaimer 1/11


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