Health Matrix by LEGACY Supply Chain Services

LEGACY Supply Chain Services, A TMSi Company

80/20 Plan BlueCard PPO Group 49992 Effective January 1, 2013

LEGACY Supply Chain Services, A TMSi Company BlueCard PPO Effective January 1, 2013 BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Benefit payments are based on the amount of the providerâ&#x20AC;&#x2122;s charge that Blue Cross and Blue Shield recognizes for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a copay, coinsurance, calendar year deductible or deductible for each admission, visit or service.

HEALTH REIMBURSEMENT ARRANGEMENT (HRA) Health Reimbursement Arrangement: Your Health Plan works in conjunction with a Health Reimbursement Arrangement (HRA). An HRA is an account where your employer contributes a specific amount of money to be used by an employee for eligible expenses. Your HRA gives you the opportunity to manage your health care expenses in partnership with your employer. Amount allocated to your HRA account: Individual Coverage: $350 Individual + 1: $450 Family Coverage: $500 Additional allocation of $50 will be provided as an incentive for completion of the health assessment on www.behealthy.com for the employee only. New Hire Provision: Allocations are prorated on a monthly basis. Change in Coverage Status: If there is a change in status from individual coverage to family coverage during the year, the HRA allocation will increase to the family coverage amount effective as of the effective date the status change based on a prorated schedule. If there is a change from family coverage to individual coverage, the HRA allocation will change to the greater of the individual coverage amount or the YTD HRA expense as of the effective date the status change. Roll-over Provision: Prior year unused HRA account balances will NOT roll over to the next plan year if you remain enrolled in the HRA option. HRA eligible expenses: HRA reimbursements are limited to all IRS eligible expenses as defined in IRS Code Section 213(d). If employment ends, you cannot take the balance of your account with you. If you elect COBRA coverage under the medical plan, you will continue to use your HRA in conjunction with your health plan. Flexible Spending Account (FSA): Your plan offers a Flexible Spending Account (FSA). If you are enrolled in the FSA, your FSA funds will reimburse first. SUMMARY OF COST SHARING PROVISIONS (Includes Mental Health and Substance Abuse) Calendar Year Deductible For family coverage, once an individual member reaches the individual deductible amount, benefits will begin for that member.

Calendar Year Out-of-Pocket Maximum

Individual coverage: $900

Individual coverage: $1,800

For family coverage: $2,400

For family coverage: $4,800

Calendar year deductible amounts met innetwork will not apply to the out-of-network calendar year deductible. Individual coverage: $3,000 (including the Individual calendar year deductible)

Calendar year deductible amounts met outof-network will not apply to the in-network calendar year deductible. No out-of-pocket maximum.

For family coverage: $9,000 (including the family calendar year deductible) Other Covered Services, In-Network inpatient coinsurance and In-Network outpatient coinsurance are the only expenses applicable to the annual out-ofpocket maximum. After you reach Calendar Year Out-of-Pocket Maximum, applicable expenses covered at 100% for remainder of calendar year.

Annual Maximum Lifetime Maximum

$2,000,000 per member on all essential health benefits. Unlimited.

INPATIENT HOSPITAL AND PHYSICIAN BENEFITS (Includes Mental Health and Substance Abuse) Preadmission Certification required for all inpatient admissions (except maternity); notification within 48 hours for emergencies. Call 1 800 248-2342 (toll free) for precertification.

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BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Subject to the calendar year deductible. No copay required. 80% coverage for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries.

Inpatient Facility Coverage (including maternity)

Subject to the calendar year deductible. 60% coverage for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries.

OUTPATIENT HOSPITAL BENEFITS (Includes Mental Health and Substance Abuse) Surgery Medical Emergency Accidental Injury Diagnostic Lab, X-ray, and Pathology Hemodialysis, IV Therapy Chemotherapy and Radiation Therapy

Covered at 80% of the allowed amount subject to the $50 facility copay. Covered at 80% of the allowed amount subject to the $150 facility copay. Covered at 80% of the allowed amount subject to the $100 facility copay. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible.

Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the $150 facility copay. Covered at 80% of the allowed amount subject to the $100 facility copay. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.

PHYSICIAN BENEFITS (Includes Mental Health and Substance Abuse) Primary Care Office Visits Specialist Office Visits Urgent Care Physician Services

Outpatient Consultations

Allergy Testing & Treatment Emergency Room Physician Fees Surgery and Anesthesia in the Physicianâ&#x20AC;&#x2122;s Office Surgery and Anesthesia in an Outpatient Facility Inpatient Surgery and Anesthesia Inpatient Visits, Second Surgical Opinions and Inpatient Consultations Maternity

Covered at 100% of the allowed amount subject to the $25 office visit copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Mental Health and Substance Abuse Services: Covered at 100% of the allowed amount subject to the $25/$30 office visit copay. Covered at 100% of the allowed amount subject to the $25 copay for services by a primary care physician or $30 copay for services by a specialist. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 80% of the allowed amount subject to the $25 physician copay. Covered at 80% of the allowed amount subject to the $30 physician copay. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible. Covered at 80% of the allowed amount subject to the calendar year deductible.

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Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.

Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 100% of the allowed amount subject to the $30 physician copay. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible. Covered at 60% of the allowed amount subject to the calendar year deductible.

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Benefit payments are based on the amount of the provider’s charge that Blue Cross and Blue Shield recognizes for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a copay, coinsurance, calendar year deductible or deductible for each admission, visit or service.

Covered at 80% of the allowed amount subject to the calendar year deductible.

Covered at 60% of the allowed amount subject to the calendar year deductible.

Note: Nurse Practitioners and Physician’s Assistants are considered eligible providers.

ENHANCED PREVENTIVE CARE BENEFITS Routine Immunizations and Preventive Services

Covered at 100%; no copay or deductible

Not covered

• See www.bcbsal.com/preventiveservices for a listing of the specific immunizations and preventive services

In addition to the preventive services listed on the web site, your group provides benefits for the following services. In some cases, the services listed below are greater than the services listed on the web site. In those cases, the greater benefit will prevail. Well Woman Exam Covered at 100%; no copay or deductible Not covered Other Routine Services • • • •

Covered at 100%; no copay or deductible

Not covered

Urinalysis – when necessary CBC – when necessary TB Skin Test – when necessary Cholesterol Screening – once every calendar year

ROUTINE VISION BENEFITS Eye Exam

Covered at 100% of the allowed amount Covered at 100% of the allowed amount subject to the $10 physician copay. subject to the $35 physician copay. Covered at 100% of the allowed amount up to a combined $200 maximum per person each calendar year.

(one eye exam per person every 12 months)

Lenses, Contact Lenses and Frames

PRESCRIPTION DRUG BENEFITS (Includes Mental Health and Substance Abuse) Prepaid Drug Card Preferred Rx Products •

Non-maintenance – up to 30 day supply at retail

•

Blue Cross Maintenance Drug List – up to a 60 day supply

Diabetic Supplies (copays apply) • Diabetic supplies are covered only through the Prescription Drug Card Program. •

Copays are combined for some products if purchased on the same day.

Participating Pharmacy: Prescription drugs will be covered at 100% subject to the following copays: Generic Drugs: $5 copay per prescription Preferred Brand Name Drugs: $35 copay per prescription Other Brand Name Drugs: $75 copay per prescription • • •

Insulin, insulin needles and syringes purchased on the same day will require only one copay. Blood glucose strips and lancets purchased on the same day will require only one copay. Glucose monitors will always require a separate copay.

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Non-Participating Pharmacy: There are no benefits available for prescription drugs purchased from a nonParticipating Pharmacy.

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

Allows up to a 90 day supply through PrimeMail (1 800 391-1886); 100% after the following copayments : Generic Drugs: $10 copayment per prescription Preferred Brand Name Drugs: $70 copayment per prescription Other Brand Name Drugs: $150 copayment per prescription

Note: To view the most current Preferred Brand Drug List, visit our web site at www.bcbsal.com.

BENEFITS FOR OTHER COVERED SERVICES (Includes Mental Health and Substance Abuse) Ambulance Service

Covered at 80% subject to in network calendar year deductible

Chiropractic Services $1,000 calendar year maximum per person

Covered at 80% subject to calendar year deductible

Covered at 60% subject to calendar year deductible

Approved Durable Medical Equipment (DME)

Covered at 80% subject to calendar year deductible

Covered at 80% subject to the in-network calendar year deductible

Physical, Occupational and Speech Therapy

Covered at 80% subject to calendar year deductible

Covered at 60% subject to calendar year deductible

Limited to 30 combined visits for all therapies

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BENEFIT

Home Health and Hospice • Precertification required for visits by home health professionals outside Alabama • For precertification call 1 800 821-7231 • Limited to a 60 day maximum per year for Home Health and a 60 day maximum per year for Hospice Care.

IN-NETWORK HOME HEALTH AND HOSPICE BENEFITS (Includes Mental Health and Substance Abuse) Covered at 80% subject to calendar year deductible

OUT-OF-NETWORK

Covered at 60% subject to calendar year deductible

HEALTH MANAGEMENT BENEFITS (Includes Mental Health and Substance Abuse) Individual Case Management

Coordinates care in event of catastrophic or lengthy illness or injury; For more information, please call 1-800-821-7231

Disease Management

Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease.

Baby Yourself

Prenatal wellness program; For more information, please call 1 800 222-4379. You can also enroll online at behealthy.com.

• • • •

Useful Information to Maximize Benefits To maximize your benefits, always use In-network providers for services covered by your health benefit plan. To find In-Network providers, check a provider directory, provider finder web site (www.bcbsal.com) or call 1 800 810-BLUE (2583). In-network hospitals, physicians and other health care providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing health care services at a reduced price (examples: BlueCard PPO, PMD, Preferred Care). In-Network Pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or Preferred Care Services, Inc. Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use Out-of-Network providers, you may be responsible for filing your own claims and paying the difference between the provider’s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to In-Network providers in the same area or the average charge for care in the area. Please be aware that providers/specialists may be listed in a PPO directory or provider finder web site, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information.

This is not a contract, benefit booklet or a Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the group contract. Please visit our web site, www.bcbsal.com. Group 49992 All divisions Revised 10-31-2012 JR

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