solutions - WhatCountsmedia.whatcounts.com/ibc_mktgcomm/BlueSolutions/2012-0405FIN… · Managing...

The benefits you need...

at the price you can afford...

from the name you know and trust

The benefits you need...

at the price you can afford...

from the name you know and trust.

Effective 4/1/2013

solutionsBLUECHOICE

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Blue Solutions Choice overview . . . . . . . . . . . . . . . . . . . . . 2We will explain how Blue Solutions Choice products are good for both you and your employees. You will be able to control your health coverage budget while allowing your employees to select a health plan from the plans provided that best fits their health coverage needs.

Plan overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4We’ll show you the differences between our copay, deductible, HRA compatible, and HSA qualified high deductible health plans so you’ll understand how to offer a diverse portfolio to your employees. And, if you’re not sure about the differences between HMO, POS, Direct POS, and Personal Choice® PPO products, we’ll help clarify. Learn when referrals are needed, when a primary care physician is required, and when services are covered both in- and out-of-network.

Health plans for groups with 2 – 50 employees . . . . . . . . . . 8

Health plans for groups with 51 – 99 employees . . . . . . . . 16

Other insurance needs . . . . . . . . . . . . . . . . . . . . . . . . . . 28Complete your benefits package by offering options like dental and life and disability coverage. Groups with more than 50 employees may also select vision and prescription drug plans.

Healthy LifestylesSM Rewards . . . . . . . . . . . . . . . . . . . . . . . 30Our employee incentive program helps your employees engage in healthy behaviors while earning dollars toward a spending account. By selecting a high deductible health plan, including plans paired with an HRA compatible or plans that are HSA qualified, you have the option to choose this program to maximize your savings and invest in your employees’ long-term health.

Tools and resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Take care of business when it’s convenient for you. With ibxpress.com, IBC gives you online, real-time account management. We even offer your employees powerful wellness tools and incentives to help them reach their health goals, so that both your employees and your business stay healthy.

Important information . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Get a better understanding of the policies and guidelines for our plans.

Contents

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Blue Solutions Choice overview

More choice, more controlManaging your health care costs should be just as easy as budgeting your yearly expenses for office supplies. Blue Solutions Choice products take the guesswork out of how much it will cost to provide comprehensive health benefits to your employees. And while you benefit from more predictable costs, your employees get the benefit of more health care coverage choices.

How It Works.Each year, you set your health care budget. You determine the fixed dollar amount you will provide your employees to spend on their health care coverage. Next, you pick the benefit plans your employees can choose from. Then, each employee uses the fixed dollar amount to shop for a health care plan that makes sense for them. Blue Solutions Choice allows employees to choose the health care plan from the plans provided that best meets their health coverage needs.

You will be able to choose health care plan options for your employees from a portfolio of 27 plans. While choice plays an important role in this new model, sometimes too many choices can be confusing. With that in mind, below is the maximum number of plans you can select for your employees to choose from.

Number of employees Maximum number of health plans you can offer2-9 5

10-19 10

20-50 15

51-99 20

Your current health plan vs. Blue Solutions Choice.Your current health care plan… Blue Solutions Choice… You should care because…

is a “one-size-fits-all” approach. gives you the ability to offer a variety of health plans to your employees who may have diverse needs.

your employees will be more satisfied.

makes it hard to budget your health care dollars because of annual premium increases.

helps you manage your annual budget because you set a fixed dollar amount to spend on each employee.

you have more control of your budget.

Could leave some employees less satisfied because you can only offer a few plans. Plus, employees don’t know the cost of their health care.

increases employee satisfaction because employees pick their health care plan based on their needs and reveals the true dollar value of the health care benefits you provide.

your employees will understand and value the money you spend on their health care benefits.

puts all the administration responsibility on you.

streamlines benefits administration because employees enroll in health plans online and call us if they have questions.

it saves you time and your employees get great service.

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Enrollment is easy!Blue Solutions Choice simplifies the administration of the enrollment process because members will choose their health plan online. You won’t have to organize an open enrollment, distribute enrollment materials, collect paperwork. You will need to provide an email address for each employee. We will use the address to send them a link to their unique page on our shopping website and to remind them when your open enrollment begins and ends.

Members will shop for their health care plan online. Blue Solutions Choice provides tools to guide employees through the experience of choosing their health care plan. They will be asked simple questions about prescription drug utilization, deductibles, and referral preferences. Then, the selection tool will suggest the health care plans that are best suited for them. Employees select their plans and enroll online. It’s that easy!

Questions? Contact your broker, call IBC at 215-241-3400, or visit www.ibx.com/bc 3

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Need help choosing? We can help.Blue Solutions Choice makes it easy to select benefits. You control how much you spend each year, and you select a variety of plans that gives your employees more choices.

Cost-sharing optionsWe offer four different types of plans in the Blue Solutions Choice portfolio — copay, deductible, health reimbursement account (HRA) compatible, and health savings account (HSA) qualified high deductible health plans. All of our plans offer comprehensive coverage and comply with applicable health care reform requirements, including 100 percent coverage for certain designated preventive care, benefits for dependents up to age 26, and no annual or lifetime dollar maximums on essential benefits.

What differentiates our plans is what your employees pay when they see a doctor or go to the hospital. With our copay plans, your employees will pay a fixed dollar amount for most services while our deductible, HRA compatible, and HSA qualified high deductible health plans help reduce costs by requiring a deductible and coinsurance for certain services. Use the chart below to determine which plans are best for your employees.

Plan overview

Copay plans Deductible plans HRA or HSA plans

Office visits Copay Copay Coinsurance after deductible

Preventive care Covered 100 percent Covered 100 percent Covered 100 percent

Emergency care Copay Coinsurance or copay after deductible

Coinsurance after deductible

Inpatient hospital Copay Coinsurance or copay after deductible


X-ray CopayCopay (HMO/DPOS)

Coinsurance or copay after deductible (PPO)


Laboratory Covered 100 percent

Covered 100 percent (HMO/DPOS)

Coinsurance or copay after deductible (PPO)


Prescription drugs1 Yes Yes Yes

Routine eye care1 Yes Yes Yes

Pair with a tax-advantaged spending account N/A N/A Yes

Cost-sharing included in the chart above applies to in-network coverage only. For out-of-network cost-sharing, refer to the benefits summary charts in this brochure.1 For groups with 2–50 employees only.

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Product options

Keystone HMO

Keystone POS

Keystone Direct POS

Personal Choice®

Access to an expansive network of more than 60,000 physicians and specialists

Selection of a primary care physician required

No referrals needed to visit in-network specialists to get the highest level of benefits

In-network benefits coast-to-coast through BlueCard® PPO

Away from Home Care® program for members who temporarily reside outside the service area

Access to emergency and urgent care across the country and around the world through BlueCard® and BlueCard Worldwide®

1 Direct POS members need a referral from their PCP for spinal manipulations, routine X-rays, and physical/occupational therapy. For lab work, members should use the facility recommended by their PCP for the lowest out-of-pocket costs.

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Copay plansDo you want predictability for your employees? A copay plan may be right for them. Most of the in-network services members typically use are covered by a fixed dollar amount known as a copay. Whether going to the doctor, seeing a physical therapist, or taking a trip to the emergency room, your employees pay a copay and we take care of the rest when they use a participating provider.

Deductible plansIf affordability is what your employees are looking for, a deductible plan may be the best solution for you. With these plans, employees still have copays for the medical care they use most and 100 percent coverage for certain preventive services. The deductible, an amount employees pay before insurance kicks in, applies only to services such as hospital and emergency care. Once the deductible is met, employees are responsible for coinsurance only.


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Health Reimbursement Accounts (HRAs) provide employers with flexibility. Because you fund HRAs, you determine what medical expenses and services are eligible for reimbursement. You receive tax advantages for providing your employees with a way to help save on medical expenses, and you may retain any funds left in an HRA when an employee leaves the company.

Since you fund HRAs throughout the year, you won’t have to set aside money up front, giving you a greater flexibility in managing your cash flow. You will fund the HRA account throughout the year by depositing a percentage of the HRA total funding, and adding more as employees use their funds.

When you offer a Personal Choice® HSA plan, your employees are eligible to open a tax-advantaged health savings account (HSA). Contributions to HSAs may be made by employers, employees, or a combination of both. Either way there are tax advantages for both you and your employees:

• Any HSA contributions you make are considered a business expense and provide tax savings. • Employee contributions reduce their taxable income.• Interest earned is tax-free when spent on qualified medical expenses.• Qualified medical expenses reimbursed from the account are tax-free.

With all of the tax advantages, HSAs are a great way to save. Plus, they may help offset increased employee costs, since HSA savings can be used to pay for deductibles and coinsurance.

Open a health savings accountYour employees may use our preferred vendor, The Bancorp Bank, an independent company, to set up an HSA or choose any bank they like. Bancorp HSA features include:

• no application or account set up fees1;• ability to earn interest with first deposit2;• free no-annual-fee Visa® Check Card;• toll-free 24/7 customer service and online access;• ability to invest HSA funds through National Financial Services once balance reaches $2,500.

To learn more, visit the Bancorp website at www.mybancorphsa.com.

You and your employees save with HRAs

Make the most of an HSA plan

Employer advantages of an HRA: Employee advantages of an HRA:

Contributions are tax deductible. Funds may be carried over each year.

Provide employees with a means to pay for higher deductible amounts.

Employer contributions are generally excluded from employee’s gross income and not taxable.

Unused funds remain with the employer. Employees may have access to the unused funds, at the employer’s discretion, subject to COBRA.

Distributions for qualified medical expenses are generally not taxable.

Plan overview (continued)

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The above chart is for illustrative purposes only. With an annual deposit of $1,500 on the first day of each year, an annual percentage yield of 3.5% with all earnings reinvested in the account, and $500 withdrawn for eligible medical expenses on the first day of each year.

The chart is not intended to be used as legal and/or tax advice. Please consult with your tax advisor and/or attorney for your particular situation.

See how HSA savings growLet’s say each year your employee contributes $1,500 to an HSA and withdraws, on average, $500 for health care expenses. With an interest rate of 3.5 percent, savings will grow each year. Depending on how money is invested in the account, savings can be even greater.

Health Account SolutionsWhen paired with our High Deductible Health plans, Health Reimbursement Accounts (HRAs) and Health Savings Accounts (HSAs) provide substantial benefits to you and your employees. These tax-advantaged savings accounts can help reduce member cost-sharing and help your employees save on medical expenses.

1Years

$14,000

$12,000

$10,000

$8,000

$6,000

$4,000

$2,000

$02 3 4 5 6 7 8 9 10

Tax savings$5,314.02

Balance at end of year 10 $11,731.39

1 Standard banking fees apply; monthly maintenance fees may apply. Visit www.mybancorphsa.com for additional details.

2 Interest paid on balances over $1

Comparing HRA and HSA plansHRA HSA

What is it? An employer-funded medical reimbursement account used to pay current qualified medical expenses and save for future medical expenses.

A bank account which is paired with a qualified high deductible health plan, to help employees save money to pay for future medical expenses on a tax-free basis.

How is it funded? Employer only Employee and/or employer

What are the maximum contributions?

No limits under IRS rules, however, IBC limits employer contributions to 50 percent of the deductible for high deductible health plans.

IRS sets Annual Limits and over age 55 acatch-up provision of an additional $1,000.

2013 maximum contribution is $3,250 for self-only and $6,450 for family.

Who owns the account? Employer Employee

Do funds carry over? Employer determines if employee can carry forward remaining balances.

Yes, funds may roll over to use for qualified medical expenses in subsequent years.

What are the tax implications? Employer contributions are tax deductible to the employer and generally excluded from an employee’s gross income.

The HSA account has three major tax savings: the money contributed into the account is tax deductible; it accumulates interest tax-free; and certain withdrawals are tax-free if they are for qualified medical expenses.

What type of deductible does the plan have?

Embedded deductible: Each covered family member only needs to satisfy his or her individual deductible, not the entire family deductible, prior to receiving plan benefits.

Aggregate deductible: For family coverage, the entire Family Annual Deductible must be met before copayments or coinsurance is applied for any individual family member.

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2 – 50 employees You pay You pay in-network You pay out-of-network*

Benefits per contract year BC HMO 1.1 BC HMO 2.1 BC HMO 3 BC HMO 5BC Direct POS

1.1BC Direct POS

2.1BC Direct POS

3.2BC Direct POS

5 BC Direct POS 1.1,

2.1, 3.2BC Direct POS

5Deductible, individual/family

None None$500/$1,500 $1,500/$4,500

Coinsurance 30% 50%Out-of-pocket maximum, individual/family (includes coinsurance) $3,000/$9,000 $10,000/$30,000

Lifetime maximum Unlimited Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0 $0

30%, no deductible 50%, no deductible

Nutrition counseling (6 visits per contract year) 30%, after deductible 50%, after deductible

Physician servicesPrimary care office visit $10 $15 $20 $30 $10 $15 $20 $30

30%, after deductible 50%, after deductibleSpecialist office visit $20 $30 $40 $50 $20 $30 $40 $50

Routine eye care (once every two calendar years) $0 $0 Not covered

Eyeglasses or contacts (once every two calendar years) $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year)$20 $30 $40 $50 $20 1 $30 1 $40 1 $50 1 30%, after deductible 50%, after deductible

Physical/occupational therapy (30 visits per contract year)

Hospital/other medical services

Inpatient hospital services/days (including maternity) $0/unlimited days$100/day, max 5

copays/admission; unlimited days

$250/day, max 5 copays/admission;

unlimited days

$400/day, max 5 copays/admission,

unlimited days$0/unlimited days


unlimited days


unlimited days


unlimited days

30%, after deductible/ 70 days


Emergency room (not waived if admitted) $100 $125 $100 $125 Covered at the in-network level

Outpatient surgery $0 $100 $250 $400 $0 $100 $250 $400

30%, after deductible


Outpatient lab/pathology $0 $0

Routine radiology/diagnostic $20 $30 $40 $50 $20 1 $30 1 $40 1 $50 1

MRI/MRA, CT/CTA scan, PET scan $40 $60 $80 $100 $40 $60 $80 $100

Biotech/specialty injectables $50 $75 $100 $125 $50 $75 $100 $125

Durable medical equipment/prosthetics 50% 50%50%, after deductible

Outpatient mental health care (20 visits/contract year) $20 $30 $40 $50 $20 $30 $40 $50

Inpatient mental health care (30 days/contract year) $0 $100/day, max 5 copays/admission

$250/day, max 5 copays/admission

$400/day, max 5 copays/admission $0 $100/day, max of 5

copays/admission$250/day, max of 5 copays/admission

$400/day, max of 5 copays/admission

30%, after deductible, up to 20 days per contract year


Outpatient serious mental illness care (60 visits/contract year) $20 $30 $40 $50 $20 $30 $40 $50 50%, after deductible

Inpatient serious mental illness care (30 days/contract year) $0 $100/day, max 5 copays/admission


$400/day, max 5 copays/admission $0 $100/day, max 5

copays/admission$250/day, max 5 copays/admission

$400/day, max 5 copays/admission 30%, after deductible 50%, after deductible

Substance abuse treatment

Detox (7 days per admission/4 admissions lifetime max)$0 $100/day, max 5




$400/day, max of 5 copays/admission 30%, after deductible 50%, after deductible Rehabilitation (30 days per contract year/90 days lifetime max)

Outpatient (60 visits per contract year/120 visits lifetime max) $20 $30 $40 $50 $20 $30 $40 $50

Prescription drugPlan name BC HMO 1.1 BC HMO 2.1 BC HMO 3 BC HMO 5 BC DPOS 1.1 BC DPOS 2.1 BC DPOS 3.2 BC DPOS 5 All BC Direct POS plans

Prescription deductible, individual/family None None None None None None None None None

Generic formulary $10 $10 $7 $7 $10 $10 $7 $7 30% of total retail cost reimbursedBrand formulary $40 $40 50% up to $125 max

per prescription50% up to $125 max

per prescription$40 $40 50% 50% up to $125 max

per prescriptionNon-formulary $70 $70 $70 $70 up to $125

Prescription mail order Included Included Included Included Included Included Included Included Not available

Copay plans (HMO and Direct POS)

1 Referral required from primary care physician

* To receive maximum benefits, services must be provided by a Keystone Health Plan East participating provider. This is a highlight of benefits available. The benefits and exclusions for in-network and out-of-network care are not the same. All benefits are provided in accordance with the HMO group contract and out-of-network benefit booklet/certificate.

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2 – 50 employees You pay You pay in-network You pay out-of-network*

Benefits per contract year BC HMO 1.1 BC HMO 2.1 BC HMO 3 BC HMO 5BC Direct POS

1.1BC Direct POS

2.1BC Direct POS

3.2BC Direct POS

5 BC Direct POS 1.1,

2.1, 3.2BC Direct POS

5Deductible, individual/family

None None$500/$1,500 $1,500/$4,500

Coinsurance 30% 50%Out-of-pocket maximum, individual/family (includes coinsurance) $3,000/$9,000 $10,000/$30,000




Nutrition counseling (6 visits per contract year) 30%, after deductible 50%, after deductible

Physician servicesPrimary care office visit $10 $15 $20 $30 $10 $15 $20 $30

30%, after deductible 50%, after deductibleSpecialist office visit $20 $30 $40 $50 $20 $30 $40 $50

Routine eye care (once every two calendar years) $0 $0 Not covered

Eyeglasses or contacts (once every two calendar years) $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year)$20 $30 $40 $50 $20 1 $30 1 $40 1 $50 1 30%, after deductible 50%, after deductible

Physical/occupational therapy (30 visits per contract year)


Inpatient hospital services/days (including maternity) $0/unlimited days$100/day, max 5



unlimited days

$400/day, max 5 copays/admission,

unlimited days$0/unlimited days


unlimited days


unlimited days


unlimited days



Emergency room (not waived if admitted) $100 $125 $100 $125 Covered at the in-network level

Outpatient surgery $0 $100 $250 $400 $0 $100 $250 $400




Routine radiology/diagnostic $20 $30 $40 $50 $20 1 $30 1 $40 1 $50 1

MRI/MRA, CT/CTA scan, PET scan $40 $60 $80 $100 $40 $60 $80 $100

Biotech/specialty injectables $50 $75 $100 $125 $50 $75 $100 $125

Durable medical equipment/prosthetics 50% 50%50%, after deductible

Outpatient mental health care (20 visits/contract year) $20 $30 $40 $50 $20 $30 $40 $50

Inpatient mental health care (30 days/contract year) $0 $100/day, max 5 copays/admission







Outpatient serious mental illness care (60 visits/contract year) $20 $30 $40 $50 $20 $30 $40 $50 50%, after deductible

Inpatient serious mental illness care (30 days/contract year) $0 $100/day, max 5 copays/admission


$400/day, max 5 copays/admission $0 $100/day, max 5




Detox (7 days per admission/4 admissions lifetime max)$0 $100/day, max 5




$400/day, max of 5 copays/admission 30%, after deductible 50%, after deductible Rehabilitation (30 days per contract year/90 days lifetime max)

Outpatient (60 visits per contract year/120 visits lifetime max) $20 $30 $40 $50 $20 $30 $40 $50

Prescription drugPlan name BC HMO 1.1 BC HMO 2.1 BC HMO 3 BC HMO 5 BC DPOS 1.1 BC DPOS 2.1 BC DPOS 3.2 BC DPOS 5 All BC Direct POS plans

Prescription deductible, individual/family None None None None None None None None None

Generic formulary $10 $10 $7 $7 $10 $10 $7 $7 30% of total retail cost reimbursedBrand formulary $40 $40 50% up to $125 max

per prescription50% up to $125 max

per prescription$40 $40 50% 50% up to $125 max

per prescriptionNon-formulary $70 $70 $70 $70 up to $125


Questions? Contact your broker, call IBC at 215-241-3400, or visit www.ibx.com/bc

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1 Combined in- and out-of-network

* Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Personal Choice, and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with hospitals and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.

Copay plans (Personal Choice)2 – 50 employees You pay out-of-network*

Benefits per contract year BC PPO 1.1 BC PPO 2.1 BC PPO 3.1 BC PPO 4 BC PPO 5 BC PPO 6BC PPO

1.1, 2.1, and 3.1 BC PPO 4 BC PPO 5 BC PPO 6Deductible, individual/family

None None

$500/$1,500 $1,500/$4,500 $3,000/$9,000 $6,000/$12,000

Coinsurance 30% 50%

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $10,000/$30,000 $15,000/$45,000 $18,000/$36,000




Nutrition counseling (6 visits per contract year1) 30%, after deductible 50%, after deductible

Physician services

Primary care office visit $10 $15 $20 $30 $30 $40 30%, after deductible 50%, after deductible

Specialist office visit $20 $30 $40 $50 $50 $75

Routine eye care (once every two calendar years1) $0 $0 Up to $35 reimbursementEyeglasses or contacts (once every two calendar years1) $100 benefit $100 benefit Up to $100 reimbursementSpinal manipulations (20 visits per contract year 1)

$20 $30 $40 $50 $50 $75 30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per contract year1)


Inpatient hospital services/days (including maternity)1 $0/unlimited days$100/day, max 5



unlimited days


unlimited days


unlimited days


unlimited days

30%, after deductible/ 70 days 50%, after deductible/70 days

Emergency room (not waived if admitted) $100 $125 $150 Covered at the in-network level

Outpatient surgery $0 $100 $250 $400 $600 $750




Routine radiology/diagnostic $20 $30 $40 $50 $50 $75

MRI/MRA, CT/CTA scan, PET scan $175 $175

Biotech/specialty injectables $50 $75 $100 $125 $125

Durable medical equipment/prosthetics 30% 50% 50%50%, after deductible

Outpatient mental health care (20 visits/contract year 1) $20 $30 $40 $50 $50 $75

Inpatient mental health care (30 days/contract year 1) $0 $100/day, max of 5 copays/admission





30%, after deductible/ 20 days per contract year 50%, after deductible, 20 days per contract year

Outpatient serious mental illness care (60 visits/contract year 1) $20 $30 $40 $50 $50 $75 50%, after deductible50%, after deductible

Inpatient serious mental illness care (30 days/contract year 1) $0 $100/day, max 5 copays/admission




$750/day, max of 5 copays/admission 30%, after deductible


Detox (7 days per admission/4 admissions lifetime maximum1)$0 $100/day, max of 5




$750/day, max 5 copays/admission 30%, after deductible 50%, after deductible Rehabilitation (30 days per contract year/90 days lifetime maximum1)

Outpatient (60 visits per contract year/120 visits lifetime maximum1) $20 $30 $40 $50 $50 $75

Prescription drugPlan name BC PPO 1.1 BC PPO 2.1 BC PPO 3.1 BC PPO 4 BC PPO 5 BC PPO 6 BC PPO 1.1, 2.1, and 3.1 BC PPO 4, 5, and 6

Prescription deductible, individual/family None None None None None None None None

Generic formulary $10 $10 $10 $7 $7 $7 30% of total retail

cost reimbursed 30% of total retail cost reimbursedBrand formulary $40 $40 $40 50% up to $125 max per prescription

50% up to $125 max per prescription

50% up to $125 max per prescriptionNon-formulary brand $70 $70 $70

Prescription mail order Included Included Included Included Included Included Not available Not available

You pay in-network

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2 – 50 employees You pay out-of-network*

Benefits per contract year BC PPO 1.1 BC PPO 2.1 BC PPO 3.1 BC PPO 4 BC PPO 5 BC PPO 6BC PPO

1.1, 2.1, and 3.1 BC PPO 4 BC PPO 5 BC PPO 6Deductible, individual/family

None None

$500/$1,500 $1,500/$4,500 $3,000/$9,000 $6,000/$12,000

Coinsurance 30% 50%

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $10,000/$30,000 $15,000/$45,000 $18,000/$36,000




Nutrition counseling (6 visits per contract year1) 30%, after deductible 50%, after deductible

Physician services

Primary care office visit $10 $15 $20 $30 $30 $40 30%, after deductible 50%, after deductible

Specialist office visit $20 $30 $40 $50 $50 $75

Routine eye care (once every two calendar years1) $0 $0 Up to $35 reimbursementEyeglasses or contacts (once every two calendar years1) $100 benefit $100 benefit Up to $100 reimbursementSpinal manipulations (20 visits per contract year 1)

$20 $30 $40 $50 $50 $75 30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per contract year1)


Inpatient hospital services/days (including maternity)1 $0/unlimited days$100/day, max 5



unlimited days


unlimited days


unlimited days


unlimited days

30%, after deductible/ 70 days 50%, after deductible/70 days

Emergency room (not waived if admitted) $100 $125 $150 Covered at the in-network level

Outpatient surgery $0 $100 $250 $400 $600 $750




Routine radiology/diagnostic $20 $30 $40 $50 $50 $75

MRI/MRA, CT/CTA scan, PET scan $175 $175

Biotech/specialty injectables $50 $75 $100 $125 $125

Durable medical equipment/prosthetics 30% 50% 50%50%, after deductible

Outpatient mental health care (20 visits/contract year 1) $20 $30 $40 $50 $50 $75

Inpatient mental health care (30 days/contract year 1) $0 $100/day, max of 5 copays/admission





30%, after deductible/ 20 days per contract year 50%, after deductible, 20 days per contract year

Outpatient serious mental illness care (60 visits/contract year 1) $20 $30 $40 $50 $50 $75 50%, after deductible50%, after deductible

Inpatient serious mental illness care (30 days/contract year 1) $0 $100/day, max 5 copays/admission




$750/day, max of 5 copays/admission 30%, after deductible


Detox (7 days per admission/4 admissions lifetime maximum1)$0 $100/day, max of 5




$750/day, max 5 copays/admission 30%, after deductible 50%, after deductible Rehabilitation (30 days per contract year/90 days lifetime maximum1)

Outpatient (60 visits per contract year/120 visits lifetime maximum1) $20 $30 $40 $50 $50 $75

Prescription drugPlan name BC PPO 1.1 BC PPO 2.1 BC PPO 3.1 BC PPO 4 BC PPO 5 BC PPO 6 BC PPO 1.1, 2.1, and 3.1 BC PPO 4, 5, and 6

Prescription deductible, individual/family None None None None None None None None

Generic formulary $10 $10 $10 $7 $7 $7 30% of total retail

cost reimbursed 30% of total retail cost reimbursedBrand formulary $40 $40 $40 50% up to $125 max per prescription

50% up to $125 max per prescription

50% up to $125 max per prescriptionNon-formulary brand $70 $70 $70

Prescription mail order Included Included Included Included Included Included Not available Not available


You pay in-network

12

Deductible plans (HMO, Direct POS and Personal Choice)

1 Referral required from primary care physician2 Combined in- and out-of-network PPO plans only3 Deductible waived on generic drugs4 PPO only. Not available for DPOS plans.


2 – 50 employees You pay You pay in-network You pay out-of-network

Benefits per contract year BC HMO 4 BC HMO 6 BC HMO 7.2 BC Direct POS 4 BC Direct POS 6 BC Direct POS 7.2 BC PPO 7.1 BC PPO 8.2All BC Direct POS* plans

and BC PPO† plansDeductible, individual/family $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $1,000/$3,000 $2,000/$6,000 $5,000/$15,000

Coinsurance 20% 30% 20% 30% 10% 20% 50%

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $5,000/$15,000 $3,000/$9,000 $5,000/$15,000 $3,000/$9,000 $15,000/$45,000

Lifetime maximum Unlimited Unlimited Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible $0, no deductible $0, no deductible

50%, no deductible

Nutrition counseling (6 visits per contract year)2 50%, after deductible

Physician servicesPrimary care office visit $20, no deductible $20, no deductible $20, no deductible $30, no deductible

50%, after deductibleSpecialist office visit $40, no deductible $40, no deductible $40, no deductible $50, no deductible

Routine eye care (once every two calendar years)2 $0, no deductible $0, no deductible $0 Up to $35 reimbursement4

Eyeglasses or contacts (once every two calendar years)2 $100 benefit $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year)2

$40, no deductible $40, no deductible1 $40, no deductible $50, no deductible 50%, after deductiblePhysical/occupational therapy (30 visits per contract year)2


Inpatient hospital services/days (includes maternity)2 20%, after deductible/unlimited days 30%, after deductible/unlimited days 20%, after deductible/unlimited days 30%, after deductible/

unlimited days10% after deductible/


unlimited days 50%, after deductible/70 days

Emergency room (not waived if admitted)20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible

10% after deductible 20% after deductible

Covered at the in-network levelOutpatient surgery


Outpatient lab/pathology $0, no deductible $0, no deductibleRoutine radiology/diagnostic $40, no deductible $40, no deductible1

MRI/MRA, CT/CTA scan, PET scan $80, no deductible $80, no deductibleBiotech/specialty injectables $100, no deductible $100, no deductible $100, no deductibleDurable medical equipment/prosthetics 50%, after deductible 50%, after deductible 50%, after deductibleOutpatient mental health care (20 visits/contract year2) $40, no deductible $40, no deductible $40 copay, no

deductible$50 copay, no

deductible

Inpatient mental health care (30 days/contract year2) 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductible 50%, after deductible, 20 days per contract year

Outpatient serious mental illness care (60 visits/contract year2) $40, no deductible $40, no deductible $40 copay, no deductible

$50 copay, no deductible 50%, after deductible

Inpatient serious mental illness care (30 days/contract year2) 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductibleSubstance abuse treatment

Detox (7 days per admission/4 admissions lifetime max2)20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductible

50%, after deductibleRehabilitation (30 days per contract year/90 days lifetime max2)

Outpatient (60 visits per contract year/120 visits lifetime max2) $40, no deductible $40, no deductible $40 copay, no deductible

$50 copay, no deductible

Prescription drugPlan name BC HMO 4 BC HMO 6 BC HMO 7.2 BC DPOS 4 BC DPOS 6 BC DPOS 7.2 BC PPO 7.1 BC PPO 8.2 All BC DPOS and BC PPO Plans

Prescription deductible, individual/family None $250 None None $250 None $2503 None NoneGeneric formulary $7 $20 $7 $7 $20 $7 $10, no deductible $7

30% of total retail cost reimbursed

Brand formulary50% up to $125 max

per prescription

$40 50% up to $125 max

per prescription

50% up to $125 max per

prescription

$40 50% up to $125 max per

prescription

$45 50% up to $125 max per

prescriptionNon-formulary brand

$60 $60 $75


13

†Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Personal Choice, and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with hospitals and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.

2 – 50 employees You pay You pay in-network You pay out-of-network

Benefits per contract year BC HMO 4 BC HMO 6 BC HMO 7.2 BC Direct POS 4 BC Direct POS 6 BC Direct POS 7.2 BC PPO 7.1 BC PPO 8.2All BC Direct POS* plans

and BC PPO† plansDeductible, individual/family $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $1,000/$3,000 $2,000/$6,000 $5,000/$15,000

Coinsurance 20% 30% 20% 30% 10% 20% 50%

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $5,000/$15,000 $3,000/$9,000 $5,000/$15,000 $3,000/$9,000 $15,000/$45,000



50%, no deductible

Nutrition counseling (6 visits per contract year)2 50%, after deductible

Physician servicesPrimary care office visit $20, no deductible $20, no deductible $20, no deductible $30, no deductible

50%, after deductibleSpecialist office visit $40, no deductible $40, no deductible $40, no deductible $50, no deductible

Routine eye care (once every two calendar years)2 $0, no deductible $0, no deductible $0 Up to $35 reimbursement4

Eyeglasses or contacts (once every two calendar years)2 $100 benefit $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year)2

$40, no deductible $40, no deductible1 $40, no deductible $50, no deductible 50%, after deductiblePhysical/occupational therapy (30 visits per contract year)2


Inpatient hospital services/days (includes maternity)2 20%, after deductible/unlimited days 30%, after deductible/unlimited days 20%, after deductible/unlimited days 30%, after deductible/



unlimited days 50%, after deductible/70 days

Emergency room (not waived if admitted)20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible

10% after deductible 20% after deductible

Covered at the in-network levelOutpatient surgery


Outpatient lab/pathology $0, no deductible $0, no deductibleRoutine radiology/diagnostic $40, no deductible $40, no deductible1

MRI/MRA, CT/CTA scan, PET scan $80, no deductible $80, no deductibleBiotech/specialty injectables $100, no deductible $100, no deductible $100, no deductibleDurable medical equipment/prosthetics 50%, after deductible 50%, after deductible 50%, after deductibleOutpatient mental health care (20 visits/contract year2) $40, no deductible $40, no deductible $40 copay, no

deductible$50 copay, no

deductible

Inpatient mental health care (30 days/contract year2) 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductible 50%, after deductible, 20 days per contract year

Outpatient serious mental illness care (60 visits/contract year2) $40, no deductible $40, no deductible $40 copay, no deductible

$50 copay, no deductible 50%, after deductible

Inpatient serious mental illness care (30 days/contract year2) 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductibleSubstance abuse treatment

Detox (7 days per admission/4 admissions lifetime max2)20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible 10% after deductible 20% after deductible

50%, after deductibleRehabilitation (30 days per contract year/90 days lifetime max2)

Outpatient (60 visits per contract year/120 visits lifetime max2) $40, no deductible $40, no deductible $40 copay, no deductible

$50 copay, no deductible

Prescription drugPlan name BC HMO 4 BC HMO 6 BC HMO 7.2 BC DPOS 4 BC DPOS 6 BC DPOS 7.2 BC PPO 7.1 BC PPO 8.2 All BC DPOS and BC PPO Plans

Prescription deductible, individual/family None $250 None None $250 None $2503 None NoneGeneric formulary $7 $20 $7 $7 $20 $7 $10, no deductible $7

30% of total retail cost reimbursed

Brand formulary50% up to $125 max

per prescription

$40 50% up to $125 max

per prescription

50% up to $125 max per

prescription

$40 50% up to $125 max per

prescription

$45 50% up to $125 max per

prescriptionNon-formulary brand

$60 $60 $75


14

HDHPs (Personal Choice)

Note: Prior to benefits being paid, the entire family deductible must be met. (Applies to HSA plans only.)1 Prior to benefits being paid, an individual must meet the single deductible.2 Combined in- and out-of-network

2 – 50 employees You pay in-network You pay in-network You pay in-network You pay out-of-network*

Benefits per contract year BC PPO HRA 31 BC PPO HDHP 1 BC PPO HDHP 3 BC PPO HDHP 4 BC PPO HDHP 5 All BC PPO PlansDeductible, individual/family $3,000/$6,000 $1,500/$3,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 $5,000/$10,000

Coinsurance, after deductible 20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductibleOut-of-pocket maximum, individual/family (includes deductibles, copays, and coinsurance) $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000

Lifetime maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible $0, no deductible $0, no deductible $0, no deductible

50%, no deductible

Nutrition counseling (6 visits per contract year2) 50%, after deductible

Physician servicesPrimary care office visit

20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductibleSpecialist office visit

Routine eye care (once every two calendar years2) $0, no deductible $0, after deductible $0, after deductible Up to $35 reimbursement

Eyeglasses or contacts (once every two calendar years2) $100 benefit $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year2)20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductible

Physical/occupational therapy (30 visits per contract year2)

Hospital/other medical servicesInpatient hospital services/days (includes maternity) 20%, after deductible/unlimited days $0, after deductible/unlimited days $0, after deductible/unlimited days 20%, after deductible/unlimited days 50%, after deductible/70 days

Emergency room (not waived if admitted)20%, after deductible $0, after deductible $0, after deductible 20%, after deductible

Covered at the in-network level

Outpatient surgery


Outpatient lab/pathology

20%, after deductible $0, after deductible $0, after deductible 20%, after deductible

Routine radiology/diagnostic

MRI/MRA, CT/CTA scan, PET scan

Biotech/specialty injectables

Durable medical equipment/prosthetics

Outpatient mental health care (20 visits/contract year2)

Inpatient mental health care (30 days/contract year2)

Outpatient serious mental illness care (60 visits/contract year2)

Inpatient serious mental illness care (30 days/contract year2)


Detox (7 days per admission/4 admissions lifetime maximum2)

Rehabilitation (30 days per contract year/90 days lifetime maximum2)

Outpatient (60 visits per year/120 visits lifetime maximum2)

Prescription drugPrescription deductible, individual/family Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical

Generic formulary $20, after deductible $20, after deductible $20, after deductible $20, after deductible $20, after deductible

50%, after deductibleBrand formulary $40, after deductible $40, after deductible $40, after deductible $40, after deductible $40, after deductible

Non-formulary brand $60, after deductible $60, after deductible $60, after deductible $60, after deductible $60, after deductible

Prescription mail order Included Included Included Included Included Not available

HRA plan HSA plans

15

*Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Personal Choice, and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with hospitals and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.


Benefits per contract year BC PPO HRA 31 BC PPO HDHP 1 BC PPO HDHP 3 BC PPO HDHP 4 BC PPO HDHP 5 All BC PPO PlansDeductible, individual/family $3,000/$6,000 $1,500/$3,000 $2,500/$5,000 $3,000/$6,000 $3,000/$6,000 $5,000/$10,000

Coinsurance, after deductible 20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductibleOut-of-pocket maximum, individual/family (includes deductibles, copays, and coinsurance) $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000

Lifetime maximum Unlimited Unlimited Unlimited Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible $0, no deductible $0, no deductible $0, no deductible

50%, no deductible



20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductibleSpecialist office visit

Routine eye care (once every two calendar years2) $0, no deductible $0, after deductible $0, after deductible Up to $35 reimbursement

Eyeglasses or contacts (once every two calendar years2) $100 benefit $100 benefit $100 benefit Up to $100 reimbursement

Spinal manipulations (20 visits per contract year2)20%, after deductible $0, after deductible $0, after deductible 20%, after deductible 50%, after deductible


Hospital/other medical servicesInpatient hospital services/days (includes maternity) 20%, after deductible/unlimited days $0, after deductible/unlimited days $0, after deductible/unlimited days 20%, after deductible/unlimited days 50%, after deductible/70 days

Emergency room (not waived if admitted)20%, after deductible $0, after deductible $0, after deductible 20%, after deductible


Outpatient surgery



20%, after deductible $0, after deductible $0, after deductible 20%, after deductible





Outpatient mental health care (20 visits/contract year2)

Inpatient mental health care (30 days/contract year2)

Outpatient serious mental illness care (60 visits/contract year2)

Inpatient serious mental illness care (30 days/contract year2)


Detox (7 days per admission/4 admissions lifetime maximum2)

Rehabilitation (30 days per contract year/90 days lifetime maximum2)

Outpatient (60 visits per year/120 visits lifetime maximum2)

Prescription drugPrescription deductible, individual/family Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical

Generic formulary $20, after deductible $20, after deductible $20, after deductible $20, after deductible $20, after deductible

50%, after deductibleBrand formulary $40, after deductible $40, after deductible $40, after deductible $40, after deductible $40, after deductible

Non-formulary brand $60, after deductible $60, after deductible $60, after deductible $60, after deductible $60, after deductible

Prescription mail order Included Included Included Included Included Not available

HSA plans

16

Copay plans (POS)

1 No referral required to see primary care physician.2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.3 Copay waived if admitted.


51 – 99 employees With a referral, you pay With a referral, you pay Without a referral, you pay*

Benefits per calendar year BC POS Plus 1A BC POS Plus 2A BC POS Plus 3A BC POS Plus 4A BC POS Plus 1A BC POS Plus 2A BC POS Plus 3A BC POS Plus 4ADeductible, individual/family

None None$5,000/$15,000

Coinsurance, after deductible 30%, after deductible 50%, after deductible

Out-of-pocket maximum, individual/family $1,500/$3,000 $3,000/$6,000 $5,000/$10,000 $5,000/$10,000 $30,000/$90,000 $15,000/$45,000




Nutrition counseling (6 visits per calendar year) 30%, after deductible 50%, after deductible

Physician servicesPrimary care office visit1 $15 $20 $30 $40

30%, after deductible 50%, after deductibleSpecialist office visit

$30 $40 $50 $60 Routine eye care (once every two years) Not covered

Spinal manipulations (20 visits per calendar year)30%, after deductible 50%, after deductible

Physical/occupational therapy (30 visits per calendar year)


Inpatient hospital services/days $100/day, max 5 copays/admission; unlimited days

$150/day, max 5 copays/admission; unlimited days


$500/day, max 5 copays/admission; unlimited days 30%, after deductible/70 days2 50%, after deductible/70 days2

Emergency room (not waived if admitted) $125 $1253 $2003 $2003 Covered at the referred level

Maternity hospitalization $100, max 5 copays/admission

$150, max 5 copays/admission



Outpatient surgery $50 $150 $400 $500

Ambulance (emergency)$0 $0

Covered at the referred level


30%, after deductible 50%, after deductibleRoutine radiology/diagnostic $30 $40 $50 $60

MRI/MRA, CT/CTA scan, PET scan $60 $120 $200 $200

Biotech/specialty injectables $100 $100

Durable medical equipment/prosthetics 30% 50% 50% 50%, after deductible

Outpatient mental health care $30 $40 $50 $60

30%, after deductible 50%, after deductibleInpatient mental health care $100, max 5 copays/

admission$150, max 5 copays/

admission$400/day, max 5 copays/


admissionOutpatient serious mental illness care $30 $40 $50 $60

Inpatient serious mental illness care2 $100, max 5 copays/admission





Detox2$100, max 5 copays/




admission 30%, after deductible 50%, after deductible Rehabilitation2

Outpatient $30 $40 $50 $60

17

51 – 99 employees With a referral, you pay With a referral, you pay Without a referral, you pay*

Benefits per calendar year BC POS Plus 1A BC POS Plus 2A BC POS Plus 3A BC POS Plus 4A BC POS Plus 1A BC POS Plus 2A BC POS Plus 3A BC POS Plus 4ADeductible, individual/family

None None$5,000/$15,000


Out-of-pocket maximum, individual/family $1,500/$3,000 $3,000/$6,000 $5,000/$10,000 $5,000/$10,000 $30,000/$90,000 $15,000/$45,000





Physician servicesPrimary care office visit1 $15 $20 $30 $40


$30 $40 $50 $60 Routine eye care (once every two years) Not covered

Spinal manipulations (20 visits per calendar year)30%, after deductible 50%, after deductible







Emergency room (not waived if admitted) $125 $1253 $2003 $2003 Covered at the referred level

Maternity hospitalization $100, max 5 copays/admission




Outpatient surgery $50 $150 $400 $500


Covered at the referred level




Biotech/specialty injectables $100 $100

Durable medical equipment/prosthetics 30% 50% 50% 50%, after deductible


30%, after deductible 50%, after deductibleInpatient mental health care $100, max 5 copays/





Inpatient serious mental illness care2 $100, max 5 copays/admission





Detox2$100, max 5 copays/





Outpatient $30 $40 $50 $60


18

1 Referral required from primary care physician.2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.


51 – 99 employees You pay in-network You pay in-network You pay out-of-network*

Benefits per calendar year BC DPOS Plus 1A BC DPOS Plus 2A BC DPOS Plus 3A BC DPOS Plus 1A and 2A BC DPOS Plus 3ADeductible, individual/family

None None$500/$1,500 $5,000/$15,000


Out-of-pocket maximum, individual/family $1,000/$2,000 $3,000/$6,000 $5,000/$10,000 $3,000/$9,000 $15,000/$45,000





Physician servicesPrimary care office visit $15 $20 $30


$30 $40 $50Routine eye care (once every two calendar years) Not covered

Spinal manipulations (20 visits per calendar year)1

30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per calendar year)1


Inpatient hospital services/days $0/unlimited days $250/day, max 5 copays/admission; unlimited days


Emergency room (not waived if admitted) $125 $150 Covered at the in-network level

Maternity hospitalization

$0

$250/day, max 5 copays/admission $400/day, max 5 copays/admission30%, after deductible 50%, after deductible

Outpatient surgery $125 $200






Routine radiology/diagnostic1 $30 $40 $50

MRI/MRA, CT/CTA scan, PET scan $60 $80 $100

Biotech/specialty injectables $75 $100 $125

Durable medical equipment/prosthetics 50% 50% 50%, after deductible

Outpatient mental health care $30 $40 $50

30%, after deductibleInpatient mental health care2 $0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission

Outpatient serious mental illness care $30 $40 $50

Inpatient serious mental illness care2 $0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission


Detox2

$0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission30%, after deductible 50%, after deductible Rehabilitation2

Outpatient $30 $40 $50

Copay plans (DPOS)

19


Benefits per calendar year BC DPOS Plus 1A BC DPOS Plus 2A BC DPOS Plus 3A BC DPOS Plus 1A and 2A BC DPOS Plus 3ADeductible, individual/family

None None$500/$1,500 $5,000/$15,000


Out-of-pocket maximum, individual/family $1,000/$2,000 $3,000/$6,000 $5,000/$10,000 $3,000/$9,000 $15,000/$45,000





Physician servicesPrimary care office visit $15 $20 $30


$30 $40 $50Routine eye care (once every two calendar years) Not covered


30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per calendar year)1


Inpatient hospital services/days $0/unlimited days $250/day, max 5 copays/admission; unlimited days



Maternity hospitalization

$0

$250/day, max 5 copays/admission $400/day, max 5 copays/admission30%, after deductible 50%, after deductible

Outpatient surgery $125 $200






Routine radiology/diagnostic1 $30 $40 $50

MRI/MRA, CT/CTA scan, PET scan $60 $80 $100

Biotech/specialty injectables $75 $100 $125

Durable medical equipment/prosthetics 50% 50% 50%, after deductible

Outpatient mental health care $30 $40 $50

30%, after deductibleInpatient mental health care2 $0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission

Outpatient serious mental illness care $30 $40 $50

Inpatient serious mental illness care2 $0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission


Detox2

$0 $250/day, max 5 copays/admission $400/day, max 5 copays/admission30%, after deductible 50%, after deductible Rehabilitation2

Outpatient $30 $40 $50


20

1 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.2 Combined in- and out-of-network.

* It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider.

Copay plans (Personal Choice)

51 – 99 employees You pay in-network You pay out-of-network*

Benefits per calendar year BC PPO Plus 1A BC PPO Plus 2A BC PPO Plus 3A BC PPO Plus 4A BC PPO Plus 1A BC PPO Plus 2A and 3A BC PPO Plus 4ADeductible, individual/family

None None

$1,500/$4,500 $500/$1,500 $1,500/$4,500


Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $10,000/$30,000




Nutrition counseling (6 visits per calendar year)2 30%, after deductible 50%, after deductible

Physician servicesPrimary care office visit $10 $15 $20 $30

30%, after deductible 50%, after deductibleSpecialist office visit $20 $30 $40 $50


$20 $30 $40 $50 30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per calendar year)2







Maternity hospitalization $50/day, max 3 copays/admission



$400, max 5 copays/ admission 30%, after deductible 50%, after deductible

Outpatient surgery

$0

$50 $125 $200






Biotech/specialty injectables $50 $75 $100 $125

Durable medical equipment/prosthetics 50% 30% 50% 50% 50%, after deductible


30%, after deductible 50%, after deductibleInpatient mental health care1 $50/day, max 3 copays/





Inpatient serious mental illness care1 $50/day, max 3 copays/admission





Detox1$50/day, max 3 copays/





Outpatient $20 $30 $40 $40

21


51 – 99 employees You pay in-network You pay out-of-network*

Benefits per calendar year BC PPO Plus 1A BC PPO Plus 2A BC PPO Plus 3A BC PPO Plus 4A BC PPO Plus 1A BC PPO Plus 2A and 3A BC PPO Plus 4ADeductible, individual/family

None None

$1,500/$4,500 $500/$1,500 $1,500/$4,500


Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $10,000/$30,000




Nutrition counseling (6 visits per calendar year)2 30%, after deductible 50%, after deductible

Physician servicesPrimary care office visit $10 $15 $20 $30

30%, after deductible 50%, after deductibleSpecialist office visit $20 $30 $40 $50


$20 $30 $40 $50 30%, after deductible 50%, after deductiblePhysical/occupational therapy (30 visits per calendar year)2







Maternity hospitalization $50/day, max 3 copays/admission



$400, max 5 copays/ admission 30%, after deductible 50%, after deductible

Outpatient surgery

$0

$50 $125 $200






Biotech/specialty injectables $50 $75 $100 $125

Durable medical equipment/prosthetics 50% 30% 50% 50% 50%, after deductible


30%, after deductible 50%, after deductibleInpatient mental health care1 $50/day, max 3 copays/





Inpatient serious mental illness care1 $50/day, max 3 copays/admission





Detox1$50/day, max 3 copays/





Outpatient $20 $30 $40 $40

22

Deductible plans (POS and DPOS)

1 Referral required from primary care physician.2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.

*To receive maximum benefits, services must be provided by a Keystone Health Plan East participating provider. This is a highlight of benefits available. The benefits and exclusions for in-network and out-of-network care are not the same. All benefits are provided in accordance with the HMO group contract and out-of-network benefit booklet/certificate.

51 – 99 employeesWith a referral,

you payWithout a referral,

you pay*You pay

in-networkYou pay

out-of-network*

Benefits per calendar year BC POS Plus 5A BC POS Plus 6A BC POS Plus 7AAll BC POS Plus deductible plans BC DPOS Plus 4A BC DPOS Plus 5A BC DPOS Plus 6A

All BC DPOS Plus deductible plans

Deductible, individual/family $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $5,000/$15,000 $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $5,000/$15,000

Coinsurance 20%, after deductible 30%, after deductible 50%, after deductible 20%, after deductible 20%, after deductible 30%, after deductible 50%, after deductible

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $5,000/$15,000 $30,000/$90,000 $3,000/$9,000 $3,000/$9,000 $5,000/$15,000 $15,000/$45,000


Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible

50%, no deductible$0, no deductible

50%, no deductible


Physician servicesPrimary care office visit $20, no deductible $40, no deductible $20, no deductible

50%, after deductible$20, no deductible $40, no deductible $20, no deductible

50%, after deductibleSpecialist office visit

$40, no deductible $50, no deductible $40, no deductible


Routine eye care (once every two calendar years) Not covered

$40, no deductible1 $50, no deductible1 $40, no deductible1

Not Covered

Spinal manipulations (20 visits per year)50%, after deductible 50%, after deductible



Inpatient hospital services/days 20%, after deductible/unlimited days 30%, after deductible/unlimited days

50%, after deductible/ 70 days2

20%, after deductible/ unlimited days

30%, after deductible/unlimited days


Emergency room (not waived if admitted)

20%, after deductible 30%, after deductible




Maternity hospitalization50%, after deductible 50%, after deductibleOutpatient surgery

Ambulance (emergency) Covered at the in-network level


Outpatient lab/pathology $0, no deductible


$0, no deductible


Routine radiology/diagnostic $40, no deductible $50, no deductible $40, no deductible $40, no deductible1 $50, no deductible1 $40, no deductible1

MRI/MRA, CT/CTA scan, PET scan $80, no deductible $100, no deductible $80, no deductible $80, no deductible1 $100, no deductible1 $80, no deductible1

Biotech/specialty injectables $100, no deductible $125, no deductible $100, no deductible $100, no deductible $125, no deductible $100, no deductibleDurable medical equipment/prosthetics 50%, after deductible 50%, after deductible

Outpatient mental health care $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductible

Inpatient mental health care2 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible

Outpatient serious mental illness care $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductibleInpatient serious mental illness care2 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductibleSubstance abuse treatment

Detox2

20%, after deductible 30%, after deductible50%, after deductible

20%, after deductible 30%, after deductible50%, after deductibleRehabilitation2

Outpatient $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductible

23

51 – 99 employeesWith a referral,

you payWithout a referral,

you pay*You pay

in-networkYou pay

out-of-network*

Benefits per calendar year BC POS Plus 5A BC POS Plus 6A BC POS Plus 7AAll BC POS Plus deductible plans BC DPOS Plus 4A BC DPOS Plus 5A BC DPOS Plus 6A

All BC DPOS Plus deductible plans

Deductible, individual/family $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $5,000/$15,000 $1,000/$3,000 $2,000/$6,000 $3,000/$9,000 $5,000/$15,000

Coinsurance 20%, after deductible 30%, after deductible 50%, after deductible 20%, after deductible 20%, after deductible 30%, after deductible 50%, after deductible

Out-of-pocket maximum, individual/family (includes coinsurance only) $3,000/$9,000 $5,000/$15,000 $30,000/$90,000 $3,000/$9,000 $3,000/$9,000 $5,000/$15,000 $15,000/$45,000


Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible

50%, no deductible$0, no deductible

50%, no deductible


Physician servicesPrimary care office visit $20, no deductible $40, no deductible $20, no deductible

50%, after deductible$20, no deductible $40, no deductible $20, no deductible

50%, after deductibleSpecialist office visit



Routine eye care (once every two calendar years) Not covered

$40, no deductible1 $50, no deductible1 $40, no deductible1

Not Covered

Spinal manipulations (20 visits per year)50%, after deductible 50%, after deductible



Inpatient hospital services/days 20%, after deductible/unlimited days 30%, after deductible/unlimited days


20%, after deductible/ unlimited days

30%, after deductible/unlimited days







Maternity hospitalization50%, after deductible 50%, after deductibleOutpatient surgery

Ambulance (emergency) Covered at the in-network level


Outpatient lab/pathology $0, no deductible


$0, no deductible


Routine radiology/diagnostic $40, no deductible $50, no deductible $40, no deductible $40, no deductible1 $50, no deductible1 $40, no deductible1

MRI/MRA, CT/CTA scan, PET scan $80, no deductible $100, no deductible $80, no deductible $80, no deductible1 $100, no deductible1 $80, no deductible1

Biotech/specialty injectables $100, no deductible $125, no deductible $100, no deductible $100, no deductible $125, no deductible $100, no deductibleDurable medical equipment/prosthetics 50%, after deductible 50%, after deductible

Outpatient mental health care $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductible

Inpatient mental health care2 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductible

Outpatient serious mental illness care $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductibleInpatient serious mental illness care2 20%, after deductible 30%, after deductible 20%, after deductible 30%, after deductibleSubstance abuse treatment

Detox2

20%, after deductible 30%, after deductible50%, after deductible

20%, after deductible 30%, after deductible50%, after deductibleRehabilitation2

Outpatient $40, no deductible $50, no deductible $40, no deductible $40, no deductible $50, no deductible $40, no deductible


24

1 Combined in- and out-of-network.2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.3 Maximum of 5 copays per admission.4 Includes aggregate deductible comprising of all prescription drug and medical expenses.5 Copay waived if admitted.6 For plans 8A, 9A, and 10A, both coinsurance and deductible are included.


Benefits per calendar year BC PPO Plus 5A BC PPO Plus 6A BC PPO Plus 7A BC PPO Plus 8A BC PPO Plus 9A BC PPO Plus 10A BC PPO Plus 5A BC PPO Plus 6A BC PPO Plus 7A BC PPO Plus 8A BC PPO Plus 9A BC PPO Plus 10ADeductible, individual/family $1,000/$3,000 $2,000/$4,000 $2,000/$6,000 $2,500/$5,0004 $3,000/$6,0004 $4,000/$8,0004 $5,000/$15,000 $5,000/$10,000 $5,000/$15,000 $5,000/$10,000 $6,000/$12,000

Coinsurance 20%, after deductible $0, after deductible 20%, after

deductible $0, after deductible 10%, after deductible 10%, after deductible 50%, after deductible

Out-of-pocket maximum, individual/family (includes coinsurance only)6 $3,000/$9,000 $5,000/$10,000 $3,000/$9,000 $5,000/$10,000 $5,000/$10,000 $15,000/$45,000 $10,000/$20,000 $15,000/$45,000 $10,000/$20,000

Lifetime maximum Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible $0, no deductible

50%, no deductible

Nutrition counseling (6 visits per calendar year)1 50%, after deductible

Physician servicesPrimary care office visit $20, no deductible $35, no deductible $20, no deductible $30, after deductible $40, after deductible $40, after deductible

50%, after deductibleSpecialist office visit $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Spinal manipulations (20 visits per year1)$40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible 50%, after deductiblePhysical/occupational therapy

(30 visits per calendar year1)


Inpatient hospital services/days20%, after deductible/

unlimited days

$0, after deductible/

unlimited days

20%, after deductible/

unlimited days

$500/day, after deductible/unlimited days3


unlimited days

10%, after deductible/unlimited days 50%, after deductible/ 70 days



$0, after deductible20%, after deductible

$200, after deductible5


$200, after deductible5 Covered at the in-network level

Maternity hospitalization $500/day, after deductible3

10%, after deductible 10%, after deductible 50%, after deductibleOutpatient surgery $500, after

deductibleAmbulance (emergency) $0, no deductible $0, no deductible Covered at the in-network level

Outpatient lab/pathology $60, after deductible$70, after deductible $70, after deductible


Routine radiology/diagnostic $60, no deductible $60, after deductible

MRI/MRA, CT/CTA scan, PET scan $200, no deductible $200, after deductible $200, after deductible

Biotech/specialty injectables $100, no deductible $50, no deductible $100, no deductible $100, after deductible $150, after deductible $150, after deductible

Durable medical equipment/prosthetics 50%, after deductible 50%, after deductible

Outpatient mental health care $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Inpatient mental health care2 20%, after deductible $0, after deductible 20%, after

deductible$500/day, after

deductible3 10%, after deductible 10%, after deductible

Outpatient serious mental illness care $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Inpatient serious mental illness care2 20%, after deductible $0, after deductible 20%, after




Detox220%, after deductible $0, after deductible 20%, after


deductible3 10%, after deductible 10%, after deductible50%, after deductibleRehabilitation2

Outpatient $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Prescription drugPrescription deductible, individual/family

Add prescription benefits, see page 28

Integrated with medical Integrated with medical


Integrated with medical

Generic formulary $20, after deductible $20, after deductible 50%, after deductible

Brand formulary $40, after deductible $40, after deductible 50%, after deductible

Non-formulary $70, after deductible $70, after deductible 50%, after deductible

Prescription mail Available Available Not available

Deductible plans (Personal Choice)

25

* It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider.


Benefits per calendar year BC PPO Plus 5A BC PPO Plus 6A BC PPO Plus 7A BC PPO Plus 8A BC PPO Plus 9A BC PPO Plus 10A BC PPO Plus 5A BC PPO Plus 6A BC PPO Plus 7A BC PPO Plus 8A BC PPO Plus 9A BC PPO Plus 10ADeductible, individual/family $1,000/$3,000 $2,000/$4,000 $2,000/$6,000 $2,500/$5,0004 $3,000/$6,0004 $4,000/$8,0004 $5,000/$15,000 $5,000/$10,000 $5,000/$15,000 $5,000/$10,000 $6,000/$12,000

Coinsurance 20%, after deductible $0, after deductible 20%, after

deductible $0, after deductible 10%, after deductible 10%, after deductible 50%, after deductible

Out-of-pocket maximum, individual/family (includes coinsurance only)6 $3,000/$9,000 $5,000/$10,000 $3,000/$9,000 $5,000/$10,000 $5,000/$10,000 $15,000/$45,000 $10,000/$20,000 $15,000/$45,000 $10,000/$20,000

Lifetime maximum Unlimited Unlimited

Preventive servicesPreventive care for adults and children (includes mammogram, routine gynecological, and pediatric immunization) $0, no deductible $0, no deductible

50%, no deductible

Nutrition counseling (6 visits per calendar year)1 50%, after deductible

Physician servicesPrimary care office visit $20, no deductible $35, no deductible $20, no deductible $30, after deductible $40, after deductible $40, after deductible

50%, after deductibleSpecialist office visit $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Spinal manipulations (20 visits per year1)$40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible 50%, after deductiblePhysical/occupational therapy

(30 visits per calendar year1)


Inpatient hospital services/days20%, after deductible/

unlimited days

$0, after deductible/

unlimited days


unlimited days

$500/day, after deductible/unlimited days3


unlimited days

10%, after deductible/unlimited days 50%, after deductible/ 70 days



$0, after deductible20%, after deductible



$200, after deductible5 Covered at the in-network level

Maternity hospitalization $500/day, after deductible3

10%, after deductible 10%, after deductible 50%, after deductibleOutpatient surgery $500, after

deductibleAmbulance (emergency) $0, no deductible $0, no deductible Covered at the in-network level

Outpatient lab/pathology $60, after deductible$70, after deductible $70, after deductible


Routine radiology/diagnostic $60, no deductible $60, after deductible

MRI/MRA, CT/CTA scan, PET scan $200, no deductible $200, after deductible $200, after deductible

Biotech/specialty injectables $100, no deductible $50, no deductible $100, no deductible $100, after deductible $150, after deductible $150, after deductible

Durable medical equipment/prosthetics 50%, after deductible 50%, after deductible

Outpatient mental health care $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Inpatient mental health care2 20%, after deductible $0, after deductible 20%, after



Outpatient serious mental illness care $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Inpatient serious mental illness care2 20%, after deductible $0, after deductible 20%, after




Detox220%, after deductible $0, after deductible 20%, after


deductible3 10%, after deductible 10%, after deductible50%, after deductibleRehabilitation2

Outpatient $40, no deductible $60, no deductible $40, no deductible $50, after deductible $60, after deductible $60, after deductible

Prescription drugPrescription deductible, individual/family


Integrated with medical Integrated with medical


Integrated with medical

Generic formulary $20, after deductible $20, after deductible 50%, after deductible

Brand formulary $40, after deductible $40, after deductible 50%, after deductible

Non-formulary $70, after deductible $70, after deductible 50%, after deductible

Prescription mail Available Available Not available

26

Note: Prior to benefits being paid, the entire family deductible must be met. (Applies to HSA plans only.)1 Combined in- and out-of-network2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental health, substance abuse, and detoxification services.3 Prior to benefits being paid, an individual must meet the single deductible.

HDHPs (Personal Choice)


Benefits per contract year BC PPO HRA Plus 3A3 BC PPO HDHP Plus 1A BC PPO HDHP Plus 3A BC PPO HDHP Plus 4A All BC PPO PlansDeductible, individual/family $4,500/$9,000 $1,500/$3,000 $2,500/$5,000 $3,000/$6,000 $5,000/$10,000

Coinsurance, after deductible $0, after deductible $0, after deductible $0, after deductible 50%, after deductibleOut-of-pocket maximum, individual/family (includes deductibles, copays, and coinsurance) $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000



50%, no deductible



$0, after deductible $0, after deductible $0, after deductible 50%, after deductibleSpecialist office visit

Spinal manipulations (20 visits per contract year1)



Inpatient hospital services/days (includes maternity)2 $0, after deductible/unlimited days $0, after deductible/unlimited days $0, after deductible/unlimited days 50%, after deductible/70 days


$0, after deductible $0, after deductible $0, after deductible


Maternity hospitalization 50%, after deductibleOutpatient surgeryAmbulance (emergency) Covered at the in-network levelOutpatient lab/pathology

$0, after deductible $0, after deductible $0, after deductible 50%, after deductible





Outpatient mental health care

Inpatient mental health care2

Outpatient serious mental illness care

Inpatient serious mental illness care2


Detox2

Rehabilitation2

Outpatient

Prescription drug

Prescription deductible, individual/family Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical

Generic formulary $20 $20 $20 $20

50%, after deductibleBrand formulary $40 $40 $40 $40

Non-formulary brand $60 $60 $60 $60

Prescription mail order Available Available Available Available Not available

HRA plan HSA plans

27

* Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Personal Choice, and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, the payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC’s fee schedule, payment is 50% of the actual charge of the provider. For services rendered by hospitals and other facility providers in the local service area, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with hospitals and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.


Benefits per contract year BC PPO HRA Plus 3A3 BC PPO HDHP Plus 1A BC PPO HDHP Plus 3A BC PPO HDHP Plus 4A All BC PPO PlansDeductible, individual/family $4,500/$9,000 $1,500/$3,000 $2,500/$5,000 $3,000/$6,000 $5,000/$10,000

Coinsurance, after deductible $0, after deductible $0, after deductible $0, after deductible 50%, after deductibleOut-of-pocket maximum, individual/family (includes deductibles, copays, and coinsurance) $5,600/$11,200 $5,600/$11,200 $5,600/$11,200 $10,000/$20,000



50%, no deductible



$0, after deductible $0, after deductible $0, after deductible 50%, after deductibleSpecialist office visit

Spinal manipulations (20 visits per contract year1)



Inpatient hospital services/days (includes maternity)2 $0, after deductible/unlimited days $0, after deductible/unlimited days $0, after deductible/unlimited days 50%, after deductible/70 days


$0, after deductible $0, after deductible $0, after deductible


Maternity hospitalization 50%, after deductibleOutpatient surgeryAmbulance (emergency) Covered at the in-network levelOutpatient lab/pathology

$0, after deductible $0, after deductible $0, after deductible 50%, after deductible





Outpatient mental health care

Inpatient mental health care2

Outpatient serious mental illness care

Inpatient serious mental illness care2


Detox2

Rehabilitation2

Outpatient

Prescription drug

Prescription deductible, individual/family Integrated with medical Integrated with medical Integrated with medical Integrated with medical Integrated with medical


50%, after deductibleBrand formulary $40 $40 $40 $40


Prescription mail order Available Available Available Available Not available

HSA plans

28

Other insurance needs

For groups with 51 – 99 employees onlyIf you add vision or prescription drug coverage to any medical plan, an employee who chooses that medical plan will receive the same vision and prescription drug coverage.

Vision coverageThe IBC Vision program, administered by Davis Vision, an independent company, offers your employees comprehensive benefits, including routine eye care, eyeglasses, and contact lenses. Members have access to more than 2,200 local providers and over 24,800 providers across the country. Employees receive maximum benefits and don’t need to file a claim form when they receive care from network providers.

Highlights of the IBC Vision program benefits and value-added services:

• eye exam, including refraction, glaucoma screening, and dilation;• eyeglass frames and lenses and/or contact lenses;• a complete pair of eyeglasses may be covered at 100 percent when using a participating provider and choosing frames from the Davis Collection of Frames;• unconditional one-year breakage warranty for frames selected from the Davis Collection and all spectacle lenses fabricated in Davis Vision’s laboratories;• Lens 123® replacement contact lens discount mail order program;• a discount on laser vision correction services at participating providers.

Prescription drug coverageWant to help your employees stay healthy and better manage chronic conditions? Providing prescription drug coverage can help. When medications are more affordable, employees are more likely to take them and keep their health in check. This means fewer sick days and more productivity for you.

IBC offers two types of drug programs so you can choose an affordable option that’s right for your company. The Select Drug Program® uses a prescription drug formulary and provides coverage based on a three-tier copayment incentive (e.g., $10 generic formulary/$45 brand formulary/$75 non-formulary).

Members pay less when using formulary medications but have access to covered non-formulary medications with a higher copayment. The Standard Drug options control costs by offering generic medications at a much more affordable price. Brand medications are available but at a significantly higher cost.

All IBC prescription plans give your employees access to:

• Affordable prescription drug coverage. Get covered medicines like antibiotics, contraceptives, asthma inhalers, self-injectable drugs, and more.

• Extensive retail pharmacy network. Choose from more than 60,000 participating pharmacies nationwide.

• Convenient mail order service. Members receive an extended supply of their medication for a lower copay.

Standard Drug options

$7/50% ($125)

Deductible N/A

Generic $7

Brand250% of discounted price up to $125 (maximum member payment per prescription)

Select Drug Program® options

$10/$20/$35 $10/$45/$75 $20/$40/$60 $250/$10/$45/$75

Deductible1 N/A N/A N/A $250 (waived for generics)


Brand formulary $20 $45 $40 $45


1 Deductible is applied per person per calendar year to all covered services purchased in network and out of network through a retail pharmacy or the mail order network.

2 Brand drugs vary in cost, and cost-sharing is based on a discounted amount that was negotiated with the pharmacy.

28

For all groupsDental coverageWe offer access to a broad range of United Concordia dental products. All programs include a comprehensive network of dentists, and members never need a claim form when using a participating provider. The programs also put a strong emphasis on prevention, early diagnosis, and treatment. Plus, if you select a dental plan, all of your employees will get the plan too.

Choose from one of these affordable options:

• Concordia Plus — dental managed care

• Concordia Preferred — dental preferred provider organization (PPO)

• Concordia Flex — traditional fee-for-service

United Concordia is an independent company that administers and underwrites the dental programs. These are not Blue Cross products/services. United Concordia is solely responsible for the dental products/services.

Life and disability coverageWe also offer life and disability coverage through an arrangement with an independent agency. This coverage gives your employees the extra financial protection they may otherwise be unable to afford. Some of the advantages of our coverage include:

• affordable group rates;• easy enrollment process;• guaranteed enrollment for Life/Accidental Death and Dismemberment (AD&D) insurance without completing health questionnaires. Participation guidelines apply.

Eligible employees Coverage amount

2 — 5 $35,000

6 — 9 $50,000

10+ Varies


30

Healthy LifestylesSM RewardsHealthy Lifestyles Rewards makes getting healthy, and staying healthy, easy. The program is available to customers who include an HRA compatible, HSA-qualified high deductible health plan, or any high-deductible health plan in their offerings. Healthy Lifestyles Rewards is an incentive-based program that awards HealthPoints to employees and their covered dependents age 18 and over for completing healthy activities, including:

• completing a health assessment

• engaging in physical fitness

• getting preventive screenings

• quitting smoking

• losing weight

• getting a dental checkup

Points accumulate to an annual maximum set by you. We’ll send you a report each month detailing the points that your employees and their dependents have earned. Based on the points earned, you deposit dollars into your employees’ HRA compatible or HSA qualified accounts.

50% of health care costs are related to lifestyle choices and behavior.

Genetic

Access

Environment

Behavior

Source: Adapted from Department of Health and Human Services, Centers for Disease Control and Prevention.

30


Rewards for your companyHere’s how it works. Select a high deductible health plan for your employees. In past years, you have passed your premium savings from choosing the high deductible plan on to your employees by funding half of their deductible through an HSA. Now, when you pair Healthy Lifestyles Rewards with a high deductible health plan, including plans paired with an HRA or plans that are HSA qualified, your employees must earn their deductible contribution by engaging in healthy behaviors. The more they participate in the program, the more dollars they earn in their spending account!

Your return is maximized when your employees and their families fully participate in the Healthy Lifestyles Rewards program. In addition to financial returns, there are other tangible benefits that come with a healthier workforce, such as:

• medical cost savings through improved employee health;

• healthier, more positive workforce;

• greater productivity through reduced absenteeism due to health issues;

• higher employee morale.

Invest in your employees — and the long-term health of your company — with Healthy Lifestyles Rewards if you have an HSA qualified, HRA compatible, or high-deductible plan.

On average, employee health care costs fall by $3.27 for every $1 spent on employee wellness programs.

Health Affairs, February 2010, Vol. 29, No. 2

31

32

Tools and resources

Solutions to help you manage your business

Solutions to help your employees manage their healthNo matter what plans your employees choose, they have access to the programs, tools, and resources they need to get engaged in their health and make informed health care decisions. Our membership advantages include cash rewards, discounts, and reminders designed to help your employees and their families lead healthier lives.

Cash reimbursements (through Healthy Lifestyles1) — We believe your employees should be rewarded for taking action to maintain and improve their health. If your employees exercise regularly, we’ll reimburse them up to $150 for fitness center fees. If they want to lose weight or quit smoking, we’ll reimburse them up to $200 for program fees to help them reach their goals. We’ll even give them money back for purchasing a bike helmet, completing a CPR class, or going to a parenting class.

Valuable discounts (through Blue365®) — When your employees carry our card they can get discounts on, national fitness clubs, diet programs, laser vision correction, hearing aids, and much more. From sneakers to spa treatments, your members can enjoy the many perks that come with an Independence Blue Cross membership2.

Important reminders — We’ll help your employees remember to schedule routine tests and screenings by sending them educational reminders for mammograms, Pap tests, and colorectal screenings. They’ll also get special reminders and resource mailings to keep the whole family up to date on immunizations.

Online tools — Our member website, ibxpress.com, is loaded with wellness tools and information to help your employees stay at peak performance. Whether they want to research symptoms, complete a health assessment, engage in an online lifestyle improvement program, or record and track important health information, our website can help. That’s not all. Members can use ibxpress.com to review their benefits, find a doctor or hospital, and check the status of claims. It’s free, secure, and convenient.

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

2 $25 yearly access fee for certain programs managed by American Specialty Network.

Manage your account with ibxpress.com We understand that running a small business means that you have a lot of responsibilities to juggle, so we want to make managing your health benefits as easy as possible. Whether you’re looking for account information or online billing, you get 24/7 access through ibxpress.com.

Account Management features:• Add or delete a member.• Change employee or dependent information.• View coverage history.• Download forms.• View your daily work log and transaction history.

eBilling and epayment features:• View current and prior invoices.• Review billing and payment history.• Get monthly billing reminders.• Receive and pay invoices online.

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Important information

Blue Solutions Choice products• For Blue Solutions Choice products employers contribute

a defined amount towards the employees’ premium. The employee is responsible to pay the remainder of the premium after the employer contribution.

• The employer can offer multiple Blue Solutions Choice products from the Choice product portfolio to its employees.

• The Choice products are available to groups of 2 – 99 employees (new and existing business).

Blue Solutions Choice product guidelines:• For 2 – 50 groups, the Blue Solutions Choice product is

packaged with a Select Drug or Basic Drug rider and Vision rider.

• For 51 – 99 groups employers may choose from several Select Drug and Basic Drug plan options.

• If the employer decides to offer vision, drug, or dental coverage with Blue Solutions Choice products, vision, drug or dental must be offered with all Blue Solutions Choice products offered by the employer.

• Employers may not offer the same Blue Solutions Choice product with different drug, dental, and/or vision products.

• Blue Solutions Choice products cannot be combined with coverage options from non-Blue Solutions Choice products.

Employer contribution requirement:• For contributory plan offerings, employers must contribute

a minimum of 25 percent of the lowest cost options gross monthly premium or 75 percent of the single tier rate of the lowest cost option offered.

Off-anniversary benefit changes:• Upgrades and downgrades to Blue Solutions Choice

products will be allowed only on anniversary.

Billing:• The employer will receive a total monthly bill. It is the

responsibility of the employer to collect the employees’ portion of the bill and submit a full payment to Independence Blue Cross.

Benefits that require preapprovalAdditional approval from Independence Blue Cross may be required before your employees may receive certain tests, procedures, and medications. When your employees need services that require preapproval, their primary care physician or provider* contacts the Care Management and Coordination (CMC) team and submits information to support the request for services. The CMC team, made up of physicians and nurses, evaluates the proposed plan of care for payment of benefits. The CMC team will notify your employee’s physician/provider if the services are

approved for coverage. If the CMC team does not have sufficient information or the information evaluated does not support coverage, your employee and his or her physician/provider are notified in writing of the decision. Employees or a provider acting on their behalf may appeal the decision. At any time during the evaluation process or the appeal, the provider or your employee may submit additional information to support the request.

For a list of services that require preapproval, visit www.ibx.com/preapproval.

Note: Other than the specific guidelines for Blue Solutions Choice products described in this section, the Small Group Underwriting Guidelines generally apply to Blue Solutions Choice products.

What’s not covered?• services not medically necessary;• services or supplies that are experimental or

investigative, except routine costs associated with qualifying clinical trials;

• hearing aids, hearing examinations/tests for the prescription/ fitting of hearing aids, and cochlear electromagnetic hearing devices;

• assisted fertilization techniques, such as in vitro fertilization, GIFT, and ZIFT;

• reversal of voluntary sterilization;• expenses related to organ donation for nonmember

recipients;• dental care, including dental implants or dentures, and

nonsurgical treatment of temporomandibular joint syndrome (TMJ);

• music therapy, equestrian therapy, and hippotherapy;• treatment of sexual dysfunction not related to organic

disease except for sexual dysfunction relating to an injury;• routine foot care, unless medically necessary or associated

with the treatment of diabetes;• foot orthotics, except for orthotics and podiatric appliances

required for the prevention of complications associated with diabetes;

• cranial prosthesis, including wigs intended to replace hair;• alternative therapies/complementary medicine such

as acupuncture;• routine physical exams for nonpreventive purposes, such

as insurance or employment applications, college, or premarital examinations;

• immunizations for travel or employment;• services or supplies payable under workers’ compensation,

motor vehicle insurance, or other legislation of similar purpose;

• cosmetic services/supplies;• outpatient services that are not performed by a member’s

designated provider (HMO plans only).

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For additional information, contact yourbroker, or call IBC at 215-241-3400.

www.ibx.com/bc

2012-0397 (2/13) 16983HMO products underwritten and administered by Keystone Health Plan East. Personal Choice PPO products underwritten and administered by QCC Insurance Company. Keystone Health Plan East and QCC Insurance Company are subsidiaries of Independence Blue Cross – independent licensees of the Blue Cross and Blue Shield Association.

ibx.com

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