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IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
IBC Individual Health Plans 2010
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IBC Individual Health Plans 2010

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New Individual Health Plans from Keystone & Personal Choice Effective 7-1-2010

New Individual Health Plans from Keystone & Personal Choice Effective 7-1-2010

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  • 1. Health Plans for The benefits you need... at the price you can afford... Individuals and Families from the name you know and trust
  • 2. Contents Why choose Blue? Because we’re dedicated to improving the health and wellness programs, discounts on health and wellness products, and 24/7 of the communities we serve in Philadelphia, Montgomery, access to a Health Coach. You also get tools and resources to Bucks, Delaware, and Chester counties. In fact, we’re the manage your benefits and make informed decisions about region’s #1 HMO and PPO provider*. With an expansive network your health through our member website, ibxpress.com. of more than 55,000 doctors and 100 hospitals to choose from, Copay plans . . . . . . . . . . . . . . . . . . 2 you can always find the care you need. Need help choosing? It’s all about predictability. Almost all of the in-network services you use are We can help. For more than 70 years, we’ve provided the best in quality, covered by a fixed dollar amount, known as a copay. Visiting your doctor for a reliability, and service to Philadelphians. Choose Independence We offer three different types of plans – copay, deductible, check-up? Pay a copay. Need physical therapy? Pay a copay, and we take care Blue Cross, the name you know and trust. and health savings account (HSA). All of our plans offer of the rest. comprehensive coverage, but what you pay each month Think a Blue plan is too expensive? depends on what you want to spend when you see the doctor Think again. or go to the hospital. With our copay plans, you pay a set Deductible plans . . . . . . . . . . . . . . . 6 dollar amount for most services while our deductible and HSA You have a wide variety of medically underwritten plans** to It’s all about affordability. With these plans, you still have copays or 100% plans help reduce monthly costs by requiring a deductible choose from at various prices. You’re bound to find a plan that coverage for the services you use most often, such as doctor visits, screenings, and coinsurance for certain services. Use the chart below to meets your needs without breaking the bank. That means you and immunizations. The in-network deductible, an amount you pay before figure out what type of plan works best for you. Still not sure? still have money left to catch a Phillies game, visit the zoo, or insurance kicks in, applies only to services such as hospital and emergency Contact your broker for more information. spend the weekend at the shore. care. After you pay your deductible, you’re responsible for coinsurance, a percentage of the provider’s charge. Plus, all of our plans include value-added extras such as reimbursements for gym fees and weight management HSA plans. . . . . . . . . . . . . . . . . . . . 10 Here’s an overview of the types of plans we offer It’s all about savings. With our health saving account (HSA) plans, you have two ways to save. First, you save money by paying lower premiums each $$$ Monthly Rate $ month. Then, you can invest your money in a tax-advantaged HSA to save for deductibles and coinsurance. Plus, if you don’t use all of your HSA dollars, the money is yours and can be rolled over year to year to pay for future expenses. Copay Deductible HSA Office visits Copay Copay Coinsurance after deductible Value-added programs . . . . . . . . . .14 Preventive care Covered 100% Covered 100% Covered 100% There are a lot of advantages to being an Independence Blue Cross member. We HMO options: Copay Emergency care PC options: Coinsurance Coinsurance after deductible Coinsurance after deductible want to make it easier for you to save money and make healthy choices. That’s HMO options: Copay why we offer the programs, tools, and resources members need to get engaged Inpatient hospital PC options: Coinsurance Coinsurance after deductible Coinsurance after deductible in their health and make informed health care decisions. HMO options: Copay HMO: Copay X-ray PC options: Coinsurance PC: Coinsurance after deductible Coinsurance after deductible Laboratory HMO options: Covered 100% HMO: Covered 100% Coinsurance after deductible Glossary . . . . . . . . . . . . . . . . . . . . . 18 PC options: Coinsurance PC: Coinsurance after deductible options Prescription drugs Yes Yes Yes Choosing a health plan doesn’t have to be difficult. Learn more about some of the common terms and definitions, such as coinsurance, deductible, and referral. Pair with a tax-free health N/A N/A Yes savings account (HSA) Important information . . . . . . . . . . 20 Cost-sharing included in the chart above applies to in-network coverage only. For PPO out-of-network cost-sharing, Get a better understanding of our policies and guidelines and the steps refer to the benefits summary charts in this brochure. *According to a leading independent consumer magazine. we take to help you receive appropriate care. **Final rate quote and approval of coverage is dependent on medical underwriting. Approval is not guaranteed, and some applications may not be approved based on medical conditions. 1
  • 3. Copay plans It’s all about predictability. Whether paying for utilities, your phone bill, or groceries, it can be hard to predict how much you’ll need to pay each month. But our copay plans offer the predictability you need to control your budget so that you aren’t surprised when your bill arrives. Almost all of the services you use are covered by a fixed copay if you use in-network providers. Visiting your doctor? Pay a copay. Need physical therapy? Pay a copay. We’ll take care of the rest. Here’s a look at what our copay plans include: • office visits • preventive care • prescription drugs • hospital stays • emergency/urgent care • X-rays • laboratory services • routine eye care (HMO plans only) • maternity (HMO plans only) Need help choosing between our Keystone HMO and Personal Choice® PPO plans? There are several key differences between our HMO and Personal Choice plans. With our HMO plans from Keystone Health Plan East, you select a primary care physician to coordinate all of your health care needs and provide you with referrals to network specialists. In comparison, our Personal Choice plans give you the flexibility to receive care from doctors both in and out of network. There’s no need to pick a primary care physician and you never need a referral. Our Personal Choice plans also provide in-network coverage coast- to-coast when you use BlueCard® PPO providers. While our Personal Choice plans offer you freedom to access care directly, they do not provide coverage for maternity and routine eye care, which are included in our HMO options. City skyline from steps of the Philadelphia Museum of Art, Philadelphia County. Our copay plans have predictable, set costs for most services. This 2 makes it easier for you to budget so that you can add in trips to the 3 movies, art museum, or any of the attractions that Philly has to offer.
  • 4. Copay plans HMO 20 Copay HMO 15 Copay HMO 10 Copay Personal Choice PPO 30 Copay Benefits per calendar year You pay You pay You pay You pay in-network You pay out-of-network** Deductible, individual/family None $5,000/$10,000 Coinsurance, after deductible 20% 50% None None None $5,000/$10,000 $10,000/$20,000 Out-of-pocket maximum, individual/family Includes coinsurance only Includes coinsurance only Preventive services Mammogram (no referral required) $0 50%, no deductible Pediatric immunizations (subject to office visit copay) $0 $0 $0 $0 Nutrition counseling (6 visits per year‡) $0 50%, after deductible Physician services Primary care office visit $20 $15 $10 $30 50%, after deductible Specialist office visit $50 Routine gynecological exam/Pap test (no referral required, 1 per year) $30 $25 $20 $30 50%, no deductible Routine eye exam (once every two years) Not covered Not covered Eyeglasses or contact lenses (once every two years) $35 benefit* $35 benefit* $35 benefit* Not covered Not covered Spinal manipulations (20 visits per year‡) $50 $30 $25 $20 50%, after deductible Physical/occupational therapy (30 visits per year‡) $50 Hospital/other medical services Inpatient hospital services 20%/unlimited days 50%, after deductible/70 days $400† $200† $100† Maternity hospitalization Not covered Not covered Emergency room (not waived if admitted) $100 $100 20% 20%, after in-network deductible $100 Outpatient surgery $400 $200 Ambulance $0 $0 $0 Outpatient lab/pathology Routine radiology/diagnostic $30 $25 $20 20% 50%, after deductible MRI/MRA, CT/CTA scan, PET scan $60 $50 $40 Biotech/specialty injectables $100 $75 $50 Durable medical equipment (HMO: up to $1,000 per year; PC: up to $2,000 per year, 50% 50% 50% which includes up to $1,000 for diabetic equiptment and supplies) Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered Not covered Prescription drug Prescription deductible, individual/family $250/$750 $100/$300 $100/$300 None None Generic formulary copay $15, after prescription deductible $15, after prescription deductible $15, after prescription deductible $10 Brand formulary copay $25, after prescription deductible $25, after prescription deductible $25, after prescription deductible $30 50%, no deductible Non-formulary copay $35, after prescription deductible $35, after prescription deductible $35, after prescription deductible $50 Prescription mail order Available Available Available Available Available Maximum prescription drug benefit, individual/family Up to $2,500/$5,000 per year Up to $2,500/$5,000 per year Up to $2,500/$5,000 per year Up to $2,500 per person per year ‡ *Paid-in-full benefit available with select group of frames at Davis Vision participating providers. ** It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, 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. † Amount shown reflects the copayment per day. There is a maximum of five copayments per admission. ‡ For PPO plans, maximums shown are combined for in- and out-of-network care. 4 Certain plan benefits may be enhanced in order to comply with health care reform legislation. 5
  • 5. Deductible plans It’s all about affordability. Our deductible plans are a great way to lower your monthly costs. Better yet, the in-network deductible applies only to services such as hospital and emergency care. You still have copays or 100% coverage for services such as doctor visits, screenings, and immunizations. Here’s a look at what our deductible plans include: • office visits • preventive care • prescription drugs • hospital stays • emergency/urgent care • X-rays • laboratory services • routine eye care (HMO plans only) • maternity (HMO plans only) Why have insurance if I have to pay a deductible? A deductible may seem like a lot of money to pay, but keep in mind, it doesn’t apply to all services. Think of the cost if you don’t have insurance. An unexpected accident or illness could result in medical bills up to $50,000 or more. A deductible is much less, and probably much easier to pay off. Plus, when you show your card to a participating provider, your deductible is based on our discounted rates. It’s typically a fraction of what people without insurance pay. Once you reach the deductible, you’re responsible for a percentage of the cost and we’ll take care of the rest. Need help choosing between HMO and Personal Choice? Turn to page 3. Linvilla Orchards, Delaware County. With a deductible plan, you get lower monthly rates and you don’t have to pay for benefits you don’t use. That makes it easier to enjoy hayrides through the fields, fishing in Orchard 6 7 Lake, and picking fresh fruit at Linvilla Orchards.
  • 6. Deductible plans HMO 5000 HMO 2500 HMO 1500 Personal Choice PPO 5000 Personal Choice PPO 2500 You pay You pay Benefits per calendar year You pay You pay You pay You pay in-network out-of-network* You pay in-network out-of-network* Deductible, individual/family $5,000/$10,000 $2,500/$5,000 $1,500/$3,000 $5,000/$10,000 $10,000/$20,000 $2,500/$5,000 $5,000/$10,000 Coinsurance, after deductible 30%, unless otherwise noted 30%, unless otherwise noted 30%, unless otherwise noted 20% 50% 20% 50% $5,000/$10,000 $10,000/$20,000 Out-of-pocket maximum, individual/family $7,500/$15,000 $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 $20,000/$40,000 Includes coinsurance only Includes coinsurance only Preventive services Mammogram (no referral required) $0, no deductible 50%, no deductible $0, no deductible 50%, no deductible Pediatric immunizations (subject to office visit copay) $0, no deductible $0, no deductible $0, no deductible Nutrition counseling (6 visits per year†) $0, no deductible 50%, after deductible $0, no deductible 50%, after deductible Physician services Primary care office visit $30, no deductible $30, no deductible $30, no deductible $30, no deductible $30, no deductible 50%, after deductible 50%, after deductible Specialist office visit $50, no deductible $50, no deductible $50, no deductible $50, no deductible $50, no deductible Routine gynecological exam/Pap test (no referral required, 1 per year) $30, no deductible $30, no deductible $30, no deductible $30, no deductible 50%, no deductible $30, no deductible 50%, no deductible Routine eye exam (once every two years) $50, no deductible $50, no deductible $50, no deductible Not covered Not covered Not covered Not covered Eyeglasses or contact lenses (once every two years) $35 benefit* $35 benefit* $35 benefit* Not covered Not covered Not covered Not covered Spinal manipulations (20 visits per year ) † $50, no deductible $50, no deductible $50, no deductible $50, no deductible 50%, after deductible $50, no deductible 50%, after deductible Physical/occupational therapy (30 visits per year†) Hospital/other medical services Inpatient hospital services/days 20%, after deductible/unlimited 50%, after deductible/70 20%, after deductible/unlimited 50%, after deductible/70 Maternity hospitalization Not covered Not covered Not covered Not covered Emergency room (not waived if admitted) 20%, after in-network 20%, after in-network 30%, after deductible/unlimited 30%, after deductible/unlimited 30%, after deductible/unlimited 20%, after deductible 20%, after deductible deductible deductible Outpatient surgery Ambulance Outpatient lab/pathology $0, no deductible $0, no deductible $0, no deductible Routine radiology/diagnostic $50, no deductible $50, no deductible $50, no deductible 20%, after deductible 50%, after deductible 20%, after deductible 50%, after deductible MRI/MRA, CT/CTA scan, PET scan $100, no deductible $100, no deductible $100, no deductible Biotech/specialty injectables Durable medical equipment (HMO: up to $1,000 per year; PC: up to $2,000 per 50%, after deductible 50%, after deductible 50%, after deductible year, which includes up to $1,000 for diabetic equiptment and supplies) Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered Not covered Not covered Not covered Prescription drug Prescription deductible, individual/family None None None None None None None Generic formulary copay $10 $10 $10 $10 $10 Brand formulary copay $30 $30 $30 $30 50%, no deductible $30 50%, no deductible Non-formulary copay $50 $50 $50 $50 $50 Prescription mail order Available Available Available Available Available Available Available Maximum prescription drug benefit, individual/family Each year you have coverage up Each year you have coverage up Each year you have coverage Up to $2,500 per person, per year† Up to $2,500 per person, per year† to $2,500/$5,000 to $2,500/$5,000 up to $2,500/$5,000 *Paid-in-full benefit available with select group of frames at Davis Vision participating providers. ** It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, 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. 8 † For PPO plans, maximums shown are combined for in- and out-of-network care. 9 Certain plan benefits may be enhanced in order to comply with health care reform legislation.
  • 7. HSA plans It’s all about savings. Finally, there’s a way to make the most of your health care dollars. When you have one of our Personal Choice® HSA-qualified medical plans, the savings are twofold. First, you save money by paying lower premiums each month. Then, you can invest your money in a tax- advantaged health savings account (HSA) to save for deductibles and coinsurance. Plus, if you don’t use all of your HSA dollars, the money is yours and can be rolled over year to year to pay for future expenses. Here’s a look at what our HSA-qualified medical plans cover, both in and out of network: • office visits • preventive care • prescription drugs • hospital stays • emergency/urgent care • X-rays • laboratory services Want to open a health savings account? You can use our preferred vendor, The Bancorp Bank, an independent company, to set up an HSA or you can pick any bank you like. To set up a Bancorp HSA, simply check the box in Section A of the application that reads: “Yes, I’d like an HSA account set up with Bancorp.” Bancorp HSA features include: • no application or account set up fees; • no monthly maintenance 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. 1 Standard banking fees apply, e.g. insufficient funds 2 Interest paid on balances over $1 Downtown West Chester, Chester County. Our HSA plans help you save money, so you can spend it on what you love most: grabbing a bite to eat with friends or browsing local stores for that next great find. 10 11
  • 8. HSA plans Want to make the most of Personal Choice PPO 5000 HSA Personal Choice PPO 3000 HSA your HSA plan? You pay in- You pay You pay Benefits per calendar year network out-of-network* You pay in-network out-of-network* Take the savings you get with your monthly Deductible, individual/family $5,000/$10,000 $10,000/$20,000 $3,000/$6,000 $6,000/$12,000 premiums and open a health savings account (HSA). Coinsurance, after deductible N/A 50% 20% 50% You can use the money in your HSA to pay for Out-of-pocket maximum, individual/family deductibles and coinsurance. If you have money left (includes deductibles, copays, and coinsurance) $5,000/$10,000 $20,000/$40,000 $5,000/$10,000 $10,000/$20,000 over at the end of the year, it carries over into your Preventive services account for next year. Mammogram 50%, no deductible 50% , no deductible Pediatric immunizations (subject to office visit copay) $0, no deductible $0, no deductible Monthly premium Nutrition counseling (6 visits per year†) 50%, after deductible 50%, after deductible Premium savings put into HSA Physician services Primary care office visit $0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible Specialist office visit Routine gynecological exam/Pap test (1 per year) $0, no deductible 50%, no deductible $20, no deductible 50% , no deductible Routine eye care Not covered Not covered Not covered Not covered Spinal manipulations (20 visits per year ) † Want to see just how much you can save with an HSA? $0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible Physical/occupational therapy (20 visits per year†) Let’s say each year you contribute $1,500 to your HSA and withdraw, on average, $500 for health care expenses. Hospital/other medical services With an interest rate of 3.5%, your savings will grow each year! Depending on how you invest your money in the $0, after deductible/ 50%, after deductible/ 20%, after deductible/ 50%, after deductible/ account, your savings can be even greater. Inpatient hospital services/days unlimited days 70 days unlimited days 70 days Maternity hospitalization Not covered Not covered Not covered Not covered $0, after in-network 20%, after in-network Balance at end of year 10 Tax savings Emergency room (not waived if admitted) $0, after deductible deductible 20%, after deductible deductible $11,731.39 $5,314.02 Outpatient surgery $14,000 Ambulance Outpatient lab/pathology $12,000 Routine radiology/diagnostic $0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible MRI/MRA, CT/CTA scan, PET scan $10,000 Biotech/specialty injectables $8,000 Durable medical equipment (up to $1,000 per year) Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered $6,000 Prescription drug $4,000 Prescription deductible, individual/family Integrated with medical Integrated with medical Integrated with medical Integrated with medical Generic formulary copay $10, after deductible $2,000 Brand formulary copay $0, after deductible 50%, after deductible $30, after deductible 50%, after deductible $0 Non-formulary copay $50, after deductible 1 2 3 4 5 6 7 8 9 10 Prescription mail order Available Available Available Available Maximum prescription drug benefit†, individual/family None None None None 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 * It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for earnings reinvested in the account, and $500 withdrawn for eligible medical expenses on the first day of each year. differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of- network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance 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. may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, 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. † Maximums shown are combined for in- and out-of-network care. Certain plan benefits may be enhanced in order to comply with health care reform legislation. 12 13
  • 9. Value-added programs A plan for better health We care about you and your health. We want to make it easier for you to save money and make healthy choices. That’s why we offer the programs, tools, and resources members need to get engaged in their health and make informed health care decisions. Enjoy big rewards with Healthy LifestylesSM Our unique Healthy Lifestyles programs offer cash rewards, discounts, and reminders designed to help you and your family lead healthier lives. Cash rewards – We believe you should be rewarded for taking action to maintain and improve your health. Exercise regularly? We’ll give you up to $150 back on your fitness center fees. Quit smoking or lost weight? We’ll reimburse you up to $200 on your program fees. We’ll even give you money back when you buy a bike helmet, complete a CPR class, or go to a parenting class. Valuable discounts – How about a discount on a massage or fitness gear? Just show your card and you’ll earn a discount at participating providers. From alternative health services like acupuncture to yoga books and DVDs, you’ll enjoy the discounts that come with an Independence Blue Cross membership. Our members also get exclusive discounts on CorCell®, a program that preserves your child’s umbilical cord blood - a resource that may help combat a variety of life-threatening diseases.* Important reminders – We’ll help you remember to schedule those routine tests and screenings that always seem to slip your mind. We’ll send you educational reminders for mammograms, Pap tests, and colorectal screenings. You’ll also get special reminders and resource mailings to keep the whole family up to date on immunizations and vaccinations. 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. *CorCell is an independent company offering a discount on cord blood preservation services to Independence Blue Cross members. CorCell does not offer Blue Cross and/or Blue Shield products or services. CorCell is solely responsible for its products and services. Valley Forge National Historical Park, Montgomery County. Our wellness programs offer cash rewards and valuable discounts. 14 It’s just the motivation you need to go for a run, ride your bike, or 15 take a walking tour on the expansive grounds of this historical site.
  • 10. Value-added programs Make informed decisions Take control of your health Receive personalized support ibxpress.com also provides the tools you need to make lifestyle You don’t have to be alone when making Our member website, ibxpess.com, provides tools and changes – like losing weight or quitting smoking – by helping important decisions regarding your resources to help you make informed health care decisions. you get started, set reachable goals, and track your progress. health. Our ConnectionsSM Health We’ve partnered with WebMD® to provide you with Management Programs give you the personalized tools and reliable information to help you make • Personal Health Profile (PHP) – This powerful one-on-one support you need when health decisions that are right for you. health assessment tool will give you a clear picture facing significant treatment decisions or • Provider Finder and Hospital Finder help you find of what you are doing right and suggest ways to stay everyday health concerns. Your personal the participating doctors and hospitals that are best healthy. After you complete the PHP, you’ll receive an Health Coach is available 24/7 to answer equipped to handle your needs. You can learn about accurate, confidential, and personalized action plan. your questions and to help you make where your doctors went to medical school, their board knowledgeable, confident decisions • Lifestyle Improvement Programs – These certification, languages spoken, and more. You can regarding your health care. Your Health personalized, self-paced, step-by-step programs also compare hospitals based on their experience, Coach can provide: will help you improve your health. You’ll find cost, patient satisfaction, and other factors you several different programs, such as exercise, weight • information on everyday health find important. management, nutrition and smoking cessation, designed concerns, such as headaches and • Symptom Checker provides a head-to-toe tool to to inspire and support your positive health changes. joint pain; help you evaluate how serious your symptoms are – and These online programs combine proven tactics with the what you should do about them. ultimate in privacy, security, and convenience. • help if you are facing a significant medical decision, such as treatment • Health Encyclopedia provides information on more • Health Trackers – Chart your progress over time options for back pain, breast or than 160 health topics and the latest news on to help you stay motivated. Track blood pressure, prostate cancer, or surgery: common conditions. cholesterol, body fat, and other health factors. Or, customize the tool by adding a new health tracker for • personalized calls about your • Treatment Cost Estimator helps you estimate your additional data you want to track – like test results, chronic condition or health costs for hundreds of common conditions – including number of push-ups, etc. concerns; tests, procedures, and health care visits – so you can plan and budget for your expenses. • Personal Health Record – Use your Personal Health • information about what types of Record to store, maintain, track, and manage your questions to ask your doctor. health information in one centralized, private, and Take a tour of our secure location. We’ll even update your Personal Health Record for you each time we process one of your claims. 1 WebMD is an independent company offering online health information and wellness education to Independence Blue member website on Cross members. www.ibxpress.com. Health information at your fingertips No matter where you take your laptop, ibxpress.com makes it easy for you to stay on top of your health. 16 17 1 1
  • 11. Glossary Choosing a health plan doesn’t have to be difficult. Learn more PPO - This stands for preferred provider organization. With a Precertification – This may also be called about some of the common terms and definitions before you PPO plan, there’s no need to select a primary care physician. preapproval or prior authorization. Basically, make a decision. You can visit any doctor or specialist in the network, without a you may need additional approval from referral. You also have the freedom to choose doctors outside your health plan before you receive certain Copay - It’s a set dollar amount you pay for a covered health the network if you’re willing to pay more for their services. tests, procedures, or medications. It’s a way service. If you have a $10 copay for a doctor’s visit, you simply to make sure the services you’re getting pay $10 and we cover the rest. Preexisting condition - It’s a health condition you received are effective. medical care or advice for before applying for insurance. Coinsurance - Some plans require you to pay a percentage All of our medically underwritten plans have exclusions for Rate guarantee - All of the plans in of your medical costs. If you use a participating provider, your preexisting conditions for the first 12 months of coverage, this brochure come with a six-month rate costs are based on our discounted rate. meaning that some conditions may not be covered for the first guarantee. This means that your final rate Deductible – This is a fixed dollar amount that you must year. Under our HMO plans, we will look at any conditions that will remain the same for the first six months pay before your insurance kicks in. If you use a participating you received services or advice for in the 90 days preceding of coverage. You will be notified in advance provider, your costs are based on our discounted rate. your enrollment. For our PPO plans, the look back period is 12 of any rate increases approved by the months. There are two ways that you can waive or reduce the Pennsylvania Insurance Department. HMO - This stands for health maintenance organization. If preexisting condition exclusion period. you pick an HMO plan, you’ll need to select a family doctor who Referral – If you have an HMO plan, your can help you with general health concerns, or refer you to a • Blue-to-Blue transfer – If you’ve had active health family doctor (or PCP) will need to write network specialist for care. coverage with a Blue Cross® or Blue Shield® plan for up you a referral before you see other network to 12 months without a break in coverage prior to your providers, such as a dermatologist. No need Health savings account (HSA) - A tax-advantaged savings requested effective date, you can receive credit for each to pick up a piece of paper, our referrals are account that can be used to save for health care expenses. You month of prior coverage up to the entire exclusion period done electronically. must be enrolled in an HSA-qualified high-deductible health of 12 months. plan to be eligible to open an HSA. There is a maximum amount that you can contribute to an HSA each year but if you don’t • Creditable Coverage – If you had active coverage with use all of the money within your benefit period, it rolls over to another insurance carrier for at least 18 months without the next year. a break in coverage of more than 63 days prior to your current application, you can receive credit for the entire Medically underwritten plan - All of the plans in this exclusion period of 12 months. brochure are medically underwritten. Your health history and If you qualify for a preexisting condition waiver, be sure to current health will be reviewed to determine whether you complete Section G of the application and provide any qualify for enrollment. If approved, some health conditions may required documentation. require you to pay a higher premium. Premium - This is the amount you pay for your health Out-of-pocket maximum – This is the maximum amount insurance coverage. This is separate from costs you pay when that you will have to pay under your plan. Once you hit your you use your benefits to get care, such as copays, deductibles, out-of-pocket maximum, we’ll cover services requiring a and coinsurance. deductible or coinsurance 100% for the remainder of the Primary care physician (PCP) – This is just another term benefit period. Check plan details to see what’s included in the for your family doctor. HMO plans require you to pick a PCP to out-of-pocket maximum calculation. Please note that none of coordinate your health care and refer you to a specialist if needed. the plans include balance billing by out-of-network providers in the out-of-pocket maximum calculation. Frankenfield Covered Bridge, Bucks County. Riding your bike is a great way to get your health in gear – 18 and admire the foliage and covered bridges of Bucks County. 19 16 1
  • 12. Important information Benefits that require preapproval Emergency services 96-hour temporary supply program – Under this program, if a member’s What’s not covered? doctor writes a prescription for a drug that requires prior authorization, has When you need services that require preapproval, your physician or provider An emergency is defined as the sudden and unexpected onset of a medical • services not medically necessary; an age limit, or exceeds the quantity level limit for a medication, and prior contacts the Care Management and Coordination (CMC) team and provides condition manifesting itself in acute symptoms of sufficient severity or severe authorization has not been obtained by the doctor, a 96-hour supply of the • any treatment of substance abuse or mental illness, including information to support the request for services. For PPO members using a pain that a prudent layperson who possesses an average knowledge of health drug will be made available while the request is being reviewed. Obtaining a serious mental illness; BlueCard® PPO or out-of-network provider, the member is responsible for and medicine could reasonably expect the absence of immediate medical 96-hour temporary supply does not guarantee that the prior authorization • services or supplies that are experimental or investigative, except contacting CMC directly for any required approvals. The CMC team, made up attention to result in any of the following: request will be approved. routine costs associated with qualifying clinical trials; of physicians and nurses, evaluates the proposed plan of care for payment • hearing aids, hearing examinations/tests for the prescription/fitting of of benefits. The CMC team notifies your physician/provider if the services are • placing the member’s health or, in the case of a pregnant member, To learn more about safe prescribing procedures, see a list of drugs requiring the health of the unborn child in jeopardy; hearing aids, and cochlear electromagnetic hearing devices; approved for coverage. If the CMC team does not have sufficient information or prior authorization, or find out how to file a request or appeal, visit • serious impairment to bodily functions; www.ibx4you.com/importantinfo. • assisted fertilization techniques, such as in vitro fertilization, the information evaluated does not support coverage, you and your physician/ • dysfunction of any bodily organ or part. GIFT, and ZIFT; provider are notified in writing of the decision. Members and providers Prescription Drug Program provider • reversal of voluntary sterilization; acting on behalf of a member may appeal the decision. At any time during Emergency care includes covered services provided to a member in an payment information • alternative therapies, such as acupuncture; the evaluation process or the appeal, the provider or member may provide emergency, including emergency transportation and related emergency services A pharmacy benefits management (PBM) company administers our additional information to support the request. provided by a licensed ambulance service. • dental care, including dental implants or dentures, and nonsurgical prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also treatment of temporomandibular joint syndrome (TMJ); For a list of services that require preapproval, Complaints and grievances • treatment of obesity, except for surgical treatment of morbid obesity visit www.ibx4you.com/importantinfo. negotiates price discounts with pharmaceutical manufacturers and provides You have a right to appeal any adverse decision through the Complaint and when medically necessary; drug utilization and quality reviews. Price discounts may include rebates Inpatient hospital stays Grievance Process. Instructions for the appeal will be described in the denial from a drug manufacturer based on the volume purchased. Independence • routine foot care, except for medically necessary treatment of During and after an approved hospital stay, Independence Blue Cross’s (IBC) notifications and in the contract. Blue Cross anticipates that it will pass on a high percentage of the expected peripheral vascular disease and/or peripheral neuropathic disease Care Management and Coordination team monitors your stay. The team reviews rebates it receives from its PBM through reductions in the overall cost of whether you are receiving medically appropriate care, sees that a plan for Privacy policy including, but not limited to, diabetes; pharmacy benefits. Under most benefit plans, prescription drugs are subject • foot orthotics, except for orthotics and podiatric appliances required your discharge is in place, and coordinates services that may be needed At IBC, protecting your privacy is very important to us. That is why we have to a member copayment. for the prevention of complications associated with diabetes; following discharge. taken numerous steps to see that your Protected Health Information (PHI) is kept confidential. Protected health information is individually identifiable health Benefits exclusions • routine physical exams for nonpreventive purposes, such as insurance Utilization review information about you. This information may be in oral, written, or electronic The benefits summaries in this brochure represent only a partial listing of or employment applications, college, or premarital examinations; To assist IBC in making coverage determinations regarding the medical form. IBC may obtain or create your PHI while conducting our business of benefits and exclusions of the plans. Benefits and exclusions may be further • contraceptive devices; necessity and appropriateness of requested services, IBC uses medical providing you with health care benefits. defined by medical policy. This managed care plan may not cover all your • immunizations for travel or employment; guidelines based on clinically credible evidence. This is called utilization review. health care expenses. Read your contract carefully to determine which health IBC has implemented policies and procedures regarding the collection, use, • services or supplies payable under Workers’ compensation, motor Utilization review can be done before a service is performed (prenotification/ care services are covered. If you need more information, please call and release or disclosure of PHI by and within our organization. We continually vehicle insurance, or other legislation of similar purpose; precertification/preservice); during a hospital stay (concurrent review); or after 1-800-263-1410. review our policies and monitor our business processes to make sure that your • cosmetic services/supplies; services have been performed (retrospective/post-service review). IBC follows information is protected while assuring that the information is available as applicable state/federal standards pertaining to how and when these reviews • outpatient services that are not performed by your primary care needed for the provision of health care services. For detailed information on our are performed. physician’s designated provider; If you want to learn more privacy policy, visit www.ibx4you.com/importantinfo. • private duty nursing; Continuity of care Procedures that support safe prescribing (Continuity of care policy applies to HMO plans only) • charges related to any medical condition or illness for which medical Terminated providers Independence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration about how health care advice or treatment was recommended or received during a certain amount of time (90 days for HMO, 12 months for PPO) preceding of its commercial prescription drug programs. As our PBM, FutureScripts the effective date of your plan policy is excluded for the first 12 reform may affect you, IBC offers members continuation of coverage for an ongoing course of treatment with a terminated provider (for reasons other than cause) for up to 90 days is responsible for providing a network of participating pharmacies, months. If you have been continuously insured for 12 months by a from the date that IBC notified the member of the provider termination. IBC will administering pharmacy benefits, and providing customer service to our participating Blue Cross® or Blue Shield® plan, or the past 18 months visit www.ibx.com. cover such continuing treatment under the same terms and conditions as if the members and providers. We support a number of procedures to support safe by another plan (without a break in coverage of more than 63 days treatment was being received from participating providers. prescribing, including: prior to the current application), you may be able to receive credit for all or part of the 12 month exclusion. To learn more about preexisting If a member is in her second or third trimester of pregnancy at the time of Prior authorization – This means that you may need additional approval condition exclusions and how they can be reduced through creditable the termination, the transitional period of authorization shall extend through from your health plan for a certain medication. Certain covered drugs require coverage, visit www.ibx4you.com/importantinfo. post-partum care related to the delivery. All authorized health care services prior authorization to ensure that the drug prescribed is medically necessary provided during this transitional period would be covered by IBC under the and appropriate and is being prescribed according to the U.S. Food and Drug In addition, the following benefits are not covered for PPO plans: same terms and conditions applicable for participating health care providers. Administration’s (FDA) guidelines. • maternity care The nonparticipating provider must agree that all authorized health care Age and gender limits – The FDA has established specific procedures that • routine eye care services provided during this transitional period would be covered by IBC govern prescription prescribing practices. These rules are designed to prevent under the same terms and conditions applicable for participating health care potential harm to patients and ensure that the medication is being prescribed providers. The plan is not required to provide health care services that are not according to FDA guidelines. For example, some drugs are approved by the FDA NOTE: Eligible unmarried dependent children are generally covered to covered benefits. only for individuals age 14 and older, or are prescribed only for females. age 19 or age 23 (if full-time student). See contract for additional details. To obtain complete copies of these policies by mail, please In order to initiate continuity of care, members must complete a Continuity Quantity level limits – These are designed to allow a sufficient supply of contact your broker. of Care form and submit it to IBC’s Care Management and Coordination medication based upon FDA-approved maximum daily doses and length of department. The form is available through Customer Service. therapy of a particular drug. There are several different types of quantity level limits, such as rolling 30-day period, refill too soon, and therapeutic drug class. 20 1 1
  • 13. For questions or to apply, contact your broker! www.ibx4you.com 2010-0053 (05/10) HMO products underwritten and administered by Keystone Health Plan East. Personal Choice PPO products underwritten and administered by QCC Insurance 1 Company, subsidiaries of Independence Blue Cross – independent licensees of the Blue Cross and Blue Shield Association.

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