2016 Business Blue Exclusive Upstate I brochure

Business Blue ExclusiveSM
Business Blue ExclusiveSM Upstate I
GROUP INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA
WITH THE CARD THAT OPENS DOORS IN 50 STATES
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Table of Contents
Overview
4
Plan Networks
5
Essentials
6-7
Services
8-9
Value Adds
10-11
Tools
12-13
Plan Benefits
14-16
Exclusions
17
Overview
4
Think Blue®
TRUST
BlueCross BlueShield of South Carolina has earned the trust of South Carolinians for
nearly 70 years, offering solutions for business owners throughout the state. Ensuring
access to quality health coverage is vital to the health and well-being of every community
in our state. We’re more than a recognized member of the community — we’re a strong
and stable partner you can count on.
CHOICE
Our goal is simple: to provide the highest quality coverage at a reasonable price. Since
there’s no such thing as one size fits all, we offer numerous choices to make sure you
have the right plan for you and your business. Let us help you find the right plan for
your company.
COMMUNITY OUTREACH
Supporting our local community — your working families living in your community —
is important to us. That’s why the BlueCross BlueShield of South Carolina Foundation
supports workplace giving programs, health care-related research, education and
service throughout the state. We also encourage our employees to volunteer their
time and talents to non-profit organizations. By supporting projects that directly
benefit South Carolina’s most vulnerable populations, we are helping to create a
strong community for everyone.
AWARD-WINNING CUSTOMER SERVICE
Year after year, independent companies recognize our Customer Service team for providing excellent service to our members. In 2014, in fact, 35 BlueCross customer service
advocates (CSAs) were recognized for providing superior service to our members. The
recognition came from a leading research firm called Service Quality Management
Group for the CSAs’ ability to resolve member issues during the first call, as well as
callers’ overall service experience.
Our world-class Customer Service team is always here to help you and your employees!
The BlueCross BlueShield of South Carolina Foundation is an
independent licensee of the Blue Cross and Blue Shield Association
Plan Networks
5
Think Networks
PROVIDER NETWORK
The network for our Business Blue Exclusive Upstate I plans is an Exclusive Provider
Organization (EPO). BlueCross has partnered with MyHealth First Network (MyHFN) to
offer exclusive savings on services offered by select doctors and hospitals within Abbeville,
Greenville, Greenwood, Laurens, Oconee, and Pickens counties. With four different plans
to choose from, you can select the plan structure and benefit level that best meets your
company’s needs, as well as the needs of your employees.
Because the plan is an EPO, if a member visits a doctor, clinic or hospital outside the
EPO network for a non-emergency, the member will be responsible for paying the full bill.
However, CVS Minute Clinics throughout the state are in network for members and their
covered dependents. In addition, Doctors Care clinics in South Carolina are in network,
except for locations inside the EPO’s six counties and Newberry County. This offers
members convenient choices for non-emergencies that occur while they are traveling.
In the event of a medical emergency, a visit or treatment in an emergency room anywhere
in the state is covered as in network. If members are traveling outside South Carolina, they
are eligible for the BlueCard® program, which covers emergency medical treatment for plan
members in an emergency room setting only.
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WHAT IS MyHealth First Network?
MyHealth First Network (MyHFN) is a select, clinically-integrated group of health care
providers in the Upstate who collaborate to deliver comprehensive, consistent, coordinated
health care. Together, BlueCross and MyHFN aim to improve health outcomes while
reducing costs for members and delivering an exceptional patient experience.
Essentials
6
Think Basics
BLUE CROSS HEALTH PLAN BASICS
Here are some key things to know before you shop for a plan. Business Blue Exclusive
Upstate I plans often are referred to as “metallic plans” (Gold and Silver) to illustrate
the value of benefits in each plan.
DEFINING GOLD AND SILVER PLANS
Each plan must cover the same set of minimum essential health benefits. While the range
of benefits is the same among the plans, the value of the benefits will vary. This means the
amounts members pay — such as copayments, coinsurance or deductibles — are different.
These metal levels can help you compare plans, monthly premiums and costs for services,
such as doctor or hospital visits.
ESSENTIAL HEALTH BENEFITS
All of our Affordable Care Act (ACA) health plans include these essential health benefits:
■Ambulatory patient services: services that ■Prescription drugs: medications your
can be completed during a single day and
doctor prescribes
don’t require a patient to be admitted to
■Rehabilitative and habilitative services
the hospital
and devices: services that help you
■Emergency services: care that is given in
recover lost abilities or services that
a hospital emergency room
help you gain functions so you can
participate in daily life
■Hospitalization: hospital stays
■Maternity and newborn care: care for
pregnant women and newborn babies
■Mental health and substance dependency
services
■Routine wellness and preventive services
and chronic disease management
services
Essentials
7
SUSTAINED HEALTH
Each of our Business Blue Exclusive Upstate I plans covers many important
preventive benefits the ACA recommends. (Note: some plans may have
different levels of preventive benefits.) The PPACA doesn’t cover some
common procedures, however, including:
■Electrocardiograms (EKGs)
■Chest X-rays
■Blood work (except lipid screenings)
■Urinalysis
Our Sustained Health Benefit is an optional program with all of our Business
Blue Exclusive Upstate I plans. Sustained Health provides $300 toward
allowable expenses for preventive services the member’s plan may not cover
when provided or directed by an in-network primary care physician (PCP). And
Sustained Health offers BlueCross’ one-of-a-kind discounted pricing on these
preventive services. Consider the benefits of Sustained Health for you and
your employees.
Services
8
TIERS
Tier 1 Drugs: Usually
generic and will generally
cost you the least amount
of money out of your
pocket.
Tier 2 Drugs: Most often
brand drugs, sometimes
referred to as “Preferred”
Drugs, because they
usually cost you less
than other brand drugs.
Tier 3 Drugs: Most often
brand drugs, sometimes
referred to as “Non-Preferred”
Drugs, because they usually
cost you more than other
brand drugs. They may
have generic equivalents.
Tier 4 Drugs: Drugs that
treat complex conditions
and are usually very
expensive. You will
usually pay more for
drugs in this tier.
Think Services
PREVENTIVE SERVICES
Services such as preventive screenings for children, women and men, including
prostate screenings according to the American Cancer Society guidelines, are provided
at 100 percent.
The American Cancer Society (ACS) is an independent organization that provides health
information on behalf of BlueCross BlueShield of South Carolina.
For a complete list of covered preventive services, please visit www.uspreventive
servicestaskforce.org. (This link leads to a third party website. That company is solely
responsible for the contents and privacy policies on its site.)
PHARMACY SERVICES
RETAIL
To receive the highest level of benefits for prescription drugs, you must get them through our
network. You can find a list of pharmacies on our website at www.SouthCarolinaBlues.com.
When you buy drugs from a network pharmacy, you must show your BlueCross ID card.
Prescription drugs filled at an out-of-network pharmacy are covered at 50 percent, and
the cost does not apply to your deductible or maximum out of pocket.
Up to 31-day supply
RETAIL 90
Retail 90 is a pharmacy program that allows Business BlueExclusive Upstate I members
to purchase up to a three-month supply of maintenance prescription medications at local
retail pharmacies at the lower mail-order copayment amount. The Retail 90 Pharmacy
Network includes more than 62,000 pharmacies across the country, including the largest
retail chains. A complete list of the Retail 90 Pharmacy Network is available on the
Prescription Drug Information page on our website.
Up to 90-day supply
MAIL ORDER
Members also can get their medications at discounted rates with our mail-order program.
Information about the mail-order program is located on our website under Prescription
Drug Information.
Up to 90-day supply
SPECIALTY DRUG
Drugs designated as specialty medications must be filled at a Caremark Specialty
Pharmacy. Caremark Specialty Pharmacy is an independent company that provides
pharmacy services on behalf of BlueCross. You’ll find the list of drugs that must be filled
at Caremark on the Business Covered Drug List.
Up to 31-day supply
Services
9
Your NavigatorSM for
Health Management
At BlueCross, we take extra steps toward improving the health of your workforce through
our comprehensive health management programs. Using a 360° approach, we offer
wellness, prevention and treatment programs to your employees dealing with an array
of chronic conditions. All of these programs are offered under the name Your Navigator
for Health Management.
There are programs for all members that focus on the early detection of illness and
the prevention of disease. Members with chronic conditions also receive more targeted
educational information and contact with our highly trained health specialists. Our
members with intensive needs receive care coordination and the support of our team
of caring nurses.
Members are automatically enrolled in the appropriate programs based on claims
history, pharmacy spending and physician referral. Members can self-refer to any
of these programs at any time.
Through Your Navigator for Health Management, we offer programs that cover the
spectrum of health and disease in four categories:
PREVENTION AND
WELLNESS
CONDITION
MANAGEMENT
DISEASE
MANAGEMENT
CRITICAL HEALTH
MANAGEMENT
Children’s Health
Cholesterol Improvement
Men’s Health
Pre-Hypertension
Tobacco Cessation
Weight Management
Women’s Health
WalkingWorksSM for South
Carolina Schools
Alcohol Management
Back Care
Healthy and Active Kids
(childhood obesity)
High Cholesterol
High Blood Pressure
(hypertension)
Irritable Bowel Syndrome
Maternity
Migraine (adult and
pediatric)
Metabolic Health
(pre-diabetes)
Neonatal Intensive Care
Unit (NICU) Case
Management
Asthma
Chronic Obstructive
Pulmonary Disease
(COPD)
Depression
Diabetes
Heart Disease
Heart Failure
Care Calls (hospitalto-home transition)
Case Management (for
conditions including
cancer, severe trauma,
multiple chronic conditions, complex wounds,
weight-loss surgery,
Hepatitis C, traumatic
brain injury, rheumatoid
arthritis, transplants and
neuro-muscular diseases)
Care Guardian (emergency
room diversion
management)
Chronic Kidney Disease
Value Adds
10
Think Value
DISCOUNT AND VALUE-ADDED PROGRAMS
Sometimes all you need to feel great is a little sprucing up. And saving money in the
process makes it even more rewarding. That’s why our members enjoy our discounts
and value-added programs. With no claims to file and no annual limits, members pay
the discounted rate directly to participating providers.
FITNESS AND WELLNESS
Fitness Center Memberships
Getting in shape is now more affordable
than ever! We make it easy for our members to save on memberships to local
fitness facilities and other exercise centers.
Children’s Fitness
With My Gym Children’s Fitness Center,
choose from a variety of structured, ageappropriate classes that use music, dance,
relays, games and more.
Weight Management
Enjoy discounts on weight-loss programs
and services, including Jenny Craig. Plus,
get one-on-one support to help you lead a
healthy lifestyle.
Allergy Relief
You’ll breathe easier thanks to special
prices on products designed to reduce
exposure to indoor allergens.
Alternative Health Care
Where does it hurt? With Natural BlueSM
you can tap into an extensive network
of credentialed acupuncturists, massage
therapists, chiropractors, plus diet advisers
— all offering extensive discounts. Members
also can get information about vitamins and
natural supplements, as well as purchase
items, such as home fitness equipment, at
a discount.
Healthy Reading
Stay health conscious and informed with
access to a wide variety of articles and
information online. Members also can
purchase books, DVDs and CDs at
discounted rates.
For more information, visit
www.SouthCarolinaBlues.com/links/discounts
Value Adds
11
HEARING AND VISION
COSMETIC
Laser Vision Correction
Our members receive exclusive
discounts on Lasik vision correction
services, including exams, surgery, and
preoperative and postoperative care.
Cosmetic Surgery
Lift your spirits with preferred rates on
face lifts; breast lifts; breast augmentation and reduction; tummy tucks; nose
reshaping; ear pinning; even cheek and
chin augmentation. Save on nonsurgical
procedures, too.
Eye Care
Open your eyes to special savings from
Vision One — eye exams, designer
frames, lenses and contacts.
Hearing Care
Hear that? With Blue, get great savings
from TruHearing — a leader in digital
hearing aids and ranked No.1 in
customer service. Save on hearing
exams and follow-up care, too.
BLUE365®
BlueCross members have access to
Blue365, a daily deal website with
discounts on everyday products that
can help families live healthier, happier
lives. Members can enjoy discounts
on personal care products, fitness,
wellness and lifestyle products and
healthy eating, as well as financial
services. Blue365 complements a
member’s health coverage by making
it easier and more affordable to make
healthy choices.
Visit: Blue365deals.com/BCBSSC
for the deal of the day!
Hair Restoration
Suffering from hair loss? You have everything to gain. As a member, you’ll save
20 percent on a hair transplantation
procedure.
Teeth Whitening
Purchase professional teeth whitening
services at a special discounted rate.
Dental Services
Through Companion Global Dental, our
members can receive dental work overseas at a fraction of what you would
pay in the United States. Global dental
services are offered by Companion Global
Dental. Because Companion Global Dental is a separate company from BlueCross,
Companion Global Dental will be responsible for all services related to global
dental services.
Tools
12
Think Smart
BLUES ENROLLSM AND BLUE E-BILLSM
We offer two great online tools to manage your company’s benefits. This means you will
have more time to focus on YOUR business.
With BluesEnroll, it’s never been easier to add or delete employees and/or dependents,
order new ID cards, pay your bill and much more.
Blue e-Bill is another online service that gives you the ability to access and manage your
account 24 hours a day, seven days a week.
MY HEALTH TOOLKIT®
We understand the importance of making the right health care decisions. My Health Toolkit
helps you and your employees make smart decisions and manage your health plan.
My Health Toolkit is the BlueCross information and customer service center. With My
Health Toolkit, members can take control of their health care from the comfort of their own
homes. Whether you need to locate an in-network doctor or want to research the cost of a
specific surgery, My Health Toolkit has resources that can help you make sound decisions
on future treatments.
As more power is placed in your hands to manage your health care benefits, we are here
to help you every step of the way.
TO SET UP AN ACCOUNT:
Go to www.SouthCarolinaBlues.com.
On the home page, find the Member Login:
My Health Toolkit box and click Register.
Create your profile by entering your member
information found on your insurance card. Follow
the remaining steps to complete your profile.
Tools
13
Think Control
MY HEALTH TOOLKIT OFFERS WAYS
TO MAKE INFORMED HEALTH CARE DECISIONS:
■Eligibility and Benefits — Read about
your benefits and coverage information
and check your eligibility.
■Compare Hospital Quality — Choose the
hospital that is right for you by comparing
up to 10 facilities on the number of patients treated, complication rates, average
lengths of stay for certain conditions and
procedures, and more.
■Ask Customer Service — Send a secure
message directly to the customer service
area for fast answers to your questions.
■Estimate Treatment Costs — Research
average costs and days of treatment for
specific medical conditions or procedures.
■Claims Summary — View claims status
and an Explanation of Benefits (EOB).
■Authorization Status — Verify your autho- ■Compare Drug Costs — Look up cost and
consumer information about prescription
rization status for inpatient and outpatient
drugs.
visits.
■Find a Doctor — Find a network doctor or
■Deductible and Out-of-Pocket Statuses
hospital across the country and around
— See how close you are to meeting your
the world.
deductible and maximum out of pocket.
■Request a New ID Card.
IMPROVE YOUR WELLNESS
■Personal Health Record — A confidential online tool providing a summary of all your
health information, including doctors’ visits, prescriptions, lab results and much more.
You also can keep track of upcoming medical appointments and print a copy of your
medical history. Additional features are available, based on your benefit plan.
■Personal Health Assessment — An online survey that helps identify risk factors and
offers ways to improve your health based on your answers.
■Health Library — This feature offers medical information, health calculators, self-care
channels and nutrition guides to help improve and protect your health.
Benefits
Benefits
15
UPSTATE I GOLD 1
UPSTATE I HEALTH REIMBURSEMENT
ACCOUNT (HRA) GOLD 2
Deductible
Individual: $400
Family: $800
Individual: $3,000
Family: $6,000
Coinsurance
50%
0%
Out-of-Pocket Maximum
Individual: $4,000
Family: $8,000
Individual: $3,000
Family: $6,000
Primary Care Physician (PCP)
$0 on first four visits, then $25
$0 on first four visits, then $25
Specialist Copayment
$50 copayment
$50 copayment
Urgent Care
$50 copayment
$50 copayment
Emergency Room Services
Deductible and Coinsurance
Deductible
Inpatient Hospitalization
Deductible and Coinsurance
Deductible
Prescription Drugs
Generic (Tier 1): $10
Preferred (Tier 2): $40
Non-Preferred (Tier 3): $80
Specialty (Tier 4): $250
Generic (Tier 1): $10
Preferred (Tier 2): $40
Non-Preferred (Tier 3): $80
Specialty (Tier 4): $250
Mail Order (90 Day)
Generic (Tier 1): $14
Preferred (Tier 2): $108
Non-Preferred (Tier 3): $216
Generic (Tier 1): $14
Preferred (Tier 2): $108
Non-Preferred (Tier 3): $216
PHARMACY BENEFITS
Benefits
16
UPSTATE I SILVER 1
UPSTATE I SILVER 2
Deductible
Individual: $5,500
Family: $11,000
Individual: $3,350
Family: $6,700
Coinsurance
40%
30%
Out-of-Pocket Maximum
Individual: $6,850
Family: $13,700
Individual: $6,850
Family: $13,700
PCP
$0 on first four visits, then $25
$35 copayment
Specialist Copayment
$50 copayment
$60 copayment
Urgent Care
$50 copayment
$60 copayment
Emergency Room Services
Deductible and Coinsurance
$300 copayment, then Deductible
and Coinsurance
Inpatient Hospitalization
Deductible and Coinsurance
Deductible and Coinsurance
Prescription Drugs
Generic (Tier 1): $10
Preferred (Tier 2): $40
Non-Preferred (Tier 3): $80
Specialty (Tier 4): $250
Generic (Tier 1): $15
Preferred (Tier 2): $40
Non-Preferred (Tier 3): $100
Specialty (Tier 4): 30%
Mail Order (90 Day)
Generic (Tier 1): $14
Preferred (Tier 2): $108
Non-Preferred (Tier 3): $216
Generic (Tier 1): $21
Preferred (Tier 2): $108
Non-Preferred (Tier 3): $270
PHARMACY BENEFITS
Exclusions
17
EXCLUDED SERVICES
We Will Not Pay Benefits For:
Other Services This Policy Does Not Cover
■Any services or benefits not specifically
covered under the terms of this policy, which
were received before this policy went into effect
or after it terminates, or claims submitted after
the time limit for filing claims has been exceeded.
■Non-emergency services when received at or from
out-of-network provider or hospitals, except true
emergency services when received in emergency
rooms of out-of-network hospitals. ■Services or charges for which the member is
entitled to payment or benefits from other sources
(e.g., workers’ compensation), for which the provider
does not charge, or for which the member is not
legally obligated to pay, including treatment
provided in a government hospital or benefits
provided under Medicare or other government
programs (except Medicaid).
■Cosmetic surgery, or surgery or treatment for
the purpose of weight reduction, including any
complications from or reversal of these procedures,
or reconstructive procedures made necessary by
weight loss.
■Refractive care, such as radial keratotomy,
laser eye surgery or Lasik.
■Hospital or skilled nursing facility charges when
preauthorization is not received. Please see
preauthorization in your policy found in
My Health Toolkit. ■Services and supplies not medically necessary,
investigational/experimental
in nature, not needed
for the diagnosis or treatment of an illness or injury,
or not specifically listed in Covered Services. ■Any service or supply provided by a member of
the patient’s family or by the patient, including
the dispensing of drugs. This means the spouse,
parent, grandparent, brother, sister, child or
spouse’s parent. ■Charges for a missed appointment or for filling
out claim forms. ■Treatment, services or supplies received because
of suicide, attempted suicide or intentionally
self-inflicted injuries unless it results from a
medical (physical or mental) condition, even if
the condition is not diagnosed prior to the injury.
■Any loss resulting from a member being legally
intoxicated or impaired, by being under the influence of alcohol, any narcotic or drug, unless
taken on the advice of a physician. The member
or member’s representative must provide any
available test result, upon our request, showing
blood alcohol or drug levels. If the member
refuses to provide these test results, we will not
provide benefits. ■Treatment resulting from war or acts of war (whether
declared or undeclared), while participating in a
riot or uprising, or while in the military service or its
auxiliary units.
■Services or supplies related to chewing or bite
problems, pain in the face, ears, jaws or neck
resulting from problems of the jaw joint(s), also
known as temporomandibular joint disorders (TMJ).
■Services for the detection and correction of
structural imbalance, distortion or subluxation
(spinal subluxation) to remove nerve interference.
■An illness you get or injury you receive while
committing or attempting to commit a crime, felony
or misdemeanor or while engaging or attempting
to engage in an illegal act or occupation.
This is a partial list of some of our exclusions. For
a full list of excluded services and supplies, or for
all limitations, please refer to your policy in
My Health Toolkit.
BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color,
national origin, disability, age, sex, gender identity, sexual orientation or health status in
the administration of the plan, including enrollment and benefit determinations.
Have Questions?
Contact your agent or broker today.
BCBSSC
18662-4-2016
BCBSSC
www.SouthCarolinaBlues.com