Medical Plan. The medical plan helps you pay for covered medical care and protects you from the financial impact of catastrophic expenses.

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1 Medical Plan The medical plan helps you pay for covered medical care and protects you from the financial impact of catastrophic expenses. For More Information Administrative details and procedures for appealing a claim can be found in the Administrative Information section. Highlights Cost Per Pay Who Is Covered Coverage Begins About this Benefit Plan Features Coverage Ends Administered by Paid for primarily by Honda; you will share in the cost of coverage for yourself and eligible dependents Eligible associates and their eligible dependents 1 st day of the month following your date of hire, if you are eligible for coverage The plan is part of the BlueCard PPO Program. To receive maximum benefits, you need to receive care from a preferred provider in the BlueCard PPO Program. You can receive benefits for medical care you receive from a non-ppo provider, but you will receive significantly reduced benefits and incur significantly higher out-of-pocket expenses Plans offer: Screened network of PPO health care providers Maximum benefits when you seek care through a PPO provider Last day of month your Honda employment ends or eligibility ends Blue Cross and Blue Shield of Alabama (Blue Cross and Blue Shield or BCBSAL) Medical Plan HMA 75 January 1, 2014

2 BlueCard Preferred Provider Organization (PPO) Program To maximize your benefits, you should seek medical services from a preferred provider who participates in the BlueCard PPO Program. Please call or log in to to find out if your provider is a PPO member. When using non-preferred providers, you can incur significant out-of-pocket expenses in addition to higher deductibles, copays and co-insurance as the provider may bill you for charges in excess of the allowed amount. Table of Contents Who Is Eligible...77 Your Cost...77 When Coverage Begins...77 How the Medical Plan Works...77 Benefits General Provisions...78 Covered Expenses...78 Physician Services...79 Preventive Care...80 Outpatient Hospital...82 Inpatient Hospital...83 Baby Yourself Program...84 Skilled Nursing Facility...85 Home Healthcare...85 Hospice Care...86 Mental Health/Substance Abuse Treatment...86 Organ Transplants...87 Vision Care...88 Other Covered Services...89 Preadmission Certification...90 Individual Case Management...90 Expenses Not Covered by the Plan...91 Claims...93 When Coverage Ends...94 Glossary...94 Medical Plan HMA 76 January 1, 2014

3 Who Is Eligible Eligibility for you and your dependents is defined in the Participating in Health Benefits section. Your Cost You pay a portion of either the Preferred or Non-preferred healthcare plan coverage for yourself and eligible dependents. When Coverage Begins When coverage begins is described in the Participating in Health Benefits section. How the Medical Plan Works Each time you need medical care, you can choose to use either a preferred provider in the Blue Cross and Blue Shield of Alabama network (a PPO provider) or a non-preferred provider (i.e., a non-ppo provider). The network is managed by Blue Cross and Blue Shield, who sets standards for network providers, monitors how care is delivered, and negotiates special rates for care You can receive care from network providers You can receive care from non-network providers The plan is part of the BlueCard PPO Program. To receive maximum benefits, you need to receive care from a preferred provider in the BlueCard PPO Program. You can receive benefits for medical care you receive from a non-ppo provider, but you will receive significantly reduced benefits and incur significantly higher out-of-pocket expenses. Please be aware that not all providers participating in the BlueCard PPO Program will be recognized by Blue Cross and Blue Shield as approved providers for the type of service or supply being furnished. Call Customer Service ( ) if you have any question whether your provider is approved for the services or supplies you plan on receiving. PPO Provider Information For information about approved PPO providers, you can: Important Note! Blue Cross and Blue Shield of Alabama (BCBSAL) is an independent corporation operating under a license from the Blue Cross and Blue Shield Association. BCBSAL is not acting as an agent of the Association and no representation is made that any organization other than Honda and BCBSAL will be responsible for honoring the benefits described in this SPD. Call Blue Cross and Blue Shield Customer Service at , Monday through Friday, 7:00 a.m. - 5:30 p.m. Log in to Medical Plan HMA 77 January 1, 2014

4 Benefits General Provisions The following chart summarizes how the medical plan pays benefits. Some benefits from the plan are paid after you pay a calendar year deductible or inpatient deductible. You pay a specified co-insurance amount for covered expenses after you meet your deductible, which depends on whether you receive care from a PPO provider or a non-ppo provider. The plan also includes an annual out-of-pocket maximum. Once you meet this out-of-pocket maximum, covered expenses will be paid at 100% of the allowed amount. For more information about coverage and plan exclusions or limits, see Covered Expenses on page 78 and Expenses Not Covered by the Plan on page 91. Deductibles, Out-of-Pocket Maximum and Lifetime Maximum PPO Non-PPO Calendar Year Deductible* $200 per person $300 per family $300 per person $900 per family Inpatient Calendar Year Deductible** $200 per admission N/A (non-ppo inpatient admissions are subject to calendar year deductibles) Annual Out-of-Pocket Maximum (includes calendar year and inpatient calendar year deductibles)*** Lifetime Maximum Benefit $2,000 per person $3,000 per person $3,000 per family $9,000 per family Covered expenses paid at 100% of the allowed amount for remainder of calendar year once out-of-pocket maximum is met Unlimited * Only one calendar year deductible is required when two or more family members have expenses resulting from injuries received in one accident. The PPO and non-ppo deductibles are separate and do not apply toward each other. ** The inpatient deductible is due for each admission or readmission; however, only one deductible is due per pregnancy, during transfers from one hospital to another, or when two or more family members are admitted as inpatients as a result of injuries received in one accident. The inpatient deductible is waived for maternity admissions for those enrolling in the Baby Yourself Program during their first trimester. *** Non-covered expenses, services provided by a non-ppo chiropractor or podiatrist and TMJ services provided by a non-ppo provider do not apply toward the out-of-pocket maximum. The PPO and non-ppo out-of-pocket maximums are separate and do not apply toward each other. Covered Expenses To be covered by the plan, medical expenses must be: Furnished after your coverage begins For medically necessary care, as determined by Blue Cross and Blue Shield before, during and after services and supplies are furnished For PPO-level benefits, for services and supplies furnished by a provider recognized by Blue Cross and Blue Shield as a PPO provider at the time services are provided Medical Plan HMA 78 January 1, 2014

5 For services and supplies furnished by a provider recognized by Blue Cross and Blue Shield as an approved provider for the type of service or supply being furnished, whether a PPO provider or not. For example, if you receive services from someone other than an M.D., benefits may not be payable, even if the services provided are within the scope of that person s license. You should check with BCBSAL s Customer Service at if you are uncertain if a person is an approved provider For services received while you are participating in the plan The following sections show the benefits and services covered by the medical plan. Physician Services The plan covers charges made by a legally qualified physician for surgery (including pre- and postoperative care, as well as administering anesthesia), second surgical opinion services, obstetrical care and other services, including: Inpatient visits while you are a hospital patient for reasons other than surgery, obstetrical care or radiation therapy (except for an unrelated condition) Specialist consultation for a medical, surgical or maternity condition, but only one for each hospital visit Diagnostic lab, x-ray and pathology services in a provider s office, when related to covered services other than allergy testing Radiation therapy and chemotherapy Emergency room care for other than surgery or maternity Exams, diagnosis and treatment for an illness or injury, other than routine office visits and allergy testing Services provided by approved PPO physicians or other preferred providers will be paid up to the PPO allowance, as defined in the Glossary on page 94. Services or supplies provided by non-ppo providers are paid up to the plan s allowed amount for that service or supply. See the Glossary for the definition of allowed amount. Physician Service Expense PPO* Non-PPO** Inpatient visits, second 100%, no deductible 70%, after calendar year deductible surgical opinions and inpatient consultations Surgery and anesthesia 90%, after calendar year deductible 70%, after calendar year deductible Diagnostic x-rays and lab 100%, no deductible 70%, after calendar year deductible exams Office visit, emergency 100%, after $25 copay 70%, after calendar year deductible room services and outpatient consultations Allergy testing 100%, after $25 copay 70%, after calendar year deductible Allergy treatment 100% 70%, after calendar year deductible Maternity care 100%, initial visit subject to $25 copay 70%, after calendar year deductible * Up to PPO allowance. ** Up to allowed amount. Medical Plan HMA 79 January 1, 2014

6 Preventive Care The following preventive care is covered: Routine immunizations if administered: to prevent diphtheria, tetanus, pertussis, polio, rubella, mumps, measles, Hib, hepatitis B, chickenpox, meningococcal disease; or during the first 24 months of life to prevent invasive pneumococcal disease; or during the sixth through the 23 rd months of life to prevent influenza Inpatient visits for routine newborn care One routine pap smear each calendar year One routine HPV (human papillomavirus) test once every three calendar years for females age 30 and over, covered at the same level as the routine pap smear Mammograms as follows: age = 1 baseline age 40 and above = 1 each calendar year One prostate specific antigen test each calendar year for men age 40 and over One cholesterol test every five years Colorectal cancer screening for ages 50 and over (see the Colorectal Cancer Screenings box below for more information) including: fecal occult blood test (FOBT), once each calendar year flexible sigmoidoscopy, once every three calendar years* double-contrast barium enema once every five calendar years* colonoscopy once every ten calendar years* Routine lab tests to include a complete blood count, urinalysis, and TB skin test, when performed with a routine office visit Nine office visits for the first two years of a baby s life Annual exams for ages two through six One routine office visit every year for ages 7 and over * Claims for facility charges will be processed under your outpatient hospital benefits and are subject to any applicable outpatient copays. Medical Plan HMA 80 January 1, 2014

7 Colorectal Cancer Screenings Benefits for colorectal cancer screening vary depending on the reason the procedure is performed and the way in which the provider files the claim: If screening is connected with the diagnosis or treatment of a medical condition, or you have a family history of colon cancer (within the meaning of Blue Cross and Blue Shield guidelines) and the provider properly files the claim with this information the claim will be processed and covered as a diagnostic or surgical procedure In all other cases, the claim will be subject to routine colorectal cancer screening benefit provisions and processed based on the guidelines outlined above in Preventive Care Preventive Service Expense PPO* Non-PPO** In-hospital routine newborn care 100%, no deductible or copay 70%, after calendar year deductible Routine well child care 100%, no deductible or copay 70%, after calendar year deductible Routine immunizations (age limits apply to certain immunizations; excludes flu vaccine) Routine tests (as listed above) Routine office visits (as listed above) * Up to PPO allowance. ** Up to allowed amount. 100%, no deductible or copay 70%, after calendar year deductible 100%, no deductible 70%, after calendar year deductible 100%, no deductible or copay 70%, after calendar year deductible Women s Preventive Health Benefits The department of Health and Human Services (HHS) adopted additional Guidelines for Women s Preventive Services including well-woman visits, gestational diabetes screening, HPV DNA testing, STI counseling, HIV screening and counseling, breastfeeding support, supplies and counseling and domestic violence screening and counseling that are covered without cost sharing to associates in health plans. These include: $0 cost generic birth control medication and brand name medications with no generic availability* $0 cost for certain birth control devices, including emergency contraception, injectable, transdermal, and implantable contraception, vaginal rings and barrier methods (such as diaphragms and cervical caps)* $0 cost folic acid tabs* $0 cost for routine prenatal visits and services explicitly identified in the Department of Health and Human Service Rules** $0 cost for sterilization** * You may contact Caremark for more specifics on these items. ** You may contact Blue Cross Blue Shield for more specifics on these items. Medical Plan HMA 81 January 1, 2014

8 Outpatient Hospital The plan covers: Outpatient care (including surgical expenses and other services and supplies) in a hospital or surgery center, provided it is best performed in this setting rather than a doctor s office Diagnostic lab and x-ray expenses (including physician fees for interpretation) provided in a doctor s office, lab facility or on an outpatient basis in a hospital The following types of service/supplies are covered: Emergency treatment of an accidental injury Chemotherapy and radiation therapy IV therapy Hemodialysis X-rays, lab and pathology services Medical emergencies Surgery Outpatient Hospital Service*** Expense PPO* Non-PPO** Accidental injury 100%, after $100 facility copay 70%, after calendar year deductible Surgery 90%, after calendar year deductible 70%, after calendar year deductible Emergency room medical emergencies Diagnostic lab and x-ray, IV therapy, radiation therapy and chemotherapy 100%, after $100 facility copay (if not a medical emergency, paid at 50% after calendar year deductible) Important Note for Hospital Services in Alabama Inpatient or outpatient hospital services or supplies you receive from a non-participating/non- PPO hospital in Alabama are not covered, except for emergency room treatment needed because of a Medical Emergency. 100%, after $100 facility copay (if not a medical emergency, 50% after calendar year deductible) 100%, no deductible 70%, after calendar year deductible * Up to PPO allowance. ** Up to allowed amount. *** Outpatient hospital services will be processed as other covered services if the facility bills for an emergency room visit but the patient s condition does not satisfy the Blue Cross and Blue Shield definition of medical emergency. This includes any lab and x-ray exams, diagnostic tests and other services and supplies associated with the emergency room visit or the services and supplies received are not listed above. Medical Plan HMA 82 January 1, 2014

9 Inpatient Hospital The plan covers semi-private room and board, other services and supplies for full-time inpatient hospital care. If Blue Cross and Blue Shield determines it is medically necessary, the plan will cover private room and board. You must be admitted to an approved PPO hospital to receive network benefits for the hospitalization. Prior to admission, you are responsible for making sure care is certified with Blue Cross and Blue Shield. Benefits will be reduced for inpatient admissions that are not certified. See Before Most Hospital Admissions A Word of Caution under Inpatient Hospital on page 83 for details. Important Note for Hospital Services in Alabama Inpatient or outpatient hospital services or supplies you receive from a non-participating/non- PPO hospital in Alabama are not covered, except for emergency room treatment needed because of a Medical Emergency. Inpatient Hospital Expense PPO* Non-PPO** Inpatient hospital 100%, $200 inpatient deductible*** 70%, after calendar year deductible*** (no limit on number of days for inpatient hospital care) Preadmission certification Required for all admissions except maternity and mental health/substance abuse; emergency admissions require certification within 48 hours of admission $200 penalty if preadmission certification is not obtained when required (see Preadmission Certification on page 90 for more information) * Up to PPO allowance. ** Up to allowed amount. *** The inpatient hospital deductible is required for each admission or readmission. Only one deductible per pregnancy, during transfers between hospitals or when the same accident causes injuries to two or more family members. The inpatient deductible for maternity admissions is waived for those enrolled in the Baby Yourself Program during their first trimester of pregnancy. Important Note Post-Mastectomy Services The Women s Health and Cancer Rights Act became effective on October 21, This law requires group health plans that provide mastectomies to also cover reconstructive surgery and prostheses following mastectomies. We are pleased to inform you that BCBSAL was already in compliance with this law. As the Act requires, Honda is adding information on the Act about the law s provisions. If you have a mastectomy, the plan will cover: Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and physical complications related to the mastectomy, including lymphedemas This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same calendar year deductibles and coinsurance provisions that apply for the mastectomy. If you have any questions about coverage for mastectomies and reconstructive surgery, please contact BCBSAL s Customer Service at Medical Plan HMA 83 January 1, 2014

10 Before Most Hospital Admissions A Word of Caution One of the several requirements for hospital benefits is that Blue Cross and Blue Shield certifies the medical necessity of your hospital stay in advance (except for emergencies or admission to a Concurrent Utilization Review Program hospital by an approved PPO provider). You must notify Blue Cross and Blue Shield ( ) within 48 hours of an emergency admission. Emergency admissions then must be certified as both medically necessary and as true medical emergencies. Failure to obtain a certificate of medical necessity will result in penalties, as described in Preadmission Certification on page 90. In addition, for benefits to be paid, you must be a plan participant at the time services are provided and the service or supply must be covered under the plan. Maternity Care Exception Length of Stay Under federal law, group health plans and issuers of group health coverage may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery (or 96 hours following a caesarean section). However, federal law generally does not prohibit an attending physician, after consulting with the mother, from discharging the mother and/or her newborn earlier than 48 hours (or 96 hours), if appropriate. In either case, plans and issuers may not require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of the minimums described above. Note: Newborns who remain hospitalized after the mother is discharged will require certification of medical necessity. Baby Yourself Program The plan includes a prenatal wellness program called the Baby Yourself Program. As soon as you confirm that you or your spouse is pregnant, you should call one of the program s registered nurses at Beginning care as early as possible and continuing care throughout your pregnancy offers your baby the best change for a healthy start by early, thorough care while you are pregnant. If you fall into one of the following risk categories, please tell your doctor and your Baby Yourself nurse: Age 35 or older High blood pressure Diabetes History of previous premature births Multiple births (twins, triplets, etc.) Inpatient Deductible The inpatient deductible required for hospital admissions is waived for maternity admissions if you or your covered spouse enrolls in the Baby Yourself Program before the end of your first trimester of pregnancy. Medical Plan HMA 84 January 1, 2014

11 Skilled Nursing Facility The plan covers charges made by a skilled nursing facility, including facility charges for room, board and routine nursing care, if you are recovering from a serious illness or injury, are confined to a bed with a long-term illness or injury or have a terminal condition. Skilled nursing facility benefits will only be paid if authorized by the Blue Cross and Blue Shield Health Management staff. You can request authorization by calling Also, see Preadmission Certification on page 90. You must be admitted to the facility within 14 days after leaving the hospital and the hospital stay must have lasted at least three consecutive days for the same illness or injury. Your doctor must visit you at least once every 30 days and these visits must be written in your medical records. A skilled nursing facility includes any Medicare participating skilled nursing facility that provides nonacute care for patients need skilled nursing services 24 hours a day. The facility must be staffed and equipped to perform skilled nursing care and other related health services. A skilled nursing facility does not provide custodial or part-time care. Skilled Nursing Facility Expense PPO* Non-PPO** Skilled nursing facility 90%, after calendar year deductible 90%, after calendar year deductible Calendar year maximum 120 days per person per year, combined for PPO and non-ppo care Precertification Precertification required; call (see Preadmission Certification on page 90 for more information) * Up to PPO allowance. ** Up to allowed amount. Home Healthcare To be covered, home healthcare agency charges must be made for care and treatment of disease or injury that is ordered by your physician. If home health nursing services are provided, benefits will only be paid if authorized by the Blue Cross and Blue Shield Health Management staff. You can request authorization by calling Also, see Preadmission Certification on page 90 for more information. Home Healthcare Agency See the Glossary on page 94 for a definition of home healthcare agency. Benefits payable for each covered person are subject to a calendar-year maximum for visits, as described in the following table. Any covered expenses for home healthcare apply toward the annual maximum for hospice care. Home healthcare expenses do not include transportation, services of a social worker or services provided by a member of your/your spouse s family or a resident of your home. Home Healthcare Expense PPO* Non-PPO** Home healthcare 90%, after calendar year deductible 70%, after calendar year deductible Calendar year maximum 120 days per person per year, combined for PPO and non-ppo care Precertification Precertification required; call (see Preadmission Certification on page 90 for more information) * Up to PPO allowance. ** Up to allowed amount. Medical Plan HMA 85 January 1, 2014

12 Hospice Care Hospice care is care arranged under a hospice care agency for terminally ill patients with a life expectancy of six months or less, as certified by his or her physician. The care must be designed to provide pain control or palliative treatment for the patient as well as supportive services to the patient and family. In addition, care must be assessed and described in a treatment plan written and reviewed by the attending physician and hospice care agency. Hospice benefits include physician home visits, medical social services, physical therapy, inpatient respite care, home health aide visits from one to four hours, durable medical equipment and symptom management. When these services are provided, benefits will only be paid if authorized by the Blue Cross and Blue Shield Health Management staff. You can request authorization by calling Also, see Preadmission Certification on page 90. Benefits for each covered person are subject to an annual maximum, as described in the following table. Any covered expenses for home healthcare apply toward the annual maximum for hospice care. Hospice care does not include expenses for funeral arrangements, pastoral, financial or legal counseling, housecleaning or caretaker services such as sitters and transportation, and respite care. Hospice Care Expense PPO* Non-PPO** Hospice care 90%, after calendar year deductible 70%, after calendar year deductible Calendar year maximum Precertification * Up to PPO allowance. ** Up to allowed amount. 120 days per person per year, combined for PPO and non-ppo care Precertification required; call (see Preadmission Certification on page 90 for more information) Mental Health/Substance Abuse Treatment The plan covers inpatient and outpatient treatment of mental health disorders and substance abuse where treatment is provided by or under the direction of a licensed clinical psychologist, psychiatrist or medical doctor. Examples of mental disorders include psychoses, neuroses, schizophrenic-affective disorders, personality disorders and psychological or behavioral abnormalities associated with temporary or permanent dysfunction of the brain or related system of hormones controlled by nerves. This includes disorders, conditions and illnesses listed in the current Diagnostic and Statistical Manual of Mental Disorders. Hospice Care Agency See the Glossary on page 94 for a definition of hospice care agency. Important Note! Inpatient hospital benefits for treatment of mental health disorders or substance abuse are available in the Alabama service area only if the hospital is an in-network provider. Services provided by specialty hospitals that do not participate with nor are considered members of any Blue Cross and/or Blue Shield Plan are not covered (except for Bradford Health Services). Medical Plan HMA 86 January 1, 2014

13 Mental Health/Substance Abuse Treatment Expense PPO* Non-PPO** Inpatient facility services for mental health/substance abuse 100%, subject to the $100 inpatient per admission deductible 70%, after calendar year deductible Physician charges for inpatient mental health/substance abuse Outpatient mental health/substance abuse * Up to PPO allowance. ** Up to allowed amount. 100%, no deductible or copay 70%, after calendar year deductible 100%, after $25 office visit copay 70%, after calendar year deductible Organ Transplants The plan covers eligible physician, hospital and other service/supply expenses for organ transplants as described below. If you have advance approval from Blue Cross and Blue Shield, you can receive care for certain transplants from a Centers of Excellence Network facility (see box). Then, the plan will pay: PPO benefits for covered medical care; and Travel and lodging expenses for you and a companion, up to a specified maximum (see below) These benefits apply to the following transplants performed in a Centers of Excellence facility: Heart Liver Lungs Pancreas Kidney Heart valve Skin Cornea Small bowel Centers of Excellence Network Blue Cross and Blue Shield has arrangements with a regional network of hospitals to provide the specialized care required for certain organ transplants. These facilities are chosen for their experience with transplant procedures and charge negotiated fees. For benefits to be paid, you must use a Centers of Excellence facility if your provider recommends an organ transplant and services/care must be approved in advance in writing. Bone marrow transplants are covered when performed in a hospital or facility on the Blue Cross and Blue Shield list of approved facilities for that type of transplant, provided you have advance written approval. Medical Plan HMA 87 January 1, 2014

14 Organ Transplants Expense Centers of Excellence facility Other facility Lodging expense $50 per night per person Does not apply maximum benefit Travel and lodging year maximum $10,000 per person per transplant performed in Centers of Excellence facility Does not apply The plan does not pay transplant benefits for: Any artificial or mechanical devices Organ or bone marrow transplants from animals Donor costs available through other group coverage Services for which government funding is provided Services when the recipient is not covered by this plan Recipient or donor room, food or transportation costs not approved in advance in writing A condition or disease for which a transplant is considered investigational Transplants performed in a facility that is not an approved facility for that type of transplant or for which Blue Cross and Blue Shield has not given written approval in advance Vision Care The plan covers the following routine vision services: Vision exam Glasses Frames Contact lenses Vision Care Expense* Routine vision care exam Frames, lenses and contact lenses * Up to allowed amount. Benefits are not payable for: Diagnostic services 100%, after $25 office copay. One routine vision exam per person per year Adults (19 and older): 100%, up to $200 per person every 24 months Pediatric (0-19 years): 100% with no dollar limit per person every 12 months Benefits for services after your coverage ends, except for lenses or frames ordered while you were covered and delivered within 60 days from that date Medical Plan HMA 88 January 1, 2014

15 Orthoptics, vision training and low vision aids Replacement of lost or broken lenses or frames unless you are eligible for benefits at the time of replacement Services or supplies required by the group as a condition of employment or provided by a medical department or health clinic maintained by or on behalf of the group, a mutual benefit association, labor union, trustee or similar person or entity Other Covered Services The plans also cover the following medical supplies and equipment; benefits for a sampling of these services are shown in the following chart. Most other covered services provided by a PPO provider are paid at 90% of the allowed amount after the calendar year deductible is satisfied. Additional covered services include: Semi-private room and board, general nursing care and all necessary hospital services and supplies when your inpatient hospital benefits are all used Anesthesia for surgery or obstetrical care when given by someone other than the surgeon, obstetrician or hospital employee Physical therapy and hydrotherapy given by a licensed physical therapist. Preferred physical therapists may be required to precertify services during the course of your treatment. If so, the preferred physical therapist will initiate the precertification process for you. If precertification is denied, you may appeal the denial Radiation therapy and chemotherapy Lab and exams and other diagnostic tests such as allergy testing Artificial arms and other prosthetics, leg braces and other orthopedic devices Medical supplies such as oxygen, crutches, casts, catheters, colostomy bags and supplies, and splints Treatment of natural teeth injured by a force outside your mouth or body, if service is received within 90 days of the injury Professional ambulance service to the closest hospital that could treat the condition Rental or purchase (whichever is less expensive) of durable medical equipment such as wheelchairs and hospital beds Hemodialysis services of a participating renal dialysis facility Occupational therapy services when medically necessary and performed by a licensed occupational therapist Chiropractic services Podiatry and TMJ phase 1 therapy (surgery, office visit, lab and x-rays) Speech therapy given by a qualified speech therapist or physician Hearing aids and routine hearing exams Medical Plan HMA 89 January 1, 2014

16 Other Covered Services Expense PPO* Non-PPO** Durable medical 90%, after calendar year deductible 70%, after calendar year deductible equipment (DME) Physical, occupational and speech therapy 90%, after calendar year deductible 70%, after calendar year deductible Ambulance service 90%, after calendar year deductible 70%, after calendar year deductible Hearing aids*** Routine hearing exam*** Chiropractic services*** Private duty nursing*** 90%, after calendar year deductible One hearing aid per year, maximum benefit of $1,000 per ear each 36 months 100% after $25 office copay One routine exam each 24 months 100% after $25 office copay Maximum payment of $50 per visit; up to 26 visits per person each calendar year 90%, after calendar year deductible Maximum of 70 days per person each calendar year 70%, after calendar year deductible One hearing aid per year, maximum benefit of $1,000 per ear each 36 months 70% after calendar year deductible One routine exam each 24 months 50%, after calendar year deductible Maximum payment of $50 per visit; up to 26 visits per person per calendar year 70%, after calendar year deductible Maximum of 70 days per person each calendar year * Up to PPO allowance. ** Up to allowed amount. ** Combined PPO and non-ppo maximum. Note: When you use a participating provider, the provider will bill Blue Cross and Blue Shield of Alabama directly. If you use a non-participating provider, you may have to file a claim, and you will be responsible for the charges that exceed the allowed amount. Preadmission Certification You are responsible for checking with your doctor or provider to ensure that services provided for inpatient hospital care, skilled nursing care, home health care and hospice care, whether for PPO or non-ppo services, are certified with Blue Cross and Blue Shield in advance. If they are not, you will need to pay a $200 penalty before benefits will be payable. In addition, you must call Blue Cross and Blue Shield within 48 hours of an emergency hospital admission or you will need to pay the $200 penalty. Individual Case Management Unfortunately, some people suffer from catastrophic, long-term and chronic illness or injury. If you have a catastrophic, long-term or chronic illness or injury, a Blue Cross Registered Nurse may assist you in accessing the most appropriate health care for your condition. The nurse case manager will work with you, your physician and other health care professionals to design a treatment Blue Cross and Blue Shield Certification The numbers to call to certify care with Blue Cross and Blue Shield are listed on your medical ID card: plan to best meet your health care needs. In order to implement the plan, you, your physician and Blue Cross must agree to the terms of the plan. The program is voluntary to you and your physician. Under no For inpatient hospital care, call For home health, skilled nursing facility or hospice care, call the Blue Cross and Blue Shield Health Management staff at Medical Plan HMA 90 January 1, 2014

17 circumstances are you required to work with a Blue Cross case management nurse. Benefits provided to you through Individual Case Management are subject to your benefit contract maximums. If you think that you may benefit from Individual Case Management, please call the Health Management division at or If you suffer from certain long-term, chronic diseases or conditions, you may qualify to participate in the Care Management Program. Care Management is designed for individuals whose long-term medical needs require disciplined compliance with a variety of medical and lifestyle requirements. If the manager of the Care Management Program determines from your claims data that you are a good candidate for Care Management, the manager will contact you and ask if you would like to participate. Participation in the program is completely voluntary. If you would like to obtain more information about the program, call Customer Service at Expenses Not Covered by the Plan The plan does not pay benefits for the following: Services/supplies that are not medically necessary as determined by Blue Cross and Blue Shield of Alabama (BCBSAL) Services, care or treatment you receive after your coverage ends Services or expenses for cosmetic surgery, which is any surgery done primarily to improve or change the way one appears. Complications of any surgery related in any way to cosmetic surgery are not covered. Contact BCBSAL before surgery to determine if a procedure is cosmetic or reconstructive Services or expenses to care for, treat, fill, extract, remove or replace teeth to increase the periodontium Braces Dental care other than physician services to treat or replace natural teeth that are harmed by accidental injury (which is covered under Other Covered Services on page 89) Dental implants Services or expenses for any disease, injury or condition related to your employment for which any benefits and/or compensation is available under Workers Compensation or employers liability laws (state or federal) Services or expenses covered in whole or in part under laws of the United States, any state, county, city town or other governmental agency, through insurance or other means. This applies even if the law does not cover all your expenses Charges for custodial care Investigational treatment, procedures, facilities, drugs, drug usage equipment or supplies, including services that are part of a clinical trial Services or expenses for routine foot care, such as removal of corns or calluses or the trimming of nails (except mycotic nails) Hospital admissions, in whole or in part, primarily for rehabilitative services, such as physical, speech or occupational therapy Medical Plan HMA 91 January 1, 2014

18 Services and expenses provided to a hospital patient that could have been provided on an outpatient basis Services or expenses for or related to sexual dysfunctions or inadequacies not related to organic disease or which are related to surgical sex transformations Services or expenses for an accident or illness related to war, riot or civil commotion Services or expenses for injury received during the commission of a crime or for treatment while confined in a prison, jail or other penal institution. This exclusion does not apply to acts of domestic violence or acts which result from mental disease or defect Services or expenses for which a claim is not properly submitted to BCBSAL Services or expenses to treat any condition that is based on weight reduction or dietary control, or services or expenses of any kind to treat obesity, weight reduction or dietary control. This exclusion does not apply to surgery for morbid obesity if medically necessary and in compliance with guidelines of the claims administrator. In this case, benefits will only be provided for one surgery for morbid obesity Services or expenses for which you are not legally obligated to pay, or for which no charge would be made if you had no health insurance Services or expenses related to organ, tissue or cell transplantations unless specifically allowed by this plan Dental treatment for or related to temporomandibular joint (TMJ) disorders, unless specifically allowed by this plan. This includes Phase II, according to the guidelines approved by the Academy of Craniomandibular Disorders Services or expenses related to Assisted Reproductive Technology (ART), for example, in vitro fertilization and gamete intrafallopian transfer Eyeglasses or contact lenses or related examination or fittings, except as specified under this plan Services or expenses for eye exercises or visual training except as specified under this plan Orthoptics, orthokeratology or refractive keratoplasty, including radial keratotomy Services or expenses for personal hygiene comfort or convenience items such as air-conditioners, humidifiers, whirlpool baths, physical fitness or exerciser apparel or exercise equipment Services or expenses for speech and occupational therapy, except as specified in this plan, or recreational and educational therapy Acupuncture, biofeedback and other forms of self-care or self-help training Services provided by psychiatric specialty hospitals that do not participate with nor are considered members of any Blue Cross and/or Blue Shield plan Services provided by substance abuse facilities, including substance abuse residential facilities, except for Bradford Health Services Services, care, treatment or supplies furnished by a provider not recognized by BCBSAL as an approved provider Medical Plan HMA 92 January 1, 2014

19 Services or supplies provided by a member of your family by blood, adoption or marriage or by one who resides in your household Travel expenses, even if prescribed by your physician, except as specified in Organ Transplants on page 87 Services or expenses of any kind provided by a non-participating hospital located in Alabama for any benefits under this plan, except for emergency room treatment needed because of a Medical Emergency Services or expenses for a claim not received by BCBSAL within 24 months after the service was rendered or the expense was incurred Services or expenses for physical therapy not requiring a licensed physical therapist Services or expenses in any federal hospital or facility except as provided by federal law Sanitarium, convalescent or rest care Anesthesia services or supplies, or both, by local infiltration Abortions, except those incidental to and whose sole purpose is for the care or treatment of a serious pathological condition of the mother Services or expenses of any kind for or related to reverse sterilizations Services provided through teleconsultation Services provided by a non-participating renal dialysis facility in Alabama Claims If you receive care from a network provider, claims will be filed by the provider. In all other cases, you need to file claims for reimbursement. You should attach proper documentation of your claim including the provider s name, the date services were received and any bills/receipts. By providing a complete claim, you will avoid unnecessary delays in processing. You have until 24 months after the date the service was provided to file a claim. Claims filed after that time are not payable unless you were unable to file because you were legally incapacitated. If You Have Questions The claims payor for the medical plan is Blue Cross and Blue Shield of Alabama (BCBSAL). If you have questions about claims, contact Customer Service at Medical benefits are payable to you. However, the plan has the right to pay any health benefits to the provider. You can indicate on the claim form if you prefer to have benefits paid directly to the provider. If a claim is denied in whole or part, you can appeal the decision in writing to BCBSAL. See the Administrative Information section. Medical Plan HMA 93 January 1, 2014

20 When Coverage Ends When medical plan coverage ends is described in the Participating in Health Benefits section. In certain cases, you or your covered dependent(s) may continue coverage for a limited time by paying the full cost. See the COBRA section. Disability, Layoff and Leave of Absence Normally, your employment ends when you cease active work. However, if you are not at work due to disability, layoff or certain leaves of absence, your employment and medical coverage may continue for a stated period. At the end of any extended coverage period, you may be entitled to continue your coverage, at your expense, under COBRA. See the COBRA section. In the Event of Your Death In the event of your death while covered under the medical plan, Honda will continue medical plan coverage for your covered dependents for up to 12 months after the end of the month of your death. Coverage will end prior to this date if a dependent no longer meets the eligibility definition (for your spouse, this includes remarriage) or becomes eligible for similar coverage under this plan. At the end of the 12-month period, your covered dependents may be entitled to continue their coverage, at their expense, under COBRA. See the COBRA section. Glossary The following definitions are provided to help you understand your medical coverage. Allowed Amount Benefit payments are covered based on the amount of the provider s charge that Blue Cross and Blue Shield of Alabama (BCBSAL) recognizes for payment of benefits. This amount is the lesser of the provider s charge for care or the amount of that charge that is determined by BCBSAL to be allowable depending on the type of provider and the state in which the services are rendered Important Note! The negotiated rate for preferred PPO providers is generally called PPO allowance in this SPD. The allowable amount under the plan for services/supplies that are provided by non-ppo providers is called the allowed amount. In-Network Providers. Blue Cross and Blue Shield plans contract with providers to furnish care at a negotiated price. This price is often at a discounted rate and the in-network provider normally accepts this rate as full payment for covered services or care. Not all participating or contracting providers are in-network providers. Each local Blue Cross and Blue Shield plan determines which of its participating or contracting providers will be considered innetwork providers. Medical Plan HMA 94 January 1, 2014

21 Non-Network Providers. The allowed amount for care for non-network providers is normally determined by the Blue Cross and/or Blue Shield plan where services are rendered. This amount may be based on the negotiated rate payable to in-network providers or on the average or anticipated charge or discount for care in the area or state, or for care from that particular provider. When the local Blue Cross and/or Blue Shield plan does not provide pricing data or when BCBSAL is determining the allowed amount, the allowed amount is determined using the following data: The charge for the same or a similar service The relative complexity of the service The preferred provider allowance for the same or a similar service The average expected or estimated provider discount for the type of provider in the service area, as reported by the Blue Cross and Blue Shield Association from time to time Applicable state health care factors The rate of inflation using a recognized measure Other reasonable limits, as required with respect to outpatient prescription drug costs Non-network providers include providers that have not signed a contract with a Blue Cross and Blue Shield plan where services are rendered as well as participating or contracting providers who have not been designated by the local Blue Cross and Blue Shield plan as preferred providers. In this situation, the provider may bill you for charges in excess of the allowed amount. The allowed amount will not exceed the amount of the provider s charge Custodial Care Care primarily to provide room and board for a person who is mentally or physically disabled. Investigational Any treatment, procedure, facility, equipment, drugs, drug usage or supplies that either Blue Cross and Blue Shield has not recognized as having scientifically established medical value, or that does not meet generally accepted standards of medical practice. When possible, Blue Cross and Blue Shield develops written criteria (called medical criteria) concerning services or supplies it considers investigational. These criteria are based on peer-reviewed literature service, recognized standards of medical practice and technology assessments. Blue Cross and Blue Shield puts these medical criteria in policies that are made available to the medical community and you. This is done so that you and your providers will know in advance, when possible, what the plan will pay for. If a service or supply is considered investigational, Blue Cross and Blue Shield will not pay for it. If the investigational nature of a service or supply is not addressed by one of the published medical criteria policies, it will be considered noninvestigational only if the following requirements are met: The technology must have final approval from the appropriate government regulatory bodies The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes The technology must improve the net health outcome The technology must be as beneficial as any established alternatives The improvement must be attainable outside the investigational setting Medical Plan HMA 95 January 1, 2014

22 You must remember that when Blue Cross and Blue Shield makes determinations about the investigational nature of a service or supply, they are made solely for the purpose of determining whether to pay for the service or supply. All decisions concerning your treatment must be made solely by your attending physician and other medical providers. Medical Emergency An acute and severe medical condition, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness or injury is of such a nature that failure to get immediate medical care could result in placing the person s health in serious jeopardy, serious impairment to bodily function, serious dysfunction of a body part or organ, or in the case of a pregnant woman, serious jeopardy to the health of the fetus. Medically Necessary When possible, Blue Cross and Blue Shield develops written criteria to determine medical necessity. These criteria are based on peer-reviewed literature service, recognized standards of medical practice and technology assessments. If a service or supply is not addressed by one of our published medical criteria policies, it will be considered medically necessary only if it is determined to be: Appropriate and necessary for the symptoms, diagnosis or treatment of your medical condition Provided for the diagnosis or direct care and treatment of your medical condition In accordance with standards of good medical practice accepted by the organized medical community Not primarily for the convenience and/or comfort of you, your family, your physician or another service provider Not investigational Performed in the least costly setting, method or manner, or with the least costly supplies required for your medical condition You must remember that when medical necessity determinations are made, Blue Cross and Blue Shield is making them solely for the purpose of determining whether to pay for the service or supply. All decisions concerning your treatment must be made solely by your attending physician and other medical providers. Non-Participating Hospital Any hospital (other than a participating hospital) that has been approved by the Alabama Hospital Association or the American Hospital Association as a general hospital or meets the requirements of the American Hospital Association for registration or classification as a general medical and surgical hospital. General hospitals do not include those that are classified or could be classified under standards of the American Hospital Association as special hospitals. PPO Hospital, PPO Physician, PPO Provider or Preferred Provider Any hospital, physician, or provider with which any Blue Cross and Blue Shield plan has a PPO contract for the furnishing of health care services. Medical Plan HMA 96 January 1, 2014