Spending Smart, Living Well. Resources from Novartis and Horizon Blue Cross Blue Shield of New Jersey

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1 Spending Smart, Living Well Resources from Novartis and Horizon Blue Cross Blue Shield of New Jersey

2 In this Guide... 1 Health Plan Overview 2 Benefits At A Glance 3 How to Make the Most of Your Benefits 4 Need Help in a Hurry? 5 Top Care at Blue Distinction Centers 6 Help with Complex Care and Conditions 7 24/7 Nurse Line Inside, you ll see all that s available to help you become a better health care consumer. Learn more about how your health plan works and how to make it work for you. 8 Using Your Preventive Care Benefits 9 The ABCs of EOBs 10 Claims and Appeals 11 Your Secure Member Online Services 12 Manage Your Health On the Go 13 Glossary 14 Find the Health Care You Need Almost Anywhere Learn about the benefits, tools and services your Novartis Medical Plans offer to help you spend smart, make good health decisions and live well.

3 Health Plan Overview A Snapshot of Your Novartis Medical Plans with Horizon BCBSNJ Novartis offers several medical plan options administered by Horizon BCBSNJ. Each has its own costs and benefits so please check your enrollment materials for detailed information. You should know: Preventive care, such as annual physicals, women s health, men s health, well-baby care and certain prescription drugs, are covered at 100 percent and are not subject to deductible. For detailed plan descriptions, go to mybenefitsdirectory.com/novartis. Below are highlights of the Horizon BCBSNJ plans available to you: Preferred Provider Organization (PPO) plan This plan offers both in- and out-of-network coverage. You have access to the national BlueCard PPO network that links providers across the country and around the world. You do not need to select a Primary Care Physician (PCP). You do not need referrals for specialty care. You are responsible for obtaining precertification for certain services out of network. Some in-network services are covered at 100%; however, most others are reimbursed at 85% after copayment or deductible. Exclusive Provider Organization (EPO) plan This plan offers in-network coverage only, except for emergencies. You must use Horizon BCBSNJ network providers. You do not need to select a Primary Care Physician (PCP). You do not need referrals for specialty care. You pay a set copayment for most covered services. There is no annual deductible to meet. 1 Click or Call Novartis Benefits Resource Center mybenefitsdirectory.com/novartis Horizon Blue Cross Blue Shield of New Jersey HorizonBlue.com/Novartis BlueCard Worldwide BLUE (2583) (call collect) Blue Distinction Centers bcbs.com/bluedistinction Chronic Care Program Complex Case Management , prompt 2 ComPsych (Employee Assistance Program [EAP]) GuidanceResources.com Express Scripts (Medco) express-scripts.com Member Online Services Member_Portal@HorizonBlue.com MetLife Dental (DPPO) metlife.com/mybenefits (Enter Novartis; select Novartis Group Companies) /7 Nurse Line Vision Service Plan (VSP) vsp.com WebMD webmdhealth.com/novartis For Your Reference

4 Benefits At A Glance Highlights of the PPO and EPO plans PPO Plan administered by Horizon Blue Cross Blue Shield of New Jersey Plan Feature In Network Out of Network Annual Deductible (Individual/Family) Annual Out-of-Pocket Maximum (Individual/Family) Coinsurance Physician Services Office Visits Consultant and Referral Services Surgery in Office Preventive Care Periodic Physical Exams (Children over age 6 and adults, once per year) Well Child Care (through age 6) Routine Mammograms (over age 35, once per year) Routine Ob/Gyn Exam (includes Pap test, once per year) Routine PSA Testing (over age 40, once per year) $400/$950 $950/$1,900 $3,500/$8,500 (includes deductible) 100% or 85%, as specified $25 copayment per visit, primary care; $40 copayment per visit, specialist 100% $6,500/$13,000 (includes deductible) 60% Reasonable & Customary 60% after deductible 60% after deductible EPO Plan administered by Horizon Blue Cross Blue Shield of New Jersey Plan Feature Annual Deductible (Individual/Family) In Network None Annual Out-of-Pocket Maximum (Individual/Family) $2,500/$5,000 Coinsurance Physician Services Office Visits Consultant and Referral Services Surgery in Office Preventive Care Periodic Physical Exams (once per year) Well Child Care (through age 3) Routine Immunizations and Injections Routine Mammograms (over age 40, once per year) Routine Ob/Gyn Exam (includes Pap test, once per year) Routine PSA Testing (over age 50, once per year) 2 does not apply $20 copayment per visit, primary care; $40 copayment per visit, specialist 100% Plan Highlights

5 How to Make the Most of Your Benefits Stay in-network to lower your out-of-pocket costs The PPO plan includes a deductible for in-network services. A deductible is the amount you pay for covered health care services before your coverage begins to pay for covered health care services. For 2015, the annual in-network deductible is $400 for individual coverage and $950 for family coverage. The deductible does not apply to all services, such as doctor s office visits and most wellness benefits. Here is how costs under the PPO plan, one subject to deductible and one not, might compare: Service Provider charge Horizon BCBSNJ allowance Deductible amount Remaining balance Horizon BCBSNJ s payment Member s total out-of-pocket cost Outpatient surgery $2,000 $1,600 $400 $1,200 $1,020 $580 Subject to a deductible Contracted rate Horizon BCBSNJ pays for 85% of the balance up to the allowance. The member pays up to the deductible amount, plus 15% of the remaining allowance. Annual exam $250 $150 $0 $0 $150 $0 Not subject to a deductible Contracted rate Horizon BCBSNJ pays the balance up to the allowance. The member does not pay for eligible preventive services. The EPO plan does not have a deductible, but some services require a copayment. However, the copayment does not apply to all services, such as most wellness benefits. Here is how costs under the EPO plan, one subject to copayment and one not, might compare: Service Provider charge Horizon BCBSNJ allowance Copay amount Remaining balance Horizon BCBSNJ s payment Member s total out-of-pocket cost Outpatient surgery $2,000 $1,600 $250 $1,600 $1,350 $250 Subject to copayment Contracted rate Horizon BCBSNJ pays 100% of the balance up to the allowance after the copayment. The member pays the $250 copayment. Annual exam $250 $150 $0 $0 $150 $0 Not subject to copayment Contracted rate Horizon BCBSNJ pays the balance up to the allowance. The member pays nothing for eligible preventive services provided in-network. 3 Maximize Your Health Dollars

6 Need Help in a Hurry? Know your best options for care When you and/or a family member need urgent care for a non-life-threatening condition, visiting a participating Urgent Care Center (UCC) or Retail Health Clinic in select chain pharmacies can be a valuable alternative to visiting the Emergency Room (ER). You can receive care faster and will likely pay less for your care. The PPO plan includes a $350 penalty for non-emergent use of the ER. * This example includes the PPO plan s $350 penalty for non-emergent use of the ER. This penalty does not apply to the EPO plan. Type of Situation Emergency A medical condition that is so severe, it poses a risk to a person s life or long-term health. Urgent An unexpected medical condition that is not life-threatening but requires medical attention within 24 hours. Nonemergent A medical condition that is not life-threatening, may not need immediate medical attention and/or may be treated with self-care. When ER services are used for non-emergencies, we all pay the price. Here s the average cost paid by Novartis for ER vs. Urgent Care Center (UCC) under the PPO plan: ER UCC Sore Throat $546* $40 Stitches $196 $40 Overall Average Visit $235 $40 Examples Difficulty breathing Heart attack or stroke High fever Loss of consciousness Poisoning Severe burns Wounds that need stitches Earache Moderate fever Sore throat Sprains Mild headache Minor cold Seasonal allergies Small cuts or bruises Vaccinations Where to Get Appropriate Care Dial 911 (or your local emergency services number) or proceed to the nearest ER. Referral is not required. Call your doctor first. You may also visit a participating Urgent Care Center or Retail Health Clinic. Call your doctor to see if an appointment is necessary. You may also visit a participating Urgent Care Center or Retail Health Clinic. You can receive care faster at a UCC or Retail Health Clinic, rather than the ER. Most UCCs and Retail Health Clinics have weekend and evening hours. Routine care is not covered at Urgent Care Centers. Routine care includes: Preventive care Routine obstetric services Visit your doctor for routine and preventive care visits. Urgent Care Find a participating Urgent Care Center Visit the National Doctor and Hospital Finder at HorizonBlue.com/Novartis. Select Find Urgent Care. 4

7 Top Care at Blue Distinction Centers Delivering quality health care for our members, every time The Blue Cross and Blue Shield Association awards Blue Distinction Center and Blue Distinction Center+ status to medical facilities that demonstrate expertise and efficiency in delivering quality specialty care. Blue Distinction evaluation is based on what impacts care the most: Know-how and expertise of the medical team Number of times the hospital has performed the procedure Track record for procedure results Blue Distinction Center+ is awarded to hospitals that meet the same quality-focused criteria as well as cost-of-care measures. Did you know? In 2015, the PPO plan will offer a 5% coinsurance incentive for spine and knee & hip surgeries when covered Novartis associates receive care at a Blue Distinction Center+ facility. That means eligible services for spine and knee & hip surgeries provided at a Blue Distinction Center+ facility will be covered at 90% after deductible, instead of 85% after deductible. Please note: This incentive applies to facility charges; it does not apply to professional services. In Massachusetts, the following facilities* have achieved recognition as a Blue Distinction Center or a Blue Distinction Center+: Baystate Medical Center, Springfield Berkshire Medical Center, Pittsfield Beth Israel Deaconess Medical Center, Boston Boston Children s Hospital, Boston Boston Medical Center, Boston Holy Family Hospital, Methuen Jordan Hospital, Plymouth Lahey Clinic, Burlington Mount Auburn Hospital, Cambridge New England Baptist Hospital, Boston Newton-Wellesley Hospital, Boston Saint Vincent Hospital, Worcester South Shore Hospital, South Weymouth Southcoast Hospitals Group Charlton Memorial, Fall River The Lowell General Hospital, Lowell Tufts Medical Center, Boston UMass Memorial Health Care, Worcester UMass Memorial Medical Center, Worcester Winchester Hospital, Winchester You can learn more about designated facilities throughout the country and search for designated facilities at bcbs.com/bluedistinction. * List accurate at the time of printing. 5 Get Top Medical Care

8 Help with Complex Care and Conditions Find the right services and get one-on-one support Our Complex Case Management program is a confidential, voluntary plan that provides the education, care and services you may need when faced with a challenging medical situation. People who have certain complex illnesses such as cancer, women with high-risk pregnancies, those who need a transplant or heart surgery, or those requiring ventilator management may benefit from case management. There is no cost to you for this service. All medical and personal information is confidential and shared only with those involved in your care. Horizon BCBSNJ Case Managers will work with you and your doctors to: Provide information so you can make informed decisions Coordinate your health care services so you get the appropriate care Help you secure authorizations you might need for services For more information or to enroll in this program, please call and select prompt 2. Our Chronic Care Program provides health education, coordinated care and one-on-one support from Horizon BCBSNJ Case Managers, an interdisciplinary team of registered nurses, dieticians and social workers. Members who have the following conditions can participate in the Chronic Care Program: Asthma Diabetes Coronary artery disease (CAD) Heart failure Please call to speak with a Case Manager. Diabetes Care Management Incentive Beginning January 1, 2015, if you have diabetes and are enrolled in the PPO plan, you can earn a $100 gift card by participating in the Diabetes Chronic Care Program. Associates and their dependents who are age 18 and older and have diabetes are eligible to participate. To earn the $100 gift card, participants will: Enroll in the Diabetes Chronic Care Program Develop an action plan with a Case Manager which includes at least three health goals or gaps in care that you wish to close Participate in at least three calls with a Case Manager following the initial program enrollment call Manage Complex Conditions Reach at least one of the goals or close at least one gap in care identified in the action plan To learn more, please call to speak with a Case Manager. 6 You may request enrollment, be referred by your doctor or be invited to participate in these programs based on your health situation. Consider talking about these free, voluntary programs with your doctor.

9 24/7 Nurse Line For Novartis associates and their families, help is a phone call away Our 24/7 Nurse Line can give you peace of mind when coping with medical issues or if you need health guidance.* Just call to speak with caring registered nurses who have an average of 15 years of clinical experience. The nurses can help you: Get answers to your health questions 24 hours a day Understand doctor-approved information to guide your health decisions Understand if the Emergency Room, a doctor visit or self-care is right for your needs Explore the risks, benefits and possible outcomes of treatment options Get tips on nutrition and exercise Learn about health screenings and immunizations Online health advice at your fingertips With our 24/7 Live Chat, you can have an individual, secure and confidential online discussion with a nurse and get the information you want all from your computer. This service is available 24 hours, every day, through Member Online Services at HorizonBlue.com/Novartis. * For informational purposes only. Nurses cannot diagnose problems or recommend specific treatment. They are not a substitute for your doctor s care. In an emergency, go to the nearest hospital or doctor or call 911 or your local emergency services number. The 24/7 Nurse Line nurses cannot provide information about or advise you on your benefits. For benefits information, including: authorizations explanation of benefits claim status claim filing and more call the Novartis-dedicated Customer Service Team at or use Member Online Services. Secure online chat Just sign in to Member Online Services at HorizonBlue.com/Novartis. Select the Tools & Resources tab and then select Nurse Chat from the lower right corner of the page. 7 Health Help 24/7

10 Using Your Preventive Care Benefits Make sure your preventive care is up to date Visiting your in-network doctor for a wellness visit is covered at no cost to you.* Annual visits for you and your dependents, including regular check-ups and annual vaccinations, are part of your Novartis medical plan. You can find preventive health information at HorizonBlue.com/Novartis, under Health & Wellness. When routine is not routine Sometimes, a routine physical exam may include tests or procedures your doctor feels are necessary, but aren t considered part of a routine visit. Talk to your doctor about your health concerns and medical costs. Questions to ask: Why do I need this test or procedure? Who will perform the test? Where will it be done? What will it cost? Review your benefits through Member Online Services at HorizonBlue.com/Novartis or by calling the Novartis-dedicated Customer Service team at Questions to ask: Is this a covered benefit? Is the doctor, lab or facility in network? What will my total cost be? What if I get a bill? When you use an in-network doctor or hospital, claims are filed for you. You should not get a bill, except if you have a copayment, deductible or coinsurance. If you do not use an in-network doctor or hospital, you may get a medical bill. You may submit the bill for reimbursement, along with a claim form. Include your Horizon BCBSNJ member ID number, name, date of birth and your relationship to the patient, if applicable. Please keep copies of bills and claim forms for your records. Follow up with your doctor Ask your doctor when you can expect the results of your test or procedure and schedule a follow-up appointment. It s important to understand your medical options, what steps are needed and possible costs to ensure that your health care needs are met. Preventive Care? Why are services sometimes considered preventive and other times considered diagnostic? Services are considered preventive or diagnostic based on the codes your doctor uses when he or she submits the claim for reimbursement. 8 * Regular deductible and coinsurance apply when using out-of-network providers.

11 The ABCs of EOBs Understand how your plan pays claims You will receive an Explanation of Benefits (EOB) so you understand how your Novartis medical plan pays claims and your role in that process. An EOB will be available up to 15 days after the claim is processed and may show up to 25 claims, giving you a comprehensive view of the services provided. Visit HorizonBlue.com/Novartis and use Member Online Services to view, download and print your EOBs. Please call the Novartis-dedicated Customer Service team at if you have questions about an EOB. This sample EOB shows what to expect on your EOB: A B C D E F G H I J K A Date of Service B Type of Service C Billed Amount D Allowed Amount E Your Coinsurance/Copayment Amount F Your Deductible Amount G Other Carrier Payment Amount H Not Covered Amount I Horizon BCBSNJ Paid Amount J Message Code K Subscriber Responsibility The date that services were provided to the patient. A brief explanation of each service. Amount charged by the doctor or health care professional for each service on the claim. The amount approved for payment based on your plan benefits prior to the deductible, coinsurance, copayment or other member cost sharing, if applicable. For services obtained out of network, the difference between billed and allowed amounts will be included in the amount shown as Subscriber Responsibility (K). The coinsurance or copayment amount that is your responsibility after you have met your deductible, if applicable. You pay this amount to the doctor or health care professional. The amount applied to this service under your benefits contract. You are responsible for paying this amount to the doctor or health care professional. The amount paid by another insurance carrier, including Medicare, if applicable. Any amount of the fee charged for the service that is not covered by your plan; expenses not covered or in excess of your benefits. You may be responsible for this amount in addition to any deductible, coinsurance or copayment. Examples of expenses that may appear in this column are costs above the negotiated rate when using an out-of-network doctor or amounts for duplicate services. The total amount paid by your medical plan for the services rendered. This amount may be paid to you, your doctor or health care professional or designated payee. A code in this column refers to specific messages below each claim that help explain how the payment was calculated. The balance due from you to the doctor or health care professional after the copayment, deductible, coinsurance and benefits are applied. 9 The ABCs of EOBs

12 Claims and Appeals What to do if you don t agree with a claim decision You, your authorized representative, or a doctor or other health care professional acting on your behalf and with your consent, have the right to appeal any decision not to provide or reimburse for an item or service (in whole or in part). No member who pursues a right of appeal will be subject to disenrollment, discrimination or penalty by Horizon BCBSNJ. The following questions and answers can help you understand the appeals process. How do I file an appeal? Your appeal must be filed within 180 days of your receipt of an Explanation of Benefits (EOB). To file an appeal, your request should be made in writing and must include all of the following information: Name and address of patient and member Date(s) of service Member ID number Claim number(s) Provider of service Reason for appeal For general health claims, send appeals to: Horizon BCBSNJ Attn: Appeals Coordinator PO Box 317 Newark, NJ Can I provide more information about my claim? You may submit any documents, records or any other information that you would like to have considered to support your appeal request. We will also consider all previous documentation that applies to your appeal. Can I request copies of information relevant to my claim? Yes, you can request copies of all information that was used in determining your claim for benefits. You are also entitled to receive a copy of any rule, guideline, protocol, diagnosis and treatment codes billed, exclusion or contract limitation, or an explanation of any clinical and/or scientific judgment that was relied upon in our decision-making process. This information can be provided to you free of charge by calling When will I have a decision on my appeal? Once we have received your appeal request, you will be notified of our determination within 30 days of our receipt of your request if your claim is for an item or service that your plan requires our approval in advance to receive benefits, or within 60 days in all other cases. What if the appeal decision is not in my favor? You will be advised of what further appeal rights you may have and how to file for further review. Do I have further appeal rights if my case involves medical judgment? You may have the right to an external review of your claim by an independent third party who will review the denial and issue a final, binding decision. If it applies to your case, you will be notified of this right during and following the completion of the internal appeals process. Filing an Appeal 10

13 Your Secure Member Online Services Medical plan information is just a click away For an easy, secure and quick way to track your health plan benefits and health information, use your Member Online Services at Novartis.HorizonBlue.com/welcome-NIBRI-associates. With Member Online Services, you can: View your benefits Check your claims status and payments View authorizations and referrals Print or request ID cards Tell us if you have other health insurance Find an in-network doctor or hospital Change your doctor Manage your account and preferences Access your personal health record Use our Treatment Cost Estimator tool To register for Member Online Services Visit HorizonBlue.com/Novartis and click Register Today. If you need help accessing Member Online Services, Member_Portal@HorizonBlue.com. When using or registering for Member Online Services, please keep these tips in mind: You must have a valid address. Member Online Services is compatible with MS Windows and Mac OS. Member Online Services is supported by Internet Explorer (up to Version 8), Firefox 3, Chrome and Safari. Mobile is supported by iphone OS, Android OS, Blackberry OS and Windows Mobile OS. Adobe Acrobat Reader 6 or higher is needed to view some content. Safe and secure Member Online Services uses the latest technology to keep your information secure. By creating your account with a personal password, your information remains confidential. 11 Your Member Website

14 Manage Your Health On the Go with the Horizon Blue App Connecting to your health care is easy. Just download* the Horizon Blue App to your Apple or Android device. With the Horizon Blue App, you can use your hand-held device to access all of your essential information. You will be able to: View your claims information View copayment, coinsurance and deductible for a specific claim Search for claims within a date range Check authorizations View authorization details Check the status of authorizations Get ID cards View or print the front and back of your ID card Request a duplicate ID card Notify us of other insurance you may have Add or update coordination of benefits (COB) information View your benefits See product and coverage information View benefits information such as copayment, coinsurance and deductible Manage your account Modify your profile Opt in or opt out for paperless Explanation of Benefits (EOB), s or text alerts Contact us Access a list of frequently used toll-free phone numbers us your questions To get the Horizon Blue App ** Scan this with your iphone. Scan this with your Android device. * There is no charge from Horizon BCBSNJ to download the Horizon Blue App, but rates from your wireless provider may apply. Data rates may apply, depending on your mobile plan/carrier. ** Download a free QR code reader from the Apple App Store or Google Play. On the Go with Mobile 12

15 Glossary Common medical insurance terms you should know Annual Deductible Annual Out-of-Pocket Maximum Coinsurance Copayment Claims Administrator In-Network Out-of-Network Reasonable and Customary (R&C) Urgent Care Center (UCC) Emergency The amount you pay for certain health care services before your medical coverage begins to pay. You pay in full for each service subject to deductible until you reach the deductible. The maximum amount you will pay out of pocket in any calendar year. The out-of-pocket limit includes your payments for the deductible, copayments and coinsurance. Once you meet the annual out-of-pocket maximum, the claims administrator will pay 100% of the allowed amount for additional covered charges for the rest of that year, subject to any maximums or limits. Your share of the costs of a health care service. It is usually a percentage (e.g., 80%) of the allowed charge for the service. You start paying coinsurance after you ve paid your plan s deductible. A copayment is the amount you pay for in-network services obtained from a PPO, EPO or HMO network provider. The company, or its affiliate, that provides certain claim administration services under the plan. Benefits for covered health services that are provided by a provider who has a network participation agreement with the claim administrator. By using a network provider, your costs are lower and the network provider cannot bill you for any services not approved by the claims administrator. Benefits for covered health services that are provided by a provider who has not agreed to the network pricing and practice requirements. Your costs will usually be higher using an out-of-network provider. Typically, the term is used for out-of-network claims. Subject to certain exceptions, R&C means the price that is the lowest of the following amounts: 1. the actual charge submitted; or 2. for in-network services, the price the provider has agreed to accept for the service or supply; or 3. for out-of-network providers, 250% of the Medicare-allowed price for that service or supply. A non-hospital facility providing health services that prevent a serious deterioration of your health due to an unforeseen sickness or injury, as well as the onset of acute or severe symptoms. A serious medical condition or symptom resulting from injury, sickness or mental illness that arises suddenly and, in the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset. 13 Important terms to know

16 HorizonBlue.com/Novartis The Blue Cross and Blue Shield names and symbols, BlueCard and Blue Distinction are registered marks of the Blue Cross and Blue Shield Association. The Horizon name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey, an independent licensee of the Blue Cross and Blue Shield Association. Products are provided by or administered by Horizon Blue Cross Blue Shield of New Jersey. Android TM and YouTube TM are trademarks of Google, Inc. Apple and iphone are registered marks of Apple, Inc. Facebook is a registered mark of Facebook, Inc. WebMD is a registered mark of WebMD, Inc. All other trademarks and trade names are the property of their respective owners Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey _NIBRI (1214) Find the Health Care You Need Almost Anywhere Ninety-one percent of doctors and 96 percent of hospitals in the United States participate in BlueCard.* Outside of the United States, you have access to doctors and hospitals in more than 200 countries and territories around the world through BlueCard Worldwide.*, ** To quickly and easily find doctors and hospitals available to you through the BlueCard Program: 1. Have your Horizon BCBSNJ ID card on hand. 2. Visit the National Doctor and Hospital Finder at HorizonBlue.com/Novartis. 3. Follow the directions and start your search. You may also download the National Doctor and Hospital Finder app*** for iphone, ipad and ipod Touch to quickly search for health care providers. 14 To find a health care provider in the United States, you may also call the Novartis-dedicated Customer Service team at for the names and addresses of doctors and hospitals in the area where you or your covered dependent need care. To find a health care provider worldwide, call the BlueCard Worldwide Service Center at BLUE (2583) or call collect at , 24 hours a day, seven days a week. An assistance coordinator, in conjunction with a medical professional, will arrange a doctor s appointment or hospitalization, if necessary. * Network numbers are current at the time of printing. ** Under the EPO plan, only emergency care is covered outside of the United States. ***There is no charge to download the National Doctor and Hospital Finder app, but rates from your wireless provider may apply. Data rates may apply, depending on your mobile plan/carrier.