2016 plans: DDP: PPO, CDHP, and EPO (EPO for PA residents only) DDNY: PPO and CDHP Effective January 1, 2016 HIGHLIGHTS Medical benefits 11 How to find a provider 12 Programs and services 13 Benefit summaries 16
Go with the plan that s right for you
When you go with the Preferred Provider Organization (PPO), Consumer-Directed Health Plan (CDHP), and Exclusive Provider Organization (EPO for PA residents only), and PPO and CDHP (DDNY), administered by Blue Shield of California, you re on your way to quality health coverage, large provider networks, and a wide range of programs and services that help provide the most value from your coverage. This booklet offers the information you need to choose the right health plan for you and your family. Plan choices During the 2016 annual enrollment period, Delta Dental is offering the following plans, administered by Blue Shield: DDP: PPO, CDHP, and EPO (EPO for PA residents only) DDNY: PPO and CDHP To make it easier to compare the plans, we ve included a description of the unique features of each and a benefit comparison chart on pages 10-11 of this booklet.
PPO By enrolling in the PPO, you can receive care from any of the physicians and hospitals within the plan s network, as well as outside of the network for covered services. If maintaining a relationship with your current doctor is important to you, then the PPO plan may be a good choice since the plan lets you continue seeing your current doctor for most covered services, even if your doctor isn t part of the plan s provider network. Keep in mind that if your physician is not part of the plan s PPO network, you will have to pay more for each visit. Estimate your medical costs Blue Shield s Treatment Cost Estimator tool provides PPO plan members with estimates of both the total cost and out-of-pocket expenses for common in-network medical treatments and services. These estimates provide the transparency and clarity to help you budget and plan for future healthcare expenses. To access the tool, log in to blueshieldca.com, then click on Help & Support and then Treatment Cost Estimator. 02 Blue Shield of California
Have questions? Get answers. Call the Blue Shield Member Services team at (855) 256-9404. Visit blueshieldca.com/deltadental to find providers, review medical benefits, and more. Download the Blue Shield mobile app for iphone or Android at blueshieldca.com/mobile. Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question. HOW THE PLAN WORKS When you see a network provider for covered services: PPO network providers will submit their claims to Blue Shield. You pay 100% of the allowed amount for services, except for preventive care, until you meet your calendar-year deductible. After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services. When you see a non-network provider for covered services: You pay 100% of the amount billed for covered services until you ve met your calendar-year deductible. Only the amount allowed by Blue Shield of California will apply to the deductible accumulation. After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services, which is based on Blue Shield s allowable amount, plus any charges above the allowable amount. The additional charges above the allowable amount can be substantial. Non-network providers will usually require you to pay 100% of the cost of the service. You will then need to submit a claim along with the itemized bill from your provider to Blue Shield. Plan highlights Here are a few highlights of the services covered by the PPO. For details on copayment and coinsurance amounts, please see the benefit overview on page 11. To find network providers, see page 12. Preventive care Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive. Specialty care You can access care through a specialist without a referral from your primary care physician. Mental health and substance abuse care You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network and non-network providers. Keep in mind that if you see a provider that is not part of the plan s PPO network, your out-of-pocket costs will be higher. Urgent care It s possible to save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/ucc-ppo. Emergency care You re covered for emergency care around the world regardless of whether or not the provider is in your plan s PPO network. Chiropractic and acupuncture services Visit any chiropractor or acupuncturist in the Blue Shield PPO network. Pharmacy benefits Offered through CVS Caremark. Note that prescription drug coverage benefits accrue to the combined plan out-of-pocket maximum. Go to blueshieldca.com/deltadental 03
Exclusive Provider Organization (EPO) plan Only available to Delta Dental Pennsylvania plan members living in Pennsylvania the Blue Shield Exclusive Provider Organization (EPO) plan is structurally similar to an HMO plan, except that you do not need to select a Personal Physician. If you seek care as an EPO member, you choose from physicians and hospitals in the preferred provider (PPO) network in the state of Pennsylvania only. Non-network services and services outside of Pennsylvania are not covered, except for emergency care. Choosing a Personal Physician This plan does not require you to choose a personal physician; however, you must choose from physicians and hospitals in the preferred provider network. 04 Blue Shield of California
Have questions? Get answers. Call the Blue Shield Member Services team at (855) 256-9404. Visit blueshieldca.com/deltadental to find providers, review medical benefits, and more. Download the Blue Shield mobile app for iphone or Android at blueshieldca.com/mobile. Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question. HOW THE PLAN WORKS For Pennsylvania residents only with the Blue Shield EPO plan, there are no deductibles or coinsurance, and you only need to pay a copayment for most covered services like doctor visits, prescription drugs, urgent care visits, and emergency care (just to name a few). Other services have no copayment. You only have access to providers in the Blue Shield PPO network. Services provided by non-network providers, except for emergencies, are not covered by the plan. For some services, Blue Shield may require that you use a specific network provider. Plan highlights Here are a few highlights of the services covered by the EPO plan. For details on copayment amounts, please see the benefit overview on page 11. To find network providers, see page 12. Preventive care Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive. Specialty care You can see any specialist in the PPO network when needed without prior authorization from your primary physician. However, some services may require prior authorization. Mental health and substance abuse care You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network. Urgent care It s possible to save time and money by going to an urgent care center instead of the emergency room. To find a network urgent care center, visit blueshieldca.com/ucc-ppo. If you receive care at an urgent care center that s not in the Blue Shield PPO network, your plan may not cover the services you receive. Emergency care You re covered for emergency care around the world regardless of whether or not the provider is in your plan s PPO network. Chiropractic and acupuncture services Visit any chiropractor or acupuncturist in the Blue Shield PPO network. Pharmacy benefits Offered through CVS Caremark. Note that prescription drug coverage benefits accrue to the combined plan out-of-pocket maximum. Go to blueshieldca.com/deltadental 05
CDHP with HSA The CDHP is a high-deductible PPO plan that is paired with a health savings account (HSA),* a federal tax-free savings account, administered by HealthEquity. To start a health savings account with HealthEquity, you must enroll in the Health Savings Account (HSA) compatible CDHP. The CDHP allows you to receive care from any of the physicians and hospitals within the plan s network, as well as outside of the network for covered services. The HSA helps you save money to help offset your deductible and other out- of-pocket medical expenses. See page 08 for the deductible amounts for this plan. Plan highlights Here are a few highlights of the services covered by the CDHP. For details on copayment and coinsurance amounts, please see the benefit summaries starting on page 16. To find network providers, see page 12. Low monthly premiums The higher deductible and outof-pocket maximum will lower your premium. That means you pay less each pay period and can choose to apply the savings to pay the deductible when you actually need care or to increase your HSA contributions. Preventive care Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca. com/preventive. Specialty care You can access care through a specialist without a referral from your primary care physician. Mental health and substance abuse care You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network and non-network providers. Keep in mind that if you see a provider that is not part of the plan s PPO network, your out-of-pocket costs will be higher. Urgent care It s possible to save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/ucc-ppo. Emergency care You re covered for emergency care around the world regardless of whether or not the provider is in your plan s PPO network. Chiropractic and acupuncture services Visit any chiropractor or acupuncturist in the Blue Shield PPO network. Pharmacy benefits Offered through CVS Caremark. Note that prescription drug coverage benefits accrue to the combined plan out-of-pocket maximum. * Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions. Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser The HSA is offered through HealthEquity, a company independent from Blue Shield of California. Blue Shield does not offer tax advice for HSAs since HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, please consult your financial or tax adviser. 06 Blue Shield of California
Health savings account (HSA) highlights The HSA* works very much like a savings account. You can contribute pre-tax dollars and let it grow from year to year. The funds are federal tax-free and can be used to pay for your deductible and qualified out-of-pocket medical expenses. You can also save it and let it grow from year to year. This can be a good way to save money for long-term care costs or in retirement. Below are a few highlights of the HSA. For more information on the HSA, go to healthequity.com/deltadental. If you change jobs, retire, or leave the health plan, you take the money with you wherever you go it s yours to keep. Once your HSA balance accrues more than $2,000, you can invest any amount in excess of the $2,000 into a mutual fund. Even though you do not need your receipts to get reimbursement from the HSA, keep your receipts in case of an IRS audit. All contributions, earnings, and withdrawals for eligible healthcare expenses are federal tax-free. Contributing to your HSA To view an up-to-date list of HSA qualified medical expenses, download or order IRS Publication 502 by calling the IRS at 1-800-TAX-FORM (1-800-829-3676) or by visiting www.irs.gov. Member contributions and limits Plan coverage effective January 2016 DELTA DENTAL CONTRIBUTION* YOUR CONTRIBUTION LIMIT (IRS LIMIT DELTA DENTAL CONTRIBUTION) IRS ANNUAL LIMITS < age 55 Single Coverage $500 $2,850 $3,350 Family Coverage $1,000 $5,750 $6,750 Age 55+ Single Coverage $500 $3,850 $4,350 Family Coverage $1,000 $6,750 $7,750 Important notes about the chart above: You and Delta Dental contributions are based on an CDHP coverage effective date of July. If your coverage is effective after July, Delta Dental contribution will be prorated for the calendar year and you should adjust your own contributions to comply with IRS limits. Family coverage includes Employee + Spouse/Domestic Partner/Adult Dependent. * Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP plan is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions. Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser. Based on a plan effective date of January 2016. Go to blueshieldca.com/deltadental 07
How the CDHP and HSA work together You can use your HSA* to pay for your plan s deductible and/or out-of-pocket maximum. Or you can leave the funds invested in the account for future medical expenses and save for long-term care costs federal tax-free. Here s how it works. Using the HSA to pay for medical or pharmacy benefits Medical services Visit a provider and receive services. Your provider bills Blue Shield. Blue Shield sends you an EOB. Your provider sends you an invoice. Pay your invoice with your HSA: Use your HSA debit card; or Pay provider directly through healthequity.com; or Use another method of payment and reimburse yourself through healthequity.com Pharmacy services Fill or refill a prescription The pharmacy verifies your pharmacy coverage and provides a cost for your prescription(s). Pay for prescription using your HSA: Use your HSA debit card; or Use another method of payment and reimburse yourself through healthequity.com Using your HSA to cover your deductible If your CDHP Plan coverage effective date is January, below are the amounts that you would need to contribute to your HSA to cover your calendar-year-deductible. NETWORK DEDUCTIBLE DELTA DENTAL CONTRIBUTION TO HSA ADDITIONAL HSA CONTRIBUTIONS NEEDED TO COVER DEDUCTIBLE Single coverage $1,500 $500 $1,000 Family coverage $3,000 $1,000 $2,000 * Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions. Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser. 08 Blue Shield of California
Growing your HSA balance with weekly or monthly contributions By contributing as little as $19 per week pre-tax to an HSA approximately the cost of four barista coffees members with single coverage can save enough to cover their deductible. Members with family coverage can save enough to meet their network deductible by contributing about $38 per week to their HSA. Examples of weekly and monthly contribution amounts The monthly and weekly contributions below are based on contributions over a 12-month or 52-week period. DESIRED HSA BALANCE IN 12 MONTHS CLIENT CONTRIBUTION EXAMPLE MEMBER CONTRIBUTION (TIMING SUBJECT TO PAYROLL CYCLE) YEARLY MONTHLY BIWEEKLY WEEKLY Single coverage $1,500 $500 $1,000 $83 $42 $19 $2,000 $500 $1,500 $125 $63 $29 Family coverage $3,000 $1,000 $2,000 $167 $83 $38 $3,500 $1,000 $2,500 $208 $104 $48 Estimating your medical/pharmacy expenditures CDHP members Blue Shield s Treatment Cost Estimator tool provides Health Savings Plan members with estimates of both the total cost and out-of-pocket expenses for common network medical treatments and services. These estimates provide the transparency and clarity to help you manage and plan for future healthcare expenses. To access this tool, go to blueshieldca.com/deltadental and select Log in to blueshieldca.com. If you don t have an online account, select Register for an online account. Once logged in, click on Help & Support and then Treatment Cost Estimator. Important: fairhealthconsumer.org does indicate whether providers are part of the Blue Shield network, and the estimated costs do not reflect Blue Shield negotiated network discounts. Actual costs for services may vary depending on the plan you enroll in and the providers you access for services. FAIR Health s agreements with third parties place limits on the number of medical and dental searches that can be done on the site. Consumers can conduct 15 searches of up to five medical codes per week and 10 searches of up to five dental codes per week. Learn more at fairhealthconsumer.org/faq. Non-members If you are not currently enrolled in the Health Savings Plan, then you can estimate your medical costs through fairhealthconsumer.org, a third-party website that is not affiliated with Blue Shield. * Contributions are pre-tax estimates and do not include accrued HSA interest. Currently, for residents of California, Alabama, and New Jersey, HSA contributions and earnings are not excluded from state income tax. For more information, please consult your tax adviser. Go to blueshieldca.com/deltadental 09
Compare plan features PPO & CDHP EPO plan (for PA residents only) NETWORK NON-NETWORK NETWORK NON-NETWORK Out-of-pocket costs Pay a copayment or coinsurance for covered services. (Calendar-year deductible may apply.) After calendaryear deductible is met, pay a percentage of costs and all costs above the allowable amount. Pay a copayment covered services. Non-network services are not covered, except for urgent and emergency care. Choosing a doctor Visit any PPO network physician. Visit any PPO network specialist; no referral is required. Visit any non-network physician, pay for the services, and submit claims to Blue Shield. Visit any non-network specialist and submit claims to Blue Shield. Visit any PPO network physician in Pennsylvania only. Visit any PPO network specialist in Pennsylvania only; no referral is required. Non-network services are not covered, except for emergency care. No referral is required. Access to specialists Visit any PPO network specialist; no referral required. Visit any non-network specialist and submit claims to Blue Shield. Visit any PPO network specialist; no referral required. Non-network services are not covered, except for urgent and emergency care. No referral is required. * To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by an MHSA network participating provider. 10 Blue Shield of California
Compare plan benefits PPO CDHP EPO plan (for PA residents only) NETWORK NON-NETWORK NETWORK NON-NETWORK NETWORK Plan -year deductible (applies to out-of-pocket maximum) $500 per individual/ $1,000 per family $1,000 per individual/ $2,000 per family $1,500 per individual/ $3,000 per family* $3,000 per individual/ $6,000 per family* None Plan-year out-of-pocket maximum or copayment maximum $2,000 per individual/ $4,000 per family $4,000 per individual/ $8,000 per family $3,000 per individual/ $6,000 per individual/ $2,000 per individual/ $6,000 per family t $12,000 per family t $4,000 per family t MEMBER COPAYMENT/COINSURANCE MEMBER COPAYMENT/COINSURANCE MEMBER COPAYMENT Physician office visit 20% 40% 10% 30% $20 per visit Specialist office visit 20% 40% 10% 30% $40 per visit Preventive health benefits Outpatient X-ray, pathology, and laboratory No charge (not subject to the calendar-year deductible) 40% No charge (not subject to the calendar-year deductible) 30% No charge 20% 40% 10% 30% No charge Outpatient surgery in hospital 20% 40% 10% 30% $100 per visit Inpatient facility services (non-emergency) 20% 40% 10% 30% $250 per admission Emergency room services (not resulting in admission) Mental health services (outpatient services) Substance abuse (inpatient/ outpatient physician visit) 20% (not subject to the calendar-year deductible) 20% (not subject to the calendar-year deductible) 10% 30% $150 per visit 20% 40% 10% 30% $20 per visit 20% 40% 10% 30% Inpatient: No charge Outpatient: $20 per visit Pregnancy and maternity care benefits 20% 40% 10% 30% No charge Acupuncture benefits 20% (up to 20 visits per plan-year) 40% (up to 20 visits per plan-year) 10% (up to 20 visits per plan-year) 30% (up to 20 visits per plan-year) Not covered Chiropractic benefits (provided by a chiropractor) 20% (up to 12 visits per plan-year) 40% (up to 12 visits per plan-year) 10% (up to 12 visits per plan-year) 30% (up to 12 visits per plan-year) $20 (up to 12 visits per plan-year) * For family coverage, the full family deductible must be met before enrollee or covered dependents can receive benefits. For family coverage, the full family out-of-pocket must be met before enrollee or covered dependents can receive 100% coverage. Prenatal and postnatal physician office visits. For inpatient hospital services, see Hospitalization Services on the benefit summary in the back of this booklet. Go to blueshieldca.com/deltadental 11
Find a network provider Blue Shield s networks are some of the largest nationwide. The PPO network includes more than 70,000 physicians and 350 hospitals. Search for a network provider Within the United States Go to provider.bcbs.com. Enter the first three letters of your member ID or DDR or select the BlueCard PPO/EPO network. Search by Keyword or by Specialty. Enter a location and a radius to search by (default is 5 miles). Click on Go. Outside of the United States Go to bluecardworldwide.com. Accept the terms and conditions. Enter the first three letters of your member ID or DDR. Click Login. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (855) 256-9404 for personal assistance or to request a provider directory. 12 Blue Shield of California
Going with Blue Shield means added programs and services Condition management programs These programs offer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. NurseHelp 24/7 Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7 SM phone number is conveniently located on the back of your member ID card. Prenatal Education Prenatal Education promotes a healthy pregnancy with helpful information about prenatal and postpartum care. Members receive an educational packet as well as a book of their choice that provide practical recommendations for maintaining a healthy lifestyle before, during, and after pregnancy, and caring for infants through the toddler years. Have questions? Get answers. Call the Blue Shield Member Services team at (855) 256-9404. Visit blueshieldca.com/deltadental to find providers, review medical benefits, and more. Download the Blue Shield mobile app for iphone or Android at blueshieldca.com/mobile. Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question. Wellness discount programs Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs 1 that can help you save money and get healthier. Weight Watchers Get discounts on three- and 12-month subscriptions, and monthly passes. 24 Hour Fitness Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues. Alternative Care Discount Program Get 25% off usual and customary fees for acupuncture, chiropractic services, and massage therapy, plus get discounts on health and wellness products, with free shipping on most items. Discount Provider Network 2 Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more. MESVision Optics Take advantage of competitive prices on contact lenses, 3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. Blue Shield vision plan members can apply their benefits to reduce their out-of-pocket costs for contact lenses. Please refer to the endnotes on inside back cover for all pertinent wellness discount program notations. Go to blueshieldca.com/deltadental 13
Quick, convenient health care for busy people Available for Blue Shield PPO members!* Whether you want your cholesterol checked, you hurt your ankle, or you have a child with a sore throat, MinuteClinic can help. They offer affordable, non-emergency health care seven days a week and you don t need an appointment. About the Clinics MinuteClinic walk-in healthcare centers are staffed by board-certified nurse practitioners focused on preventive care, vaccinations, and treatment for minor illnesses and injuries. The clinics are: Quick Visits take about 15 minutes, and you never need an appointment. Affordable Copayments are the same as a visit to your primary care physician. Convenient They re located in select CVS locations and are open every day. Find a MinuteClinic Visit MinuteClinic next time you need affordable, non-emergency medical care. To find a contracted MinuteClinic, just go to blueshieldca.com/findaprovider. Choose Facilities and click on Advanced Search. Under Facility type, choose Retail Health Clinics. Edit the Located near field, or keep the defaults. Click Find now to see results. MinuteClinic national locator on CVS website: cvs.com/minuteclinic/clinic-locator. * Members must access locations currently contracted with their Blue Shield PPO network in order to receive network rates. For a full list of services available, go to minuteclinic.com. Visit times may vary based on services provided. 14 Blue Shield of California
Review benefit summaries Delta Dental of Pennsylvania ASO PPO 500 80-60 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Calendar Year Medical Deductible (Participating and Non-Participating deductibles accrue separately) Calendar Year Out-of-Pocket Maximum (Includes the calendar year medical deductible. Copayments or coinsurance for covered services from Participating Providers accrue to both the Participating and Non-Participating Provider Calendar-Year out-ofpocket maximum amounts) Lifetime Benefit Maximum Covered Services Participating Providers 1 $500 per individual / $1,000 per family $2,000 per individual / $4,000 per family None Member Copayment Non-Participating Providers 2 $1,000 per individual / $2,000 per family $4,000 per individual / $8,000 per family OUTPATIENT PROFESSIONAL SERVICES Participating Providers 1 Non-Participating Providers 2 Professional (Physician) Benefits Physician and specialist office visits 20% 40% Outpatient diagnostic x-ray, imaging, pathology, laboratory and 20% 40% other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections (separate office visit copayment may apply) Preventive Health Benefits 11 Preventive health services (as required by applicable Federal law) 20% 40% 20% 40% (not subject to the calendar year medical deductible) OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery 20% 40% 3 center Outpatient surgery performed in a hospital or a hospital affiliated 20% 40% 3 ambulatory surgery center Outpatient services for treatment of illness or injury and necessary 20% 40% 3 supplies (except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") Outpatient diagnostic x-ray, imaging, pathology, laboratory and 20% 40% 3 other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) 20% 40% 3 Bariatric surgery (prior authorization is required; medically necessary surgery for 20% 40% 3 weight loss, for morbid obesity only) 4 HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 20% 40% Inpatient non-emergency facility services (semi-private room and board, 20% 40% 5 and medically necessary services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically necessary surgery for 20% 40% 5 weight loss, for morbid obesity only) 4 40% Go to blueshieldca.com/deltadental 15
Inpatient Skilled Nursing Benefits 6 Covers up to 100 days per calendar year combined with Hospital Skilled Nursing Facility Unit. Free-standing skilled nursing facility 20% 20% 7 Skilled nursing unit of a hospital 20% 40% 5 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not apply if the member is directly admitted to the hospital for inpatient services) 20% (not subject to the calendar year medical deductible) 20% (not subject to the calendar year medica deductible) Emergency room services resulting in admission (when the member is 20% 20% admitted directly from the ER) Emergency room physician services 20% 20% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 20% 20% PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may 20% 40% apply) Orthotic equipment and devices (separate office visit copayment may apply) 20% 40% DURABLE MEDICAL EQUIPMENT Breast pump Not Covered (not subject to the calendar year medical deductible) Other durable medical equipment 20% 40% MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 8,9 Inpatient hospital services 20% 40% 5 Residential care 20% 40% 5 Inpatient physician services 20% 40% Routine outpatient mental health and substance abuse services (includes professional/physician visits) Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, psychological testing and transcranial magnetic stimulation) HOME HEALTH SERVICES 20% 40% 20% 40% Home health care agency services (up to 100 visits per calendar year) 6 20% Not Covered 10 Home infusion/home injectable therapy and infusion nursing visits 20% Not Covered 10 provided by a home infusion agency HOSPICE PROGRAM BENEFITS Routine home care 20% Not Covered 10 Inpatient respite care 20% Not Covered 10 24-hour continuous home care 20% Not Covered 10 Short-term inpatient care for pain and symptom management 20% Not Covered 10 CHIROPRACTIC BENEFITS 6 Chiropractic spinal manipulation (up to 12 visits per calendar year) 20% 40% ACUPUNCTURE BENEFITS 6 Acupuncture services (up to 20 visits per calendar year) 20% 40% REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) 20% 40% SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services) Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) 20% 40% 20% 40% 20% 40% 16 Blue Shield of California
FAMILY PLANNING BENEFITS Counseling and consulting (includes insertion of IUD, as well as injectable and implantable contraceptives for women) Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) Plan designs may be modified to ensure compliance with Federal requirements. ASO (1/16) SD 092215 40% (not subject to the calendar year medical deductible) 40% (not subject to the calendar year medical deductible) 20% 40% DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies 20% 40% Diabetes self-management training 20% 40% CARE OUTSIDE OF PLAN SERVICE AREA Benefits provided through the BlueCard Program are paid at the participating level. Member s cost share will be either a copayment or coinsurance based on the lower of billed charges or the negotiated allowable amount for participating providers as agreed upon with the local Blue s Plan. Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for copayments/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services. 2 Non-participating providers can charge more than Blue Shield s allowable amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 The maximum allowed charges for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a nonparticipating hospital is $350 per day. Members are responsible for 40% of this $350 per day, and all charges in excess of $350 per day. Amounts that exceed the benefit maximums do not count toward the calendar year out-of-pocket maximum and continue to be the member s financial responsibility after the calendar year maximums are reached. 4 Bariatric surgery is covered when prior authorized by Blue Shield. Refer to the Plan Contract for further details. 5 The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, and all charges in excess of $600 per day. Amounts that exceed the benefit maximum do not count toward the calendar year out-of-pocket maximum and continue to be the member s responsibility after the calendar year maximums are reached. 6 For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 7 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. 8 Mental Health and Substance Abuse services are accessed through Blue Shield s participating and non-participating providers. 9 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 10 Services from non-participating providers for home health care and hospice services are not covered unless prior authorized. When these services are prior authorized, the member s copayment or coinsurance will be calculated at the participating provider level, based upon the agreed upon rate between Blue Shield and the agency. 11 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance Go to blueshieldca.com/deltadental 17
Delta Dental of Pennsylvania ASO EPO Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Participating Providers 1 Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum $2,000 per individual / $4,000 per family Lifetime Benefit Maximum None Covered Services Member Copayment OUTPATIENT PROFESSIONAL SERVICES Participating Providers 1 Professional (Physician) Benefits Physician office visits (Includes OB/GYN, Pediatrician, Internal Medicine, Family $20 per visit Practice and General Practice) 2 Specialist office visits (Includes all other provider designations) 2 $40 per visit Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections (separate office visit copayment may apply) Preventive Health Benefits 7 Preventive health services (as required by applicable Federal law) OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) Bariatric surgery HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medically necessary services and supplies, including subacute care) Bariatric surgery Inpatient Skilled Nursing Benefits 3,4 Combined maximum of up to 60 days per calendar year. Free-standing skilled nursing facility Skilled nursing unit of a hospital $100 per visit $100 per visit Not Covered $250 per admission Not Covered $50 per day $50 per day 18 Blue Shield of California
EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is admitted directly from the ER) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 5,6 Inpatient hospital services Residential care Inpatient physician services Routine outpatient mental health and substance abuse services (includes professional/physician visits) Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization program, psychological testing and transcranial magnetic stimulation) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) 3 Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency HOSPICE PROGRAM BENEFITS Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management CHIROPRACTIC BENEFITS 3 Chiropractic spinal manipulation (up to 12 visits per calendar year) ACUPUNCTURE BENEFITS Acupuncture services REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services) Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) FAMILY PLANNING BENEFITS Counseling and consulting (includes insertion of IUD, as well as injectable and implantable contraceptives for women) Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits) Diabetes self-management training $150 per visit $250 per admission $100 per trip $250 per admission $250 per admission $20 per visit $20 per visit $20 per visit $75 per day $75 per day $20 per visit Not Covered $20 per visit $20 per visit $100 per surgery $75 per surgery $20 per visit Go to blueshieldca.com/deltadental 19
CARE OUTSIDE OF PLAN SERVICE AREA Benefits provided through the BlueCard Program are paid at the participating level. Member s cost share will be either a copayment or coinsurance based on the lower of billed charges or the negotiated allowable amount for participating providers as agreed upon with the local Blue s Plan. Within US: BlueCard Program See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for copayments/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services. 2 When services are provided by a Participating Specialist, a $40 copayment per visit applies. 3 For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 4 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. 5 Mental Health and Substance Abuse services are accessed through Blue Shield s participating and non-participating providers. 6 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 7 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance Plan designs may be modified to ensure compliance with Federal requirements. ASO (1/16) SD 092115 20 Blue Shield of California
Delta Dental of Pennsylvania ASO CDHP Aggregate Deductible 1500/3000 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Calendar Year Medical Deductible (Participating and Non-Participating deductibles accrue separately.) For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. Calendar Year Out-of-Pocket Maximum (Includes the calendar year medical deductible.) For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services. Lifetime Benefit Maximum Covered Services OUTPATIENT PROFESSIONAL SERVICES Participating Providers 1 $1,500 per individual / $3,000 per family $3,000 per individual / $6,000 per family Participating Providers 1 None Member Copayment Non-Participating Providers 2 $3,000 per individual / $6,000 per family $6,000 per individual / $12,000 per family Non-Participating Providers 2 Professional (Physician) Benefits Physician and specialist office visits 10% 30% Outpatient diagnostic x-ray, imaging, pathology, laboratory and other 10% 30% testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) 10% 30% Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections (separate office visit copayment may apply) Preventive Health Benefits 11 Preventive health services (as required by applicable Federal law) OUTPATIENT FACILITY SERVICES 10% 30% (not subject to the calendar year medical deductible) Outpatient surgery performed at a free-standing ambulatory surgery 10% 30% 3 center Outpatient surgery performed in a hospital or hospital affiliated 10% 30% 3 ambulatory surgery center Outpatient services for treatment of illness or injury and necessary 10% 30% 3 supplies (except as described under "Rehabilitation Benefits" and Speech Therapy Benefits ) Outpatient diagnostic x-ray, imaging, pathology, laboratory and other 10% 30% 3 testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) 10% 30% 3 Bariatric surgery (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only) 4 10% 30% 3 HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 10% 30% Inpatient non-emergency facility services (semi-private room and board, and 10% 30% 5 medically necessary services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically necessary surgery for 10% 30% 5 weight loss, for morbid obesity only) 4 Inpatient Skilled Nursing Benefits 6 (combined maximum of up to 100 days per benefit period; semi-private accommodations) Free-standing skilled nursing facility 10% 10% 7 Skilled nursing unit of a hospital 10% 30% 5 30% Go to blueshieldca.com/deltadental 21
EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not 10% 10% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 10% 10% admitted directly from the ER) Emergency room physician services 10% 10% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 10% 10% PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) 10% 30% Orthotic equipment and devices (separate office visit copayment may apply) 10% 30% DURABLE MEDICAL EQUIPMENT Breast pump Not Covered (not subject to the calendar year medical deductible) Other durable medical equipment 10% 30% MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 8,9 Inpatient hospital services 10% 30% 5 Residential care 10% 30% 5 Inpatient physician services 10% 30% Routine outpatient mental health and substance abuse services (includes professional/physician visits) Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization program, psychological testing and transcranial magnetic stimulation) HOME HEALTH SERVICES 10% 30% 10% 30% Participating Providers 1 Non-Participating Providers 2 Home health care agency services (up to 100 visits per calendar year) 6 10% Not Covered 10 Home infusion/home injectable therapy and infusion nursing visits 10% Not Covered 10 provided by a home infusion agency HOSPICE PROGRAM BENEFITS 10 Routine home care 10% Not Covered 10 Inpatient respite care 10% Not Covered 10 24-hour continuous home care 10% Not Covered 10 Short-term inpatient care for pain and symptom management 10% Not Covered 10 CHIROPRACTIC BENEFITS 6 Chiropractic spinal manipulation (up to 12 visits per calendar year) 10% 30% ACUPUNCTURE BENEFITS 6 Acupuncture services (up to 20 visits per calendar year) 10% 30% REHABILITATION and HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) 10% 30% SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services) Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) FAMILY PLANNING BENEFITS Counseling and consulting (includes insertion of IUD, as well as injectable and implantable contraceptives for women) Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) 10% 30% 10% 30% 10% 30% 30% (not subject to the calendar year medical deductible) 30% (not subject to the calendar year medical deductible) 10% 30% 22 Blue Shield of California