Blue cross pposm (prudent buyer)

SISC High Deductible Plan B
PPO
(HSA Compatible Plan)
B
In addition to dollar and percentage copays, Insured Persons are responsible for deductibles, as described below. Certain Covered Services en
have maximum visit and/or day limits per year. The number of visits and/or days allowed for these services wil begin accumulating on the first e
visit and/or day regardless of whether your Deductible has been met. Please review the deductible information to know if a deductible applies fits
to a specific covered service. Members are also responsible for all costs over the plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Explanation of Covered Expense
Plan payments apply to the lesser of the charges bil ed by the provider or the following: PPO Providers—PPO negotiated rates. Members are not responsible for the dif erence between the provider’s
usual charges & the negotiated amount. Non-PPO Providers & Other Health Care Providers—For non-emergency services, the scheduled amount. For emergency services, same as
other health care providers.
Other Health Care Providers (includes those not represented in the PPO provider network)—The customary & reasonable charge for
professional services or the reasonable charge for institutional services.
Calendar year deductible for all providers
(applicable to medical care & prescription drug benefits)  No last quarter carry-over
Annual Out-of-Pocket Maximums (including calendar year deductibles, copays, prescription drug covered expense)
The following do not apply to out-of-pocket maximums: Non-covered expenses and for non-PPO providers and Other Health Care Providers, amounts in excess of the covered expense.
Covered Services
PPO: Per Insured
Non-PPO: Per Insured
Person Copay
Person Copay
Hospital Medical Services (Subject to Utilization Review for
Inpatient services; waived for emergency admissions)  Semi-private room, meals & special diets,  Outpatient Hospital medical care, surgical services & supplies 10% 0%  Single Hip or Knee Joint Replacement Surgery - up to $30,000 per surgery. Travel expense when member’s home is 50 miles or more from a low cost facility. ($3000 maximum travel benefit per surgery)
Ambulatory Surgical Centers
 Outpatient surgery, services & supplies Hemodialysis
 Outpatient hemodialysis services & supplies Skilled Nursing Facility (Subject to Utilization Review)
 Semi-private room, services & supplies (limited to 100 days per calendar year) Hospice Care 0% 0%
 Inpatient or outpatient services; family bereavement services 1Coverage is 100% of fee schedule. Insured Person is responsible for all charges exceeding the non-par fee schedule. 2These providers are not represented in the PPO network. Anthem Blue Cross Life and Health Insurance Company
Covered Services
PPO: Per Insured
Non-PPO: Per Insured
Person Copay
Person Copay1
Home Health Care (Subject to Utilization Review)
Services & supplies from a home health agency (limited to 100 visits/calendar year, one visit by a home health aide equals four hours or less; not covered while insured person receives hospice care) Home Infusion Therapy (Subject to Utilization Review)
 Includes medication, ancil ary services & supplies; caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services Physician Medical Services
 Hospital & skilled nursing facility visits  Surgeon & surgical assistant; anesthesiologist or anesthetist Diagnostic X-ray & Lab
 MRI, CT scan, PET scan & nuclear cardiac scan  Other diagnostic x-ray & lab Physical Exams for Members (Adults & Children- al ages)
 Routine physical exams, immunizations, diagnostic X-ray & lab for routine physical exam Adult Preventive Services (including mammograms,
Pap smears, prostate cancer screenings & colorectal cancer screenings) Physical Therapy, Physical Medicine, & Occupational
Therapy, including Chiropractic Services
Speech Therapy
Acupuncture
 Services for the treatment of disease, il ness or injury (limited to $30/visit & 12 visits/calendar year) Services for the treatment of
Temporomandibular Joint Disorder (TMJ)
 Splint Therapy and Surgical Treatment Pregnancy & Maternity Care
(services cover subscriber, spouse & dependent daughters)  Normal delivery, cesarean section, complications of pregnancy & abortion including pre and post natal care (newborn routine nursery care covered when natural mother 1Coverage is 100% of fee schedule. Insured Person is responsible for all charges exceeding the non-par fee schedule. Covered Services
PPO: Per Insured
Non-PPO: Per Insured
Person Copay
Person Copay
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed at Centers of Medical Excellence [CME])  Inpatient services provided in connection with non-investigative organ or tissue transplants  Transplant travel expense for an authorized, (recipient & companion transportation limited to  Unrelated donor search, limited to $30,000 per transplant
Bariatric Surgery (subject to utilization review; medically
necessary surgery for weight loss, only for morbid obesity covered only when performed at Centers of Medical Excellence [CME])  Inpatient services provided in connection with medically necessary surgery for weight loss, only for morbid obesity  Bariatric travel expense when member’s home is 50 miles or more from the nearest Bariatric CME ($3,000 maximum travel benefit per surgery.) Diabetes Education Programs (requires physician supervision)
Teach insured persons & their families about the disease process, the daily management of diabetic therapy & self-management training
Prosthetic Devices
 Coverage for breast prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; & the first pair of contact lenses or eyeglasses when Durable Medical Equipment
 Rental or purchase of DME , dialysis equipment & supplies, & therapeutic shoes & inserts for  Hearing Aid supplies and equipment (limited to $700 Related Outpatient Medical Services & Supplies2
 Ground or air ambulance transportation, services  Blood transfusions, blood processing & the cost of  Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) 1Coverage is 100% of fee schedule. Insured Person is responsible for all charges exceeding the non-par fee schedule. 2These providers are not represented in the PPO network.
Covered Services
PPO: Per Insured
Non-PPO: Per Insured
Person Copay
Person Copay1
Specialty Pharmacy Drugs (utilization review may be required)
 Specialty pharmacy drugs fil ed through the specialty pharmacy program (limited to 30-day supply; not covered if benefits are provided through prescription drug benefits, If member does not get specialty pharmacy drugs from the
specialty pharmacy program, member wil not receive any
specialty pharmacy drug benefits under this plan, unless the
member qualifies for an exception as specified in the EOC.
Emergency Care
 Emergency room services & supplies  Inpatient hospital services & supplies (unless member can not be moved safely) Mental or Nervous Disorders and Substance Abuse
 Facility-based care (subject to utilization review;  Facility-based care (subject to utilization review; (pre-service review required after the 12th visit) 1 The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount. Member is responsible for all charges exceeding 2 20% copay if member or non-PPO physician obtains drug from Specialty Pharmacy Program; otherwise, not covered. 3 The allowable rate for emergency within 48 hours is based on a reasonable charge, not the scheduled amount.
Medical Exclusions and Limitations
0
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
nervosa. Surgical treatment for morbid obesity is covered as described in the Evidence of Coverage Experimental or Investigative. Any experimental or investigative procedure or medication.
But, if member is denied benefits because it is determined that the requested treatment Sex Transformation. Procedures or treatments to change characteristics of the body to those
is experimental or investigative, the member may request an independent medical review, as described in the Evidence of Coverage (EOC). Sterilization Reversal.
Crime or Nuclear Energy. Conditions that result from (1) the member’s commission of or attempt
Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and
to commit a felony, as long as any injuries are not a result of a medical condition or an act of treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer. government funds are available for the treatment of il ness or injury arising from the release Surrogate Mother Services. For any services or supplies provided to a person not covered under the
plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by Not Covered. Services received before the member’s effective date. Services received
after the member’s coverage ends, except as specified as covered in the EOC. Orthopedic Supplies. Orthopedic supplies, orthopedic shoes (other than shoes joined to braces),
Excess Amounts. Any amounts in excess of covered expense or the lifetime maximum.
or non-custom molded and cast shoe inserts, except for therapeutic shoes and inserts for the Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by
prevention and treatment of diabetes-related feet complications as specified as covered adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, whether or not the member claims those benefits. If there is a dispute 1 of substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to Air Conditioners. Air purifiers, air conditioners or humidifiers.
workers’ compensation, we wil provide the benefits of this plan for such conditions, subject to a Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital
right of recovery and reimbursement under California Labor Code Section 4903, as specified as stay primarily for environmental change or physical therapy. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skil ed nursing facility or custodial care or rest cures, except as specified as covered in the EOC. Government Treatment. Any services the member actually received that were provided by a
local, state or federal government agency, except when payment under this plan is expressly Chronic Pain. Treatment of chronic pain, except as specified as covered in the EOC.
required by federal or state law. We wil not cover payment for these services if the member is not Health Club Memberships. Health club memberships, exercise equipment, charges from a physical
required to pay for them or they are given to the member for free. fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for Services of Relatives. Professional services received from a person living in the member’s
developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to home or who is related to the member by blood or marriage, except as specified as covered Personal Items. Any supplies for comfort, hygiene or beautification.
Voluntary Payment. Services for which the member has no legal obligation to pay, or for which
Education or Counseling. Educational services or nutritional counseling, except as specified
no charge would be made in the absence of insurance coverage or other health plan coverage, as covered in the EOC. This exclusion does not apply to counseling for the treatment of anorexia except services received at a non-governmental charitable research hospital. Such a hospital must Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or
1. it must be internationally known as being devoted mainly to medical research; as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary 2. at least 10% of its yearly budget must be spent on research not directly related to supplements that can be purchased over the counter, which by law do not requirement either a writ en prescription or dispensing by a licensed pharmacist. 3. at least one-third of its gross income must come from donations or grants other than gifts Telephone and Facsimile Machine Consultations. Consultations provided by telephone
4. it must accept patients who are unable to pay; and Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual
il ness, injury or condition, including those required by employment or government authority, two-thirds of its patients must have conditions directly related to the hospital’s research. except as specified as covered in the EOC. Not Specifically Listed. Services not specifically listed in the plan as covered services.
Acupuncture. Acupuncture treatment, except as specified as covered in the EOC. Acupressure
Private Contracts. Services or supplies provided pursuant to a private contract between the
or massage to control pain, treat il ness or promote health by applying pressure to one or more member and a provider, for which reimbursement under Medicare program is prohibited, as specific areas of the body based on dermatomes or acupuncture points. specified in Section 1802 (42 U.S.C. 1395a) of Title XVI I of the Social Security Act. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of
Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. primarily for diagnostic tests which could have been performed safely on an outpatient basis. Contact lenses and eyeglasses required as a result of this surgery. Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation.
Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical
Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these medicine, except when provided during a covered inpatient confinement or as specified conditions, except as specified as covered in the EOC. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use.
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications
and insulin, except as specified as covered in the EOC. Any non-prescription, over-the-counter Orthodontia. Braces, other orthodontic appliances or orthodontic services.
patent or proprietary drug or medicine. Cosmetics, health or beauty aids. Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty
dental implants, dental services, extraction of teeth, treatment to the teeth or gums, or treatment to pharmacy program, but, which are obtained from a retail pharmacy, are not covered by this plan. or for any disorders for the temporomandibular (jaw) joint, except as specified as covered in the Member wil have to pay the ful cost of the specialty pharmacy drugs obtained from a retail
EOC. Cosmetic dental surgery or other dental services for beautification. pharmacy that should have been obtained from the specialty pharmacy program.
Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
Optometric Services or Supplies. Optometric services, eye exercises including orthoptics.
Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
Routine eye exams and routine eye refractions, as specified as covered in the EOC. Eyeglasses or contact lenses, except as specified as covered in the EOC. Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health
Lifestyle Programs. Programs to alter one’s lifestyle which may include but are not limited to diet,
agency, hospice, or home infusion therapy provider, as specified as covered in the EOC. exercise, imagery or nutrition. This exclusion wil not apply to cardiac rehabilitation programs Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to
Third Party Liability — Anthem Blue Cross is entitled to reimbursement of benefits paid if the
alter or reshape normal (including aged) structures or tissues of the body to improve appearance. member recovers damages from a legally liable third party. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, il ness, or injury for the purpose Coordination of Benefits — The benefits of this plan may be reduced if the member has any
of improving bodily function or symptomatology or to create a normal appearance), including other group health or dental coverage so that the services received from all group coverages do surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons. Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the
Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under
Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,
medical or physician supervision, unless specifically listed as covered in this plan. Inc. The Blue Cross name and symbol are registered marks of the
This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Blue Cross Association.
Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia
Prescription Drugs
(Subject to combined Medical/Pharmacy Deductible)
Per Member Copay for Each Prescription or Refil
Retail Participating Pharmacies
 Generic drugs(includes self-injectable drugs)
 Generic drugs obtained at Costco Pharmacy (Excludes narcotics, pain relievers and cough syrup with pain reliever)  Brand name drugs1, (includes self-injectable drugs)  Preventive vaccines and immunizations administered by a retail Pharmacy (including, but not limited to, flu shot and shingles vaccine)  Female oral contraceptives generic and single source brand $0
(deductible waived)
Mail Service
 Generic drugs(includes self-injectable drugs)
 Brand name drugs1(includes self-injectable drugs)  Female oral contraceptives generic and single source brand $0
(deductible waived)
Specialty Pharmacy Drugs (may only be obtained
through the specialty pharmacy program)  Generic drugs(includes self-injectable drugs)  Brand name drugs1, 2(includes self-injectable drugs) Non-participating Pharmacies
Member pays the above retail participating pharmacies copay plus: (compound drugs & specialty pharmacy drugs not covered 50% of the remaining prescription drug maximum allowed amount at retail participating pharmacies) & costs in excess of the prescription drug maximum allowed amount Supply Limits2
 Retail Pharmacy (participating and non-participating)
30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs 1Preferred Generic Program. A generic drug wil always be dispensed if one is available. If you purchase a brand-name drug or a compound drug with a brand component
when a generic alternative is available, you wil pay the generic co-payment plus the dif erence in cost between the brand and the generic, even if your doctor writes “dispense as 2 Supply limits for certain drugs may be dif erent. Please refer to the EOC/Certificate for complete information.
The Prescription Drug Benefit covers the following:
 Preventive immunizations and vaccines administered by a participating retail pharmacy
 Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician for the treatment of phenylketonuria. These formulas are subject to the copay for brand name drugs.  Insulin.  Syringes when dispensed for use with insulin and other self-injectable drugs or medications.  Prescription oral contraceptives; contraceptive diaphragms.  Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member. Drugs that have Food and Drug Administration (FDA) labeling for self-administration  Al compound prescription drugs that contain at least one covered prescription ingredient.  Diabetic supplies (i.e., test strips and lancets).  Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.  Inhaler spacers and peak flow meters for the treatment of pediatric asthma. These items are subject to the copay for brand
Prescription Drug Exclusions & Limitations
Immunizing agents, biological sera, blood, blood products or blood plasma Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin), Hypodermic syringes &/or needles, except when dispensed for use with insulin & other self-injectable unless medically necessary for another covered condition. Anorexiants and drugs used for weight loss, except when used to treat morbid obesity Drugs & medications used to induce spontaneous & non-spontaneous abortions (e.g., diet pil s & appetite suppressants) Drugs & medications dispensed or administered in an outpatient setting, including outpatient hospital Drugs obtained outside the U.S., unless they are furnished in connection with urgent care Professional charges in connection with administering, injecting or dispensing drugs Al ergy desensitization products or allergy serum Drugs & medications that may be obtained without a physician’s writ en prescription, except insulin or Infusion drugs, except drugs that are self-administered subcutaneously niacin for cholesterol lowering and certain over-the-counter drugs approved by the Pharmacy Herbal supplements, nutritional and dietary supplements, except for formulas for the treatment and Therapeutics Commit ee to be included in the prescription drug formulary. Drugs & medications dispensed by or while confined in a hospital, skil ed nursing facility, Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except insulin rest home, sanatorium, convalescent hospital or similar facility and OTC Non-Sedating Antihistamines (Claritin, Claritin-D, Zyrtec, Zyrtec-D and generics) This does not Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, except apply if an over-the-counter equivalent was tried and was ineffective. contraceptive diaphragms, as specified as covered in the EOC/Certificate Services or supplies for which the member is not charged a. There is at least one component in it that is a prescription drug; and b. It is obtained from a participating pharmacy. Member wil have to pay the ful cost of the
compound medications if member obtains drug at a non-participating pharmacy.
Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, Drugs labeled “Caution, Limited by Federal Law to Investigational Use,” or Non-FDA approved which are obtained from a retail pharmacy are not covered by this plan. Member wil have to pay the ful
investigational drugs. Any drugs or medications prescribed for experimental indications cost of the specialty pharmacy drugs obtained from a retail pharmacy that member should have
Any expense for a drug or medication incurred in excess of the prescription drug maximum obtained from the specialty pharmacy program.
Growth Hormones
Drugs which have not been approved for general use by the State of California Department Legend Prescription Vitaimins except Oral Rocaltrol/calcitrol, oral vitamin D ; legend pediatric
of Health Services or the Food and Drug Administration. This does not apply to drugs that are medically fluoride vitamins covered up to 50 day supply;
necessary for a covered condition. Drugs to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products. Third Party Liability
This does not apply to medically necessary drugs that the member can only get with a prescription under Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this wil not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem
Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross
Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue
Cross name and symbol are registered marks of the Blue Cross Association.

Source: http://www.inyo.k12.ca.us/docs/10-40509K,LBenefitSummary_224201480918.pdf