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Premera Blue Cross Plus Bronze 6350 SAMPLE WELCOME Thank you for choosing Premera Blue Cross Blue Shield of Alaska for your healthcare coverage. This benefit booklet tells you about this plan’s benefits and how to make the most of them. Please read this benefit booklet to find out how your healthcare plan works. Some words have special meanings under this plan. Please see Definitions at the end of this booklet. In this booklet, the words “we,” “us,” and “our” mean Premera Blue Cross Blue Shield of Alaska. The words “you” and “your” mean any member enrolled in the plan. The word “plan” means your healthcare plan with us. Please contact Customer Service if you have any questions about this plan. We are happy to answer your questions and listen to any of your comments. On our website at premera.com you can also:  Learn more about this plan  Find a healthcare provider near you  Look for information about many health topics We look forward to serving you and your family. Thank you again for choosing Premera. HOW TO CONTACT US Please call or write Customer Service for help with the following:  Questions about the benefits of this plan  Questions about your claims  Questions or complaints about care or services you receive  Change of address or other personal information

CUSTOMER SERVICE Mailing Address: Telephone Numbers: Premera Blue Cross Blue Shield of Alaska (Premera) Local and toll-free number: 1-800-508-4722 For Claims Only Local and toll-free TTY: 1-800-842-5357 P.O. Box 240609 Anchorage, AK 99524-0609 Physical Address: 3800 Centerpoint Dr, Suite 940 Anchorage, AK 99503-5825

WHERE TO SEND CLAIMS Mail Your Claims To: Premera Blue Cross Blue Shield of Alaska P.O. Box 240609 Anchorage, AK 99524-0609

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska PRESCRIPTION DRUG CLAIMS Mail Your Prescription Drug Claims To Contact the Pharmacy Benefit Administrator at: Express Scripts 1-800-391-9701 P.O. Box 747000 www.express-scripts.com Cincinnati, OH 45274-7000

COMPLAINTS AND APPEALS Premera Blue Cross Local and toll-free number: 1-800-722-1471 Attn: Appeals Department Fax: 1-425-918-5592 P.O. Box 91102 Seattle, WA 98111-9202

DENTAL ESTIMATE OF BENEFITS Premera Blue Cross Fax: 1-425-918-5956 Attn: Dental Review P.O. Box 91059, MS 173 Seattle, WA 98111-9159

BLUECARD WEBSITE 1-800-810-BLUE(2583) Visit our website at premera.com for information and secure online access to claims information

TELADOC Log on to your account at member.teladoc.com/premera or call 1-855-332-4059

Group Name: SAMPLE Effective Date: January 1, 2017 Group Number: SAMPLE Plan: Premera Blue Cross Plus Bronze 6350 Certificate Form Number: PBCBSAK SCER (01-2017)

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska INTRODUCTION This is a SAMPLE BOOKLET used solely as a model of our standard benefit booklet format and design. THIS IS NOT A CONTRACT. Possession of this booklet does not entitle you or your employer to any right or benefit named or implied in it. This benefit booklet is for members enrolled in this plan. This benefit booklet describes the benefits and other terms of this plan. It replaces any other benefit booklet you may have received. We know that healthcare plans can be hard to understand and use. We hope this benefit booklet helps you understand how to get the most from your benefits. The benefits and provisions described in this plan are subject to the terms of the master group contract (contract) issued to the employer. The employer is the firm, corporation or partnership that contracts with us. This benefit booklet is a part of the contract on file at the employer’s office. This plan will comply with state laws and the federal health care reform law, called the Affordable Care Act (see Definitions), including any applicable requirements for distribution of any medical loss ratio rebates and actuarial value requirements. If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the calendar year, this plan will comply even if they are not or are in conflict with a statement made in this benefit booklet. Medical and payment policies. These policies are used to administer the terms of this plan. Medical policies are generally used to further define medical necessity or investigational status for specific procedures, drugs, biological agents, devices, level of care or services. Payment policies define our provider billing and payment rules. Our policies are based on accepted clinical practice guidelines and industry standards accepted by organizations like the American Medical Association (AMA), other professional societies and the Center for Medicare and Medicare Services (CMS). Our policies are available to you and your provider on our website at premera.com or by calling Customer Service.

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska HOW TO USE THIS BENEFIT BOOKLET Every section in this benefit booklet has important information. You may find that the sections below are especially useful.  HOW TO CONTACT US – Our website, phone numbers, mailing addresses and other contact information are located inside the front cover of this benefit booklet.  SUMMARY OF YOUR COSTS – Lists your costs for covered services.  IMPORTANT PLAN INFORMATION – Describes the applicable cost-shares, out-of-pocket maximums and allowed amount.  HOW PROVIDERS AFFECT YOUR COSTS – How your choice of a provider affects your benefits and your out-of-pocket costs.  CARE MANAGEMENT – Describes prior authorization, clinical review provisions and personal health support programs.  COVERED SERVICES – A detailed description of what is covered under this plan.  EXCLUSIONS – Describes services that are limited or not covered under this plan.  OTHER COVERAGE - Describes how benefits are paid when you have other coverage or what you must do when a third party is responsible for an injury or illness.  SENDING US A CLAIM – Instructions on how to send in a claim.  COMPLAINTS AND APPEALS – What to do if you want to share ideas, ask questions, file a complaint, or send in an appeal.  ELIGIBILITY AND ENROLLMENT – Information on who is eligible for the plan and how to enroll.  TERMINATION OF COVERAGE – Describes when coverage ends under this plan.  OTHER PLAN INFORMATION – Lists the general information about how this plan is administered and required state and federal notices.  DEFINITIONS – Specific meanings of words and terms used in this plan.

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska TABLE OF CONTENTS SUMMARY OF YOUR COSTS...... 1 IMPORTANT PLAN INFORMATION ...... 9 Allowed Amount ...... 9 Calendar Year Deductible ...... 10 Copay ...... 10 Coinsurance ...... 10 Out-of-Pocket Maximum...... 10 HOW PROVIDERS AFFECT YOUR COSTS ...... 11 Medical Services ...... 11 Pediatric Dental Services ...... 15 CARE MANAGEMENT...... 15 Prior Authorization...... 15 Clinical Review ...... 18 Personal Health Support Programs...... 18 COVERED SERVICES ...... 18 Common Medical Services...... 19 Other Covered Services ...... 33 EXCLUSIONS...... 41 OTHER COVERAGE...... 45 Coordinating Benefits With Other Plans...... 45 Subrogation and Reimbursement...... 46 SENDING US A CLAIM...... 47 COMPLAINTS AND APPEALS ...... 49 ELIGIBILITY AND ENROLLMENT ...... 52 Who Is Eligible For Coverage...... 52 When Coverage Begins ...... 53 Special Enrollment ...... 54 TERMINATION OF COVERAGE ...... 55 Events That End Coverage ...... 55 CONTINUATION OF COVERAGE...... 56 OTHER PLAN INFORMATION ...... 57 DEFINITIONS ...... 60

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to all of the following:  The allowed amount. This is the most this plan allows for a covered service.  The copays. These are set dollar amounts you pay at the time you get services. Copays apply to the out-of- pocket maximum unless noted otherwise.  The coinsurance. This is the amount you pay after your deductible is met.  The deductibles. Most of your cost shares are subject to the deductible. Sometimes the deductibles are waived and these are shown below. When covered services are subject to the Preferred INN Provider coinsurance, the Preferred INN Provider deductible applies.

Preferred INN Providers Non-Preferred and Non- Participating Providers Individual Deductible: $6,350 $12,700 Family Deductible: $12,700 Not applicable

 The out-of-pocket maximum. This is the most you pay each calendar year for services from Preferred INN Providers. There is an out-of-pocket maximum for Non-Preferred and Non-Participating providers.

Preferred INN Providers Non-Preferred and Non-Participating Providers Individual Out-of-Pocket Maximum: $7,150 $45,000 Family Out-of-Pocket Maximum: $14,300 $90,000

 Prior authorization. Some services must be authorized by us in writing before you get them. See Prior Authorization for details.  The conditions, time limits and maximum limits described in this contract. Some services have special rules. See Covered Services for these details.

PBCBSAK SSYC 01-2017 1 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS COMMON MEDICAL SERVICES

Office and Clinic Visit

 First 6 office, clinic, e-visit or home visits $30, waived deductible Deductible, then 40% Deductible, then 60% with your designated PCP  All other office, clinic, e-visit or home $30, waived deductible Deductible, then 40% Deductible, then 60% visits with your designated PCP  Specialist, non-designated PCP office, e- Deductible, then 30% Deductible, then 40% Deductible, then 60% visit, clinic, and home visits  Telehealth visit $30, waived deductible Deductible, then 40% Deductible, then 60%  Office visits with your Gynecologist (even $30, waived deductible Deductible, then 40% Deductible, then 60% if not your selected PCP)  All other provider office, clinic or home Deductible, then 30% Deductible, then 40% Deductible, then 60% visits You may have additional costs for things such as x-rays, lab, therapeutic injections and facility charges. See those covered services for details. Preventive Care Limited to how often you can get services based on your age and if you are male or female  Routine care, such as exams, No Charge Deductible, then 40% Deductible, then 60% screenings, immunizations, contraceptive management and nutritional therapy  Seasonal immunizations you get at a No Charge No Charge No Charge pharmacy or other mass immunizer, health education and nicotine cessation programs You may have additional costs for things such as x-rays, lab and therapeutic injections. See those covered services for details. Pediatric Care Limited to members under age 19 Pediatric Vision Exams and Hardware  Routine exams limited to 1 per $25, waived deductible calendar year

 1 pair of lenses for glasses or hard No Charge contact lenses, or 12-month supply of disposable contact lenses per calendar year  1 pair of frames per calendar year No Charge

PBCBSAK SSYC 01-2017 2 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS  1 comprehensive low vision evaluation $25, waived deductible every five years; and 4 follow up visits in any five year period  Low vision devices, high powered No Charge spectacles, magnifiers and telescopes when medically necessary

Pediatric Dental  Class I Services No Charge Waived deductible, Waived deductible, then 10% then 10%  Class II Services Waived deductible, then Waived deductible, Waived deductible, 30% then 50% then 50%  Class III Services (including medically Deductible, then 50% Deductible, then 50% Deductible, then 50% necessary orthodontia for cleft lip and palate, cleft palate, cleft lip with alveolar process involvement or other craniofacial anomalies) Diagnostic X-ray, Lab and Imaging See Preventive Care for preventive screening cost share  Professional services Deductible, then 30% Deductible, then 40% Deductible, then 60%  Outpatient services Deductible, then 30% Deductible, then 40% Deductible, then 60%  High technology diagnostic imaging Deductible, then 30% Deductible, then 40% Deductible, then 60% services  Inpatient Services Deductible, then 30% Deductible, then 40% Deductible, then 60% Surgery Services Deductible, then 30% Deductible, then 40% Deductible, then 60% Includes the surgeon, assistant surgeon, anesthesiology, office surgeries, ambulatory surgical centers, and inpatient and outpatient hospital services. Emergency Services  Emergency Room Facility $200, deductible then 30%  Emergency Room Physician Deductible, then 30% Emergency Ambulance Services  Emergency air and surface (ground and $25 copay, deductible then 30% water) ambulance services and non- emergency ground or water transport  Non-emergency air ambulance services, $25 copay, deductible Deductible, then 40% Deductible, then 60% including transfer from one facility to then 30% another facility Urgent Care Centers

 Office visits $60, waived deductible Deductible, then 40% Deductible, then 60%  Services from centers based in a hospital $200, deductible then $200, deductible then $200, deductible then 30% 30% 30%

PBCBSAK SSYC 01-2017 3 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS facility or emergency room You may have additional costs for other services such as x-rays, lab, therapeutic injections and hospital facility charges. See those covered services for details

Hospital Services Deductible, then 30% Deductible, then 40% Deductible, then 60% Outpatient care and inpatient care services Mental Health, Behavioral Health and Deductible, then 30% Deductible, then 40% Deductible, then 60% Substance Abuse Services to treat mental health, behavioral health and substance abuse conditions apply to this benefit, including services such as physical, speech or occupational therapy.

 Office visits You may have additional costs for facility charges.  Other professional services Deductible, then 30% Deductible, then 40% Deductible, then 60%  Inpatient and residential - facility services Deductible, then 30% Deductible, then 40% Deductible, then 60%  Outpatient facility services Deductible, then 30% Deductible, then 40% Deductible, then 60% Maternity and Newborn Care Deductible, then 30% Deductible, then 40% Deductible, then 60% Prenatal, postnatal, delivery and inpatient care. Includes hospital, birthing centers or short-stay facilities, diagnostic test during pregnancy and professional services. Home Health Care Deductible, then 30% Deductible, then 40% Deductible, then 60% Limited to 130 visits per calendar year. Hospice Care Deductible, then 30% Deductible, then 40% Deductible, then 60% Limited to a lifetime maximum of 6 months and to 10 days of inpatient care and 240 hours of respite care. All hospice services are subject to the lifetime maximum. Rehabilitation Therapy

 Outpatient services to treat non-chronic Deductible, then 30% Deductible, then 40% Deductible, then 60% conditions limited to 45 visits per calendar year  Outpatient services to treat chronic Deductible, then 30% Deductible, then 40% Deductible, then 60% conditions, unlimited  Inpatient services limited to 30 days per Deductible, then 30% Deductible, then 40% Deductible, then 60% calendar year

Habilitation Therapy Neuropsychological testing to diagnose is

PBCBSAK SSYC 01-2017 4 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS not subject to any maximum. See Mental Health, Behavioral Health and Substance Abuse for therapies provided for mental health conditions such as autism. Habilitation Therapy includes neurodevelopmental therapy.

 Outpatient services to treat non-chronic Deductible, then 30% Deductible, then 40% Deductible, then 60% conditions limited to 45 visits per calendar year  Outpatient services to treat chronic Deductible, then 30% Deductible, then 40% Deductible, then 60% conditions, unlimited  Inpatient services limited to 30 days per Deductible, then 30% Deductible, then 40% Deductible, then 60% calendar year Skilled Nursing Facility and Care Deductible, then 30% Deductible, then 40% Deductible, then 60% Limited to 60 days per calendar year Home Medical Equipment (HME), Deductible, then 30% Deductible, then 40% Deductible, then 60% Orthotics, Prosthetics and Supplies Foot orthotics and orthopedic shoes for other conditions other than diabetes are limited to $300 per calendar year OTHER COVERED SERVICES (Alphabetical Order) Acupuncture Services Limited to 12 visits per calendar year  Office visits $30, waived deductible Deductible, then 40% Deductible, then 60% You may have additional costs for hospital facility charges.  Facility charges Deductible, then 30% Deductible, then 40% Deductible, then 60% Air or Surface Transportation Deductible, then 30% (Commercial) Limited to the member needing the transportation. For a child under the age 18, this benefit will also cover a parent or guardian to accompany the child. Limited to 3 round trip transports per medical occurrence per calendar year. Allergy Testing and Treatment Deductible, then 30% Deductible, then 40% Deductible, then 60%

PBCBSAK SSYC 01-2017 5 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS Chemotherapy, Radiation Therapy and Deductible, then 30% Deductible, then 40% Deductible, then 60% Kidney Dialysis Chemotherapy includes infusion, injectable drug services you get as an inpatient or outpatient You may have additional costs for hospital facility charges. See those covered services for details. Clinical Trials  Office visits See Office and Clinic See Office and See Office and You may have additional costs for Visits Clinic Visits Clinic Visits hospital facility charges. See those covered services for details.  Other outpatient services and inpatient Deductible, then 30% Deductible, then 40% Deductible, then 60% services, including facility charges  Transportation for Cancer Clinical Trials Deductible, then 30% only Community Wellness and Safety No Charge Programs Limited up to $250 per calendar year Dental Accidents Limited to services you get within 12 months of the accident  Office visits See Office and Clinic See Office and See Office and Visits Clinic Visits Clinic Visits  Other outpatient and inpatient services, Deductible, then 30% Deductible, then 40% Deductible, then 60% including facility charges Foot Care Deductible, then 30% Deductible, then 40% Deductible, then 60% Routine care that is medically necessary for treatment of diabetes Hearing  Hearing Exam Limited to one exam every two calendar Deductible waived, then 20% coinsurance years  Hearing Test Waived deductible, then 20% Limited to one test every two calendar years  Hearing Hardware No Charge Limited to $1,000 every three calendar years Your cost shares for hearing services do not accrue to the out-of-pocket maximum. Infusion Therapy (Outpatient) Deductible, then 30% Deductible, then 40% Deductible, then 60% Mastectomy and Breast Reconstruction Deductible, then 30% Deductible, then 40% Deductible, then 60% Medical Travel Support No Charge

PBCBSAK SSYC 01-2017 6 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED SERVICES PREFERRED INN NON-PREFERRED NON- PROVIDERS PROVIDERS PARTICIPATING PROVIDERS Limited to:  One round-trip commercial air transportation for member and companion per episode (additional medical travel services may be approved based on medical necessity)  Surface transportation and parking limited up to $35 per day. Mileage expenses are reimbursed at 19 cents per mile per trip.  Ferry transportation limited to up to $50 per person each way  Lodging expenses are limited up to $50 per day per person Psychological and Neuropsychological Deductible, then 30% Deductible, then 40% Deductible, then 60% Testing Spinal Manipulation Services Limited to 12 visits per calendar year  Office visits $30, waived deductible Deductible, then 40% Deductible, then 60% You may have additional costs for hospital facility charges  Facility charges Deductible, then 30% Deductible, then 40% Deductible, then 60% Therapeutic Injections Deductible, then 30% Deductible, then 40% Deductible, then 60% Transplants Donor covered services are limited to $75,000 per transplant.  Office visits; you may have additional See Office and Clinic Not Covered Not Covered costs for hospital facility charges. See Visits those covered services for details.  Other outpatient care services and Deductible, then 30% Not Covered Not Covered inpatient services  $7,500 for travel and lodging expenses Deductible then 0% per transplant  Mileage expenses are reimbursed at 19 cents per mile per trip  Ferry transportation limited up to $50 per person each way  Lodging expenses are limited up to $50 per day per person

YOUR COSTS OF THE ALLOWED AMOUNT COVERED PRESCRIPTION DRUGS IN-NETWORK PHARMACIES OUT-OF-NETWORK PHARMACIES Prescription Drugs– Retail Pharmacy Limited up to a 90-day supply. You pay one copay for each 30-day supply. Copays

PBCBSAK SSYC 01-2017 7 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE YOUR COSTS OF THE ALLOWED AMOUNT COVERED PRESCRIPTION DRUGS IN-NETWORK PHARMACIES OUT-OF-NETWORK PHARMACIES apply to the out-of-pocket maximum.  Preventive drugs, limited to prescribed No Charge drugs required by health care reform  Tobacco cessation drugs, oral generic No Charge and single-source brand name contraceptive drugs and devices  Formulary Preferred Generic Drugs Deductible, then 30%  Formulary Preferred Brand Drugs Deductible, then 30%  Formulary Non-Preferred Drugs Deductible, then 30%  Anti-cancer Medications Waived deductible, then 30% Prescription Drugs– Mail Order Pharmacy Limited up to a 90-day supply. Copays apply to the out-of-pocket maximum.  Preventive drugs, limited to prescribed No Charge Not Covered drugs required by health care reform  Tobacco cessation drugs, oral generic No Charge Not Covered and single-source brand name contraceptive drugs and devices  Formulary Preferred Generic Drugs Deductible, then 30% Not Covered  Formulary Preferred Brand Drugs Deductible, then 30% Not Covered  Formulary Non-Preferred Drugs Deductible, then 30% Not Covered  Anti-cancer Medications Waived deductible, then 30% Not Covered Prescriptions – Specialty Pharmacy Deductible, then 30% Limited up to a 30-day supply for formulary.

PBCBSAK SSYC 01-2017 8 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Bronze 6350 SAMPLE, SAMPLE geographical area for which we receive claims. IMPORTANT PLAN INFORMATION The allowed amount will be no less than 80th percentile of billed charges for that service. If we This plan is a Preferred Provider Plan (PPO) and are unable to obtain sufficient data from a given provides you benefits for covered services from geographical area, we will use a wider providers within the Heritage Plus network in Alaska. geographical area. If inclusion of the wider You have access to one of the many providers geographical area still does not provide sufficient included in our network of providers for covered data, we will set the allowed amount to no less services included in this plan without referral. than the equivalent of the 80th percentile or no Please see How Providers Affect Your Costs for lower than 250% of Medicare allowed amount for more information. You also have access to facilities, the same services or supplies, whichever is emergency rooms, surgical centers, equipment greater. vendors or pharmacies providing covered services Using this methodology, the allowed amount will throughout the United States and wherever you may be the least of the following: travel.  An amount that is no less than the lowest ALLOWED AMOUNT amount we pay for the same or similar service from a comparable provider that has a This plan provides benefits based on the allowed contracting agreement with us amount for covered services. The allowed amount is described below.  250% of the fee schedule determined by the Centers for Medicare and Medicaid Services  Providers In Alaska and Washington Who (Medicare), if available Have Agreements With Us  The provider’s billed charges. Ambulance For any given service or supply, the allowed providers that don’t have agreements with us or amount is the lesser of the following: another Blue Cross Blue Shield Licensee are  The provider’s billed charge; or always paid based on billed charges.  The fee that we have negotiated as a In no case will the allowed amount be less than “reasonable allowance” for medically necessary the 80th percentile of charges in the geographical covered services and supplies. area where services are received, or as otherwise Contracting providers agree to seek payment from required by law. us when they furnish covered services to you. Pediatric Dental Services You will be responsible only for any applicable  Providers Who Have Signed A Contracting cost-sharing, including deductibles, copays, Agreement With Us coinsurance, charges in excess of the stated benefit maximums and charges for services and The allowed amount is the fee that we have supplies not covered under this plan. negotiated with contracting dental providers.  Providers Outside Alaska and Washington  Providers Who Have Not Signed A Who Have Agreements With Other Blue Cross Contracting Agreement With Us Blue Shield Licensees The allowed amount will be the maximum For covered services and supplies received allowed amount in the geographical area where outside Alaska and Washington or in Clark the services were provided. In no case will the th County, Washington, allowed amount is allowed amount be less than the 80 percentile th determined as stated in BlueCard Program. or no higher than the 90 percentile of provider fees in that area where the services are  Providers Who Don’t Have Agreements With received. Us Or Another Blue Cross Blue Shield Licensee  Emergency Care The allowed amount shall be defined as indicated Consistent with the requirements of the Affordable below. When you receive services from a Care Act the allowed amount will be the greater of provider who does not have an agreement with us the following: or another Blue Cross Blue Shield Licensee, you  The median amount providers who contract are responsible for any amounts not paid by us, with us have agreed to accept for the same including amounts over the allowed amount. services In determining the allowed amount, we establish a  The amount Medicare would allow for the same profile of billed charges, using statistically services creditable data for a period of 12 months by  The amount calculated by the same method the examining the range of charges for the same or plan uses to determine payment to providers similar service from providers within each who do not have contracting agreements with

PBCBSAK SCER 01-2017 9 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska us There is no family deductible for services received In addition to your applicable cost-sharing, you from Non-Preferred and Non-Participating providers. will be responsible for charges above the The individual and family deductibles (if any) are allowed amount when services are received subject to the following: from providers who do not have contracting agreements with us.  Deductibles add up during a calendar year, and renew each year on January 1 Note: Ambulance providers that don’t have  There is no carry over provision. Amounts agreements with us or another Blue Cross Blue credited to your deductible during the current year Shield Licensee are always paid based on billed will not carry forward to the next year’s deductible. charges.  Amounts credited to the deductible will not exceed the allowed amount CALENDAR YEAR DEDUCTIBLE  Copays (if any) do not apply to the deductible The calendar year deductible is the amount you pay  Prior authorization penalties do not apply to the each year before this plan starts to pay for covered deductible services. Copays, if any, do not count toward  Amounts credited toward the deductible do not meeting your deductible. Your calendar year add to benefits with an annual dollar maximum deductible amount for this plan is shown on the  Amounts credited toward the deductible accrue to Summary of Your Costs. benefits with visit limits and other annual If you and one or more of your dependents are durational maximums enrolled in this plan, the family deductible applies. COPAY When you add or drop dependents from coverage during the year, your deductible will change to the Copay is a fixed amount that you pay at the time of family or individual deductible as required by the service for each healthcare visit. If this plan includes change in family status. copays, your provider may ask you to pay the copay at the time of service. Individual Deductible Note: Not all of our plans include a copay. See This plan includes an individual deductible for Summary of Your Costs for any copays required covered services received from Preferred INN by your plan. providers and a separate individual deductible for Non-Preferred and Non-Participating providers. COINSURANCE After you have met the individual deductible for Coinsurance is a percentage of healthcare costs services received from Preferred INN providers, this you’re responsible for. You start paying coinsurance plan will begin paying for your covered services from after you pay your deductible. Your plan’s these providers for the remainder of the calendar coinsurance is shown on the Summary of Your year. Costs. After you have met the individual deductible for services received from Non-Preferred and Non- OUT-OF-POCKET MAXIMUM Participating providers combined, this plan will begin The out-of-pocket maximum is the most you or your paying for your covered services from these family will pay each calendar year for covered providers for the remainder of the calendar year. services received from any provider before this plan Family Deductible begins to pay 100%. See the Summary of Your Costs for your out-of-pocket maximum. Preferred INN Providers If you add or drop dependents from coverage during This plan includes a family deductible for Preferred the year, your out-of-pocket maximum will change to INN provider services. If you add or drop the family or individual out-of-pocket maximum as dependents from coverage during the calendar year, required by the change in family status. your calendar year deductible will change to the individual or family calendar year deductible, as Individual Out-of-Pocket Maximum appropriate. If two enrolled family members meet This plan includes an individual out-of-pocket their individual deductibles for services from maximum for covered services received from Preferred INN providers, we will consider the family Preferred INN providers and separate individual out- deductible to have been met for the year and this of-pocket maximum for Non-Preferred and Non- plan will begin paying for covered services for all Participating providers. The out-of-pocket maximum enrolled family members. is the total amount of deductible, coinsurance and Non-Preferred and Non-Participating Providers copays (if any), you must pay each year. Once you

PBCBSAK SCER 01-2017 10 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska meet this maximum, the benefits of this plan that are to one of the many providers included in our subject to the out-of-pocket maximum will be Heritage Plus network. In Alaska your network provided to you at 100% of the allowed amount for includes any provider that has signed a contract with covered services from Preferred INN providers for Blue Cross Blue Shield of Alaska. You also have the remainder of the calendar year. access to qualified practitioners, facilities, emergency rooms, surgical centers, equipment Once you meet this maximum, the benefits of this vendors or pharmacies providing covered services plan that are subject to the out-of-pocket maximum throughout the United States and wherever you may will be provided to you at 100% of the allowed travel. See BlueCard® Program below. Hospitals, amount for covered services from Non-Preferred and doctors and other providers in these networks are Non-Participating providers for the remainder of the called "in-network providers." calendar year. A list of network providers is available in our provider Family Out-of-Pocket Maximum directory. These providers are listed by This plan includes a family out-of-pocket maximum geographical area, specialty and in alphabetical for covered services received by you and one or order to help you select a provider that is right for more of your enrolled family members from you. We update this directory regularly but it is Preferred INN providers and a separate family out- subject to change. We suggest that you call us for of-pocket maximum for Non-Preferred and Non- current information and to verify that your provider, Participating providers. The family out-of-pocket their office location or provider group is included in maximum is the total amount of deductible, our network before you receive services. coinsurance and copays (if any) your family must The Heritage Plus provider directory is available any pay each year. time on our website at premera.com. You may also If two family members meet their individual out-of- request a copy of this directory by calling Customer pocket maximums, we will consider the individual Service at the number located inside the front cover out-of-pocket maximum of all of your enrolled family or on your Premera ID card. members to be met for that calendar year. Benefits will then be paid at 100% of the allowed amount for YOU CAN BENEFIT BY DESIGNATING A covered services from Preferred INN providers, Non- PRIMARY CARE PROVIDER Preferred and Non-Participating providers for all of We believe wellness and overall health is enhanced your enrolled family members for the remainder of by working closely with one provider. Although this the calendar year. plan does not require the use of a primary care Expenses that do not apply to the Individual and provider (PCP) or a referral for specialty care, we Family out-of-pocket maximums include: encourage you to designate a PCP at the time you enroll in this plan and notify us of your selection.  Charges above the allowed amount Selecting a PCP gives you a partner to help you  Services above any benefit maximum limit or manage your care. If you have difficulty locating an durational limit available PCP, contact us and we will help you in  Services not covered by this plan selecting one.  Prior authorization penalties If you do not select a PCP, we may assign as your  Any benefit shown on the Summary of Your PCP a provider you have previously seen. You may Costs as not applying to the out-of-pocket change this PCP selection by contacting us. maximum HOW DO YOU PAY THE LOWEST COPAY HOW PROVIDERS AFFECT YOUR When you use your designated PCP you will have a lower cost-share than if you use other PCPs or COSTS specialists in our network. Preferred OB/GYN MEDICAL SERVICES providers are always covered at the lower cost-share no matter if you selected a PCP or not. This plan is a Preferred Provider Plan (PPO). That means that this plan provides you benefits for Here is an example when you select a PCP and see covered services from providers of your choice. that PCP for a cut that needs stitches. You will pay Throughout this section you will find information on the lower copay amount for the office visit. For the how to control your out-of-pocket costs and how the stitching procedure, you will pay the plan’s providers you see for covered services can affect deductible and coinsurance. If you do not select a your plan benefits. PCP, your office visit copay will be the higher copay amount shown on the Summary of Your Costs. To help you manage the cost of healthcare, we have a network of healthcare providers. You have access Only one copay, per provider, per day will apply. If

PBCBSAK SCER 01-2017 11 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska you receive multiple services from the same provider IF YOU WANT TO CHANGE YOUR PCP in the same visit and the copay amounts are different, then the highest copay will apply. You have the option to change your designated PCP. You may change your PCP at any time by WHO YOU MAY SELECT AS YOUR contacting us. To change your PCP, please select DESIGNATED PCP one from our provider directory at premera.com or contact our Customer Service Department by calling A PCP must be a Preferred In-Network (Preferred the phone number listed on your Premera ID card. INN) provider. You can choose one of the following Once you have selected a PCP, call us and we will providers: update your selection.  General practitioners WHEN YOU RECEIVE CARE IN ALASKA OR  Family practitioners WASHINGTON  Internal medicine practitioners Network providers agree to accept our allowed  Pediatricians amount (please see Definitions) as payment in full.  Nurse practitioners You must pay copays (if any), deductibles,  OB/GYN practitioners coinsurance, amounts in excess of stated benefit maximums and charges for services that are not  Physician assistant practitioners covered.  Naturopathic practitioners Preferred INN Providers  Geriatric practitioners The Preferred INN providers are part of our Heritage If your PCP is part of a group practice, you can see Plus network, or providers who are a part of a Host any provider type listed above in that practice and Blue's provider network. Preferred INN providers receive the PCP office visit copay. provide medical services at a negotiated fee. This Gynecologist Visits fee is the allowed amount. You also have access to qualified practitioners, facilities, emergency rooms, Gynecologist visits are covered as shown on the surgical centers, equipment vendors or pharmacies Summary of Your Costs. Preferred INN providing covered services throughout the United gynecologists are always covered at the lower cost- States and wherever you may travel. See share no matter if you have selected one as a PCP BlueCard® Program below. or not. If a covered service is not available from a Preferred Specialist Visits INN provider, you may receive benefits for services Specialist visits are covered as shown on the provided by a Non-Preferred or Non-Participating Summary of Your Costs. Specialists include provider at the Preferred INN provider benefit level. providers such as surgeons, anesthesiologists, Please see Prior Authorization for details. psychologists, psychiatrists, and optometrists. This You do not need a referral from Premera or from any also applies if you see these providers at an urgent other person for access to specialty care. care center. In order to receive the highest level of benefits HOW TO DESIGNATE A PCP available under this plan for non-emergent services, You can designate any Preferred INN provider listed you must use a Preferred INN provider. Preferred above who is available to accept you or your family INN providers have agreed to accept the allowed members. Each enrolled family member may select amount as payment in full. They have also agreed a different PCP. To designate a PCP, please select to bill us directly for the covered portion of the one from our provider directory at premera.com or services you receive, and we make payments contact our Customer Service Department by calling directly to them. Your portion of the charges for the phone number listed on your Premera ID card. covered services you get from Preferred INN Once you have selected a PCP, call us and we will providers will be the lowest. update your information. Services you receive in a Preferred INN hospital IF YOUR PCP IS NOT AVAILABLE may be provided by doctors, anesthesiologists, radiologists or other professionals who are not part If you need to see your PCP and your PCP is not of our network. When you receive non-emergent available, you may see any PCP within the same services from these providers, the Non-Preferred or clinic. You will pay the lower copay. Non-Participating provider cost-share will apply. You will be responsible for amounts over the allowed If your PCP is the only provider in a clinic, you may amount for services received from Non-Participating see a PCP that your provider has asked to cover in providers. Amounts in excess of the allowed their absence. You will pay the lower copay.

PBCBSAK SCER 01-2017 12 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska amount do not count toward your deductible, Special Circumstances coinsurance or out-of-pocket maximum, if any. The following services and/or providers will always Non-Preferred Providers be covered at the Preferred INN provider benefit level based on the allowed amount: Non-Preferred providers are not included in our network, but do have a contract with Premera. Your  Emergency care medical bills will be reimbursed at a lower  Non-emergency care services received from a percentage when you use a Non-Preferred provider. Non-Preferred or a Non-Participating provider in This means that your out-of-pocket costs will be Alaska when the nearest Preferred INN Provider higher because your benefit level is lower. You are is more than 50 miles from your home. We not responsible for any charges over the allowed suggest that you contact us before you receive amount. These providers also bill us directly for your non-emergency care covered services from a care. Non-Preferred or Non-Participating provider. See Non-Participating Providers Prior Authorization for additional information.  Care received from Non-Preferred or Non- Non-Participating providers are not in our provider Participating providers for covered stays at network and do not have a contract with Premera. Preferred INN hospitals when you have no choice This means that your out-of-pocket costs will be the as to who performs the services highest because your benefit level is the lowest and you are responsible for any charges over the  Certain categories of providers that we do not allowed amount. Amounts in excess of the allowed have contracting agreements amount also do not count toward your deductible or You must pay your deductibles, copays, coinsurance coinsurance. You may have to pay for services and and any charges over the allowed amount. send us a claim for reimbursement. See Prior Authorization for more information about Accepted Rural Providers requesting the Preferred INN provider benefit level Accepted Rural Providers are providers practicing in when you receive other covered services from Non- a medically under-served area of Alaska. They do Participating providers. not contract with us and are not in our network. WHEN YOU RECEIVE CARE IN Your cost-shares for services you get from these WASHINGTON Providers are the same as the cost-shares for Preferred INN providers. Because accepted rural You have access to a network of providers when providers are not in our network, you must also pay you receive care in Washington. Like Preferred In- for any charges over the allowed amount. You may network providers in Alaska, you will receive the also have to pay the provider for services and send highest benefit level and lowest out-of-pocket costs us a claim for reimbursement. when you see these providers. All the requirements of your plan described in this booklet apply to Finding a Network Provider services received in Washington. A list of network providers is available in our To find an in-network provider in Washington, see Heritage Plus provider directory. These providers our provider directory at premera.com, or call are listed by geographical area, specialty and in Customer Service. alphabetical order to help you select a provider that is right for you. PROVIDER STATUS The provider directory also shows which Preferred A provider’s agreement with us is subject to change in-network providers you can select as your PCP. at any time. Therefore, it is important to verify a provider’s status before you receive services. This We update this directory regularly and it is subject to will help you avoid additional out-of-pocket costs. change. We suggest that you call us for current You can call our Customer Service Department at information and to verify that your provider, their the number listed inside the front cover of this office location or provider group is included in the contract booklet to verify a provider’s status. If you Heritage Plus network before you get services. are outside Alaska, Washington or Clark County, The Heritage Plus provider directory is available any Washington, call 1-800-810-BLUE (2583) to locate time on our website at premera.com. You may also or verify the status of a provider. request a copy of this directory by calling Customer If you are seeing a provider and their written Service at the number located inside the front cover agreement with us is terminated while you are of this benefit booklet or on your Premera ID card. receiving pregnancy care or other active treatment, we will consider the provider to still have an agreement with us for the purpose of that care until

PBCBSAK SCER 01-2017 13 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska one of the following occurs: directly, not through an Inter-Plan Arrangement.  This plan is terminated BlueCard Program  The provider’s status will change on the date the Except for copays, we will base the amount you provider’s medically necessary treatment of a must pay for claims from Host Blues’ network terminal condition ends. “Terminal” means that providers on the lower of: the patient is expected to live less than one year from the date the provider’s agreement is  The provider’s billed charges for your covered terminated. services; or In all other cases, the provider’s status will change  The allowed amount that the Host Blue made on the last of 3 dates to occur: available to us.  The 90th day after the date the provider’s Often, the allowed amount is a discount that reflects agreement is terminated an actual price that the Host Blue pays to the provider. Sometimes it is an estimated price that  The date the current plan year ends takes into account a special arrangement with a  The date postpartum care is completed single provider or a group of providers. In other WHEN YOU ARE OUTSIDE OF ALASKA AND cases, it may be an average price, based on a discount that results in expected average savings for WASHINGTON services from similar types of providers. If you are outside Alaska and Washington, you may Host Blues may use a number of factors to set receive covered services from any provider licensed estimated or average prices. These may include to provide the service. For non-emergent doctor and settlements, incentive payments, and other credits hospital services in Washington (except Clark or charges. Host Blues may also need to adjust County, Washington), you will receive the higher their prices to correct their estimates of past prices. level of benefits available under this plan when you However, we will not apply any further adjustments use network doctors and hospitals. Except as stated to the price of a claim that has already been paid. below, for the same services outside of Alaska and Washington or in Clark County, Washington, you will Clark County Providers receive the higher level of benefits available by Services in Clark County, Washington are processed using doctors and hospitals with PPO agreements through the BlueCard® Program. Some providers in with the Blue Cross or Blue Shield Licensee in the Clark County do have contracts with us. These area where you are receiving services. providers will submit claims directly to us, and benefits will be based on our allowed amount for the OUT-OF-AREA CARE covered service or supply. As a member of the Blue Cross Blue Shield Taxes, Surcharges and Fees Association (“BCBSA”), Premera Blue Cross Blue Shield of Alaska has arrangements with other Blue A law or regulation may require a surcharge, tax or Cross and Blue Shield Licensees (“Host Blues”) for other fee be added to the price of a covered service. care outside our service area. These arrangements If that happens, we will add that surcharge, tax or are called “Inter-Plan Arrangements”. Our Inter-Plan fee to the allowed amount for the claim. Arrangements help you get covered services from Non-Contracted Providers providers within the geographic area of a Host Blue. It could happen that you receive covered services The BlueCard® Program is the Inter-Plan from providers outside our service area that do not Arrangement that applies to most claims from Host have a contract with the Host Blue. In most cases Blues’ network providers. The Host Blue is we will base the amount you pay for such services responsible for its network providers and handles all on either our allowed amount for these providers or interactions with them. Other Inter-Plan the pricing requirements under applicable law. Arrangements apply to providers that are not in the Please see the definition of “Allowed Amount” in Host Blues’ networks (non-contracted providers). “Definitions” in this booklet for details on allowed This Out-Of-Area Care section explains how the plan amounts. pays both types of providers. In these situations, you may owe the difference You’re getting services through these Inter-Plan between the amounts that the non-contracted Arrangements does not change what the plan provider bills and the payment the plan makes for covers, benefit levels, or any stated eligibility the covered services as set forth above. requirements. Please call us if your care needs prior BlueCard Worldwide® Program authorization. If you are outside the United States, Puerto Rico, We process claims for the Prescription Drugs benefit and the U.S. Virgin Islands (the “BlueCard service

PBCBSAK SCER 01-2017 14 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska area”), you may be able to take advantage of These providers can bill you for charges above the BlueCard Worldwide. BlueCard Worldwide is unlike allowed amount. If you receive services from out-of- the BlueCard Program in the BlueCard service area network dental care providers, you’ll get the highest in some ways. For instance, although BlueCard out-of-pocket costs under this plan for covered Worldwide helps you access a provider network, you services. You may also have to pay for services and will most likely have to pay the provider and send us send us a claim for reimbursement. See Sending the claim yourself in order for the plan to reimburse Us a Claim for details. you. See Claims Section for more information. However, if you need hospital inpatient care, the CARE MANAGEMENT BlueCard Worldwide Service Center can often direct Care Management services work to help ensure that you to hospitals that will not require you to pay in full you receive appropriate and cost-effective medical at the time of service. In such cases, these care. Your role in the Care Management process is hospitals also send in the claim for you. simple, but important, as explained below. If you need to find a doctor or hospital outside the BlueCard service area, need help submitting claims You must be eligible on the dates of service and or have other questions, please call the BlueCard services must be medically necessary. We Worldwide Service Center at 1-800-810-BLUE encourage you to call Customer Service to verify (2583). The center is open 24 hours a day, seven that you meet the required criteria for claims days a week. You can also call collect at 1-804-673- payment and to help us identify admissions that 1177. might benefit from personal health support program. More Questions PRIOR AUTHORIZATION If you have questions or need to find out more about Your coverage for some services depends on the BlueCard Program, please call our Customer whether the service is approved by us before you Service Department. To find a provider outside our receive it. This process is called prior authorization. service area, go to www.premera.com or call 1- 800-810-BLUE (2583). You can also get BlueCard A planned service is reviewed to make sure it is Worldwide information by calling the toll-free phone medically necessary and eligible for coverage under number. this plan. We will let you know in writing if the service is authorized. We will also let you know if PEDIATRIC DENTAL SERVICES the services are not authorized and the reasons An enrolled member under the age of 19 is eligible why. If you disagree with the decision, you can for pediatric dental services. A member is eligible request an appeal. See Complaints and Appeals for these services up to the last day of the month or call us. following their 19th birthday, as long as all other There are three situations where prior authorization eligibility requirements are met. is required: In-Network Dental Providers  Before you receive certain medical services and drugs, or prescription drugs This plan is designed to provide the lowest out-of- pocket costs when you receive services from in-  Before you schedule a planned admission to network providers. Your claims will be submitted certain inpatient facilities directly to us and available benefits will be paid  When you want to receive the Preferred INN directly to the pediatric dental care provider. Our in- provider benefit level for services you receive from network dental providers agree to accept our a Non-Preferred or Non-Participating provider allowed amount as payment in full. When you are outside of the service area, you also have access to Each situation has different requirements. a nationwide network of contracted pediatric dental How To Ask For Prior Authorization providers who can provide covered pediatric dental services. The plan has a specific list of services or supplies that must have prior authorization with You are only responsible for your in-network dental any provider. The detailed list of medical services cost-shares, and charges for non-covered services. requiring prior authorization can be obtained by See Summary of Your Costs for cost-share contacting Customer Service, or at our website at amounts. For the most current information on dental premera.com. network providers, please see our website at premera.com or contact Customer Service. Services from Preferred INN Providers and Non- Preferred Providers: Out-of-Network Dental Providers It is your Preferred INN provider or Non-Preferred Out-of-network dental providers are not in your provider’s responsibility to get prior authorization. provider network and do not have a contract with us.

PBCBSAK SCER 01-2017 15 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska They must call us at the number listed on your ID removals, mastectomy, prophylactic card to request a prior authorization. mastectomy, and reduction mammoplasty Services from Non-Participating Providers:  Cochlear implantation It is your responsibility to get prior authorization  Hyperbaric oxygen therapy for any of the services on the Prior Authorization  Facility based sleep studies (Polysomnography) list when you see a Non-Participating provider.  Radiofrequency tumor ablation You or your provider must call us at the number  Outpatient imaging tests such as: listed on your ID card to request a prior authorization.  Positron Emission Tomography (PET and PET/CT) The detailed list of medical services requiring prior authorization can be obtained by contacting  Contrast Enhanced Computed Tomography Customer Service, or on our website at (CT) Angiography of the heart premera.com. The following are types of services  Computed Tomography (CT) Scans that require prior authorization, including but not  Magnetic Resonance Imaging (MRI) limited:  Magnetic Resonance Angiography (MRA)  Planned admission into hospitals or skilled nursing facilities  Magnetic Resonance Spectroscopy  Planned admission to an inpatient rehabilitation  Nuclear Cardiology facility  Echocardiograms  Planned admission to residential treatment  Certain prescription drugs. See Prior facilities Authorization for Prescription Drugs below.  Non-emergency air or ambulance transport You can also see the Pharmacy section on our website at premera.com.  Transplant and donor services We will respond to your request for prior  Injectable medications you get in a healthcare authorization within 72 hours of receipt of all provider’s office information necessary to make a decision. If your  Prosthetics and orthotics other than foot orthotics situation is clinically urgent (meaning that your life or or orthopedic shoes health would be put in serious jeopardy if you did not  Reconstructive surgery, including repairs of receive treatment right away), you may request an defects caused by injury and correction of expedited review. Expedited reviews are responded functional disorders to as soon as possible, but no later than 24 hours after we get the all information necessary to make a  Home medical equipment costing $500 or more decision. We will provide our decision in writing.  Selected surgical, medical therapeutic, diagnostic and reconstructive procedures, such as: Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your Abdominoplasty/Panniculectomy  continued coverage under the plan. If you don’t  Bone anchored and implantable hearing aids receive the service or supply within that time, you  Cardiac devices, including implantation will have to ask us for another prior authorization.  Cardiac Percutaneous Interventions Prior Authorization Penalty  Corneal remodeling For Services from Preferred INN Providers and  Deep brain stimulation Non-Preferred Providers  Endoscopy Upper Gastrointestinal These providers will get a prior authorization for you.  Hysterectomy You should verify with your provider that a prior authorization request has been approved in writing  Knee arthroplasty and arthoscopy by us before you receive the services.  Implantation or application of electric stimulator For Services from Non-Participating Providers  Radiation therapy such as gamma knife, proton beam, intensity modulated radiation therapy It is your responsibility to get prior authorization (IMRT), interoperative radiation therapy for any of the services on the Prior Authorization  Spine surgery/treatments, such as cervical list when you receive services from these spinal fusion and lumbar spinal fusion providers. If you do not get prior authorization, you will pay a penalty. The penalty is in addition  Blepharoplasty (eyelid surgery), non-cosmetic to any deductibles, copays or coinsurance this  Breast surgeries, such as certain implant plan requires for covered services.

PBCBSAK SCER 01-2017 16 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska The prior authorization penalty is 50 percent of be based on the allowed amount. See Sending Us the allowed amount. The maximum penalty is a Claim for details. $1,500 per occurrence. The prior authorization The list below includes examples of drug categories penalty does not count toward this plan’s that require prior authorization. This list does not deductibles or out-of-pocket maximum. include specific drugs and it may change from time Exceptions: The following services are not subject to time. You can call Customer Service or check the to this prior authorization requirement, but they have Pharmacy Section at premera.com for a detailed list other requirements: of drugs that require authorization.  Emergency hospital admissions, including  Androgens, Estrogens, Hormones and related admissions for drug or alcohol detoxification. drugs They do not require prior authorization, but you  Angiotensin II Receptor Blockers must notify us as soon as reasonably possible.  Anticonvulsants If you are admitted to a Non-Preferred or Non- Participating hospital due to an emergency  Antidepressant agents condition, those services will always be covered at  Antipsoriatic/Antiseborrheic the Preferred INN cost-share. We will continue to  Antipsychotics cover those services until you are medically stable and can safely transfer to a Preferred INN  Drugs with significant changes in product labeling hospital. If you choose to remain at the Non-  Glaucoma drugs Preferred or Non-Participating hospital after you  Growth hormones are stable to transfer, coverage will revert to the Non-Preferred or Non-Participating benefit level.  Headache therapy We pay services based on our allowed amount. If  Hypnotic agents the hospital is non-contracted, you may be billed  Hypoglycemic agents for charges over the allowed amount.  Interferons  Childbirth admission to a hospital, or admissions for newborns who need medical care at birth.  Intranasal steroids They do not require prior authorization, but you  Miscellaneous analgesics must notify us as soon as reasonably possible.  Miscellaneous antineoplastic drugs Admissions to a Non-Preferred or Non-  Miscellaneous antivirals Participating Provider hospital will be covered at the Non-Preferred or Non-Participating Provider  Miscellaneous gastrointestinal agents cost-shares unless the admission was an  Miscellaneous neurological therapy drugs emergency.  Miscellaneous psychotherapeutic agents Prior Authorization for Prescription Drugs  Miscellaneous pulmonary agents Certain prescription drugs you receive through a  Miscellaneous rheumatological agents pharmacy must have prior authorization before you  Narcotics get them at a pharmacy, in order for us to provide benefits. Your provider can ask for a prior  Newly FDA-approved drugs authorization by faxing a prior authorization form to  NSAIDS/Cox II inhibitors us. This form is on the pharmacy section of our  Osteoporosis therapy website at premera.com.  Proton pump inhibitors You can find out if a specific drug requires prior  Smoking deterrents authorization by contacting Customer Service, or checking our website at premera.com. If your  Specialty drugs prescription drug requires prior authorization and  Tetracyclines you do not get prior authorization when you go to a network pharmacy to fill your prescription, your Services from Non-Preferred or Non- pharmacy will tell you that it needs to be prior Participating Providers authorized. You or your pharmacy should call your This plan provides benefits for non-emergency provider to let them know. Your provider can fax us services from Non-Preferred and Non-Participating a prior authorization form for review. providers at a lower benefit level. You may receive You can buy the prescription drug before it is prior benefits for these services at the Preferred INN cost- authorized, but you must pay the full cost. If the share if the services are medically necessary and drug is authorized after you bought it, you can send not available from a Preferred INN provider within 50 us a claim for reimbursement. Reimbursement will miles of your home. You or your provider may

PBCBSAK SCER 01-2017 17 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska request a prior authorization for the Preferred INN your Premera ID card. benefit before you see the Non-Preferred or Non- Participating provider. COVERED SERVICES These services will be covered at the Preferred INN This section describes the services this plan covers. cost-share. In addition to the cost-shares, you will Covered service means medically necessary pay any amounts over the allowed amount if the services (see Definitions) and specified preventive provider does not have a contracting agreement with care services you get when you are covered for that us or, for out-of-state providers, with the local Blue benefit. This plan provides benefits for covered Cross and/or Blue Shield Licensee. services only if all of the following are true when you get the services: If there are Preferred INN providers who can give you the same non-emergency care and are within 50  The reason for the service is to prevent, diagnose miles of your home, your request will not be or treat a covered illness, disease or injury approved.  The service takes place in a medically necessary setting. This plan covers inpatient care only when CLINICAL REVIEW you cannot get the services in a less intensive Premera has developed or adopted guidelines and setting. medical policies that outline clinical criteria used to  The service is not excluded make medical necessity determinations. The criteria  The provider is working within the scope of their are reviewed annually and are updated as needed to license or certification ensure our determinations are consistent with current medical practice standards and follows This plan may exclude or limit benefits for some national and regional norms. Practicing community services. See the specific benefits in this section doctors are involved in the review and development and Exclusions for details. of our internal criteria. You or your provider may review them at premera.com. You or your provider Benefits for covered services are subject to the may request a copy of the criteria used to make a following: medical necessity decision for a particular condition  Copays (if any) or procedure. To obtain the information, please  Deductibles send your request to Care Management at the  Coinsurance address or fax number located inside the front cover of this benefit booklet.  Benefit limits Premera reserves the right to deny payment for  Prior authorization. Some services must be services that are not medically necessary or that are authorized in writing by us before you get them. considered experimental or investigational. A These services are identified in this section. For decision by Premera following this review may be more information, see Prior Authorization. appealed in the manner described in Complaints  Medical and payment policies. These policies are and Appeals. When there is more than one used to administer the terms of this plan. Medical alternative available, coverage will be provided for policies are generally used to further define the least costly among medically appropriate medical necessity or investigational status for alternatives. specific procedures, drugs, biological agents, level of care or services. Payment policies define our PERSONAL HEALTH SUPPORT PROGRAMS provider billing and provider payment rules. Our Premera offers participation in our Personal Health policies are based on accepted clinical practice Support programs to help members with such things guidelines and industry standards accepted by as managing complex medical conditions, a recent organizations like the American Medical surgery, or admission to a hospital. Our services Association (AMA), other professional societies include: and the Center for Medicare and Medicaid Services (CMS). Our policies are available to you  Helping to overcome barriers to health and your provider at premera.com or by calling improvement or following providers’ treatment Customer Service. plan  Coordinating care services including access If you have any questions regarding your benefits and how to use them, call Customer Service at the  Helping to understand the health plan’s coverage number listed on the How to Contact Us section of  Finding community resources this booklet or on the back of your Premera Blue Cross Blue Shield of Alaska ID card. Participation is voluntary. To learn more about the Personal Health Support program, contact Customer Service at the phone number listed on the back of

PBCBSAK SCER 01-2017 18 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska COMMON MEDICAL SERVICES outpatient department of a hospital or facility The services listed in this section are covered as  Preventive medical care and immunizations shown on the Summary of Your Costs. Please see  Professional services received while an inpatient the Summary of Your Costs for your deductible, in a facility copays (if any), and coinsurance and benefit limits.  Psychological and neuropsychological testing OFFICE AND CLINIC VISITS  Rehabilitation therapy and chronic pain care This plan covers professional office and home visits.  Routine vision exams The visits can be for examination, consultation and  Routine hearing exams diagnosis of an illness or injury. You may have to  Spinal and other manipulations pay a separate copay (if any) or coinsurance for other services you get during a visit. This includes  Substance abuse outpatient services services such as x-rays, lab work, therapeutic  Surgical procedures performed in a provider’s injections and office surgeries. Some outpatient office, surgical suite or other facility services you get from a specialist must be prior  Obstetrician/Gynecologist visits with Preferred authorized. See Prior Authorization for details. INN providers are always covered at the lower This benefit covers all of the following: cost-share no matter if you have designated a  Primary care provider (PCP) visits. See How PCP or not. Providers Affect Your Costs for details about  Specialists visits how to select a PCP.  Second opinions for covered medical conditions The calendar year deductible and coinsurance, if or treatment plans any, are waived for the first 6 office or home visits  Prostate, colorectal and cervical cancer exams, each calendar year as long as you use a preferred unless they meet the guidelines for preventive in-network provider who you selected as your PCP care as described on the Summary of Your Costs. The  Biofeedback for migraines and other conditions first 6 visits are an aggregate total, meaning that for that are not considered experimental and each member, office and home visits from all investigational preferred in-network PCP provider combined count toward the 6-visit limit.  Telehealth services. This plan covers access to care via online and telephonic methods when After the 6-visit limit is reached, subsequent home medically appropriate and is real-time and office visits are subject only to the calendar year communication between your doctor and you. deductible and coinsurance, if any. Eligible services must be medically necessary to Please note that the specialist visit copay treat a covered illness, injury or condition. doesn’t apply when you use a participating  Electronic Visits doctor or a doctor who isn’t in the network. For This benefit includes electronic visits (e-visits). E- these providers, services are subject to the visits are structured, secure online messaging calendar year deductible and coinsurance, if any. protocol (email) consultations between an Certain benefits provide a limited number of visits approved doctor and you. They are not real-time each calendar year. These limits apply, regardless visits. Your approved doctor will determine which of whether the visit falls within the first 6 visits of the conditions and circumstances are appropriate for calendar year. e-visits in their practice. E-visits are covered only when provided by an approved provider and all of Office visits received from preferred in-network the following are true: provider for the services listed below don’t count  The doctor has been approved for e-visits by us towards the 6-visit limit:  You have been treated by the doctor before and  Acupuncture outpatient services have established a patient-doctor relationship  Diabetes health education and training with that specific doctor  Emergency room visits  The e-visit is medically necessary  Home health or Hospice care You can call us at the number listed on the back  Mental health outpatient services of your Premera ID card for help finding a doctor approved to provide e-visits.  Habilitative therapy services  Nutritional therapy outpatient care This benefit does not cover:  Outpatient professional services received in an  Surgical services. See Surgery Services for those covered services.

PBCBSAK SCER 01-2017 19 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  EEG biofeedback or neurofeedback services services:  Mental health services including biofeedback  Covered preventive services include those with an services. See Mental Health, Behavioral Health “A” or “B” rating by the United States Preventive and Substance Abuse for those covered Services Task Force (USPSTF); immunizations services. recommended by the Centers for Disease Control  Home health or hospice care visits. See Home and Prevention and as required by state law; and Health Care and Hospice Care for those covered preventive care and screening recommended by services. the Health Resources and Services Administration (HRSA).  Facility charges. When you get care at a hospital based clinic or hospital based doctor’s office, you  Routine exams, also included are exams for must pay your deductible and coinsurance for the school, sports and employment facility charges. See Hospital Services for those  Well-baby care, including those provided by a costs. qualified health aide PREVENTIVE CARE  Women’s preventive exams. Includes pelvic exams, pap smears and clinical breast exams Preventive care is a specific set of evidence-based  Screening mammograms. See Diagnostic Lab, services expected to prevent future illness. These X-ray and Imaging for mammograms needed services are based on guidelines established by because of medical condition. government agencies and professional medical societies.  Pregnant women’s services such as diabetic supplies, breast feeding counseling before and Please go to this government website for more after delivery and maternity diagnostic screening information:  Electric breast pumps and supplies. Includes the https://www.healthcare.gov/coverage/preventive- purchase of a non-hospital grade breast pump or care-benefits/ rental of a hospital grade breast pump. The cost Preventive services provided by in-network providers of the rental cannot be more than the purchase are covered in full. But they have limits on how price. For electric breast pumps and supplies often you should get them. These limits are often purchased at a retail location you will need to pay based on your age and gender. After a limit has out of pocket and submit a claim for been exceeded, these services are not covered in reimbursement. See Sending Us a Claim for full and may require you to pay more out-of-pocket instructions. costs.  BRCA genetic testing for women at risk for certain Some of the services your doctor does during a breast cancers routine exam may not meet preventive guidelines.  Professional services to prevent falling for These services are then covered the same as any members who are 65 years and older and have a medical service and are not covered in full, and you history of falling or mobility issues may be responsible for part of the costs.  Prostate cancer screening. Includes digital rectal For example: exams and prostate-specific antigen (PSA) tests. Annual tests for prostate cancer for high risk men During your preventive exam, your doctor may find under 40, all men 40 years of age and older, or as an issue or problem that requires further testing or recommended by a doctor. screening for a proper diagnosis to be made. Also, if you have a chronic disease, your doctor may  Colon cancer screening for high risk individuals check your condition with tests. These types of under 50 years of age, all individuals 50 years of screenings and tests help to diagnose or monitor age or older, or as recommended by a doctor. your illness and would not be covered under your Includes pre-colonoscopy consultations, exams, preventive benefits. They would require you to pay colonoscopy, sigmoidoscopy and fecal occult a greater share of the costs. blood tests. Removal and pathology (biopsy) related to polyps found during a screening You can also get a complete list of the preventive procedure are covered as part of the preventive care services with the limits on our website at screening. Includes anesthesia your doctor premera.com or call us for a list. This list may be considers medically appropriate for you. changed as required by state and federal preventive  Outpatient lab and radiology for preventive guidelines change. The list will include website screening and tests addresses where you can see current federal preventive guidelines.  Diabetes screening This plan covers the following as preventive  Routine immunizations and vaccinations as recommended by your doctor. These include

PBCBSAK SCER 01-2017 20 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska seasonal, travel, and certain other immunization PEDIATRIC CARE provided by a pharmacy or other mass immunizer location. You can also get flu shots, flu mist, and This plan covers vision and dental services for immunizations for shingles, pneumonia and covered children. A child is eligible for these pertussis (whooping cough) at a pharmacy or services up to the end of the month following the th other seasonal immunization center. If you use child’s 19 birthday, when all eligibility requirements an out-of-network provider for seasonal and travel are met. immunizations you may need to pay out of pocket Vision Services and submit a claim for reimbursement. See Sending Us a Claim for instructions. This plan covers routine eye exams and glasses as follows:  Obesity screening and counseling for weight loss  Vision exams by an ophthalmologist or an  Contraceptive management. Includes exams, optometrist. A vision exam may consist of treatment you get at your provider’s office, external and ophthalmoscopic examination, prescribed generic emergency contraceptives, determination of the best corrected visual acuity, and prescribed contraceptive supplies and determination of the refractive state, gross visual devices. Tubal ligation, vasectomy, and fields, basic sensorimotor examination and implanted devices (including removal) are also glaucoma screening. covered. See Prescription Drugs for prescribed oral contraceptives and devices.  Low vision evaluation and follow up visits by an ophthalmologist or an optometrist  Removal of contraceptive devices approved by the U.S. Food and Drug Administration (FDA)  Glasses, frames and lenses  Health education and training for covered  Contact lenses in lieu of lenses for glasses, conditions such as diabetes, high cholesterol and including those required for medical reasons obesity. Includes outpatient self-management  Low vision devices, high powered spectacles, programs, training, classes and instruction. magnifiers and telescopes when medically  Nutritional therapy. Includes outpatient visits with necessary a doctor, nurse, pharmacist or registered  Sales tax, shipping and handling charges for dietitians. The purpose of the therapy must be to vision hardware manage a chronic disease or condition such as Dental Services diabetes, high cholesterol and obesity. The number of therapy visits that are covered as This plan provides pediatric dental services for preventive depends on your medical needs. covered members.  Preventive drugs required by federal law. See The covered services under this plan are classified Prescription Drugs. as Class I – Diagnostic and Preventive, Class II –  Approved tobacco cessation programs Basic, and Class III – Major Services. The lists of recommended by your doctor. After you have services that relate to each type are outlined in the completed the program, please provide us with following pages under Covered Services. These proof of payment and a completed reimbursement services are covered once all of the following form. You can get a reimbursement form on our requirements are met. It is important to understand website at premera.com. See Prescription all of these requirements so you can make the most Drugs for covered drug benefits. of your dental benefits. This Preventive Care benefit does not cover: This plan covers dental services if all the following  Prescription contraceptives, including over the are true: counter (OTC) items, dispensed and billed by your  Services are medically necessary (see provider or a hospital. See Prescription Drugs Definitions) for prescribed contraceptives.  Services must be provided by a licensed dentist  Gym memberships or exercise classes and (D.M.D. or D.D.S.). Services may also be programs provided by a dental hygienist under the  Inpatient newborn exams while the child is in the supervision of a licensed dentist, or other hospital following birth. See Maternity and individual, performing within the scope of his or Newborn Care for those covered services. her license or certification, as allowed by law.  Physical exams for basic life or disability  Services must not be excluded from coverage insurance under this benefit.  Work-related disability evaluations or medical At times we may need to review diagnostic materials disability evaluations such as dental x-rays to determine your available

PBCBSAK SCER 01-2017 21 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska benefits. We will request these materials directly year from your dental provider. If we are not able to  Periapical, occlusal, and cephalometric x-rays obtain the necessary materials, we will provide benefits only for those dental services we can verify  Either a complete series (full-mouth series) x- as covered. ray or panoramic films once every 60 months but not both Alternative Benefits  Fixed and removable space maintainers To determine benefits available under this plan,  Re-cement or re-bond space maintainers alternative procedures or services with different fees  Collection and preparation of genetic sample for that are consistent with acceptable standards of laboratory analysis is limited to once per lifetime dental practice are utilized. In all cases where there is an alternative course of treatment that is less  Genetic test and analysis for susceptibility to costly for a service that is covered under the plan, diseases is limited to once per lifetime benefits for the treatment with the lesser fee will be  Diagnostic casts (study models) provided. If you and your dental care provider  2D or 3D oral/facial photographic images choose a more costly treatment, you are responsible for additional charges beyond those for the less  Interpretation of diagnostic image by a provider costly alternative treatment. that is not associated with capture of the image including report Estimate of Dental Benefits Class II – Basic Services You can ask for an Estimate of Benefits. An Estimate of Benefits verifies, for the dental provider  Diagnostic professional consultation provided by a and yourself, your eligibility and benefits. It may dentist or physician other than the requesting also clarify, before services are provided, treatment dentist or physician that is not covered in whole or in part. This can  Protective restoration (sedative filling) protect you from unexpected out-of-pocket  Fillings, consisting of amalgam and resin-based expenses. composite, on any tooth surface An Estimate of Benefits is not required for you to  Prefabricated stainless steel crowns and receive your dental benefits. However, we suggest prefabricated porcelain crowns are covered for that your dental care provider submit an estimate to members under age 15 and limited to once per us for any proposed dental services in which you are tooth every 60 months concerned about your out-of-pocket expenses.  Pin retention in addition to restoration Our Estimate of Benefits is not a guarantee of  Endodontic services include: payment. Payment of any service will be based on  Therapeutic pulpotomy your eligibility and benefits available at the time services are provided. See How to Contact Us for  Partial pulpotomy for apexogenesis on the address and fax for an estimate of benefits, or permanent teeth call Customer Service.  Pulpal therapy (resorbable filling) is covered for Dental care coverage includes the following: members up to age 11 and is limited to once per tooth in a lifetime Class I – Diagnostic and Preventive Services  Non-surgical periodontal service include:  Comprehensive,periodic and problem-focused  Periodontal scaling and root planing is limited to oral evaluations are limited to 2 per calendar year once every 24 months  Prophylaxis (cleanings) are limited to 2 per  Periodontal maintenance following periodontal calendar year therapy is limited to 4 visits every 12 months  Topical application of fluoride (including fluoride  Full mouth debridement is limited to once per varnish) is limited to 2 treatments per calendar lifetime year  Simple and surgical extractions (includes local  Sealants on permanent molars, preventive resin anesthesia and routine postoperative care) restorations on permanent teeth, and sealant repair on permanent teeth are limited to once per  Other oral surgery of the tooth and gum includes: tooth every 36 months  Surgical access of an unerupted tooth  Interim caries medicament on permanent teeth is  Alveoloplasty limited to once per tooth every 36 months  Removal of exostosis  Covered x-rays include:  Incision and drainage of abscess (intra oral soft  Bitewing x-rays are limited to 2 per calendar tissue)

PBCBSAK SCER 01-2017 22 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Suture of wound up to 5 cm  Hemisection  Bone replacement grafts for ridge preservation  Periodontal surgery includes:  Excision of pericoronal gingiva  Osseous surgery, gingivectomy or  Treatment of post-surgical complications due to gingivoplasty, and gingival flap procedures are unusual circumstances limited to once every 36 months  Collection and application of autologous blood  Clinical crown lengthening concentrate product is limited to once every 36  Bone replacement graft and soft tissue allograft months is limited to once every 36 months  Emergency palliative treatment. We require a  Pedical, subepithelial and free soft tissue grafts written description and/or office records of  Dentures and fixed partial dentures (bridges) are services provided limited to once every 60 months  Therapeutic drug injections provided in the dental  Implants, implant services, and implant supported office prosthetics are subject to dental necessity and  Adjustment to complete and partial dentures when limited to once every 60 months performed 6 or more months after the initial  General anesthesia or intravenous conscious installation of the denture sedation  Repair to complete and partial dentures  Occlusal guard (nightguard) designed to minimize  Repair and re-cement fixed partial dentures the effects of bruxism or other occlusal factors (bridges) for members age 13 and older and is limited to  Reline and rebase of dentures are limited to once once every 12 months every 36 months when performed 6 or more  Occlusal guard adjustment is limited to once every months after the initial installation of the denture 24 months  Tissue conditioning  Implants, implant services and implant supported  Cleaning and inspection of removable complete prosthetics including abutments are subject to and partial dentures is limited to once every 60 dental necessity and limited to once every 60 months months  Orthodontia Services Class III – Major Services Orthodontia services are covered only for  Crowns, onlays, and labial veneers when there is medically necessary conditions, such as cleft significant loss of clinical crown and no other palate or cleft lip. We highly recommend a pre- dentally appropriate restoration will restore service review prior to receiving orthodontia function is limited to once per tooth every 60 services. A pre-service review is used to months determine if a service meets medical necessity  Inlays will be reduced to the corresponding criteria. A pre-service review is not a guarantee of amalgam filling allowance payment. Ask your dental provider to contact our  Crown core buildup when done in conjunction Customer Service Department to request a pre- with a covered crown when there is significant service review on your behalf to confirm your loss of clinical crown and no other dentally services are medically necessary. This benefit appropriate restoration will restore function is does not cover cosmetic orthodontia services. limited to once per tooth every 60 months This benefit does not cover:  Prefabricated post and core in addition to crown  Re-evaluations  Crown, inlay, onlay, and veneer repair  Sialography  Resin infiltration of incipient smooth surface  Tomographic survey lesions is limited to once every 36 months  Cone beam, MRI or ultrasounds  Endodontic services include:  Oral pathology laboratory  Endodontic therapy (root canal)  Oral tests and examinations except those listed in  Retreatment of previous endodontic therapy the “Covered Section” of this contract (root canal)  Oral hygiene instructions for control of dental  Apexification/recalcification disease  Pulpal regeneration  Plaque control programs including home fluoride  Apicoectomy/periradicular surgery kits  Root amputation  Removal of space maintainer

PBCBSAK SCER 01-2017 23 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Gold foils external bleaching  Post removal  Stress breakers and athletic mouth guards  Coping  Services received or ordered when this plan is not  Direct and indirect pulp caps in effect or when you are not covered under this plan (including services and supplies started  Surgical procedure for isolation of tooth with before your coverage effective date or after the rubber dam, canal preparation and fitting of date coverage ends) preformed dowel or post  Anatomical crown exposure DIAGNOSTIC X-RAY, LAB AND IMAGING  Periodontal splinting and/or crown and bridgework This plan covers diagnostic medical tests that help in conjunction with periodontal splinting find or identify diseases. Covered services include interpreting these tests for covered medical  Connector bar conditions.  Precision attachments, personalization, precious metal bases and other specialized techniques Preventive Care Screening and Tests  Duplicate appliances Preventive care screening and tests are services  Cleaning of appliances based on guidelines established by government agencies and professional medical societies. For  Temporary, interim or provisional services for more information about what services are covered crowns, bridges or dentures as preventive see Preventive Care.  Maxillofacial prosthetics, including fluoride gel Basic Diagnostic Lab, X-ray and Imaging carrier services includes:  Sinus augmentation  Diagnostic imaging and scans such as x-rays  Bone grafts when done in connection with  Blood and blood services (storage and extractions or apicoectomies procurement, including blood banks) when  Biopsy of hard and soft oral tissue medically necessary  Surgical excision of soft tissue lesions  Cardiac testing, including pulmonary function  Harvest of bone for use in grafting procedures studies  Radical resection of maxilla or mandible  Mammograms for a medical condition  Removal of foreign body and removal of reaction  Bone density screening for osteoporosis producing foreign bodies  Barium enema  Surgical placement of temporary anchorage  Lab services devices  Neurological and neuromuscular tests  Appliance removal  Pathology tests  Intraoral placement of a fixation device not in  Echocardiograms conjunction with a fracture  Standard ultrasounds  Sialolithotomy, excision of salivary gland, sialodochoplasty and closure of salivary fistula Major Diagnostic X-ray and Imaging  Local, regional block, trigeminal division block  Computed Tomography (CT) scan anesthesia, and non-intravenous conscious  High technology ultrasound sedation  Nuclear Cardiology  Analgesia, anxiolysis, inhalation of nitrous oxide  Magnetic Resonance Imaging (MRI)  Evaluation for deep sedation or general anesthesia  Magnetic Resonance Angiography (MRA)  House, extended care facility and hospital calls  Positron Emission Tomography (PET) scans  Case presentation This benefit does not cover:  Behavior management  Preventive screening and tests. See Preventive Care for those covered services.  Occlusal orthotic device  Diagnostic services from an inpatient facility, an  Occlusal orthotic device adjustment outpatient facility, or emergency room that are  Occlusion analysis and limited and complete billed with other hospital or emergency room occlusal adjustments services. These services are covered under  Enamel microabrasion, odontoplasty,internal and inpatient, outpatient or emergency room benefits.

PBCBSAK SCER 01-2017 24 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Diagnostic surgeries, biopsies and scope insertion  Routine colonoscopy, sigmoidoscopy and barium procedures. See Surgery Services and Hospital enema screening. See Preventive Care for Services for covered services. details.  Allergy tests. See Allergy Testing and  Breast reconstruction. See Mastectomy and Treatment for covered services. Breast Reconstruction for those covered services. SURGERY SERVICES  Transplant services. See Transplants for details. This plan covers inpatient and outpatient surgical  Vasectomy. See Preventive Care for details. services at a hospital or ambulatory surgical facility, surgical suite or provider’s office. Some inpatient EMERGENCY ROOM and outpatient surgeries must be prior authorized before you have them. See Prior Authorization for This plan covers services you get in a hospital details. emergency room for an emergency medical condition. An emergency medical condition includes Services of an assistant surgeon are covered as things such as heart attack, stroke, serious burn, stated in the Summary of Your Costs only when chest pain, severe pain or bleeding that does not medically necessary. Assistant surgeons are not stop. You should call 911 or the emergency number involved in the pre-operative or post-operative care for your local area. You can go to the nearest and only assist during a surgical procedure at the hospital emergency room that can take care of you. direction of the primary surgeon. Benefits allowed If it is possible, call your doctor first and follow their for an assistant surgeon are based on their instructions. participation in this one element of your care and will be their billed charges or 20% of the primary You do not need prior authorization for emergency surgeon’s allowed amount, whichever is less. room services. You must let us know if you are admitted as an inpatient from the emergency room Sometimes more than one procedure is done during as soon as reasonably possible. See Prior the same surgery. These may be two separate Authorization for details. procedures or the same procedure on both sides of the body. In these cases, benefits for the main If you get emergency care from a Non-Participating procedures will be based on the allowed amount for provider or hospital emergency room, you must pay the first or main procedure. Benefits for the for any charges over the allowed amount. secondary procedure will be one half of the allowed Covered services include the following: amount for the main procedure.  The emergency room and the emergency room Covered services include, but not limited to: doctor as shown on the Summary of Your Costs  Anesthesia or sedation and postoperative care, as  Supplies and drugs used in the emergency room medically necessary or urgent care center  Cornea transplants and skin grafts  Services used for emergency medical screening  Cochlear implants, including bilateral implants exams and for stabilizing an emergency medical condition  Blood transfusion, including blood derivatives  Outpatient diagnostic tests billed by the  Biopsies and scope insertion procedures such as emergency room and that you get with other endoscopies emergency room services  Colonoscopy and sigmoidoscopy services when  Prescription drugs associated with an emergency needed because of a medical condition and that medical condition, including those purchased in a do not meet the preventive guidelines foreign country  Abortions, elective and medically necessary  Medically necessary detoxification  Reconstructive surgery that is needed because of  Services that are furnished and provided in a an injury, infection or other illness hospital based urgent care clinic and billed by the  Sexual reassignment surgery if medically hospital or emergency room necessary and not for cosmetic purposes Please contact your doctor for non-emergency This benefit does not cover: conditions. This could be for things like minor  The use of an anesthesiologist for monitoring and illnesses such as cold, check-ups, follow-up visits administering general anesthesia for endoscopies, and prescription drug requests. colonoscopies and sigmoidoscopies unless EMERGENCY AMBULANCE SERVICES medically necessary when specific medical conditions and risk factors are present This plan covers emergency (ground, water or air) ambulance services to the nearest facility that can

PBCBSAK SCER 01-2017 25 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska treat your condition. The medical care you get  Operating rooms, procedure rooms and recovery during the trip is also covered. These services are rooms covered only when any other type of transport would  Doctor services put your health or safety at risk. Covered services also include transport from one medical facility to  Anesthesia another as needed for your condition, or to your  Services, medical supplies and drugs, blood and home when medically necessary. blood derivatives, dressings, equipment and oxygen that the hospital provides for your use in This plan covers ambulance services from licensed the hospital providers only and only for the member who needs transport.  Lab and testing services billed by the hospital and done with other hospital services Prior authorization is required for non-emergency ambulance services. See Prior Authorization for Anesthesia for Dental Services details. In some cases, this plan covers anesthesia services URGENT CARE CENTERS for dental procedures. Covered services include general anesthesia and fees paid to the This plan covers care you get in an urgent care anesthesiologist. Also covered are the related center. Urgent care centers have extended hours facility charges (inpatient or outpatient) for a hospital and are open to the public. You can go to an urgent or ambulatory surgical center. These services are care center for an illness or injury that needs covered only when medically necessary for one of treatment right away. Examples are minor sprains, the reasons: cuts, and ear, nose and throat infections. Covered services include the doctor services.  The member is under age 19 or has a disability and it would not be safe and effective to treat You may have to pay a separate copay (if any) or them in a dental office coinsurance for other services you get during a visit.  You have a medical condition (besides the dental This includes things such as x-rays, lab work, condition) that makes it unsafe to do the dental therapeutic injections and office surgeries. See treatment outside a hospital or ambulatory those covered services for details. surgical center HOSPITAL SERVICES This benefit does not cover: This plan covers services you get in a hospital.  Hospital stays that are only for testing, unless the Benefits are limited to the least costly treatment tests cannot be done without inpatient hospital setting that is medically necessary for your condition. facilities, or your condition makes inpatient care If you get services from Non-Preferred or Non- medically necessary Participating provider at a Preferred INN Provider  Any days of inpatient care beyond what is hospital, you will pay any amounts over the allowed medically necessary to treat the condition amount.  Dental treatment or procedures Inpatient Care MENTAL HEALTH, BEHAVIORAL HEALTH All planned (elective) inpatient care requires prior AND SUBSTANCE ABUSE authorization from us before you get treatment. See Prior Authorization for details. This plan covers mental health care and treatment for alcohol and drug dependence. A mental health Covered services include: condition is any condition listed in the current  Room and board, general duty nursing and Diagnostic and Statistical Manual (DSM), special diets published by the American Psychiatric Association,  Doctor services and visits excluding diagnosis and treatments for substance abuse. Benefits are limited to the least costly  Use of an intensive care or special care units treatment setting that is medically necessary for your  Detoxification condition. This plan complies with federal mental  Operating rooms, surgical supplies, anesthesia, health parity requirements. drugs, blood and blood derivatives, dressing, All planned inpatient care requires prior equipment and oxygen authorization from us before you get treatment. See  X-ray, lab and testing Prior Authorization for details. Outpatient Care Mental Health and Behavioral Health Care Covered services include: This plan covers all of the following services:

PBCBSAK SCER 01-2017 26 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Inpatient, residential treatment, partial neurologist hospitalization and outpatient therapeutic visits to  A state-licensed psychiatric nurse practitioner manage or reduce the effects of the mental health (NP), advanced nurse practitioner (ANP) or condition advanced registered nurse practitioner (ARNP)  Individual, family or group therapy  A state-licensed masters-level mental health  Lab and testing clinician (e.g., licensed clinical social worker,  Take-home drugs you get in a facility licensed marriage and family counselor, licensed mental health counselor)  Applied behavior analysis (ABA) for the treatment of autism  A state-licensed occupational or speech therapist when providing ABA services  Physical, speech and occupational therapy provided to treat a mental health condition,  A state-licensed psychologist including autism spectrum disorders  Licensed Community Mental health or Behavioral  Biofeedback Health agency that is also state certified for ABA  Services received from individuals supervised by  Board certified Behavior Analyst, licensed in an autism service provider treating autism states with behavior analyst licensure, spectrum disorders. See Definitions for otherwise, certified by the Behavior Analyst description of autism service providers. Certification Board  Telehealth visits. Covered telehealth visits must  Other providers, including therapy use secure, real-time video or audio services. assistants/behavioral technicians/ paraprofessionals; when services are For this benefit, “outpatient therapeutic visit” means supervised and billed by a licensed provider or a clinical treatment session with a mental health Board Certified Behavioral Analyst (BCBA) provider.  Any other provider with appropriate training in Substance Abuse behavioral analysis, or whose scope of licensure includes behavioral analysis This plan covers all of the following services: Covered services include:  Inpatient, residential treatment, partial hospitalization and outpatient visits to manage or  Direct treatment or direct therapy services for reduce the effects of the alcohol or drug identified patients and/or family members when dependence provided by a licensed provider, Board Certified Behavioral Analyst (BCBA), or therapy  Individual, family or group therapy assistants who are supervised by a licensed  Lab and testing provider or BCBA  Take-home drugs you get in a facility  Also covered when performed by a licensed Please Note: Medically necessary detoxification is provider or BCBA: covered in any medically necessary setting.  Initial evaluation/assessment Detoxification in the hospital is covered under the  Treatment review and planning Emergency Room and Hospital Services – Inpatient Care benefits.  Supervision of therapy assistants  Communication/coordination with other Applied Behavioral Analysis (ABA) Therapy providers or school personnel This plan covers Applied Behavioral Analysis (ABA) Please Note: Delivery of all ABA services for an Therapy. The member must be diagnosed with one individual may be managed by a BCBA or licensed of the following disorders: provider who is called a Program Manager.  Autistic disorder This Mental Health, Behavioral Health and  Autism spectrum disorder Substance Abuse benefit does not cover:  Asperger’s disorder  Treatment of alcohol or drug use or abuse that  Childhood disintegrative disorder does not meet the definition of “Substance Abuse”  Pervasive developmental disorder as stated in Definitions  Rett’s disorder  Training of therapy assistants/behavioral technicians/paraprofessionals (as distinct from Benefits must be provided by: supervision)  A physician (MD or DO) who is a psychiatrist,  Accompanying the member/identified patient to developmental pediatrician, or pediatric appointments or activities outside of the home

PBCBSAK SCER 01-2017 27 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska (e.g., recreational activities, eating out, shopping, when provided for an illness or injury treated in an play activities, medical appointments), except acute care hospital, or inpatient/residential when the member/identified patient has treatment provided for a mental health condition demonstrated a pattern of significant behavioral  Neurofeedback and EEG biofeedback difficulties during specific activities and such accompaniment is medically necessary as part of  Family and marriage counseling or therapy, continuing therapy except when it is medically necessary to treat your mental condition  Transporting the member/identified patient in lieu of parental/other family member transport  Therapeutic or group homes, foster homes, nursing homes, boarding homes or schools and  Assisting the member with academic work or child welfare facilities functioning as a tutor, except when the member has demonstrated a pattern of significant  Outward bound, wilderness, camping or tall ship behavioral difficulties during school work and such programs or activities assistance is medically necessary as part of  Mental health tests that are not used to assess a continuing therapy covered mental health condition or plan of  Functioning as an educational or other aide for the treatment. This plan does not cover tests to member/identified patient in school decide legal competence or for school or job placement.  Provision of services that are part of an Individualized Education Program (IEP) and  Detoxification services that do not consist of therefore should be provided by school personnel, active medical management. See Definitions. or other services that schools are obligated to  Support groups, such as Alanon or Alcoholics provide Anonymous  Provider doing house work or chores, or assisting  Services that are not medically necessary. This is the member/identified patient with house work or true even when a court orders them or you must chores, except when the member has get them to avoid being tried, sentenced or losing demonstrated a pattern of significant behavioral the right to drive. difficulties during specific house work or chores,  Sober living homes, such as halfway houses or acquiring the skills to do specific house work or chores is part of the ABA treatment plan for the  Residential treatment programs or facilities that member/identified patient and such assistance is are not units of hospitals, or that the state has not medically necessary as part of continuing therapy licensed or approved for residential treatment  Babysitting  Caffeine dependence  Respite for parents/family members MATERNITY AND NEWBORN CARE  Provider residing in the member’s home and Maternity Care functioning as live-in help (e.g., in an au-pair role) This plan covers doctors and facility charges for  Peer-mediated groups or interventions prenatal care, delivery and postnatal care. The  Training or classes for groups of parents of hospital stay for the mother is covered up to 48 different patients hours for a vaginal delivery or up to 96 hours  Hippotherapy/equestrian therapy following a cesarean section. A length of stay that will be longer than these limits must be prior  Pet therapy authorized. See Prior Authorization for details.  Auditory Integration Therapy Home birth and birthing center services are also  Sensory Integration Therapy covered. The services must be provided by a  Prescription drugs. These are covered under the licensed women’s health care provider who is Prescription Drugs benefit. working within their license and scope of practice.  Any other activity that is not considered to be a Newborn Care behavioral assessment or intervention utilizing applied behavioral analysis techniques This plan covers newborn hospital nursery care and includes pediatrician services. Benefits for the  For ABA, any other activity that is not considered newborn services are subject to the newborn’s cost- to be a behavioral assessment or intervention shares. The hospital stay for the newborn is utilizing applied behavioral analysis techniques covered up to 48 hours for a vaginal delivery or up to  Treatment of sexual dysfunctions, such as 96 hours following a cesarean section. Prior impotence authorization is not required. However, we suggest  Institutional care, except services that are covered that you let us know of the newborn’s admission as

PBCBSAK SCER 01-2017 28 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska soon as reasonably possible. This benefit does not cover: Newborn children of a covered member are covered  Over the counter (OTC) drugs, solutions and from the moment of birth. See the dependent nutritional supplements eligibility and enrollment guidelines under Eligibility  Services provided to someone other than the ill or and Enrollment for details. injured member Covered newborn care services include the  Services provided by family members or following: volunteers  Hospital nursery care  Services, supplies, or providers not in the written  Circumcision plan of care or not named as covered in this benefit  Newborn hearing screening exams. Your costs for these services depend on where the services  Custodial care are received. If the newborn is tested in the  Nonmedical services, such as housekeeping hospital, you pay your cost-share for Hospital  Services that provide food, such as Meals on Services. For office visits, you pay the Office and Wheels or advice about food Clinic Visits cost-share. For diagnostic services, you pay the cost-share for Diagnostic X-ray, Lab HOSPICE CARE and Imaging. This plan covers hospice care. The benefit limit  One screening within 30 days of the date of birth shown on the Summary of Your Costs may be  A diagnostic hearing evaluation for children up to extended for an extra 6 months when medically age 24 months if the newborn screening shows an necessary for your condition. impairment All inpatient hospice care requires prior authorization This benefit does not cover routine outpatient well from us before you receive treatment. See Prior baby care. See Preventive Care for those covered Authorization for details. services. Covered services include: This benefit does not cover:  Palliative care for members facing serious, life-  Complications of pregnancy. These services are threatening conditions, including expanded covered as other medical conditions and benefits access to home based care and care are based on the type of services you get. For coordination. Participation in palliative care is example, office visits are covered as shown under usually approved for 12 months at a time and may Office and Clinic Visits. be extended based on the member’s specific condition.  Outpatient x-ray, lab and imaging. These services are covered under Diagnostic Lab, X-ray and  Nursing care provided by or under the supervision Imaging. of a registered nurse  Home birth services provided by family members  Medical social services provided by a medical or volunteers social worker who is working under the direction of a doctor; this may include counseling for the HOME HEALTH CARE purpose of helping you and your caregivers to Home health care services must be part of a written adjust to the approaching death home health care plan. These services are covered  Services provided by a qualified provider when a qualified provider certifies that the services associated with the hospice program are provided or coordinated by a state-licensed or  Short term inpatient care provided in a hospice Medicare-certified Home Health Agency or certified inpatient unit or other designated hospice bed in a Rehabilitation Agency. hospital or skilled nursing facility. This care may Covered services include: be for the purpose of occasional respite for your caregivers, or for pain control and symptom  Home visits and acute nursing (short-term nursing management. care for illness or injury) by a home health agency  Home medical equipment, medical supplies and  Therapeutic services such as respiratory therapy devices, including medications used primarily for and phototherapy provided by the home health the relief of pain and control of symptoms related agency to the terminal illness  Prescription drugs and insulin provided by and  Home health aide services for personal care, billed by a home healthcare provider or home maintenance of a safe and healthy environment health agency and general support to the goals of the plan of care

PBCBSAK SCER 01-2017 29 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Rehabilitation therapies provided for purposes of care, this benefit will start when your care becomes symptom control or to enable you to maintain mainly rehabilitative. activities of daily living and basic functional skills You must get prior authorization from us before you  Continuous home care during a period of crisis in get inpatient treatment. See Prior Authorization for which you require skilled intervention to achieve details. palliation or management of acute medical symptoms This plan covers inpatient rehabilitative therapy only when all of the following are true: This benefit does not cover:  You get the services within 24 months after the  Over the counter (OTC) drugs, solutions and injury occurred, the date the illness started, or the nutritional supplements date of the surgery that made you need  Services provided to someone other than the ill or rehabilitation. injured member  You cannot get the services in a less intensive  Services provided by family members or setting volunteers  The care is part of a written plan of treatment to  Services, supplies or providers not in the written be provided by several specialists. A doctor plan of care or not named as covered in this specializing in rehabilitative medicine prescribed benefit this treatment plan and reviews it regularly.  Custodial care, except for hospice care services Outpatient Care  Nonmedical services, such as housekeeping, This plan covers these services only when all of the dietary assistance or spiritual bereavement, legal following are true: or financial counseling  You are not staying in a hospital or other medical  Services that provide food, such as Meals on facility. Wheels or advice about food  The therapy is a part of a formal written treatment REHABILITATION THERAPY plan prescribed by a doctor. This plan covers medically necessary inpatient and  Services are provided and billed by a hospital, a outpatient rehabilitation therapies. Rehabilitative rehabilitation facility approved by us, or another therapy services or devices are provided when licensed provider. medically necessary for the restoration of bodily or A “visit” is one session of treatment for each type of cognitive functions lost due to a medical condition. therapy. Each type of therapy counts toward the These services must be provided by a state-licensed combined benefit maximum limit listed in the or state-certified provider acting within the scope of Summary of Your Costs. If you have two or more their license or certification. therapy sessions in one day with the same provider, Covered services include all of the following: it counts as one visit.  Physical, speech, and occupational therapies The outpatient visit limit listed in the Summary of  Chronic pain care. Chronic pain is pain that is Your Costs applies to non-chronic conditions. It hard to control or that will not stop. Treatment for does not apply to chronic conditions such as cancer, chronic pain is not subject to the 24-month limit for chronic pulmonary or respiratory disease, cardiac inpatient care. disease or other similar chronic conditions or diseases.  Cardiac and pulmonary rehabilitation  Massage therapy. If provided by a massage This benefit does not cover: therapist who is not licensed by the state, the  Recreational, vocational or educational therapy services must be billed by a supervising doctor to  Exercise programs be covered.  Maintenance therapy, therapy performed to  Assessments and evaluation related to maintain a current level of functioning without rehabilitative therapy documentation of significant improvement  Rehabilitative devices that have been approved  Social or cultural therapy by the FDA and prescribed by a qualified provider  Treatment that the ill, injured or impaired member Inpatient Care does not actively take part in You must get inpatient care in a specialized  Gym or swim therapy rehabilitative unit of a hospital or in a separate  Custodial care rehabilitation facility. If you are already in inpatient  Inpatient rehabilitative therapy received more than

PBCBSAK SCER 01-2017 30 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska 24 months after the accidental injury, the start of approved skilled nursing facility. Sometimes a the illness, or the date of surgery patient goes from acute nursing care to skilled  Neurodevelopmental therapy or treatment of nursing care without leaving the hospital. When that developmental or neurodevelopmental disabilities. happens, this benefit starts on the date that the care See Habilitation Therapy for details. becomes primarily skilled nursing care.  Treatment for mental health, behavioral health or Skilled nursing care is covered only during certain substance abuse. See Mental Health, stages of your recovery. It must be a time when Behavioral Health and Substance Abuse for inpatient hospital care is no longer medically those covered services. necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively HABILITATION THERAPY supervise your care while you are in the skilled This plan covers medically necessary and nursing facility. appropriate services and devices for development of You must get prior authorization from us before you bodily or cognitive functions to perform activities of get treatment. See Prior Authorization for details. daily living that never developed or did not develop appropriately based on the chronological age of the This benefit does not cover: member.  Custodial care Habilitative services include:  Care that is mainly for senile deterioration, mental  Physical therapy deficiency or retardation  Neurodevelopmental therapy  Treatment for substance abuse  Occupational therapy HOME MEDICAL EQUIPMENT (HME),  Speech language therapy ORTHOTICS, PROSTHETICS AND SUPPLIES  Massage therapy. If provided by massage Covered services include home medical equipment, therapist who is not licensed by the state, the orthotics, prosthetics, certain medical foods, supplies services must be billed by a supervising doctor and sales tax for covered items. Some services to be covered. require prior authorization. See the Prior Authorization section for details.  Habilitative devices that have been approved by FDA and prescribed by a qualified provider. Medical and Respiratory Equipment The outpatient visit limit listed in the Summary of The rental costs for medical and respiratory Your Costs applies to non-chronic conditions. It equipment and the fitting expenses are covered. does not apply to chronic conditions such as Benefits will not be greater than the purchase price cancer, chronic pulmonary or respiratory of the equipment. It must be medically necessary disease, cardiac disease or other similar chronic and prescribed by a doctor to treat a covered illness conditions or diseases. This benefit does not or injury. cover: Benefits may also be provided for the initial  Respite care purchase of equipment, in lieu of the rental cost. In  Day habilitation services designed to provide cases where an alternative type of equipment is less training, structured activities and specialized costly and serves the same medical purpose, we will assistance provide benefits only up to the lesser amount.  Chore services to assist with basic needs Repair or replacement of medical or respiratory equipment medically necessary due to normal use  Educational, vocational and recreational services or growth of a child is covered.  Custodial care This plan covers the following types of equipment:  Treatment for mental health, behavioral health or substance abuse. See Mental Health,  Wheelchairs Behavioral Health and Substance Abuse for  Hospital-type beds those covered services.  Traction equipment SKILLED NURSING FACILITY SERVICES  Ventilators This plan covers skilled nursing facility services  Diabetic equipment such as blood glucose provided by a licensed or Medicare-approved skilled monitors, insulin pumps and supplies, and insulin nursing facility. Covered services include room and infusion devices. board for a semi-private room, plus services you get Medical Supplies while confined in a state-licensed or Medicare- This plan covers medically necessary supplies

PBCBSAK SCER 01-2017 31 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska ordered by your doctor, including but not limited to replace all or part of an absent body limb or to the following: replace all or part of the function of a permanently  Dressings, braces, splints, rib belts and crutches inoperative or malfunctioning body organ.  Ostomy supplies Covered services include the following:  Blood glucose monitors, insulin pumps and  Prosthetic devices such as an artificial limb, accessories external breast prosthesis following mastectomy, artificial eye  Casts, braces and supportive devices when used in the treatment of medical or surgical conditions  Orthotic devices, supports or braces applied to an in acute or convalescent stages or as immediate existing portion of the body for weak or ineffective post-surgical care joints or muscles  Medical devices surgically implanted in a body  Maxillofacial prosthetic devices that are required cavity to replace or aid the function of an internal for the restoration and management of head and organ facial structures that cannot be replaced by living tissue, are defective due to disease, trauma or Medical Foods developmental deformity, to control or eliminate This plan covers medically necessary medical foods infection and pain and restore facial configuration for supplementation or dietary replacement for the and function treatment of an inborn error of metabolism. It must Benefits will only be provided for the initial purchase be prescribed by a doctor. An example of an inborn of a prosthetic device, unless the existing device error of metabolism is phenylketonuria (PKU). In cannot be repaired. Replacement devices must be some cases of severe malabsorption (eosinophilic prescribed by a doctor because of a change in your gastrointestinal disease) a medical food called physical condition. “elemental formula” may be covered. Orthopedic Shoes and Shoe Inserts Medical foods are foods that are formulated to be consumed or administered orally or enterally under Benefits are provided for medically necessary strict medical supervision. Medical foods generally shoes, inserts or orthopedic shoes for the treatment provide most of a person’s nutrition. Medical foods of diabetes or for other correction purposes. are designed to treat a specific problem that can be Covered services also include training and fitting. diagnosed using medical tests. This benefit does not cover: This benefit does not cover other oral nutrition or  Needles, syringes, lancets, test strips, testing supplements not used to treat inborn errors of agents and alcohol swabs. See Prescription metabolism, even if prescribed by a doctor. This Drugs for covered services. includes but is not limited to specialized infant  Supplies or equipment not primarily intended for formulas and lactose free foods. medical use Medical Vision Hardware  Special or extra-cost convenience features Benefits for medical vision hardware, including  Fitness items such as exercise equipment and eyeglasses, contact lenses and other corneal lenses weights are covered when such devices are required for the  Whirlpools, whirlpool baths, portable whirlpool following medical conditions: pumps, sauna baths and massage devices  Corneal ulcer  Over bed tables, elevators, vision aids and  Bullous keratopathy telephone alert systems  Recurrent erosion of cornea  Structural modifications to your home and/or  Tear film insufficiency personal vehicle  Aphakia  Orthopedic appliances prescribed primarily for use during participation of a sport, recreation or similar  Sjogren’s syndrome activity  Congenital cataract  Penile prostheses  Corneal abrasion  Routine eye care services including eye glasses  Keratoconus and contact lenses Prosthetics  Items which are replaced due to loss or negligence This benefit covers external prosthetic devices and  Items which are replaced due to the availability of fitting expenses when such devices are used to a newer or more efficient model, unless

PBCBSAK SCER 01-2017 32 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska determined otherwise Allergy Testing and Treatment  Prosthetics, intraocular lenses, appliances or This plan covers allergy tests and treatments. devices requiring surgical implantation. These Covered services include testing, shots given at the items are covered under surgical benefits. Items doctor’s office, serums, needles and syringes. provided and billed by a hospital are covered under the Hospital Services benefit for inpatient Chemotherapy, Radiation Therapy and and outpatient care. Kidney Dialysis  Items provided and billed by a hospital. These This plan covers services for chemotherapy, are covered under Hospital Services. radiation therapy and kidney dialysis. Covered  Over the counter orthotic braces and/or cranial services include the following: banding  Anti-cancer medications used to kill or slow the  Non-wearable defibrillator, trusses and ultrasonic growth of cancerous cells nebulizers  Outpatient professional services, supplies, drugs  Blood pressure cuff/monitor (even if prescribed by and solutions ordered by your doctor and a doctor) outpatient facility charges.  Enuresis alarm This benefit does not cover prescribed drugs. See  Compression stockings which do not require a Prescription Drugs for those covered services. prescription Prior authorization is required for radiation therapy OTHER COVERED SERVICES and for some drugs. See Prior Authorization for details. Acupuncture Clinical Trials This plan covers acupuncture. Services include treatment to relieve pain, to help with anesthesia for This plan covers the routine costs of a qualified surgery, or to treat a covered illness, injury, or clinical trial. Routine costs mean medically condition. necessary care that is normally covered under this plan outside a clinical trial. Benefits are based on A “visit” is one session of consultation, diagnosis, or the type of services you get. For example, benefits treatment with a provider. Two or more visits on the of an office visit are covered under Office and same day with the same provider count as one visit. Clinic Visits, and lab tests are covered under Two or more visits on the same day with different Diagnostic X-ray, Lab and Imaging. providers count as separate visits. A qualified clinical trial is a trial that has been Air or Surface Transportation (Commercial) approved by an institutional review board that complies with federal law. It must also be approved This benefit covers transportation via commercial by the National Institutes of Health, the Center for carrier when you have a serious medical condition Disease Control and Prevention, the Agency for that cannot be treated locally. Round trip air or Healthcare Research and Quality, the Centers for surface transportation by a licensed commercial Medicare and Medicaid Services, the United States carrier is provided only for the ill or injured member. Department of Defense or the United States The trip must begin in Alaska where you became ill Department of Veterans Affairs. or injured and end at the closest in-network provider equipped to provide treatment not available in a Cancer Clinical Trials local facility. Transportation outside Alaska will be limited to Seattle, Washington. In addition to routine medical care described above, benefits for a cancer clinical trial also include: When transportation is for a child under the age of  Palliative care, diagnosis and treatment of the 18, this benefit will also cover a parent or guardian symptoms of cancer, any complications and the to accompany the child. FDA approved drug or device used in the clinical To submit a claim for these services, see Sending trial. Us a Claim.  Costs for reasonable and necessary travel when In addition to “What’s Not Covered?” this Air or you are enrolled in the clinical trial and for one Surface Transportation benefit doesn’t cover: companion. These services are limited to the following:  Transportation for routine dental, vision and hearing services  Travel between where you are living and the place of the cancer clinical trial  Transport by taxi, bus, private car or rental car  Commercial coach (economy) fare for air  Meals and lodging transportation

PBCBSAK SCER 01-2017 33 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Travel for follow-up care that cannot be Services for those costs. provided near your home Services are covered when all of the following are For ambulance benefits see Emergency true: Ambulance Services.  Treatment is needed because of an accidental This benefit does not cover: injury  Clinical trials not approved as described above  The treatment is done within 12 months of the accidental injury. If the treatment cannot be  The drug, device or services being tested, except completed within 12 months, you can ask for an as described under Cancer Clinical Trials extension. We must receive your request for an  Travel costs, except as described under Cancer extension no more than 12 months after the injury. Clinical Trials  The treatment is done on the natural tooth  Services required only for the provision or structure and the teeth were free from decay and monitoring the drug functionally sound when the injury happened.  Housing, meals, or other nonclinical expenses “Functionally sound” means that the teeth do not have:  Services needed for the prevention, diagnosis or treatment of complications of the drug being  Extensive restoration, veneers, crowns or tested, except as described under Cancer splints Clinical Trials  Periodontal (gum) disease or any other  Services only for data collection and analysis and condition that would make them weak that are not used directly for your care This plan does not cover damage from biting or  Items or services excluded from coverage under chewing, even when caused by a foreign object in this plan food.  Services that are free of charge from the sponsor We recommend that your provider call Customer of the clinical trial or the manufacturer, distributor Service before you get treatment. or provider of the drug or device Foot Care  Items or services paid for, or usually paid for, through grants or other funding This plan covers medically necessary foot care.  Services that are not routine costs normally Foot care may be considered medically necessary covered under this plan for a member with impaired blood flow to the legs and feet when the complexity of the condition puts We encourage you or your provider to call Customer the member at risk and care requires the services of Service before you enroll in a clinical trial. We can a professional. help you verify that the clinical trial is a qualified clinical trial. You may also be assigned a Case In addition to medical foot care described above, Manager to work with you and your provider. See benefits for foot care also include: Personal Health Support Programs for details.  Bunion Community Wellness and Safety Programs  Bursitis  Hammer toe This plan covers programs that promote health and life choices. These programs include adult, child  Heel spur and infant CPR, safety, babysitting skills, back pain  Ingrown toenail prevention, how to deal with stress, bike safety and  Neuroma parenting skills. You pay for the cost of the program and send us proof of payment with a reimbursement  Plantar fasciitis form. You can get a copy of this form on our website  Sprain/strain of the foot at premera.com. You can also call Customer  Warts, including plantar warts Service to request a copy of the reimbursement form. Hearing Exams and Hardware Dental Accidents This plan covers hearing exams and hardware. Before you receive your hearing hardware benefit: This plan covers accidental injuries to teeth, gums or jaw. Covered services include exams, consultations  You must be examined by a licensed doctor and dental treatment. When you get care at a before obtaining hearing aids, and hospital based clinic or hospital based doctor’s  You must purchase a hearing aid device office, you must pay your deductible and coinsurance for the facility charges. See Hospital Covered services include:

PBCBSAK SCER 01-2017 34 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  One otologic (ear) examination by a doctor Drugs for those covered services.  One audiologic (hearing) examination and hearing Mastectomy and Breast Reconstruction evaluation by a certified or licensed audiologist, including a follow-up consultation This plan covers a mastectomy needed because of disease, illness, accidental injury, or a genetic  Hearing aids (monaural or binaural) prescribed as predisposition to a high risk of breast cancer and a result of the examinations breast reconstruction. For any member electing  Ear molds breast reconstruction in connection with a  Hearing aid instruments mastectomy, this benefit covers:  Hearing aid rental while the primary unit is being  Reconstruction of the breast on which repaired mastectomy has been performed including but not limited to nipple reconstruction, skin grafts and  Initial batteries, cords, and other necessary stippling of the nipple and areola ancillary equipment  Surgery and reconstruction of the other breast to  A warranty produce a symmetrical appearance  A follow-up consultation within 30 days following  Prostheses delivery of the hearing aids with either the prescribing doctor or audiologist  Complications of all stages of mastectomy, including lymphedemas  Repairs, servicing, and alteration of hearing aid equipment  Inpatient care related to the mastectomy and post- mastectomy services This benefit does not cover: Services are provided in a manner determined by  Replacement of a hearing aid for any reason more the attending doctor with the patient in accordance often than once in a three consecutive calendar with state requirements and federal WHCRA 1998 year period requirements.  Batteries or other ancillary equipment other than that obtained upon purchase of the hearing aids Some services require prior authorization before you get treatment. See Prior Authorization for details.  Hearing aids which exceed the specifications prescribed for correction of hearing loss Medical Travel Support  Expenses incurred after your coverage ends This benefit provides travel costs for members who under this plan unless hearing aids were ordered reside in Alaska only for specified non-emergent prior to that date and were delivered within 90 medical procedures performed at certain in-network days after the day your coverage ended providers. Please contact Customer Service for a  Hearing aid charges in excess of this benefit are list of eligible procedures and providers. Before you not eligible under this plan’s other benefits travel to a provider not on the list you must get prior approval. Approval is based on the member’s  Hearing aids purchased prior to your effective medical condition, and the provider who will be date of coverage on this plan performing the services. Please contact Customer Infusion Therapy (Outpatient) Service for assistance with the process. This plan covers outpatient infusion therapy Benefits are provided for: services, supplies, solutions and drugs. Infusion  One roundtrip airfare by a licensed commercial therapy is using a needle or catheter to administer carrier for the member and one companion per fluids into a vein. Most often this is done to help: episode  Maintain fluid and electrolyte balance  Air transportation expenses for the member and a  Correct fluid volume deficiencies after an companion from the member’s home in Alaska to excessive loss of body fluids and from the medical facility where services will  Members who cannot take sufficient volumes of be provided. Air travel expenses cover fluids orally unrestricted, flexible and fully refundable round trip airfare from a licensed commercial carrier. Some drugs may require prior authorization; see the  Surface transportation, car rental, taxicab fares Prior Authorization section for details. and parking fees, for the member and a This benefit does not cover the following: companion between the hotel and the medical facility where services will be provided  Over the counter drugs, solutions and nutritional supplements  Mileage expenses for the member’s personal automobile are covered based on IRS guidelines  Outpatient prescription drugs. See Prescription

PBCBSAK SCER 01-2017 35 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Ferry transportation expenses for the member and You must also attach the following documents: a companion from the member’s home community  The boarding pass and a copy of the ticket from  Lodging expenses at commercial establishments the airline or other transportation carrier. The (hotels and motels) for the member and a tickets must indicate the name(s) of the companion while traveling between home and the passenger(s), dates and total cost of travel, and medical facility where services will be provided, the origination and final destination points; or based on current IRS guidelines  A copy of the detailed itinerary as issued by the Air travel and lodging arrangements can be made by airline, transportation carrier, travel agency or Premera’s travel partner or by the member. online travel website. The itinerary must identify the name(s) of the passenger(s), the dates of Expenses must be incurred while the member is travel and total cost of travel, and the origination covered under the plan. and final destination points. Please Note: Companion travel and lodging  Receipts for all covered travel expenses expenses are only covered if they must, as a matter  A Utilization Management Authorization number of medical necessity or safety, accompany the for travel to providers not on the list member. Credit card statements or other payment receipts are The full price for these expenses must be paid in not acceptable forms of documentation. advance, and a claim for reimbursement must be submitted. Please see How To File a Medical Psychological and Neuropsychological Travel Support Claim below for more information. Testing This benefit does not cover: Covered services include interpretation and report  Reimbursement for travel to an in-network facility preparation needed to prescribe an appropriate not on the list of eligible providers before treatment plan. This includes later re-testing to contacting us and receiving approval. If a make sure the treatment is achieving the desired procedure is performed at a facility that is not on medical results. the list, travel expenses will not be reimbursed if Coverage for autism spectrum disorders includes the total cost of the procedure, plus travel services received from individuals supervised by an expenses, exceeds the cost of having that autism service provider (see Definitions). procedure performed at a facility in Alaska. This benefit does not cover:  Travel to providers outside the network  Physical, speech or occupational assessments  International travel and evaluations for rehabilitation. See  Airline charges and fees for booking changes Rehabilitation Therapy or Mental Health,  Reimbursement for mileage rewards or frequent Behavioral Health and Substance Abuse for flier coupons those covered services.  Travel for ineligible medical procedures  Physical, speech or occupational therapy assessments related to neurodevelopmental  Lodging at any establishment that is not a hotel or disabilities. See Habilitation Therapy. motel  Travel in a mobile home, RV, or travel trailer Spinal Manipulation  Meals This plan covers medically necessary spinal  Personal care items manipulation services to treat a covered illness, injury or condition. Related diagnostic laboratory or  Pet care, except for service animals x-rays services consistent with Current Procedural  Phone service and long distance calls Terminology (CPT) guidelines are covered as outpatient x-ray and lab services as shown on the How To File a Medical Travel Support Claim: Summary of Your Costs. When you get care at a To make a claim for travel expenses covered under hospital based clinic or hospital based doctor’s this benefit, please complete a Medical Travel office, you must pay your deductible and Support Claim Form. A separate Medical Travel coinsurance for the facility charges. See Hospital Support Claim Form is necessary for each patient Services for those costs. and each carrier or transportation service used. Covered services do not include services provided You must include a statement or letter from your for examinations, and/or treatment of strictly non- doctor attesting to the medical necessity of neuromusculoskeletal disorders. extending your stay past the recommended travel This benefit does not cover: duration guidelines.

PBCBSAK SCER 01-2017 36 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  X-ray and lab, except when they are consistent Covered services consist of all phases of treatment: with Current Procedural Terminology (CPT)  Evaluation guidelines. See Diagnostic Lab, X-ray and Imaging for covered services  Pre transplant care  Transplant Therapeutic Injections  Follow up treatment This plan covers therapeutic injections given at a doctor's office, including serums, needles and Donor Costs syringes. This plan covers donor or procurement expenses for Some injectable medications require prior a covered transplant as shown in the Summary of authorization; see Prior Authorization for details. Your Costs. Covered services include:  Selection, removal (harvesting) and evaluation of Transplants the donor organ, bone marrow or stem cell This plan covers transplant services. These  Transportation of the donor organ, bone marrow services are covered only when they are provided at or stem cells, including the surgical and an approved transplant center. An approved harvesting teams transplant center is a hospital or other provider that  Donor acquisition costs such as testing and typing Premera Blue Cross Blue Shield of Alaska has expenses approved for solid organ transplants or bone marrow or stem cell reinfusion. Please call us as soon as  Storage costs for bone marrow and stem cells for you learn you need a transplant. Some services up to 12 months require prior authorization from us before you get Transportation and Lodging treatment. See Prior Authorization for details. This plan covers costs for transportation and lodging Covered Transplants for the member getting the transplant (while not This plan covers only transplant procedures that are confined). The member getting the transplant must not considered experimental or investigational for live more than 50 miles from the facility, unless your condition. Solid organ transplants and bone treatment protocols require them to remain closer to marrow/stem cell reinfusion procedures must meet the transplant center. coverage criteria. We review the medical reasons Travel Allowances: Travel is reimbursed between for the transplant, how effective the procedure is and the patient’s home and the facility for round trip (air, possible medical alternatives. This plan covers the train, or bus) transportation costs (coach class only). following types of transplants: If traveling by auto to the facility, mileage, parking  Heart and toll costs are reimbursed. Mileage  Heart/double lung reimbursement will be based on the current IRS medical mileage reimbursement. Please refer to the  Single lung IRS website http://www.irs.gov for current rates.  Double lung Lodging Allowances: Expenses incurred by a  Liver transplant patient and companion for hotel lodging  Kidney away from home is reimbursed based on current IRS guidelines.  Pancreas  Pancreas with kidney Companions:  Bone marrow (autologous and allogeneic) Companion travel and lodging expenses are only  Stem cell (autologous and allogeneic) covered if they must, as a matter of medical necessity or safety, accompany the member. This benefit does not include cornea transplants or  Adult Patient – 1 companion is permitted skin grafts. It also does not include transplants of blood or blood derivatives (except bone marrow or  Child Patient – 2 parents or guardians are stem cells). These procedures are covered the permitted same way as other covered surgical procedures; This benefit does not cover the following: see Surgery Services.  Transplants or related services from a provider Recipient Costs not approved by us This plan covers services from an approved  Services that will be paid by any government, transplant center and related professional services. foundation, or charitable grant. This includes This benefit also provides coverage for anti-rejection services performed on potential or actual living drugs given by the transplant center. donors or recipients and on cadavers.

PBCBSAK SCER 01-2017 37 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Donor costs for a transplant that is not covered Benefits are not available for any drug when the under this benefit or when the recipient is not a U.S. Food and Drug Administration (FDA) has member determined its use to be contra-indicated, or for  Donor costs that may be covered by other group experimental or investigational drugs not otherwise or individual coverage approved for any indication by the FDA.  Nonhuman or mechanical organs that are Prescription Drug Formulary experimental or investigative This benefit uses a specific list of covered  Planned blood storage for more than 12 months prescription drugs, sometimes referred to as a for possible future use formulary. Our Pharmacy and Therapeutics  Alcohol/tobacco Committee, which includes medical practitioners and pharmacists from the community, frequently reviews  Car rental current medical studies and pharmaceutical  Entertainment (such as movies, visits to information. The committee then makes museums, additional mileage for sightseeing, etc.) recommendations on which drugs are included in  Meals our drug lists. The drug lists are updated quarterly based on the committee’s recommendations.  Personal care items (such as: shampoo, deodorant, etc.) The formulary includes preferred generic drugs,  Souvenirs (such as t-shirts, sweatshirts, toys, etc.) preferred name drugs and non-preferred drugs. Consult the Pharmacy Benefit Guide or RX search  Telephone calls tool listed on our website at premera.com. You can PRESCRIPTION DRUGS also call Customer Service for a complete list of this plan’s covered prescription drugs. This plan covers prescription drugs. Some prescription drugs require prior authorization. See Drugs not included in the formulary are not covered Prior Authorization for details. by this plan. This plan also covers prescription drugs for “off- You or your provider may request that you get a label” use, including administration, of prescription non-formulary drug or a dose that is not on the drug drugs for treatment of a covered condition when use list either in writing, electronically, or by telephone. of the drug is recognized as effective for treatment of Under some circumstances, such as the ones listed such condition by one of the following: below, a non-formulary drug may be covered if one of the following is true:  One of the following standard reference compendia:  There is no formulary drug or alternative available  The American Hospital Formulary Service-Drug  You cannot tolerate the formulary drug Information  The formulary drug or dose is not safe or effective  The American Medical Association Drug for your condition Evaluation Your provider must give us a written or oral  The United States Pharmacopoeia-Drug statement providing a justification in support of the Information need for the non-formulary drug to treat your  Other authoritative compendia as identified condition, including a statement that all covered from time to time by the Federal Secretary of formulary drugs on any tier will be (or have been) Health and Human Services or the Insurance ineffective, would not be as effective as the non- Commissioner formulary drug, or would have adverse side effects. We will review your request and let you know in  If not recognized by one of the standard reference writing if it is approved. An expedited review will be compendia cited above, then recognized by the completed within 24 hours, and a standard review majority of relevant, peer-reviewed medical will be completed within 72 hours. During this literature (original manuscripts of scientific studies review process, the drug will be covered. If published in medical or scientific journals after approved, your cost will be as shown on the critical review for scientific accuracy, validity and Summary of Your Costs for formulary preferred reliability by independent, unbiased experts) generic and formulary non-preferred brand name  The Federal Secretary of Health and Human drugs, and will be covered for the duration of the Services prescription. If your request is not approved, the drug will not be covered. “Off-label use” means the prescribed use of a drug that is other than that stated in its FDA-approved labeling.

PBCBSAK SCER 01-2017 38 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Expedited Exceptions Request for Non-  FDA approved oral contraceptive drugs and Formulary Drugs devices such as diaphragms and cervical caps If exigent circumstances exist, you or your provider  Oral chemotherapy drugs may request that you get a non-formulary drug or a  Drugs associated with an emergency medical dose that is not on the drug list. Exigent condition (including drugs from a foreign country) circumstances include when you are suffering from a health condition that may seriously jeopardize your Dispensing Limits life, health or ability to regain maximum body Benefits are limited to a certain number of days’ function or when you are undergoing a current supply as shown in the Summary of Your Costs. course of treatment using a non-formulary drug. In Sometimes a drug maker’s packaging may affect the addition to your provider’s justification for the non- supply in some other way. We will cover a supply formulary drug as described above, your provider greater than normally allowed under this plan if the will need to give us an oral or written statement that packaging does not allow a lesser amount. You confirms that an exigency exists, including the basis must pay your applicable cost-share for each limited for the exigency (the harm that could reasonably days’ supply. come to you if the requested non-formulary drug was not provided within the timeframes of the Preventive Drugs standard Exceptions Request). Benefits for certain preventive care drugs are External Review for Non-Formulary Drugs covered as shown in the Summary of Your Costs when prescribed by your provider. These drugs are If you disagree with our decision, you may ask for an limited to those required by federal health care additional review by an independent review reform, such as aspirin, folic acid and certain organization (IRO). We will let you and your supplements. These drugs require a prescription provider know the decision within 72 hours (24 hours and may be limited to a certain age, condition, in the case of an expedited exception) of the IRO’s dosage or type. You can get a complete list of these receipt of the request. See Complaints and drugs by logging into your secure website and Appeals. visiting My Plan Information at premera.com. You If your provider determines that a generic FDA drug can also call Customer Service at the number on approved for female contraception is medically your ID Card to get a list of these drugs. inappropriate for you based upon the provider’s Using In-Network Pharmacies determination of medical necessity, your cost for a preferred brand name or non-preferred name drug When you use a network pharmacy, always show prescribed in its place will be covered the same as your Premera ID Card. As a member, you will not formulary preferred generic drugs. be charged more than the allowed amount for each prescription or refill. The pharmacy will also submit If you disagree with our decision you may ask for an your claims to us. You only have to pay the appeal. See Complaints and Appeals for details. deductible, copay (if any) or coinsurance as shown Covered Prescription Drugs in the Summary of Your Costs.  FDA approved formulary prescription drugs. If you do not show your Premera ID Card, you will be Federal law requires a prescription for these charged the full retail cost. Then you must send us drugs. They are known as “legend drugs.” your claim for reimbursement. Reimbursement is  Compound drugs when the main drug ingredient based on the allowed amount. See Sending Us a is a covered prescription drug Claim for instructions.  Oral drugs for controlling blood sugar levels, Specialty Pharmacy Programs insulin and insulin pens The Specialty Pharmacy Program includes drugs  Throw-away diabetic test supplies such as test that are used to treat complex or rare conditions. strips, testing agents and lancets These drugs need special handling, storage,  Drugs for shots that you give yourself administration, or patient monitoring.  Needles, syringes and alcohol swabs you use for Specialty drugs are high-cost often self-administered shots injectable drugs. They are used to treat conditions such as rheumatoid arthritis, hepatitis, multiple  Glucagon emergency kits sclerosis or growth disorders (excluding idiopathic  Inhalers, supplies and peak flow meters short stature without growth hormone deficiency). Drugs for nicotine dependency We contract with specific specialty pharmacies that  Human growth hormone drugs when medically specialize in these drugs. It is a good idea for you necessary and your health care provider to work with these

PBCBSAK SCER 01-2017 39 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska network specialty pharmacies to arrange ordering  The number of units and days’ supply dispensed and delivery of these drugs, however, it is not a on the last refill requirement. Please note that out-of-network mail-  The total units or days’ supply dispensed for the order Specialty pharmacies are not covered. same medication in the 180 days immediately Contact Customer Service for details on which drugs preceding the last refill. are included in the specialty pharmacy program, or You may request an early refill for topical eye visit our website at premera.com. medication when prescribed for a chronic eye Diabetic Injectable Supplies condition. Your request must be made no earlier than all of the following: Whether injectable diabetic drug needles and syringes are purchased along with injectable  23 days after a prescription for a 30-day supply is diabetic drugs or separately, the deductible and dispensed applicable cost-share applies to all items. The  45 days after a prescription for a 60-day supply is deductible and applicable cost-share also applies to dispensed purchases of alcohol swabs, test strips, testing  68 days after a prescription for a 90-day supply is agents and lancets. dispensed Anti-Cancer Medications An early refill will be allowed if it does not exceed the This benefit covers medications that are injected or number of refills prescribed by your doctor and only intravenously administered by your doctor and self- once during the approved dosage period. administered anti-cancer drugs when the medication Tablet Splitting Program is dispensed by a pharmacy. Anti-cancer medication means a drug or biologic used to kill The Tablet Splitting Program allows members to cancerous cells to slow or prevent the growth of have reduced copays on certain prescription cancerous cells or to treat related side effects. medications. These drugs are covered as shown in the Summary Participation in the program is voluntary. When you of Your Costs. participate, selected drugs are dispensed at double Drug Discount Programs strength. The individual tablets are then split by the member into half-tablets for each use. We will Premera may receive drug rebates or discounts. provide you with a tablet splitter. The drugs eligible  Your benefit programs include per-claim rebates for the program have been selected because they that Premera receives from its pharmacy benefit are safe to split without jeopardizing quality or manager or other vendors. We consider these effectiveness. rebates when we set the subscription charges, or If you participate in the program, you will pay one- we credit them to administrative charges that we half the copays specified above for retail or mail would otherwise pay. These rebates are not order drugs included in the program. If your plan reflected in your allowed amount. requires coinsurance rather than copays, the  We also may receive discounts from our coinsurance percentage will remain the same, but pharmacy benefit manager. These discounts are you will have lower out-of-pocket costs because the reflected in your allowed amount. If the allowed double strength tablets are less expensive than the amount for prescription drugs is higher than the single-strength medication. price we pay after our discount, then Premera does one of two things with this difference: Because the drugs are dispensed at double strength and will be split, they will be dispensed at one-half  We keep the difference and apply it to the cost the normal dispensing limits listed above. of our operations and the prescription drug benefit program Contact Customer Service to find out which drugs  We credit the difference to premium rates for are eligible for the Tablet Splitting Program and to the next benefit year request a tablet splitter. If your benefit includes a copay, coinsurance This benefit does not cover: calculated as a percentage, or a deductible, the  Drugs and medicines that you can legally buy amount you pay and your account calculations are over the counter (OTC) without a prescription. based on the allowed amount. OTC drugs are not covered even if you have a prescription. Examples include, but are not Refills limited to, nonprescription drugs and vitamins, Benefits for refills will be provided when the member herbal or naturopathic medicines, and nutritional has used 75% of a supply of a single medication. and dietary supplements such as infant formulas The 75% is based on all of the following: or protein supplements. This exclusion does not

PBCBSAK SCER 01-2017 40 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska apply to OTC drugs that are required to be Benefits from Other Sources covered by state or federal law. This plan does not cover services that are covered  Non-formulary generic and brand name drugs by such types of insurance as:  Drugs from out-of-network specialty pharmacies  Motor vehicle medical or no-fault coverage  Drugs for cosmetic use such as for wrinkles  Any type of no-fault coverage, such as Personal  Drugs to promote or stimulate hair growth injury protection (PIP), Medical Payment coverage or Medical premises coverage  Biological, blood or blood derivatives  Any type of liability insurance, such as home  Any prescription refill beyond the number of refills owners’ coverage or commercial liability coverage shown on the prescription or any refill after one year from the original prescription  Any type of excess coverage  Lost or stolen medication  Boat coverage  Infusion therapy drugs or solutions, drugs  School or athletic coverage requiring parenteral administration or use, and Benefits That Have Been Exhausted injectable medications. Exceptions to this exclusion are injectable drugs for self- This plan does not cover benefits that have been administration such as insulin and glucagon and exhausted growth hormones. See Infusion Therapy - Biofeedback Outpatient for covered infusion therapy services.  Drugs dispensed for use in a healthcare facility or This plan does not cover biofeedback services that provider’s office or take-home medications. are not medically necessary or determined to be Exceptions to this exclusion are injectable drugs experimental or investigational, including EEG for self-administration such as insulin and biofeedback and neurofeedback. glucagon and growth hormones. Broken or Missed Appointments  Immunizations. See Preventive Care. This plan does not cover charges for broken or  Drugs to treat infertility, to enhance fertility or to missed appointments. treat sexual dysfunction Charges for Records or Reports  Weight management drugs This plan does not cover separate charges from  Therapeutic devices or appliances. See Home providers for supplying records or reports, except Medical Equipment (HME), Orthotics, those we request for clinical review. Prosthetics and Supplies. Clinical Trials EXCLUSIONS This plan does not cover: This section lists the services that are either limited  Clinical trials that are not an approved clinical trial or not covered by this plan. In addition to the as described in Clinical Trials services listed as not covered under Covered Services, all of the following are excluded from  Travel costs, except as described for Cancer coverage under this plan. Clinical Trials  A drug or device associated with the approved Amounts Over the Allowed Amount clinical trial that has not been approved by the Amounts over the allowed amount, as defined in this FDA plan, are not covered. If you get services from a  Housing, meals, or other nonclinical expenses Non-Participating provider, you will have to pay charges over the allowed amount.  Items or services provided to satisfy data collection and analysis and not used in the clinical Assisted Reproduction management of the patient This plan does not cover:  An item or service excluded from coverage under this plan  Assisted reproduction methods, such as artificial insemination or in-vitro fertilization  An item or service paid for or customarily paid for through grants or other funding  Services to make you more fertile or for multiple births Comfort or Convenience  Undoing of sterilization surgery This plan does not cover:  Complication of these services  Items that are mainly for your convenience or that of your family. For instance, this plan does not

PBCBSAK SCER 01-2017 41 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska cover personal services or items like meals for while committing a felony, an act of terrorism, or an guests, long-distance phone, radio or TV and act of riot or revolt. personal grooming. Please see Transplants for Custodial Care the transportation and lodging expenses exception. This plan does not cover custodial care.  Normal living needs, such as food, clothes, Dental Care housekeeping and transport. This does not apply to chores done by a home health aide as This plan does not cover dental services except as prescribed in your treatment plan. See Home stated in Pediatric Dental Services (under age 19). Health Care and Hospice Care for details. Dietary Services  Help with meals, diets and nutrition. This includes Dietary planning or nutritional counseling for the Meals on Wheels. control of dental caries Cosmetic Services Donor Breast Milk This plan does not cover services, drugs, or supplies This plan does not cover donor breast milk. for cosmetic purposes, including direct or indirect complications and aftereffects are also not covered. Drugs and Food Supplements Examples of what is not covered are: This plan does not cover the following:  Reshaping normal structures of the body in order  Over the counter drugs, solutions, supplies, to improve or change your appearance and self- vitamins, food, or nutritional supplements, except esteem and not primarily to restore an impaired as required by law function of the body  Herbal, naturopathic, or homeopathic medicines  Genital surgery for the purpose of changing or devices genital appearance  Breast mastectomy or augmentation for the Employee Wellness Services purpose of changing the appearance of the This plan does not cover employee wellness breasts, with or without chest reconstruction activities or programs. The only exceptions to this exclusion are: Environmental Therapy  Repair of a defect that is the direct result of an This plan does not cover therapy to provide a injury, but only when the repair was started within changed or controlled environment. 12 months of the date of the event  Repair of a dependent child’s congenital anomaly Experimental or Investigational Services (see Definitions) This plan does not cover any service that is  Reconstructive breast surgery in connection with experimental or investigational, see Definitions. a mastectomy, except as stated under This plan also does not cover any complications or Mastectomy and Breast Reconstruction effects of such services.  Correction of functional disorders. The plan does This does not apply to certain services that are part not cover removing extra skin or fat that came of a covered clinical trial. See Clinical Trials. about as a result of weight loss surgery or weight loss drugs. Family Members or Volunteers Counseling, Education or Training This plan does not cover services that you give to yourself. It also does not cover a provider who is an This plan does not cover counseling or training in immediate relative. Immediate relative is: the absence of illness, job help and outreach, social  Your spouse, mother, father, child, brother or or fitness counseling or training. The exception is sister for family counseling when medically necessary to treat the diagnosed mental disorder or diagnosed  Your mother, father, child, brother or sister related substance abuse of a member. by marriage  Your stepmother, stepfather, stepchild, Court-Ordered Services stepbrother or stepsister This plan does not cover services that you must get  Your grandmother, grandfather, grandchild or the to avoid being tried or sentenced or losing the right spouse of one of these people to drive when they are not medically necessary.  A volunteer, except as described in Home Health Crimes and Terrorism Care and Hospice Care This plan does not cover illness or injury you get

PBCBSAK SCER 01-2017 42 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Government Facilities Laser Therapy This plan does not cover services provided by a Benefits are not provided for low-level laser therapy state or federal hospital which is not a participating for any diagnosis, including vitiligo. facility, except for emergency services or other Military-Related Disabilities covered services as required by law or regulation. This plan does not cover services to which you are Growth Hormone legally entitled for a military service-connected This plan does not cover growth hormones for the disability and for which facilities are reasonably following: available.  To stimulate growth, except when it meets Military Service and War medical standards This plan does not cover illness or injury that is  Treatment of idiopathic short stature without caused by or arises from: growth-hormone deficiency  Acts of war, such as armed invasion, no matter if Hair Analysis war has been declared or not This plan does not cover hair analysis.  Services in the armed forces of any country. This includes the air force, army, coast guard, marines, Hair Loss navy or National Guard. It also includes any This plan does not cover services to replace hair, related civilian forces or units. slow hair loss, or make hair grow. This includes No Charge or You Do Not Legally Have to Pay wigs, hair weaves, hair transplants and implants, and drugs or other supplies. This plan does not cover services for which there is no charge, or if no charge would have been made if Home Medical Equipment and Supplies this plan were not in effect. The plan also does not This plan does not cover: cover services that you do not legally have to pay,  Supplies or equipment not primarily intended for except as required by law. medical use Non-Covered Services  Special or extra-cost convenience features This plan does not cover services, supplies, drugs,  Items such as exercise equipment and weights and medications furnished in connection with or  Orthopedic appliances prescribed primarily for use directly related to any condition, service, or supply during participation in sports, recreation or similar that is not covered under this plan. activities Non-Treatment Facilities, Institutions or  Penile prostheses Programs  Whirlpools, whirlpool baths, portable whirlpool Benefits are not provided for institutional care, pumps, sauna baths, and massage devices housing, incarceration or programs from facilities  Over bed tables, elevators, vision aids and that are not licensed to provide medical or telephone alert systems behavioral health treatment for covered conditions. Examples are prisons, nursing homes, juvenile  Structural modifications to your home and/or detention facilities, group homes, foster homes and personal vehicle adult family homes. Benefits are provided for  Hypodermic needles, syringes, lancets, test strips, medically necessary medical or behavioral health testing agents and alcohol swabs used for self- treatment received in these locations. administered medications, except as specified in Prescription Drugs Not Medically Necessary Hospital Admission Limitations This plan does not cover services that are not medically necessary, even if they are court-ordered. This plan does not cover hospital stays solely for This rule also applies to the place where you get the diagnostic studies, physical examinations, checkups, services. medical evaluations, or observations, unless: Orthodontia Services  The services cannot be provided without the use of a hospital This plan does not cover orthodontia services in  There is a medical condition that makes hospital excess of the Pediatric Dental Services; including care medically necessary services for members age 19 and older (see Pediatric Care).

PBCBSAK SCER 01-2017 43 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Orthognathic Surgery  Arthritic problems with the TMJ This plan does not cover procedures to make the  The TMJ has a limited range of motion or its jaw longer or shorter, no matter why they are range of motion is not normal needed. Vision Care for Adults Preventive Care This plan does not cover services to improve visual This plan does not cover preventive care in excess sharpness for members age 19 or older. The of the preventive care benefits, including services following items are not covered: that exceed the frequency, age and gender  Routine vision exams guidelines as described under Preventive Care.  Glasses, frames and contact lenses Private Duty Nursing  Vision therapy, eye exercise or training This plan does not cover private duty or 24-hour  Surgeries to improve the refractive character of nursing care. See Home Health Care for home the cornea and any results of such treatment nursing care benefits. Please see Home Medical Equipment under the Provider's License or Certification Covered Services section for medical eye care This plan does not cover services that the provider's covered services. license or certification does not allow him or her Voluntary Support Groups perform. It also does not cover a provider that does not have the license or certification that the state This plan does not provide coverage for patient requires. support, consumer or affinity groups such as diabetic support groups or Alcoholics Anonymous. Serious Adverse Events and Never Events Weight Loss (Surgery or Drugs) This plan does not cover serious adverse events and never events. These are serious medical errors This plan does not cover surgery, drugs or that the U.S. government has identified and supplements for weight loss or weight control. It published. A “serious adverse event” is an injury also does not cover any complications, follow-up that is caused by treatment in the hospital and not services, or effects of those treatments, except by a disease. Such events make the hospital stay services defined as Emergency Care. This is true longer or cause another health problem. A “never even if you have an illness or injury that might be event” should never happen in a hospital. A never helped by weight loss surgery or drugs. This plan event is when the wrong surgery is done, or a does not cover removal of extra skin or fat that came procedure is done on the wrong person or body part. about as a result of weight loss surgery or drugs. You do not have to pay for services of in-network When You Are Not Covered providers for these events and their follow-up care. The plan does not cover services that are: In-network providers may not bill you or the plan for  Received or ordered when this plan is not in force these services.  Received or ordered when you are not covered Not all medical errors are serious adverse events or under this plan never events. These events are very rare. You can ask us for more details. You can also get more  Given to someone other than an ill or injured details from the U.S government. You will find them member at www.cms.hhs.gov.  Directly related to any condition or service that this plan does not cover Sexual Problems Work-Related Illness or Injury This plan does not cover problems with your sexual function or response. It does not matter what the This plan does not cover any illness or injury for cause is. This includes drugs, implants or any which you can get benefits under: complications or effects.  Separate coverage for injuries on the job, even if Temporomandibular Joint (TMJ) Disorders you did not have to buy it  Worker’s compensation laws This plan does not cover treatment of TMJ disorders. TMJ disorders are problems with the lower jaw joint  Any other law that will repay you for an illness or that have one or more of the features below: injury you get from your job  Pain in the muscles near the TMJ This contract does not replace, change or add to any  Internal derangements of the parts of the TMJ law that requires worker’s compensation, employer liability or other insurance like these. When an

PBCBSAK SCER 01-2017 44 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska employer can buy this kind of coverage and does or employee benefit organization plans not, this plan will not cover conditions that arise from  Government programs that provide benefits for your job that would be covered by such insurance. their own civilian employees or their OTHER COVERAGE dependents  Group coverage required or provided by any COORDINATING BENEFITS WITH OTHER law, including Medicare. This does not include PLANS workers’ compensation. If you have other health plan coverage, this plan will  Group student coverage that’s sponsored by a work with other group or individual plans so that both school or other educational institution and plans may share a part of the costs. includes medical benefits for illness or disease All of the benefits of this plan are subject to  Dental Plan means all of the following dental care coordination of benefits. coverages, even if they do not have their own coordination provisions: If you have other coverage besides this plan, we  Group, individual or blanket disability insurance recommend that you submit your claim to the policies and health care service contractor and primary carrier first, then submit the claim to the health maintenance organization group or secondary carrier with the primary carrier processing individual agreements issued by insurers, information. In that way, the proper coordinated health care service contractors, and health benefits may be most quickly determined and paid. maintenance organizations Definitions Applicable To Coordination Of  Labor-management trusteed plans, labor Benefits organization plans, employer organization plans or employee benefit organization plans To understand coordination of benefits, it is important to know the meanings of the following  Government programs that provide benefits for terms: their own civilian employees or their dependents  Allowable Medical Expense means the usual, customary and reasonable charge for any Each contract or other arrangement for coverage medically necessary health care service or supply described above is a separate plan. It is also provided by a licensed medical professional when important to note that for the purpose of this plan, the service or supply is covered at least in part we will coordinate benefits for allowable medical under this plan. When a plan provides benefits in expenses separately from allowable dental the form of services or supplies rather than cash expenses, as separate plans. payments, the reasonable cash value of each Effect On Benefits service rendered or supply provided shall be considered an allowable expense. An important part of coordinating benefits is  Allowable Dental Expense means the usual, determining the order in which the plans provide customary and reasonable charge for any dentally benefits. One plan is responsible for providing necessary service or supply provided by a benefits first. This is called the “primary” plan. The licensed dental professional when the service or primary plan provides its full benefits as if there were supply is covered at least in part under this plan. no other plans involved. The other plans then When a plan provides benefits in the form of become “secondary.” When this plan is secondary, services or supplies rather than cash payments, it will reduce its benefits for each claim so that the the reasonable cash value of each service benefits from all medical plans aren’t more than the rendered or supply provided shall be considered allowable medical expense for that claim and the an allowable expense. benefits from all dental plans aren’t more than the allowable dental expense for that claim.  Medical Plan means all of the following health Coordination of benefits applies only on a per-claim care coverages, even if they do not have their basis, and is not cumulative. own coordination provisions:  Group, individual or blanket disability insurance We will coordinate benefits when you have other policies and health care service contractor and health care coverage that is primary over this plan. health maintenance organization group or Coordination of benefits applies whether or not a individual agreements issued by insurers, claim is filed with the primary coverage. health care service contractors, and health Here is the order in which the plans should provide maintenance organizations benefits:  Labor-management trusteed plans, labor First: A plan that does not provide for coordination organization plans, employer organization plans of benefits.

PBCBSAK SCER 01-2017 45 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Next: A plan that covers you as other than a benefits with Medicare. Benefits will be coordinated dependent. up to Medicare’s allowed amount, as required by federal regulations. If the provider does not accept Next: A plan that covers you as a dependent. Medicare assignment, this allowed amount is the For dependent children, the following rules apply: Medicare Limiting Charge. When the parents are not separated or divorced: SUBROGATION AND REIMBURSEMENT The plan of the parent whose birthday falls earlier in the year will be primary, if that’s in accord with the If we make claims payment on your behalf for injury coordination of benefits provisions of both plans. or illness for which another party is liable, or for Otherwise, the rule set forth in the plan that does not which uninsured/underinsured motorist (UIM) or have this provision shall determine the order of personal injury protection (PIP) insurance exists, we benefits. are entitled to be repaid for those payments out of any recovery from that liable party. The liable party When the parents are separated or divorced: If a is also known as the “third party” because it is a court decree makes one parent responsible for party other than you or us. This party includes a paying the child’s health care costs, that parent’s UIM carrier because it stands in the shoes of a third plan will be primary. Otherwise, the plan of the party tortfeasor and because we exclude coverage parent with custody will be primary, followed by the for such benefits. plan of the spouse of the parent with custody, followed by the plan of the parent who does not Definitions The following terms have specific have custody. If the rules above do not apply, the meanings in this contract: plan that has covered you for the longest time will be  Subrogation means we may collect directly from primary, except that benefits of a plan that covers third parties to the extent we have paid on your you as a laid-off or retired employee, or as the behalf for illnesses or injury caused by the third dependent of such an employee, shall be party. determined after the benefits of any plan that covers  Reimbursement means that you are obligated you as other than a laid-off or retired employee, or under the contract to repay any monies advanced as the dependent of such an employee. However, by us from amounts received on your claim. this applies only when other plans involved have this  Restitution means all equitable rights of recovery provision regarding laid-off or retired employees. that we have to the monies advanced under this If none of the rules above determine the order of plan. Because we have paid for your illness or benefits, the plan that’s covered the employee or injuries, we are entitled to recover those subscriber for the longest time will be primary. expenses. Right Of Recovery/Facility Of Payment To the fullest extent permitted by law, we’re entitled to the proceeds of any settlement or judgment that We have the right to recover any payments we make results in a recovery from a third party, up to the that are greater than those required by the amount of benefits paid by us for the condition. Our coordination of benefits provisions from 1 or more of right to recover exists regardless of whether it is the following: the persons we paid or for whom we based on subrogation, reimbursement or restitution. have paid, providers of service, insurance We are entitled under our right of recovery to be companies, service plans or other organizations. If reimbursed for our benefit payments even if you are a payment that should have been made under this not “made whole” for all of your damages in the plan was made by another plan, we may also pay recoveries that you receive. Our right of recovery is directly to another plan any amount that should have not subject to reduction for attorney’s fees and costs been paid by us. Our payment will be considered a under the “common fund” or any other doctrine. benefit under this plan and will meet our obligations Such recoveries will not be sought more than 365 to the extent of that payment. days after we receive notice of the settlement or This plan has the right to appoint a third party to act judgment. Exceptions will be allowed when required on its behalf in recovery efforts. by law or regulation. In recovering benefits provided, we may at our election hire our own COORDINATING BENEFITS WITH attorney or be represented by your attorney. We will MEDICARE not pay for any legal costs incurred by you or on If you are also covered under Medicare, federal law your behalf, and you will not be required to pay any determines how we provide the benefits of this plan. portion of the costs incurred by us or on our behalf. Those laws may require this plan to be primary over Before accepting any settlement on your claim Medicare. against a third party, you must notify us in writing of When this plan is not primary, we will coordinate any terms or conditions offered in a settlement, and you must notify the third party of our interest in the

PBCBSAK SCER 01-2017 46 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska settlement established by this provision. You also Step 3 must cooperate with us in recovering amounts paid If you are also covered by Medicare, attach a copy by us on your behalf. If you retain an attorney or of the Explanation of Medicare Benefits. other agent to represent you in the matter, you must require your attorney or agent to reimburse us Step 4 directly from the settlement or recovery. If you fail to cooperate fully with us in the recovery of benefits we Check to make sure that all the information from have paid as described above, you are responsible Steps 1, 2, and 3 is complete. Your claim will be for reimbursing us for such benefits. returned if all of this information is not included. To the extent that you recover from any available Step 5 third party source, you agree to hold any recovered Sign the claim form. fund in trust or in a segregated account until our subrogation and reimbursement rights are fully Step 6 determined. Mail your claims to the address located inside the UNINSURED AND UNDERINSURED front cover of this benefit booklet. MOTORIST/PERSONAL INJURY Prescription Drug Claims PROTECTION COVERAGE To make a claim for covered prescription drugs, We have the right to be reimbursed for benefits please follow these steps: provided, but only to the extent that benefits are also Participating Pharmacies paid for such services and supplies under the terms of a motor vehicle uninsured motorist and/or For retail pharmacy purchases, you do not have to underinsured motorist (UIM) policy, personal injury send us a claim. Just show your ID card to the protection (PIP) or similar type of insurance or pharmacist, who will bill us directly. If you do not contract. show your ID card, you will have to pay the full cost of the prescription and submit the claim yourself. SENDING US A CLAIM You will need to fill out a prescription drug claim form, attach your prescription drug receipts and A claim is a request to an insurance company for submit the information to the address shown on the payment of amount due. Many providers will send claim form. claims to us directly. When you need to send a claim to us, follow these simple steps: For mail-order pharmacy purchases, you do not have to send us a claim, but you will need to follow Step 1 the instructions on the mail-order pharmacy order Complete a claim form. You can get claim forms by form and submit it to the address printed on the calling Customer Service or you can print them from form. Please allow up to 14 days for delivery. our website at premera.com. Non-Participating Pharmacies Be sure to use a separate claim form for each You will have to pay the full cost for new member and each provider. prescriptions and refills purchased at these Step 2 pharmacies. You will need to fill out a prescription drug claim form, attach your prescription drug Attach the bill that lists the services you received. receipts and submit the information to the address Your claim must show all of the following shown on the claim form. information:  Name of the subscriber and the member who Coordination of Prescription Claims received the services If this plan is the secondary plan as described under  Identification numbers for both the subscriber and Other Coverage, you must submit your pharmacy the Group (these are shown on your identification receipts attached to a completed claim form for card) reimbursement. Please send the information to the  Name, address, and IRS tax identification number address listed under Secondary Prescription Claims of the provider included on the drug claim form.  Diagnosis (ICD) code. You must get this from If you need a supply of envelopes or prescription your provider. drug claim forms, contact Customer Service at the number located inside the front cover of this benefit  Procedure codes (CPT or HCPCS). You must get booklet. these from your provider.  Date of service and charges for each service

PBCBSAK SCER 01-2017 47 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Timely Payment of Claim cannot complete the review of your claim within this time period, we will notify you of a 15-day extension You should submit all claims within 365 days of the before the 30-day time limit ends. If we need more date you received services. No payments will be information from you or your provider to complete made by us for claims received more than 365 days the review of your claim, we will ask for that after the date of service. Exceptions will be made if information in our notice and allow you 45 days to we receive documentation of your legal send us the information. Once we receive the incapacitation. Payment of all claims will be made information we need, we will review your claim and within the time limits required. notify you of our decision within 15 days. Notice Required for Reimbursement and Please Note: If your provider requires a copay Payment of Claims when you receive medical services or supplies, it is In accordance with federal and state law, we may not considered a claim for benefits. However, you pay the benefits of this plan to the eligible member, always have the right to request and obtain from us provider, other carrier, or other party legally entitled a paper copy of your explanation of benefits in to such payment under federal or state medical child connection with such a medical service by calling support laws, or jointly to any of these. Such Customer Service. The phone number is on the payment will discharge our obligation to the extent of front cover of your booklet and on your Premera ID the amount paid so that we will not be liable to card. Or, you can visit our website, premera.com, anyone aggrieved by our choice of payee. for information and secure online access to claims information. To file a claim, please see Sending Us Air or Surface Transportation Claims A Claim for more information. If your claim is denied in whole or in part, you may submit a To make a claim for covered air or surface complaint or appeal as outlined under Complaints transportation services, please follow these steps: and Appeals section. Complete a Member Submitted Claim Form. A If your claim is denied, in whole or in part, our written separate Member Submitted Claim Form is notice (see Notices) will include: necessary for each patient and each carrier or transportation service used.  The reasons for the denial and a reference to the plan provisions used to decide your claim Attach one of the following forms of documentation:  A description of any additional information needed  A copy of the ticket from the airline or other to reconsider your claim and why the information transportation carrier. The tickets must indicate is needed the names of the passenger(s), dates and total cost of travel, and the origination and final  A statement that you have the right to submit a destination points. complaint or appeal  A copy of the detailed itinerary as issued by the  A description of the plan’s complaint or appeal airline, transportation carrier, travel agency or processes online travel website. The itinerary must identify If there were clinical reasons for the denial, you will the name of the passenger(s), the dates of travel receive a letter from us stating these reasons. and total cost of travel, and the origination and final destination points. If we do not pay the claim or provide notice within the time frames stated above, interest shall accrue Please Note: Credit card statements or other at a rate of 15% annually. Interest will not be paid if payment receipts are not acceptable forms of the amount of interest is $1 or less. documentation. At any time, you have the right to appoint someone Your claim also must include a statement or letter to pursue the claim on your behalf. This can be a from your doctor attesting to the medical necessity of doctor, lawyer, or a friend or relative. You must the services you received that required the air or notify us in writing and give us the name, address, service travel. and telephone number where your appointee can be Claim Procedure for Groups Subject to the reached. Employee Retirement Income Security Act If a claim for benefits or an appeal is denied or of 1974 (ERISA) ignored, in whole or in part, or not processed within the time shown in these claims procedures, you may We will make every effort to review your claims as have the right to file suit in a state or federal court. quickly as possible. If you are dissatisfied with our denial of your claim We will send a written notice to you no later than 30 you may submit a complaint as outlined under days after we receive your claim to let you know if Complaints and Appeals. this plan will cover all or part of the claim. If we

PBCBSAK SCER 01-2017 48 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Some services and supplies covered under this plan coverage decision. There may be times when require prior authorization. Please see Prior Customer Service will ask you to submit your Authorization for additional information. complaint for review through the formal appeals process outlined below. Claims for Care Received Outside the United States When this happens, we will review your complaint and notify you of the outcome of our decision in When you submit a claim for care you received writing. We will provide you with the reasons for our outside the United States, please include whenever decision as soon as possible, but no later than 30 possible: a detailed description, in English, of the days from the date we received your complaint. services, drugs, or supplies received; the names and credentials of the treating providers, and medical WHEN YOU DO NOT AGREE WITH A records or chart notes. PAYMENT OR BENEFIT DECISION To process your foreign claim, we will convert the If we declined to provide payment in whole or in part foreign currency amount on the claim into U.S. on a benefit, and you disagree with our decision, you dollars for claims processing. We use a national have the right to request we formally review the currency converter (available at www.oanda.com) adverse benefit determination through our internal as follows: appeals process.  For professional outpatient services and other This plan’s appeal process will comply with any new care with single dates of service, we use the requirements as necessary under state and federal exchange rate on the date of service laws and regulations.  For inpatient stays of more than one day, we use Adverse Benefit Determinations the exchange rate on the date of discharge An adverse benefit determination means a denial, COMPLAINTS AND APPEALS reduction, termination of, or a failure to provide or make payment, in whole or in part for services based As a Premera member, you have the right to offer on: your ideas, ask questions, voice complaints and request a formal appeal to reconsider decisions we  An individual's eligibility to participate in a plan or have made. Our goal is to listen to your concerns health insurance coverage; and improve our service to you.  A determination that a benefit is not a covered If you need an interpreter to help with oral translation benefit; services, please call us. Customer Service will be  A limitation on otherwise covered benefits; able to guide you through the service.  A clinical review determination; or WHEN YOU HAVE IDEAS  A determination that a service is experimental, investigational, or not medically necessary or We would like to hear from you. If you have an idea, appropriate. suggestion, or opinion, please let us know. You can contact us at the address and telephone number WHEN YOU HAVE AN APPEAL found inside the front cover of this benefit booklet. After you are notified of an adverse benefit WHEN YOU HAVE QUESTIONS determination, you can request an internal appeal. This plan includes two levels of internal appeals. You can call us when you have questions about a benefit or coverage decision, the quality or Your Level I internal appeal will be reviewed by availability of a health care service or our service. individuals who were not involved in the initial We can quickly and informally correct errors, clarify adverse benefit determination. If the adverse benefit benefits, or take steps to improve our service. determination involved medical judgment, the review will be provided by a health care provider who holds We suggest that you call your provider of care when the same professional license as the treating you have questions about the health care services provider. They will review all of the information they provide. relevant to your appeal and will provide a written WHEN YOU HAVE A COMPLAINT determination. If you are not satisfied with the decision, you may request a Level II appeal. You can call or write to us when you have a complaint about a benefit or coverage decision, Your Level II internal appeal will be reviewed by a Customer Service, or the quality or availability of panel that includes individuals who were not health care services. We recommend, but do not involved in the Level I appeal. If the adverse benefit require, that you take advantage of this process determination involved medical judgment, the review when you have a concern about a benefit or will be provided by a health care provider who holds

PBCBSAK SCER 01-2017 49 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska the same professional license as the treating description of the appeals process by visiting our provider and has had no prior decisions in your website at premera.com. appeal. There will be a meeting during your Level II We will acknowledge our receipt of your request in Appeal for the panel to review. You may participate writing within 7 days. in the Level II panel meeting in person or by phone to present evidence and testimony. Please contact Clinically Urgent Situations us for additional information about this process. If your provider believes that your situation is Once the Level II appeal review is complete, we will clinically urgent under law, your appeal will be provide you with a written decision. If you are not conducted on an expedited basis. A clinically urgent satisfied with the final internal appeal decision, you situation means one in which your health may be in may be eligible to request an External Review, as serious jeopardy or, in the opinion of your doctor, described below. you may experience pain that cannot be adequately controlled while you wait for a decision on your Internal Appeals appeal. You may request an expedited internal You or your authorized representative, someone you appeal by calling Customer Service at the number have named to act on your behalf, may file an located inside the front cover of this benefit booklet. appeal. To appoint an authorized representative, If your situation is clinically urgent, you may also you must sign an authorization form and mail or fax request an expedited external review at the same the signed form to the address or phone number time you request an expedited internal appeal. listed below. By completing an authorization form, it provides us with the authorization for the name Additional Information For Your Appeal person to discuss and represent you in the appeals process and allows us to release your authorized You may supply new or additional information to information, if any, to them. support your appeal at the time you file an appeal or at a later date by mailing or faxing to the address Please call us for an Authorization for Appeals form. and fax number listed above. Please provide us You can also obtain a copy of this form on our with this information as soon as possible to give us website at premera.com. sufficient time to review. Filing An Internal Appeal Copies Of Information Relevant To Your Appeal You or your authorized representative may file an You can request copies of information relevant to appeal by writing to us at the address listed below. the adverse benefit determination. We will provide We must receive your appeal request as follows: this information, as well as any new or additional  For a Level I internal appeal, within 180 calendar information we considered, relied upon or generated days of the date you are notified of an adverse in connection to your appeal as soon as possible benefit determination and free of charge. You will have the opportunity to review this information and respond to us before we  For a Level II internal appeal, within 60 calendar make our decision. days of the date you are notified of the Level I determination. If you are hospitalized or traveling; What Happens Next or for other reasonable cause beyond your We will review your appeal and provide you with a control, we may extend this timeline to allow you written decision as stated below: to obtain additional medical documentation, doctor consultations or opinions.  Expedited appeals, as soon as possible, but no later than 72 hours after we received your You can mail your written appeal request to: request. We will call, fax or email our decision Premera Blue Cross Blue Shield of Alaska and will follow-up with a decision in writing. Attn: Appeals Department, MS 123  Appeals for benefit determinations made prior to P.O. Box 91102 you receiving services are reviewed and a decision is made within 15 calendar days of the Seattle, WA 98111-9202 date we received your request. Or, you may fax your request to:  Clinical review determinations are made within 18 Appeals Department business days of the date we received your (425) 918-5592 request. If you need help filing an appeal, or would like a  All other appeals decisions are made within 30 copy of the appeals process, please call Customer calendar days of the date we received your Service at the number located inside the front cover request. of this benefit booklet. You can also get a If we uphold our initial decision, you will be provided

PBCBSAK SCER 01-2017 50 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska information about your right to a Level II internal reasonably available to us. appeal or your right to an External Review at the end When The IRO Has Completed The External of the internal appeals process. Review Appeals Regarding Ongoing Care The IRO will review your request and send you and If you appeal a decision to change, reduce or end us a written notification of their decision as stated coverage of ongoing care for a previously approved below: course of treatment because the service or level of  Expedited external review, as soon as possible, service is no longer medically necessary or but no later than 72 hours after receiving your appropriate, we will suspend our denial of benefits request. The IRO will notify you and us during the internal appeal period. Our provision of immediately by phone, email or fax and will follow benefits for services received during the internal up with a written decision by mail. appeal period does not, and should not be construed to, reverse our denial. If our decision is upheld, you  All other external review requests, no later than 45 must repay us all amounts that we paid for such days from the date the IRO receives your request. services. You will also be responsible for any Appeals Of Drug Formulary Decisions difference between our allowed amount and the provider's billed charge. You also have the right to appeal to the IRO any decision we have made regarding coverage for ELIGIBILITY FOR EXTERNAL REVIEW drugs not on the plan’s formulary. To request an IRO review, contact Customer Service at the If you are not satisfied with the final internal adverse telephone number on your Premera ID card. benefit determination based on medical judgment (including medical necessity or appropriateness of What Happens Next care, or experimental or investigative care), or a rescission of coverage, you may have the right to Premera is bound by the IRO's decision. If the IRO have our decision reviewed by an Independent overturned the final internal appeal adverse benefit Review Organization (IRO). You also have the right determination, we will implement their decision in a to an external review if we fail to strictly comply with timely manner. our internal appeals process and with state and If the IRO upheld our decision, there is no further federal requirements for internal appeals. An IRO is review available under this plan's internal appeals or an independent organization of medical reviewers external review process. If you disagree with the who are qualified to review medical and other IRO's decision, you may appeal the IRO's decision relevant information. There is no cost to you for an in Superior Court. You must file this request with the external review. Superior Court within 6 months of the date you were We will send you an External Review Request form notified of the IRO's decision. You may also have at the end of the internal appeal process notifying other remedies available under state or federal law, you of your rights to an external review. We must such a filing a lawsuit. receive your written request for an external review OTHER RESOURCES TO HELP YOU within 4 months of the date you received the final internal adverse benefit determination. Your request If you have questions about understanding a denial must include a signed waiver granting the IRO of a claim or your appeal rights, you may contact access to medical records and other materials that Premera Customer Service for assistance at the are relevant to your request. number located inside the front cover of this benefit booklet. If you are not satisfied with our decisions You can request an expedited external review when and wish to make a complaint or need help filing an your provider believes that your situation is clinically appeal, you can contact the Alaska Division of urgent under law. Please call Customer Service at Insurance at any time during this process. If this the number located inside the front cover of this plan is governed by the Federal Retirement Income benefit booklet to request an expedited external Security Act of 1974 (ERISA), you can contact the review. Employee Benefits Security Administration of the We will notify the IRO of your request for an external U.S. Department of Labor. review. The IRO will let you, your authorized representative and/or your attending doctor know Alaska Division of Insurance where additional information may be submitted directly to the IRO and when the information must be 550 W 7th Ave., Suite 1560 provided. We will forward your medical records and Anchorage, Alaska 99501-3567 other relevant materials for your external review to 1-800-INSURAK (467-8725) (within Alaska) the IRO. We will also provide the IRO with any 1-907-269-7900 (outside Alaska) additional information they request that is

PBCBSAK SCER 01-2017 51 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska Email: [email protected] the Group who meets the requirements in Online: “Employee Eligibility” earlier in this section, the www.commerce.state.ak.us/insurance spouse can only enroll as a subscriber.  The domestic partner of the subscriber. Employee Benefits Security Administration  Lives with the subscriber (EBSA)  Is at least 18 years old 1-866-444-EBSA (3272)  Has a close personal relationship with the subscriber in which they each take care of the other ELIGIBILITY AND ENROLLMENT  Shares the costs of basic living, such as food You do not have to be a citizen of or live in the and shelter, with the subscriber. The partners United States if you are otherwise eligible for do not need to pay these expenses equally or coverage. jointly as long as they agree that both are responsible. This section shows who is eligible for coverage and  Is not married to anyone who can be covered under this plan. Only members enrolled on this plan can receive its benefits.  Is not related to the subscriber by blood more closely than Alaska allows a married couple to WHO IS ELIGIBLE FOR COVERAGE be Employee Eligibility  Is mentally able to agree to a contract when the domestic partnership begins Under this small employer health benefit plan, an eligible employee is an employee who works on a  Is the subscriber’s only domestic partner full-time basis, with a normal work week of the If all of these statements above are true, the plan minimum hours stated on the Group’s application. will give a spouse’s rights and benefits to the Eligible employee means a sole proprietor, a partner domestic partner. Where this benefit booklet of a partnership or an independent contractor, refers to marriage, it also means the start of a provided the sole proprietor, partner, or contractor is domestic partnership. Where this contract refers included as an employee under a health benefit plan to divorce or legal separation, it also means the of a small employer. Eligible employee does not end of a domestic partnership. include an employee who works on a part-time,  An eligible child under 26 years of age. An temporary, or substitute basis. The employee must eligible child is one of the following: also satisfy any probationary period, if one is  A biological child of either or both the required by the Group. subscriber, spouse or domestic partner Employees Performing Employment  A legally adopted child of either or both the Services in Hawaii subscriber, spouse or domestic partner For employers other than political subdivisions, such  A child placed with the subscriber, spouse or as state and local governments, and public schools domestic partner for the purpose of legal and universities, the State of Hawaii requires that adoption in accordance with state law. A child benefits for employees living and working in Hawaii is placed when the subscriber, spouse or (regardless of where the Group is located) be domestic partner takes the legal duty to support administered according to Hawaii law. If the Group the child. The child must be less than 18 years is not a governmental employer as described in this old when the child was placed. paragraph, employees who reside and perform any  A minor or foster child for whom the subscriber, employment services for the Group in Hawaii are not spouse or domestic partner has a legal eligible for coverage. When an employee moves to guardianship. There must be a court order or Hawaii and begins performing employment services other order signed by a judge or state agency, for the Group there, he or she will no longer be which grants guardianship of the child to the eligible for coverage under this plan. subscriber, spouse or domestic partner as of a Dependent Eligibility specific date. When the court order terminates or expires, the child is no longer an eligible An “eligible dependent” is defined as one of the child. following:  A newborn child of a covered dependent. The  The legal spouse of the subscriber, unless legally newborn’s mother or father must be an enrolled separated. However, if the spouse is an dependent and the newborn is enrolled as employee, owner, partner, or corporate officer of described under the “Newborn Grandchildren”

PBCBSAK SCER 01-2017 52 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska section below. The term “Grandchildren” in this date of adoption or placement for adoption. provision means the natural offspring of However, if payment of additional subscription dependent children, including dependent charges is required to provide coverage for an children for whom the subscriber, spouse or adoptive dependent child, and the subscriber domestic partner has a legal guardianship. desires coverage of the adoptive child to extend beyond the 31-day period following the dependent WHEN COVERAGE BEGINS child’s date of adoption or placement for adoption, Enrollment we must receive a completed enrollment application and the required additional subscription charges The employee must enroll on forms provided and/or within the 60-day period following the date of accepted by us. To obtain coverage, an employee adoption or placement for adoption. must enroll within 60 days after becoming eligible. When the employee enrolls within 60 days of If we do not receive the completed enrollment becoming eligible, coverage for the employee and application and the required additional subscription enrolled dependents will become effective on the charges within the 60-day period, initial coverage will latest of the applicable dates below: be limited to the 31-day period referenced above. The child may then be enrolled at a later date, The employee's date of hire  subject to the Open Enrollment provisions  The date the employee enters a class of described later in this section. employees to which the Group offers coverage under this plan Children Acquired Through Legal Guardianship  The next day following the date the probationary period ends, when one is required by the Group When we receive the completed enrollment  Another date as designated in the Group Master application, any required subscription charges, and Application or Group Contract a copy of the guardianship papers within 60 days of the date legal guardianship began with the When we do not receive the enrollment application subscriber, coverage for an otherwise eligible child within 60 days of the date you became eligible, none will begin on the date legal guardianship began. of the dates above will apply. Please see Open When the enrollment application is not received by Enrollment and Special Enrollment below. us within 60 days of the date legal guardianship Dependents Acquired Through Marriage or began, refer to Open Enrollment below. Domestic Partnership After The Children Covered Under Medical Child Subscriber's Effective Date Support Orders When we receive the completed enrollment When we receive the completed enrollment application and any required subscription charges application within 60 days of the date of the medical within 60 days after the marriage or domestic child support order, coverage for an otherwise partnership, coverage will become effective on the eligible child that is required under the order will first of the month following the date of marriage or become effective on the date of the order. domestic partnership. When the enrollment Otherwise, coverage will become effective on the application is not received by us within 60 days of date we receive the enrollment application for marriage or domestic partnership, refer to Open coverage. The enrollment application may be Enrollment later in this section. submitted by the subscriber, the child's custodial Newborn And Adoptive Children parent, or a state agency. When subscription charges being paid do not already include coverage Natural newborn dependent children of the for dependent children, such charges will begin from subscriber born on or after the subscriber’s effective the child’s effective date. Please contact your Group date will be covered from their date of birth. for detailed procedures. However, if payment of additional subscription charges is required to provide coverage for a Court-Ordered Dependent Coverage newborn child, and the subscriber desires coverage When we receive the completed enrollment of the newborn child to extend beyond the 31-day application within 60 days of the date of the court period following the newborn child’s date of birth, we order, coverage for a lawful spouse and/or must receive a completed enrollment application and dependent children will become effective on the date the required additional subscription charges within of the order. Otherwise, coverage will become the 60-day period following the date of birth. effective on the first of the month following the date Adoptive dependent children of the subscriber who we receive the enrollment application for coverage. are adopted or placed for adoption on or after the When subscription charges being paid do not subscriber’s effective date will be covered from their already include coverage for a spouse and/or

PBCBSAK SCER 01-2017 53 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska dependent children, such charges will begin from the as required by the federal Consolidated dependent’s effective date. Omnibus Budget Reconciliation Act of 1986 (COBRA) at the time coverage under this plan Newborn Grandchildren was previously offered and COBRA coverage Natural newborn children born on or after the has been exhausted. subscriber’s effective date to a covered dependent An eligible employee who qualifies as stated above child (referred to as “grandchildren”) will be covered may also enroll all eligible dependents. When only from their date of birth. The grandchild’s parent an eligible dependent qualifies for special must be covered and remain covered under this plan enrollment, but the eligible employee is not enrolled in order for the grandchild to be covered. in any of the Group's plans or is enrolled in a If payment of additional subscription charges is different plan sponsored by the Group, the employee required to provide coverage for a newborn is also allowed to enroll in this plan in order for the grandchild, and the subscriber desires coverage of dependent to enroll. the newborn grandchild to extend beyond the 31-day When we receive the employee and/or dependent’s period following the newborn grandchild’s date of completed enrollment application and any required birth, we must receive written notice and any subscription charges within 60 days of the date such required additional subscription charges within the other coverage ended, coverage under this plan will 60-day period following the date of birth. become effective on the first of the month following If we do not receive the written notice and any the date the other coverage was lost. required additional subscription charges within the When we do not receive the employee and/or 60-day period, initial coverage for the newborn dependent’s completed enrollment application within grandchild will be limited to the 31-day period 60 days of the date prior coverage ended, refer to referenced above. Open Enrollment below. A newborn grandchild who is not properly enrolled Subscriber And Dependent Special as stated above may not be enrolled at a later date, including during Open Enrollment or Special Enrollment Enrollment periods, even if the grandchild’s parent is An eligible employee and otherwise eligible a covered dependent child under this plan. dependents who previously elected not to enroll in SPECIAL ENROLLMENT any of the employer’s group health plans when such coverage was previously offered, may enroll in this Involuntary Loss Of Other Coverage plan at the same time a newly acquired dependent is enrolled under “Enrollment” in the case of marriage, If an employee and/or dependent does not enroll in birth, adoption, or placement for adoption. The this plan or another plan sponsored by the Group eligible employee may also choose to enroll alone, when first eligible because they aren’t required to do with some or all eligible dependents or change so, that employee and/or dependent may later enroll plans, if applicable. in this plan outside of the annual open enrollment period if each of the following requirements is met: When we receive the completed enrollment application and any required subscription charges  The employee and/or dependent were covered within 60 days of the date of marriage, birth, under group health coverage or a health adoption, or placement for adoption. Coverage insurance program at the time coverage under the under this plan will become effective on the first of Group's plan was offered the month following the date the other coverage was  The employee and/or dependent’s coverage lost. under the other group health coverage or health insurance program ended as a result of one of the Subscriber And Dependent Special following: Enrollment With Medicaid and Children's  Loss of eligibility for Medicaid or a public Health Insurance Program (CHIP) Premium program providing health benefits Assistance  Loss of eligibility for coverage (including , but You and your dependents may have special not limited to, the result of legal separation, enrollment rights under this plan if you meet the divorce, death, termination of employment, or eligibility requirements described under When the reduction in the number of hours of Coverage Begins and: employment)  You qualify for premium assistance for this plan  Termination of employer contributions toward from Medicaid or CHIP; or such coverage  You no longer qualify for healthcare coverage  The employee and/or dependent were covered under Medicaid or CHIP.

PBCBSAK SCER 01-2017 54 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska If you and your dependents are eligible as outlined will continue to be eligible if all of the following are above, you qualify for a 60-day special enrollment true: period. This means that you must request  The child is disabled before reaching 26 years of enrollment in this plan within 60 days of the date you age qualify for premium assistance under Medicaid or CHIP or lose your Medicaid or CHIP coverage.  The child is not married  We are notified of the child’s disability within 31 Coverage under this plan for the eligible employee days of the date the child reached age 26 and any dependents will start on the first of the month following: Within 31 days after the child turns age 26, the  The date the eligible employee and any subscriber must send us proof that the child meets dependents qualify for Medicaid or CHIP premium these conditions. We also have the right to ask for assistance; or proof. We cannot ask for such proof more often than once a year. If the subscriber does not send us  The date the eligible employee and any satisfactory proof when we ask for it, the child’s dependents lose coverage under Medicaid or coverage will not continue after the last date of CHIP. eligibility. The eligible employee and any dependents may be PLAN TRANSFERS required to provide proof of eligibility from the state for this special enrollment period. Subscribers (with their enrolled dependents) may be allowed to transfer to this plan from another plan If we do not receive the enrollment application within offered by the Group. Transfers also occur if the the 60-day period as outlined above, you will not be Group replaces another plan with this plan. All able to enroll until the next open enrollment period. transfers to this plan must occur during “open Please refer to Open Enrollment below. enrollment” or on another date agreed upon by us OPEN ENROLLMENT and the Group. If you are not enrolled when you first become When we update the contract for this plan, or you eligible, or as allowed under Special Enrollment transfer from the Group’s other plan, and there is no above, you cannot be enrolled until the Group's next lapse in your coverage, the following provisions that “open enrollment” period. An open enrollment apply to this plan will be reduced to the extent they period occurs once a year unless otherwise agreed were satisfied and/or credited under the prior plan: upon between the Group and us. During this period,  Out-of-pocket maximum eligible employees and their dependents can enroll  Deductibles. We will credit expenses applied to for coverage under this plan. your prior plan's deductible only when they were If the Group offers multiple healthcare plans and you incurred in the current calendar year. Expenses are enrolled under one of the Group’s other incurred during October through December of the healthcare plans, enrollment for coverage under this prior year are not credited toward this plan's plan can only be made during the Group’s open deductible for the current year. enrollment period. TERMINATION OF COVERAGE Please Note: Grandchildren are not eligible to be enrolled during Open Enrollment. Please see EVENTS THAT END COVERAGE Newborn Grandchildren above. Coverage will end without notice on the last day of CHANGES IN COVERAGE the month in which one of these events occurs: No rights are vested under this plan. Its terms,  For the subscriber and dependents when any of benefits, and limitations may be changed at any the following occur: time. All changes to this plan will apply as of the  The Group Contract is terminated date the change becomes effective to all members  The next monthly subscription charge is not and to employees and dependents that become paid when due or within the grace period covered under this plan after the date the change becomes effective.  The subscriber dies or is otherwise no longer eligible as a subscriber ELIGIBILITY FOR A DISABLED CHILD  In the case of a collectively bargained program, An eligible child can stay on this plan after they the employer fails to meet the terms of an reach age 26 if they are developmentally or applicable collective bargaining agreement or to physically disabled and are not able to support employ employees covered by a collective themselves. The child must be dependent upon the bargaining agreement subscriber for support and maintenance. The child  For a spouse when his or her marriage to the

PBCBSAK SCER 01-2017 55 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska subscriber is annulled, or when he or she conditions which must be followed to be eligible for becomes legally separated or divorced from the continuation of coverage and which are generally subscriber outlined below. Please contact your employer/group  For a child when he or she no longer meets the as soon as possible for details if you think you may requirements for dependent coverage shown in qualify for continuation of coverage. Eligibility And Enrollment If you become ineligible you may continue coverage  For a grandchild of the subscriber or spouse when as required by the federal Consolidated Omnibus the grandchild’s parent is no longer enrolled in the Budget Reconciliation Act of 1986 (COBRA). plan or no longer meets the requirements for COBRA is a federal law which requires most dependent coverage shown in Eligibility And employers with 20 or more employees to offer Enrollment continued coverage. You may be eligible to continue coverage on a self-pay basis for 18 or 36  For intentional fraud or intentional months through COBRA. How long you may misrepresentation of material fact under the terms continue coverage on COBRA will depend on the of the coverage by the subscriber or the circumstances which caused you to lose coverage subscriber’s dependents under the group plan. The subscriber must promptly notify the Group when an enrolled family member is no longer eligible to be WHO MAY BE ELIGIBLE enrolled as a dependent under this plan. The Group The enrolled employee or enrolled dependent may must give us written notice of a member's be eligible for COBRA if: termination within 30 days of the date the Group is  Coverage ends because the employee’s work notified of such event. hours were reduced CONTINUATION OF COVERAGE  Coverage ends because the employee’s employment was terminated. The termination FOR A DISABLED CHILD must not be due to gross misconduct as defined Coverage for a dependent child who cannot support by the group. himself or herself may continue beyond the  Coverage ends because the employee becomes dependent age limit if all of the following are true: eligible for Medicare  The child is not able to earn his or her own living  Coverage ends because the enrolled employee because of a developmental or physical disability dies  The child became disabled before reaching the  Coverage ends because the enrolled employee dependent age limit and spouse legally separate or divorce  The child mainly depends on the enrolled  Coverage ends because domestic partnership employee for support and maintenance. ends  The enrolled employee continues to be covered  Coverage ends because the enrolled dependent under this plan no longer qualifies as a dependent  The child’s subscription charges, if any, continue If you are eligible, you must apply for COBRA to be paid coverage within a certain time period. You may also  Within 31 days of the child reaching the have to pay the subscription charges for it. Please dependent age limit, the enrolled employee gives contact your employer for details. us a Request for Certification of Disabled Dependent form. We must approve the request MEMBER IS INPATIENT WHEN COVERAGE for coverage to continue. ENDS (EXTENDED INPATIENT COVERAGE)  The enrolled employee gives us proof of the If coverage ends, the inpatient benefits of this plan child’s disability and dependent status when we will continue if: request it. After the child has been covered under  Coverage did not end because of fraud by you or this provision for two years, we do not ask for the Group; proof more often than once a year.  Coverage did not end because of an intentional Please Note: This provision does not apply to misrepresentation of material fact under the terms dependent grandchildren. of the coverage by you or the Group; FOR GROUPS SUBJECT TO THE FEDERAL  Coverage had been in effect for more than 31 CONSOLIDATED OMNIBUS BUDGET days; RECONCILIATION ACT OF 1986 (COBRA)  You were admitted to a medical facility before the date coverage ended; and There are specific requirements, time frames and

PBCBSAK SCER 01-2017 56 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  You remained as an inpatient in a medical facility upon us unless it is in writing and approved over the for the same medical condition for which you were signature of an officer of ours. admitted Evidence of Medical Necessity Inpatient coverage will end when the first of the We have the right to require proof of medical following occurs: necessity for any services or supplies you receive  You are covered under another health plan that before benefits are provided under this plan. provides benefits for your confinement; or would Members or providers must provide evidence of provide benefits for your confinement if this plan medical necessity when requested. If this evidence did not exist; is not provided when required, benefits will not be  You are covered under another health plan that available. See the Definitions section to learn how would provide benefits for your confinement if this the plan defines medically necessity. plan did not exist; Group As The Agent  You are discharged from the facility or from any Your Group is your agent for all purposes under this other facility to which you were transferred in plan and not the agent of Premera Blue Cross Blue which you are confined; Shield of Alaska. Any action taken by your Group  Inpatient care is no longer medically necessary will be binding on you. (see Definitions) Health Care Providers - Independent Contractors OTHER PLAN INFORMATION All health care providers who provide services and This section tells you about how your Group’s supplies to a member do so as independent contract and this plan are administered. It also contractors. None of the provisions of this contract includes information about federal and state are intended to create, nor shall they be deemed or requirements we must follow and other information construed to create, any employment or agency we must provide to you. relationship between us and the provider of service other than that of independent contractors. We are BENEFITS NOT TRANSFERABLE not legally responsible for any harm that comes to a This plan’s benefits are not transferable. This member while in a provider’s care. This includes, means no one except you has the right to receive without limitation, any general damages, pain and the benefits of this plan. If you use plan benefits in a suffering. false or misleading way, we will cancel your plan. INDEPENDENT CORPORATION We may also take legal action against you. The subscriber hereby expressly acknowledges the Conformity With The Law understanding that this contract constitutes a The Group Contract is issued and delivered in the contract solely between the subscriber and Premera state of Alaska. This plan conforms with the 10 Blue Cross Blue Shield of Alaska. essential health benefits and is consistent with the The subscriber further acknowledges and agrees requirements of the Affordable Care Act (federal that he or she has not entered into this contract healthcare reform). It is governed by the laws of based upon representations by any person other Alaska, except to the extent preempted by federal than us, and that no person, entity, or organization law. If any part of this contract or any endorsement other than us shall be held accountable or liable to to it is found to be in conflict with applicable state or the subscriber for any of our obligations to the federal laws or regulations, we will administer this subscriber created under this contract. This contract with those laws and regulations as of their provision shall not create any additional obligations effective date. whatsoever on our part other than those obligations Entire Contract created under other provisions of this contract.  The entire contract between the Group and us Intentionally False Or Misleading Statements consists of all of the following: If this plan's benefits are paid in error due to any  The Employer Agreement intentionally false or misleading statements, we will  This benefit booklet be entitled to recover these amounts.  The Group’s signed application If you make any intentionally false or misleading  All attachments, endorsements and options statements on any application or enrollment form included or issued hereafter that affects your acceptability for coverage, we may, at our option: No change to this contract, including any change  Deny your claim; made by a producer of the Group, will be binding

PBCBSAK SCER 01-2017 57 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Reduce the amount of benefits provided for your generally may not, under federal law, restrict claim; or benefits for any hospital length of stay in connection  Void your coverage under this plan (void means to with childbirth for the mother or newborn child to less cancel coverage back to its effective date as if it than 48 hours following a vaginal delivery, or less had never existed at all.) Your coverage cannot than 96 hours following a cesarean section. be voided based on a misrepresentation you However, federal law generally does not prohibit the made unless you have performed an act or mother’s or newborn’s attending provider, after practice that constitutes fraud; or made an consulting with the mother, from discharging the intentional misrepresentation of material fact that mother or her newborn earlier than 48 hours (or 96 affects your acceptability for coverage. hours as applicable). In any case, group health plans and health insurance issuers may not, under Finally, intentionally false or misleading statements federal law, require that a provider obtain on any group form required by us, which affect the authorization from the plan or the insurance issuer acceptability of the Group or the risks to be assumed for prescribing length of stay not in excess of the 48 by us, may cause the voiding of the Group Contract hours (or 96 hours). for this plan. Such recoveries will not be sought more than 365 days from the date we discovered, or Not all plans include coverage for dependents and could have reasonably discovered the intentionally newborns may not be eligible for coverage. See the false or misleading statements. Eligibility and Enrollment section of this booklet for details. Legal Action Non-Transferability of Benefits No action at law or in equity shall be brought to recover under this contract before the expiration of No person other than a member is entitled to receive 60 days after written proof of loss has been benefits under this contract. Such right to benefits is furnished in accordance with the requirements of nontransferable. this contract. No action shall be brought after the Nonwaiver expiration of three years after the written proof of loss is required to be furnished. No delay or failure when exercising or enforcing any right under this contract shall constitute a waiver or Limitations of Liability relinquishment of that right and no waiver or any We’re not legally responsible for any of the following: default under this contract shall constitute or operate as a waiver of any subsequent default. No waiver of  Situations such as epidemics or disasters that any provision of this contract shall be deemed to prevent members from getting the care they need have been made unless and until such waiver has  The quality of services or supplies received by been reduced to writing and signed by the party members, or the regulation of the amounts waiving the provision. charged by any provider, since all those who Notice provide care do so as independent contractors  Providing any type of hospital, medical, dental, Any notice we are required to submit to the Group or vision, or similar care subscriber will be considered to be delivered if mailed to the Group or subscriber, at the most recent  Harm that comes to a member while in a address appearing on our records. We will use the provider's care date of postmark in determining the date of our  Amounts in excess of the actual cost of services notification. If you or your Group is required to and supplies submit notice to us, it will be considered delivered on  Amounts in excess of this plan's maximums. This the postmark date or the date we receive it, if not includes recovery under any claim of breach. postmarked.  General or special damages including, without A notice of a material modification to the benefits or limitation, alleged pain, suffering, mental anguish provisions in this plan will be provided to the or consequential damages member 60 days in advance of the material modification, including changes in preventive Member Cooperation benefits. You must cooperate with us in a timely and Notice of Information Use and Disclosure appropriate way as we manage and provide benefits. You must also cooperate with us if there is We may collect, use, or disclose certain information a lawsuit. about you. This protected personal information (PPI) may include health information, or personal Newborn’s and Mother’s Health Protection Act data such as your address, telephone number or Group health plans and health insurance issuers Social Security number. We may receive this

PBCBSAK SCER 01-2017 58 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska information from, or release it to, healthcare Recovery of Claims Overpayments providers, insurance companies, or other sources. We have the right to recover money we overpay in This information is collected, used or disclosed for error. We may recover this money from the member conducting routine business operations such as: or anyone else that was paid, including a provider.  Determining your eligibility for benefits and paying We may deduct the money from future benefits of claims. (Genetic information is not collected or the employee or any of his or her dependents (even used for enrollment purposes.) if the original payment was not for that member). We can only do this if we would otherwise pay those  Coordinating benefits with other healthcare plans benefits directly to the subscriber or to a provider  Conducting care management, Personal Health that does not have a contract with us. We will Support Programs, or quality reviews provide a minimum of 30 calendar days’ notice of  Fulfilling other legal obligations that are specified the recovery and you will have the right to challenge under the Group contract the recovery. We will do any recovery no later than 365 days after the original claim is settled. This information may also be collected, used or disclosed as required or permitted by law. Right To And Payment Of Benefits To safeguard your privacy, we take care to ensure The benefits of this plan are available only to that your information remains confidential by having enrolled members. Except as required by law, we a company confidentiality policy and by requiring all will not honor any attempted assignment, employees to sign it. garnishment, or attachment of any right of this plan. If a disclosure of PPI is not related to a routine Payment of benefits of this plan are subject to the business function, we remove anything that could be following provisions: used to easily identify you or we obtain your prior  Preferred and Non-Preferred Providers: For written authorization. covered services from these providers, we pay the providers directly. You only have to pay You have the right to request inspection and /or deductibles, copays, coinsurance, and amounts amendment of records retained by us that contain for services that are not covered. your PPI. Please contact Customer Service and ask a representative to mail a request form to you.  Non-Participating Providers: Except as required by law, we will pay benefits for covered Notice of Other Coverage services from providers who are not in our As a condition of receiving benefits under this plan, network to you. you must notify us of: If we get a request in writing within 30 days of a  Any legal action or claim against another party for claim, we will pay the provider directly. You or an a condition or injury for which we provide benefits, individual named in a qualified domestic relations and the name and address of that party’s order may make this request. Once you send us this insurance carrier request, it can only be changed by sending another  The name and address of any insurance carrier written request to us and the provider of services. that provides:  Federal or state laws may require us to pay  Personal injury protection (PIP) benefits to certain agencies. These may include a state child support enforcement agency, a public  Underinsured motorist coverage health program, or other agencies.  Uninsured motorist coverage Payment as stated above satisfies our obligation to  Any other insurance under which you are or may pay benefits. be entitled to recover compensation Severability  The name of any other group or individual insurance plans that cover you Invalidation of any term or provision herein by judgment or court order shall not affect any other Premera Blue Cross Blue Shield of Alaska ID provisions, which shall remain in full force and effect. Card Venue The Premera Blue Cross Blue Shield of Alaska ID card is issued by Premera Blue Cross Blue Shield of All suits and legal proceedings, including arbitration Alaska for member identification purposes only. It proceedings, brought against us by you or anyone does not confer any right to services or other claiming any right under this plan must be filed: benefits under this contract.  Within 3 years of the date we denied, in writing, the rights or benefits claimed under this plan, or of the completion date of the independent review

PBCBSAK SCER 01-2017 59 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska process if applicable; and Applied Behavior Analysis (ABA)  In the state of Alaska The design, implementation and evaluation of Women’s Health and Cancer Rights Act of 1998 environmental modifications, using behavioral stimuli and consequences, including direct observation, This plan, as required by the Women’s Health and measurement and functional analysis of the Cancer Rights Act of 1998 (WHCRA), provides relationship between environment and behavior to benefits for mastectomy-related services including produce socially significant improvement in human all stages of reconstruction and surgery to achieve behavior or to prevent the loss of an attained skill or symmetry between the breasts, prostheses, and function. complications resulting from a mastectomy, including lymphedemas. See Covered Services. Autism Spectrum Disorders Workers’ Compensation Insurance Pervasive developmental disorders or a group of conditions having substantially the same This contract is not in lieu of, and does not affect, characteristics as pervasive developmental any requirement for coverage by Workers’ disorders, as defined in the current Diagnostic and Compensation insurance. Statistical Manual (DSM) published by the American Psychiatric Association, as amended or DEFINITIONS reissued from time to time. Some words we use to describe this plan have Autism Service Provider special meanings in the benefit booklet. The information here will help you understand what these An individual who is licensed, certified, or registered words mean. by the applicable state licensing board or by a nationally recognized certifying organization, and Accepted Rural Provider who provides direct services to an individual with A selected provider practicing in a medically under- autism spectrum disorder. served area of Alaska. These providers are paid at Benefit the highest benefit level, however, since we do not have a contract with these providers you are What this plan provides for a covered service. The responsible for amounts above the allowed amount. benefits you get are subject to this plan’s cost- shares. Accidental Injury Benefit Booklet Physical harm caused by a sudden, unexpected event at a certain time and place. Benefit booklet describes the benefits, limitations, exclusions, eligibility and other coverage provisions Accidental injury does not mean any of the following: included in this plan and are part of the entire  An illness, except for infection of a cut or wound contract.  Over-exertion or muscle strains Benefit Waiting Period  Dental injuries caused by biting or chewing Means a period during which specified treatment or Affordable Care Act services are excluded from coverage under this plan. The benefit exclusion periods begins on your The Patient Protection and Affordable Care Act of effective date of coverage. 2010 (Public Law 111-148) as amended by the Health Care and Education Reconciliation Act of Calendar Year (Year) 2010 (Public Law 111-152). A 12-month period that starts on January 1 at 12:01 Allowed Amount a.m. and ends on December 31 at midnight. See Important Plan Information. Calendar Year Maximum Ambulatory Surgical Facility See Important Plan Information. A healthcare facility where people get surgery Claim without staying overnight. An ambulatory surgical A request to us for payment of amount due. center must be licensed or certified by the state it is in. It also must meet all of these criteria: Clinical Trials  It has an organized staff of doctors An approved clinical trial means a scientific study  It is a permanent facility that is equipped and run using human subjects designed to test and improve mainly for doing surgical procedures prevention, diagnosis, treatment, or palliative care of cancer, or the safety and effectiveness of a drug,  It does not provide inpatient services or rooms

PBCBSAK SCER 01-2017 60 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska device, or procedure used in the prevention, or cesarean) diagnosis, treatment, or palliative care, if the study is Comprehensive Oral Evaluation approved by the following:  An institutional review board that complies with 45 Comprehensive oral evaluations include complete CFR Part 46; and dental/medical history and general health assessment, complete thorough evaluation of extra-  One or more of the following: oral and intra-oral hard and soft tissue; the  The United States Department of Health and evaluation and recording of dental caries, missing or Human Services, National Institutes of Health, unerupted teeth, restoration, occlusal relationships, or its institutes or centers periodontal conditions (including periodontal  The United States Department of Health and charting), hard and soft tissue anomalies, and oral Human Services, United States Food and Drug cancer screenings. Administration (FDA) Congenital Anomaly  The United States Department of Defense A marked difference from the normal structure of a  The United States Department of Veterans’ body part that is different from the normal structure Affairs at the time of birth.  A nongovernmental research entity abiding by Consolidated Omnibus Budget Reconciliation current National Institutes of Health guidelines Act of 1986 (COBRA) Coinsurance COBRA is a federal law which requires most See Important Plan Information. employers with 20 or more employees to give employees and their families who lose their health Complication of Pregnancy benefits the right to choose to continue group health A medical condition related to pregnancy or benefits provided by their group health plan for childbirth that falls into one of these three limited periods of time under certain circumstances categories: such as voluntary or involuntary job loss, reduction in the hours worked, transfer or promotion between  A condition of the fetus that needs surgery while jobs, death, divorce, and other life events. still in the womb (in utero)  A disease the mother has during pregnancy that is Copay not caused by the pregnancy. The disease is See Important Plan Information. made worse by the pregnancy. Cosmetic Services  A condition the mother has that is caused by the pregnancy. It is more difficult to treat because of Services that are performed to reshape normal the pregnancy. These conditions are limited to: structures of the body in order to improve your  Ectopic pregnancy appearance and self-esteem and not primarily to restore an impaired function of the body.  Hydatidiform mole/molar pregnancy Cost-Share  Incompetent cervix that requires treatment  Complications of administration of anesthesia The part of healthcare costs that you have to pay. or sedation during labor or delivery Examples are deductibles, coinsurance, copays, and similar charges. It does not include subscription  Obstetrical trauma, such as uterine rupture charges, amount over the allowed amount billed by before onset or during labor health care providers who are out of the network, or  Hemorrhage before or after delivery that the cost of services not covered by this plan. See requires medical or surgical treatment Summary of Your Costs for your cost-shares.  Placental conditions that require surgical Covered Service intervention A medically necessary service that is eligible for  Preterm labor and monitoring benefits under this plan.  Toxemia Custodial Care  Gestational diabetes Any part of a covered service that is mainly to:  Hyperemesis gravidarum  Maintain your health over time, and not to treat  Spontaneous miscarriage or missed abortion specific illness or injury A complication of pregnancy needs services that are  Help you with activities of daily living. Examples more than the usual maternity services. This are help in walking, bathing, dressing, eating, and includes care before, during, and after birth (normal

PBCBSAK SCER 01-2017 61 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska preparing special food. This also includes assure, within reasonable medical probability that supervising the self-administration of medication no material deterioration of the condition is likely when it does not need the constant attention of to result from or occur during the transfer of the trained medical providers. member from a medical facility. Deductible  Ambulance transport as needed in support of the services above. See Important Plan Information. Emergency Medical Condition Dependent A medical condition that you believe puts your The employee’s spouse, domestic partner, children health, a part of your body or the health of an unborn and any eligible grandchildren who are enrolled on child at risk. Examples are severe pain, a possible this plan. heart attack or a broken bone. You need medical Dental Emergency care right away. Routine care for sore throats or colds, follow-up care and prescription requests are A condition requiring prompt or urgent attention due not emergencies. to trauma and/or pain caused by a sudden unexpected injury, acute infection or similar Endorsement occurrence. A document that is attached to and made a part of Dentally Necessary and Dental Necessity this contract. An endorsement changes the terms of the contract. Those covered services which are determined to meet all of the following requirements: Essential Health Benefits  Essential to, consistent with, and provided for the Benefits defined by the Secretary of Health and diagnosis or the direct care and treatment of a Human Services that shall include at least the disease, injury, or condition harmful or following general categories: ambulatory patient threatening to the member’s dental health, unless services, emergency care, hospitalization, maternity provided for preventive services when specified and newborn care, mental health and substance as covered under this plan abuse services, including behavioral health  Appropriate and consistent with authoritative treatment, prescription drugs, rehabilitative and dental or scientific literature habilitative services and devices, laboratory services, preventive and wellness services and  Not primarily for the convenience of the member, chronic disease management and pediatric services, the member’s family, the member’s dental care including oral and vision care. The designation of provider or another provider health benefits as essential shall be consistent with Detoxification the requirements and limitations set forth under the Affordable Care Act and applicable regulations as Detoxification is active medical management of determined by the Secretary of Health and Human medical conditions due to substance intoxication or Services. withdrawal, which requires repeated examination appropriate to the substance ingested, and use of Experimental or Investigational Services medication. Observation alone is not active medical Services that meet one or more of the following: management.  A drug or device which cannot be lawfully Effective Date marketed without the approval of the U.S. Food The date your coverage under this plan begins. and Drug Administration and does not have approval on the date the service is provided Emergency Care  It is subject to oversight by an Institutional Review  A medical screening examination to evaluate a Board medical emergency that is within the capability of  There is no reliable evidence showing that the the emergency department of a hospital, service is effective in clinical diagnosis, including ancillary services routinely available to evaluation, management or treatment of the the emergency department condition  Further medical examination and treatment to  It is the subject of ongoing clinical trials to stabilize the member to the extent the services determine its maximum tolerated dose, toxicity, are within the capabilities of the hospital staff and safety or efficacy facilities, or if necessary, to make an appropriate transfer to another medical facility. “Stabilize”  Evaluation of reliable evidence indicates that means to provide such medical treatment of the additional research is necessary before the medical emergency as may be necessary to service can be classified as equally or more

PBCBSAK SCER 01-2017 62 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska effective than conventional therapies Home Medical Equipment (HME) Reliable evidence means only published reports and Equipment ordered by a healthcare provider for articles in authoritative medical and scientific everyday or extended use to treat an illness or literature, scientific results of the provider of care’s injury. HME may include: oxygen equipment, written protocols, or scientific data from another wheelchairs or crutches. provider studying the same service. Hospice Explanation of Benefits A facility or program designed to provide a caring An explanation of benefits is a statement that shows environment for supplying the physical and what you will owe and what we will pay for emotional needs of the terminally ill. healthcare services received. It’s not a bill. Hospital Facility (Medical Facility) A healthcare facility that meets all of these criteria: A hospital, skilled nursing facility, state-approved  It operates legally as a hospital in the state where substance abuse treatment program, or hospice. it is located Not all health care facilities are covered under this Group contract.  It has facilities for the diagnosis, treatment and acute care of injured and ill persons as inpatients Group  It has a staff of doctors that provides or A small employer, including a person, firm, supervises the care corporation, partnership, or political subdivision, that  It has 24-hour nursing services provided by or is actively engaged in business and is a party to the supervised by registered nurses Group Contract. The “Group” is responsible for collecting and paying all subscription charges, A facility is not considered a hospital if it operates receiving notice of additions and changes to mainly for any of the purposes below: employee and dependent eligibility and providing  As a rest home, nursing home, or convalescent such notice to us, and acting on behalf of its home employees.  As a residential treatment center or health resort Habilitation Therapy  To provide hospice care for terminally ill patients Habilitative services or devices are medical services  To care for the elderly or devices provided when medically necessary for  To treat substance abuse or tuberculosis development of bodily or cognitive functions to perform activities of daily living that never developed Illness or did not develop appropriately based on the A sickness, disease, medical condition or chronological age of the insured. Habilitative complication of pregnancy. services include physical therapy, occupational therapy, and speech-language therapy when Injury provided by a state-licensed or state-certified Physical harm caused by a sudden event at a provider acting within the scope or his or her license. specific time and place. It is independent of illness, Therapy to retain skills necessary for activities of except for infection of a cut or wound. daily living and prevent regression to a previous level of function is a habilitative service, if medically In-network necessary and appropriate. Habilitative devices The specified doctors, hospitals or labs that Premera may be limited to those that have FDA approval and contracts with to provide healthcare services. When are prescribed by a qualified provider. Habilitative you have an in-network healthcare service, you services do not include respite care, day habilitation usually pay less. services designed to provide training, structured activities and specialized assistance for adults, Inpatient chore services to assist with basic needs, Someone who is admitted to a healthcare facility for educational, vocational, recreational or custodial an overnight stay. We also use this word to services. describe the services you get while you are an Home Health Agency inpatient. An organization that provides covered home health Limited Oral Evaluation – Problem Focused services to a member. A limited oral evaluation – problem focused is an evaluation limited to a specific oral health problem or complaint and may include evaluation of a specific

PBCBSAK SCER 01-2017 63 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska dental problem or oral health complaint, dental Plan emergency and referral for other treatment. The benefits, terms, and limitations stated in this Medically Necessary and Medical Necessity Group contract. Services and supplies that a doctor, exercising Prescription Drug prudent clinical judgment, would use with a patient Drugs and medications that by law require a to prevent, evaluate, diagnose or treat an illness, prescription. This includes “biologicals” (medicines injury, disease or its symptoms. These services made from living things or their products) used in must: chemotherapy to treat cancer. It also includes  Agree with generally accepted standards of biologicals used to treat people with HIV or AIDS. medical practice According to the Federal Food, Drug and Cosmetic  Be clinically appropriate in type, frequency, extent, Act, as amended, the label of a prescription drug site and duration. They must also be considered must have this statement on it: “Caution: Federal effective for the patient’s illness, injury or disease law prohibits dispensing without a prescription.”  Not be mostly for the convenience of the patient, Primary Care Providers doctor, or other health care provider. They do not cost more than another service or series of A doctor (M.D. – Medical Doctor or D.O. – Doctor of services that are at least as likely to produce Osteopathic Medicine), nurse practitioner, clinical equivalent therapeutic or diagnostic results for the nurse specialist or doctor assistant, as allowed diagnosis or treatment of that patient’s illness, under state law, who provides, coordinates or helps injury or disease. a patient access a range of healthcare services. For these purposes, “generally accepted standards Prior Authorization of medical practice” means standards that are based Planned services that must be reviewed for medical on credible scientific evidence published in peer necessity and approved by us before you receive reviewed medical literature. This published them. See the Prior Authorization section for evidence is recognized by the relevant medical details. community, doctor specialty society recommendations and the views of doctors Provider practicing in relevant clinical areas and any other A doctor or other healthcare professional or facility relevant factors. named in this plan that is licensed or certified as Member required by the state in which the services were received to provide a medical service or supply, and Any person covered under this plan. who does so within the lawful scope of that license Mental Health Condition or certification. Not all services they provide are covered under this plan. See Covered Services Any condition listed in the current Diagnostic and and Exclusions for additional information. Statistical Manual (DSM), published by the American Psychiatric Association, excluding For providers of medical care within the service diagnosis and treatments for substance abuse. area, we use the following terms.  Preferred INN Providers are contracted Orthotic providers that are in your provider network. You A support or brace applied to an existing portion of receive the highest benefit level when you use a the body for weak or ineffective joints or muscles, to Preferred INN provider. Preferred INN providers aid, restore or improve function. will not bill you for the amount above the allowed amount for a covered service. Out-of-network  Non-Preferred Providers are providers that have Services from doctors, hospitals, and other a contract with us, but they are not in your healthcare professionals that have not contracted provider network. You receive lower benefit with your plan. Depending on the healthcare coverage for services provided by Non-Preferred professional, the service could cost more or not be providers. Non-Preferred providers will not bill covered at all by your plan. you the amount above the allowed amount for a Outpatient covered service.  Non-Participating Providers are providers that A person who gets medical services without an do not have a contract with us. You receive the overnight stay in a medical facility. This word also lowest benefit coverage for services provided by describes the services a person receives while they Non-Participating providers, and they will bill you are an outpatient. for amounts over the allowed amount for a

PBCBSAK SCER 01-2017 64 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska covered service. Skilled Nursing Care For providers of medical care outside the service Medical care you get in your home or in a skilled area, we use the following terms: nursing facility. Care is ordered by a doctor and  In-Network Providers are providers who have requires the knowledge and training of a licensed contracts with other Blue Cross and/or Blue Shield registered nurse. Licensees outside the service area. Skilled Nursing Facility  Out-Of-Network Providers are providers who do A medical facility licensed by the state to provide not have contracts with other Blue Cross and/or nursing services to patients after an illness or injury. Blue Shield Licensees outside the service area. A skilled nursing facility must meet all of the See BlueCard Program for details. following criteria: For providers of dental care within the service area,  Services it provides are directed by a doctor we use the following terms:  Nursing care is supervised by a registered nurse  In-Network Providers are contracted providers  The facility is approved by Medicare, or would that are in your provider network. You receive the qualify for Medicare approval if it were requested highest benefit level when you use an in-network Small Employer provider. In-network providers will not bill you for the amount above the allowed amount for a A small employer is an employer who employed an covered service. average of at least 1 but not more than 50 common  Out-Of-Network Providers are providers that are law employees on business days during the not in your provider network. You receive lower preceding calendar year and who employs at least 1 benefit coverage for services provided by out-of- common law employee on the first day of the current network dental providers. An out-of-network plan year. dental provider will bill you the amount over the In the case of an employer that was not in existence allowed amount for a covered service. throughout the preceding calendar year, the Reconstructive Surgery determination of whether the employer is a small employer be based on the average number of Reconstructive surgery is surgery: employees that it is reasonably expected the  Which restores features damaged as a result of employer will employ on business days in the current accidental injury (see Definitions) or illness calendar year.  To correct a congenital deformity or anomaly Specialist Rehabilitation Therapy A doctor who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent Rehabilitative services or devices are medical or treat certain types of symptoms and conditions. services or devices provided when medically necessary for restoration of bodily or cognitive Spouse functions lost due to a medical condition. Someone who is legally married to the subscriber. A Rehabilitative services include physical therapy, spouse can also be the subscriber’s domestic occupational therapy, and speech-language therapy partner. when provided by a state-licensed or state-certified Subscription Charges provider acting within the scope or his or her license. Therapy performed to maintain a current level of The monthly rates we establish as consideration for functioning without documentation of significant the benefits offered under this contract. improvement is considered maintenance therapy and is not a rehabilitative service. Rehabilitative Substance Abuse devices may be limited to those that have FDA Dependent on or addicted to drugs or alcohol. It is approval and are prescribed by a qualified provider. an illness in which a person is dependent on alcohol Service Area and/or a controlled substance regulated by state or federal law. It can be a physiological (physical) Service area means the states of Alaska and dependency or a psychological (mental) Washington (except Clark County, Washington). dependency or both. People with substance abuse usually use drugs or alcohol in a frequent or intense Services pattern that leads to: Procedures, surgeries, consultations, advice,  Losing control over the amount and diagnosis, referrals, treatment, supplies, drugs, circumstances of use devices, technologies or places of service.

PBCBSAK SCER 01-2017 65 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska  Developing a tolerance of the substance, or having withdrawal symptoms if they reduce or stop the use  Making their health worse or putting it in serious danger  Not being able to function well socially or on the job Substance abuse includes drug psychoses and drug dependence syndromes. Urgent Care Treatment of unscheduled, drop-in patients who have minor illnesses and injuries. These illnesses or injuries need treatment right away but they are not life-threatening. Examples are high fevers, minor sprains and cuts, and ear, nose and throat infections. Urgent care is provided at a medical facility that is open to the public and has extended hours. Visit A visit is one session of consultation, diagnosis, or treatment with a provider. We count multiple visits with the same provider on the same day as one visit. Two or more visits on the same date with different providers count as separate visits. Visual Oral Screenings or Assessments Performed by a licensed dentist or dental hygienist under the supervision of a licensed dentist to determine the need for sealants, fluoride treatment, and/or when triage services are provided in settings other than dental offices or dental clinics. We, Us and Our Premera Blue Cross Blue Shield of Alaska (“Premera”) in the state of Alaska and Premera Blue Cross in the state of Washington. You and Your Means any member enrolled in this plan.

PBCBSAK SCER 01-2017 66 Premera Blue Cross Plus Bronze 6350 Premera Blue Cross Blue Shield of Alaska

where to send claims

MAIL YOUR CLAIMS TO: Premera Blue Cross Blue Shield of Alaska P.O. Box 240609 Anchorage, AK 99524-0609

MAIL PRESCRIPTION DRUG CLAIMS TO: Express Scripts P.O. Box 747000 Cincinnati, OH 45274-7000

www.premera.com 1-6B2U3P 38344AK0710012

036469 (10-2016)

Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association