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Benefit Booklet for Employees of Wake Forest University For Benefit Booklet for Employees of Wake Forest University for LOW PLAN An Independent Licensee of the Blue Cross and Blue Shield Association L1338, 7/13 Blue Options / FS002844 BENEFIT BOOKLET This benefit booklet describes the Wake Forest University EMPLOYEE health plan(the PLAN). Blue Cross and Blue Shield of North Carolina provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims. Please read this benefit booklet carefully. The benefit plan described in this booklet is an EMPLOYEE health benefit plan, subject to the Employee Retirement Income Security Act of 1974 (ERISA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A summary of benefits, conditions, limitations and exclusions is set forth in this benefit booklet for easy reference. In the event of a conflict between this benefit booklet and the terms in the PLAN document, the PLAN document will control. Amendment and/or Termination of the PLAN The PLAN SPONSOR expects this PLAN to be continued indefinitely, but the PLAN SPONSOR reserves the right to terminate the PLAN at any time with respect to its EMPLOYEES by a written instrument signed by an officer of the PLAN SPONSOR. Such termination may be made without the consent of the MEMBERS, or any other persons. The PLAN SPONSOR also reserves the right to amend the PLAN, including reduction or elimination of benefits or COVERED SERVICES. Amendments shall be made only in accordance with the provisions of the PLAN. The PLAN ADMINISTRATOR will provide notice to MEMBERS within sixty days of the adoption of any amendment that results in a material reduction in COVERED SERVICES or benefits. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. TABLE OF CONTENTS GETTING STARTED WITH BLUE OPTIONS ......................................................................... 1 GETTING STARTED ..................................................................................................................................... 1 NOTES ON WORDS ............................................................................................................................. 1 THIS BOOKLET TELLS YOU ABOUT .................................................................................................. 1 PRIOR REVIEW AND CERTIFICATION ....................................................................................................... 1 EXCLUSIONS AND LIMITATIONS ........................................................................................................ 2 NO ASSIGNMENT OF BENEFITS ....................................................................................................... 2 MORE INFORMATION UPON REQUEST ............................................................................................ 2 MEDICAL AND REIMBURSEMENT POLICIES ................................................................................... 2 REDUCED OR WAIVED PAYMENTS .......................................................................................................... 2 COMMON INSURANCE TERMS .......................................................................................................... 3 FOR HELP IN READING THIS BENEFIT BOOKLET .................................................................................. 4 WHO TO CONTACT? ..............................................................................................................5 TOLL-FREE PHONE NUMBERS, WEBSITE AND ADDRESSES .............................................................. 5 VALUE-ADDED PROGRAMS ....................................................................................................................... 6 SUMMARY OF BENEFITS ..................................................................................................... 8 HOW BLUE OPTIONS WORKS ............................................................................................17 MOST COST-EFFECTIVE BENEFIT LEVEL ............................................................................................ 17 OUT-OF-NETWORK BENEFIT EXCEPTIONS ........................................................................................ 20 BUNDLED CARE AND PAYMENTS PROGRAM .............................................................................. 20 CARRY YOUR IDENTIFICATION CARD .................................................................................................. 20 THE ROLE OF A PRIMARY CARE PROVIDER (PCP) OR SPECIALIST ............................................... 21 COVERED SERVICES .......................................................................................................... 22 OFFICE SERVICES .................................................................................................................................... 22 PREVENTIVE CARE .................................................................................................................................. 23 ROUTINE PHYSICAL EXAMINATIONS AND SCREENINGS .................................................... 24 WELL-BABY AND WELL-CHILD CARE ........................................................................................... 24 WELL-WOMAN CARE ................................................................................................................. 24 TABLE OF CONTENTS (cont.) CONTRACEPTIVE METHODS ........................................................................................................... 24 IMMUNIZATIONS .......................................................................................................................... 24 TOBACCO CESSATION ...................................................................................................................... 24 BONE MASS MEASUREMENT SERVICES ............................................................................... 25 COLORECTAL SCREENING .............................................................................................................. 25 GYNECOLOGICAL EXAM AND CERVICAL CANCER SCREENING ........................................ 25 NEWBORN HEARING SCREENING .................................................................................................. 26 OVARIAN CANCER SCREENING ...................................................................................................... 26 PROSTATE SCREENING ................................................................................................................... 26 SCREENING MAMMOGRAMS .................................................................................................... 26 PREVENTIVE CARE EXCLUSIONS .......................................................................................................... 26 EMERGENCY AND AMBULANCE SERVICES .................................................................................. 27 WHAT TO DO IN AN EMERGENCY .................................................................................................. 27 AMBULANCE SERVICES ........................................................................................................................... 28 AMBULANCE SERVICE EXCLUSIONS (GROUND OR AIR) ..........................................29 URGENT CARE .......................................................................................................................................... 29 HOSPITAL (INPATIENT) AND OTHER FACILITY CARE ................................................................. 29 ALTERNATIVES TO HOSPITAL STAYS ............................................................................................ 30 HOME HEALTH CARE ....................................................................................................................... 30 HOSPICE SERVICES .......................................................................................................................... 30 PRIVATE DUTY NURSING .......................................................................................................... 30 FAMILY PLANNING ............................................................................................................................. 31 MATERNITY CARE ............................................................................................................................. 31 TERMINATION OF PREGNANCY (ABORTION) ........................................................... 32 COMPLICATIONS OF PREGNANCY .................................................................................................. 32 INFERTILITY SERVICES ..................................................................................................................... 33 SEXUAL DYSFUNCTION SERVICES .......................................................................................... 33 STERILIZATION ................................................................................................................................... 33 TABLE OF CONTENTS (cont.) FAMILY PLANNING EXCLUSIONS .................................................................................................... 34 SPECIFIC THERAPIES AND TESTS. ........................................................................................................ 34 HOME INFUSION THERAPY SERVICES .......................................................................................... 34 REHABILITATIVE THERAPY AND HABILITATIVE SERVICES ..................................................
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