Premera Blue Cross Plus Gold 500 SAMPLE WELCOME Thank You for Choosing Premera Blue Cross Blue Shield of Alaska for Your Healthcare Coverage

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Premera Blue Cross Plus Gold 500 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 Gold 500 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 Gold 500 Certificate Form Number: PBCBSAK SCER (01-2017)

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 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 Gold 500 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 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 Gold 500 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 ...... 32 EXCLUSIONS...... 40 OTHER COVERAGE...... 44 Coordinating Benefits With Other Plans...... 44 Subrogation and Reimbursement...... 46 SENDING US A CLAIM...... 46 COMPLAINTS AND APPEALS ...... 48 ELIGIBILITY AND ENROLLMENT ...... 51 Who Is Eligible For Coverage...... 51 When Coverage Begins ...... 52 Special Enrollment ...... 53 TERMINATION OF COVERAGE ...... 55 Events That End Coverage ...... 55 CONTINUATION OF COVERAGE...... 55 OTHER PLAN INFORMATION ...... 56 DEFINITIONS ...... 59

PBCBSAK SCER (01-2017) Premera Blue Cross Plus Gold 500 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: $500 $1,000 Family Deductible: $1,000 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: $5,000 $45,000 Family Out-of-Pocket Maximum: $10,000 $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 Gold 500 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

 The first two office, clinic, e-visit or home No Charge Deductible, then 40% Deductible, then 60% visits per calendar year with your designated PCP  Subsequent office, clinic, e-visit or home $25, waived deductible Deductible, then 40% Deductible, then 60% visits per calendar year with your designated PCP  Telehealth visit $25, waived deductible Deductible, then 40% Deductible, then 60%  Office visits with your Gynecologist (even $25, waived deductible Deductible, then 40% Deductible, then 60% if not your selected PCP)  All other provider office, clinic or home $50, waived deductible 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 Gold 500 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 20% Deductible, then 40% Deductible, then 60%  Outpatient services Deductible, then 20% Deductible, then 40% Deductible, then 60%  High technology diagnostic imaging Deductible, then 20% Deductible, then 40% Deductible, then 60% services  Inpatient Services Deductible, then 20% Deductible, then 40% Deductible, then 60% Surgery Services Deductible, then 20% 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 20%  Emergency Room Physician Deductible, then 20% Emergency Ambulance Services  Emergency air and surface (ground and $25 copay, deductible then 20% 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 20% another facility Urgent Care Centers

 Office visits $50, waived deductible Deductible, then 40% Deductible, then 60%  Services from centers based in a hospital $200, deductible then $200, deductible then $200, deductible then 20% 20% 20%

PBCBSAK SSYC 01-2017 3 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Gold 500 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 20% Deductible, then 40% Deductible, then 60% Outpatient care and inpatient care services Mental Health, Behavioral Health and 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 $50, waived deductible Deductible, then 40% Deductible, then 60% You may have additional costs for facility charges.  Other professional services Deductible, then 20% Deductible, then 40% Deductible, then 60%  Inpatient and residential - facility services Deductible, then 20% Deductible, then 40% Deductible, then 60%  Outpatient facility services Deductible, then 20% Deductible, then 40% Deductible, then 60% Maternity and Newborn Care Deductible, then 20% 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 20% Deductible, then 40% Deductible, then 60% Limited to 130 visits per calendar year. Hospice Care Deductible, then 20% 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

Habilitation Therapy Neuropsychological testing to diagnose is

PBCBSAK SSYC 01-2017 4 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Gold 500 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 $50 Deductible, then 40% Deductible, then 60% conditions limited to 45 visits per calendar year  Outpatient services to treat chronic Deductible, then $50 Deductible, then 40% Deductible, then 60% conditions, unlimited  Inpatient services limited to 30 days per Deductible, then 20% Deductible, then 40% Deductible, then 60% calendar year Skilled Nursing Facility and Care Deductible, then 20% Deductible, then 40% Deductible, then 60% Limited to 60 days per calendar year Home Medical Equipment (HME), Deductible, then 20% 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 $25, waived deductible Deductible, then 40% Deductible, then 60% You may have additional costs for hospital facility charges.  Facility charges Deductible, then 20% Deductible, then 40% Deductible, then 60% Air or Surface Transportation Deductible, then 20% (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 20% Deductible, then 40% Deductible, then 60%

PBCBSAK SSYC 01-2017 5 Premera Blue Cross Blue Shield of Alaska Premera Blue Cross Plus Gold 500 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 20% 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 20% Deductible, then 40% Deductible, then 60% services, including facility charges  Transportation for Cancer Clinical Trials Deductible, then 20% 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 20% Deductible, then 40% Deductible, then 60% including facility charges Foot Care Deductible, then 20% 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 $50 copay, deductible waived years  Hearing Test No Charge 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 20% Deductible, then 40% Deductible, then 60% Mastectomy and Breast Reconstruction Deductible, then 20% 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 Gold 500 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 20% Deductible, then 40% Deductible, then 60% Testing Spinal Manipulation Services Limited to 12 visits per calendar year  Office visits $25, waived deductible Deductible, then 40% Deductible, then 60% You may have additional costs for hospital facility charges  Facility charges Deductible, then 20% Deductible, then 40% Deductible, then 60% Therapeutic Injections Deductible, then 20% 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 20% 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 Gold 500 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 $20, waived deductible  Formulary Preferred Brand Drugs $40, waived deductible  Formulary Non-Preferred Drugs $100, waived deductible  Anti-cancer Medications Waived deductible, then 20% 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 $60, waived deductible Not Covered  Formulary Preferred Brand Drugs $120, waived deductible Not Covered  Formulary Non-Preferred Drugs $300, waived deductible Not Covered  Anti-cancer Medications Waived deductible, then 20% Not Covered Prescriptions – Specialty Pharmacy Deductible, then 20% 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 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 Gold 500 Premera Blue Cross Blue Shield of Alaska COMMON MEDICAL SERVICES  The doctor has been approved for e-visits by us The services listed in this section are covered as  You have been treated by the doctor before and shown on the Summary of Your Costs. Please see have established a patient-doctor relationship the Summary of Your Costs for your deductible, with that specific doctor copays (if any), and coinsurance and benefit limits.  The e-visit is medically necessary OFFICE AND CLINIC VISITS You can call us at the number listed on the back of your Premera ID card for help finding a doctor This plan covers professional office and home visits. approved to provide e-visits. The visits can be for examination, consultation and diagnosis of an illness or injury. You may have to This benefit does not cover: pay a separate copay (if any) or coinsurance for  Surgical services. See Surgery Services for other services you get during a visit. This includes those covered services. services such as x-rays, lab work, therapeutic  EEG biofeedback or neurofeedback services injections and office surgeries. Some outpatient services you get from a specialist must be prior  Mental health services including biofeedback authorized. See Prior Authorization for details. services. See Mental Health, Behavioral Health and Substance Abuse for those covered This benefit covers all of the following: services.  Primary care provider (PCP) visits. See How  Home health or hospice care visits. See Home Providers Affect Your Costs for details about Health Care and Hospice Care for those covered how to select a PCP. services. The first 2 visits with your designated primary care  Facility charges. When you get care at a hospital provider (PCP) in an office or clinic setting are based clinic or hospital based doctor’s office, you covered as described on the Summary of Your must pay your deductible and coinsurance for the Costs. Urgent care, telehealth, preventive and facility charges. See Hospital Services for those specialty visits are not included in this limit. costs.  Obstetrician/Gynecologist visits with Preferred PREVENTIVE CARE INN providers are always covered at the lower cost-share no matter if you have designated a Preventive care is a specific set of evidence-based PCP or not. services expected to prevent future illness. These services are based on guidelines established by  Specialists visits government agencies and professional medical  Second opinions for covered medical conditions societies. or treatment plans Please go to this government website for more  Prostate, colorectal and cervical cancer exams, information: unless they meet the guidelines for preventive https://www.healthcare.gov/coverage/preventive- care care-benefits/  Biofeedback for migraines and other conditions Preventive services provided by in-network providers that are not considered experimental and are covered in full. But they have limits on how investigational often you should get them. These limits are often  Telehealth services. This plan covers access to based on your age and gender. After a limit has care via online and telephonic methods when been exceeded, these services are not covered in medically appropriate and is real-time full and may require you to pay more out-of-pocket communication between your doctor and you. costs. Eligible services must be medically necessary to treat a covered illness, injury or condition. Some of the services your doctor does during a routine exam may not meet preventive guidelines.  Electronic Visits These services are then covered the same as any This benefit includes electronic visits (e-visits). E- medical service and are not covered in full, and you visits are structured, secure online messaging may be responsible for part of the costs. protocol (email) consultations between an approved doctor and you. They are not real-time For example: visits. Your approved doctor will determine which During your preventive exam, your doctor may find conditions and circumstances are appropriate for an issue or problem that requires further testing or e-visits in their practice. E-visits are covered only screening for a proper diagnosis to be made. Also, when provided by an approved provider and all of if you have a chronic disease, your doctor may the following are true: check your condition with tests. These types of

PBCBSAK SCER 01-2017 19 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska screenings and tests help to diagnose or monitor Includes pre-colonoscopy consultations, exams, your illness and would not be covered under your colonoscopy, sigmoidoscopy and fecal occult preventive benefits. They would require you to pay blood tests. Removal and pathology (biopsy) a greater share of the costs. related to polyps found during a screening procedure are covered as part of the preventive You can also get a complete list of the preventive screening. Includes anesthesia your doctor care services with the limits on our website at considers medically appropriate for you. premera.com or call us for a list. This list may be 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  Diabetes screening preventive guidelines.  Routine immunizations and vaccinations as This plan covers the following as preventive recommended by your doctor. These include services: seasonal, travel, and certain other immunization  Covered preventive services include those with an provided by a pharmacy or other mass immunizer “A” or “B” rating by the United States Preventive location. You can also get flu shots, flu mist, and Services Task Force (USPSTF); immunizations immunizations for shingles, pneumonia and recommended by the Centers for Disease Control pertussis (whooping cough) at a pharmacy or and Prevention and as required by state law; and other seasonal immunization center. If you use preventive care and screening recommended by an out-of-network provider for seasonal and travel the Health Resources and Services Administration immunizations you may need to pay out of pocket (HRSA). and submit a claim for reimbursement. See Sending Us a Claim for instructions.  Routine exams, also included are exams for school, sports and employment  Obesity screening and counseling for weight loss  Well-baby care, including those provided by a  Contraceptive management. Includes exams, qualified health aide treatment you get at your provider’s office, prescribed generic emergency contraceptives,  Women’s preventive exams. Includes pelvic and prescribed contraceptive supplies and exams, pap smears and clinical breast exams devices. Tubal ligation, vasectomy, and  Screening mammograms. See Diagnostic Lab, implanted devices (including removal) are also X-ray and Imaging for mammograms needed covered. See Prescription Drugs for prescribed because of medical condition. oral contraceptives and devices.  Pregnant women’s services such as diabetic  Removal of contraceptive devices approved by supplies, breast feeding counseling before and the U.S. Food and Drug Administration (FDA) after delivery and maternity diagnostic screening  Health education and training for covered  Electric breast pumps and supplies. Includes the conditions such as diabetes, high cholesterol and purchase of a non-hospital grade breast pump or obesity. Includes outpatient self-management rental of a hospital grade breast pump. The cost programs, training, classes and instruction. of the rental cannot be more than the purchase  Nutritional therapy. Includes outpatient visits with price. For electric breast pumps and supplies a doctor, nurse, pharmacist or registered purchased at a retail location you will need to pay dietitians. The purpose of the therapy must be to out of pocket and submit a claim for manage a chronic disease or condition such as reimbursement. See Sending Us a Claim for diabetes, high cholesterol and obesity. The instructions. number of therapy visits that are covered as  BRCA genetic testing for women at risk for certain preventive depends on your medical needs. breast cancers  Preventive drugs required by federal law. See  Professional services to prevent falling for Prescription Drugs. members who are 65 years and older and have a  Approved tobacco cessation programs history of falling or mobility issues recommended by your doctor. After you have  Prostate cancer screening. Includes digital rectal completed the program, please provide us with exams and prostate-specific antigen (PSA) tests. proof of payment and a completed reimbursement Annual tests for prostate cancer for high risk men form. You can get a reimbursement form on our under 40, all men 40 years of age and older, or as website at premera.com. See Prescription recommended by a doctor. Drugs for covered drug benefits.  Colon cancer screening for high risk individuals This Preventive Care benefit does not cover: under 50 years of age, all individuals 50 years of  Prescription contraceptives, including over the age or older, or as recommended by a doctor.

PBCBSAK SCER 01-2017 20 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 benefits. We will request these materials directly PEDIATRIC CARE from your dental provider. If we are not able to This plan covers vision and dental services for obtain the necessary materials, we will provide covered children. A child is eligible for these benefits only for those dental services we can verify services up to the end of the month following the as covered. th child’s 19 birthday, when all eligibility requirements Alternative Benefits are met. To determine benefits available under this plan, Vision Services alternative procedures or services with different fees This plan covers routine eye exams and glasses as that are consistent with acceptable standards of follows: dental practice are utilized. In all cases where there is an alternative course of treatment that is less  Vision exams by an ophthalmologist or an costly for a service that is covered under the plan, optometrist. A vision exam may consist of benefits for the treatment with the lesser fee will be external and ophthalmoscopic examination, provided. If you and your dental care provider determination of the best corrected visual acuity, choose a more costly treatment, you are responsible determination of the refractive state, gross visual for additional charges beyond those for the less fields, basic sensorimotor examination and costly alternative treatment. glaucoma screening.  Low vision evaluation and follow up visits by an Estimate of Dental Benefits ophthalmologist or an optometrist You can ask for an Estimate of Benefits. An  Glasses, frames and lenses Estimate of Benefits verifies, for the dental provider and yourself, your eligibility and benefits. It may  Contact lenses in lieu of lenses for glasses, also clarify, before services are provided, treatment including those required for medical reasons that is not covered in whole or in part. This can  Low vision devices, high powered spectacles, protect you from unexpected out-of-pocket magnifiers and telescopes when medically expenses. necessary An Estimate of Benefits is not required for you to  Sales tax, shipping and handling charges for receive your dental benefits. However, we suggest vision hardware that your dental care provider submit an estimate to Dental Services us for any proposed dental services in which you are concerned about your out-of-pocket expenses. This plan provides pediatric dental services for covered members. Our Estimate of Benefits is not a guarantee of payment. Payment of any service will be based on The covered services under this plan are classified your eligibility and benefits available at the time as Class I – Diagnostic and Preventive, Class II – services are provided. See How to Contact Us for Basic, and Class III – Major Services. The lists of the address and fax for an estimate of benefits, or services that relate to each type are outlined in the call Customer Service. following pages under Covered Services. These services are covered once all of the following Dental care coverage includes the following: requirements are met. It is important to understand Class I – Diagnostic and Preventive Services all of these requirements so you can make the most of your dental benefits.  Comprehensive,periodic and problem-focused oral evaluations are limited to 2 per calendar year This plan covers dental services if all the following Prophylaxis (cleanings) are limited to 2 per are true: 

PBCBSAK SCER 01-2017 21 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska calendar year  Periodontal maintenance following periodontal  Topical application of fluoride (including fluoride therapy is limited to 4 visits every 12 months varnish) is limited to 2 treatments per calendar  Full mouth debridement is limited to once per year lifetime  Sealants on permanent molars, preventive resin  Simple and surgical extractions (includes local restorations on permanent teeth, and sealant anesthesia and routine postoperative care) 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 limited to once per tooth every 36 months  Alveoloplasty  Covered x-rays include:  Removal of exostosis  Bitewing x-rays are limited to 2 per calendar  Incision and drainage of abscess (intra oral soft year tissue)  Periapical, occlusal, and cephalometric x-rays  Suture of wound up to 5 cm  Either a complete series (full-mouth series) x-  Bone replacement grafts for ridge preservation ray or panoramic films once every 60 months  Excision of pericoronal gingiva but not both  Treatment of post-surgical complications due to  Fixed and removable space maintainers unusual circumstances  Re-cement or re-bond space maintainers  Collection and application of autologous blood  Collection and preparation of genetic sample for concentrate product is limited to once every 36 laboratory analysis is limited to once per lifetime months  Genetic test and analysis for susceptibility to  Emergency palliative treatment. We require a diseases is limited to once per lifetime written description and/or office records of services provided  Diagnostic casts (study models)  Therapeutic drug injections provided in the dental  2D or 3D oral/facial photographic images office  Interpretation of diagnostic image by a provider  Adjustment to complete and partial dentures when that is not associated with capture of the image performed 6 or more months after the initial including report installation of the denture Class II – Basic Services  Repair to complete and partial dentures  Diagnostic professional consultation provided by a  Repair and re-cement fixed partial dentures dentist or physician other than the requesting (bridges) dentist or physician  Reline and rebase of dentures are limited to once  Protective restoration (sedative filling) every 36 months when performed 6 or more  Fillings, consisting of amalgam and resin-based months after the initial installation of the denture composite, on any tooth surface  Tissue conditioning  Prefabricated stainless steel crowns and  Cleaning and inspection of removable complete prefabricated porcelain crowns are covered for and partial dentures is limited to once every 60 members under age 15 and limited to once per months tooth every 60 months Class III – Major Services  Pin retention in addition to restoration  Crowns, onlays, and labial veneers when there is  Endodontic services include: significant loss of clinical crown and no other  Therapeutic pulpotomy dentally appropriate restoration will restore  Partial pulpotomy for apexogenesis on function is limited to once per tooth every 60 permanent teeth months  Pulpal therapy (resorbable filling) is covered for  Inlays will be reduced to the corresponding members up to age 11 and is limited to once amalgam filling allowance per tooth in a lifetime  Crown core buildup when done in conjunction  Non-surgical periodontal service include: with a covered crown when there is significant loss of clinical crown and no other dentally  Periodontal scaling and root planing is limited to appropriate restoration will restore function is once every 24 months limited to once per tooth every 60 months

PBCBSAK SCER 01-2017 22 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Prefabricated post and core in addition to crown This benefit does not cover:  Crown, inlay, onlay, and veneer repair  Re-evaluations  Resin infiltration of incipient smooth surface  Sialography lesions is limited to once every 36 months  Tomographic survey  Endodontic services include:  Cone beam, MRI or ultrasounds  Endodontic therapy (root canal)  Oral pathology laboratory  Retreatment of previous endodontic therapy  Oral tests and examinations except those listed in (root canal) the “Covered Section” of this contract  Apexification/recalcification  Oral hygiene instructions for control of dental  Pulpal regeneration disease  Apicoectomy/periradicular surgery  Plaque control programs including home fluoride  Root amputation kits  Hemisection  Removal of space maintainer  Periodontal surgery includes:  Gold foils  Osseous surgery, gingivectomy or  Post removal gingivoplasty, and gingival flap procedures are  Coping limited to once every 36 months  Direct and indirect pulp caps  Clinical crown lengthening  Surgical procedure for isolation of tooth with  Bone replacement graft and soft tissue allograft rubber dam, canal preparation and fitting of is limited to once every 36 months preformed dowel or post  Pedical, subepithelial and free soft tissue grafts  Anatomical crown exposure  Dentures and fixed partial dentures (bridges) are  Periodontal splinting and/or crown and bridgework limited to once every 60 months in conjunction with periodontal splinting  Implants, implant services, and implant supported  Connector bar prosthetics are subject to dental necessity and  Precision attachments, personalization, precious limited to once every 60 months metal bases and other specialized techniques  General anesthesia or intravenous conscious  Duplicate appliances sedation  Cleaning of appliances  Occlusal guard (nightguard) designed to minimize the effects of bruxism or other occlusal factors  Temporary, interim or provisional services for for members age 13 and older and is limited to crowns, bridges or dentures once every 12 months  Maxillofacial prosthetics, including fluoride gel  Occlusal guard adjustment is limited to once every carrier 24 months  Sinus augmentation  Implants, implant services and implant supported  Bone grafts when done in connection with prosthetics including abutments are subject to extractions or apicoectomies dental necessity and limited to once every 60  Biopsy of hard and soft oral tissue months  Surgical excision of soft tissue lesions  Orthodontia Services  Harvest of bone for use in grafting procedures Orthodontia services are covered only for medically necessary conditions, such as cleft  Radical resection of maxilla or mandible palate or cleft lip. We highly recommend a pre-  Removal of foreign body and removal of reaction service review prior to receiving orthodontia producing foreign bodies services. A pre-service review is used to  Surgical placement of temporary anchorage determine if a service meets medical necessity devices criteria. A pre-service review is not a guarantee of  Appliance removal payment. Ask your dental provider to contact our Customer Service Department to request a pre-  Intraoral placement of a fixation device not in service review on your behalf to confirm your conjunction with a fracture services are medically necessary. This benefit  Sialolithotomy, excision of salivary gland, does not cover cosmetic orthodontia services. sialodochoplasty and closure of salivary fistula

PBCBSAK SCER 01-2017 23 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Local, regional block, trigeminal division block Major Diagnostic X-ray and Imaging anesthesia, and non-intravenous conscious  Computed Tomography (CT) scan sedation  High technology ultrasound  Analgesia, anxiolysis, inhalation of nitrous oxide  Nuclear Cardiology  Evaluation for deep sedation or general anesthesia  Magnetic Resonance Imaging (MRI)  House, extended care facility and hospital calls  Magnetic Resonance Angiography (MRA)  Case presentation  Positron Emission Tomography (PET) scans  Behavior management This benefit does not cover:  Occlusal orthotic device  Preventive screening and tests. See Preventive Care for those covered services.  Occlusal orthotic device adjustment  Diagnostic services from an inpatient facility, an  Occlusion analysis and limited and complete outpatient facility, or emergency room that are occlusal adjustments billed with other hospital or emergency room  Enamel microabrasion, odontoplasty,internal and services. These services are covered under external bleaching inpatient, outpatient or emergency room benefits.  Stress breakers and athletic mouth guards  Diagnostic surgeries, biopsies and scope insertion  Services received or ordered when this plan is not procedures. See Surgery Services and Hospital in effect or when you are not covered under this Services for covered services. plan (including services and supplies started  Allergy tests. See Allergy Testing and before your coverage effective date or after the Treatment for covered services. date coverage ends) SURGERY SERVICES DIAGNOSTIC X-RAY, LAB AND IMAGING This plan covers inpatient and outpatient surgical This plan covers diagnostic medical tests that help services at a hospital or ambulatory surgical facility, find or identify diseases. Covered services include surgical suite or provider’s office. Some inpatient interpreting these tests for covered medical and outpatient surgeries must be prior authorized conditions. before you have them. See Prior Authorization for Preventive Care Screening and Tests details. Preventive care screening and tests are services Services of an assistant surgeon are covered as based on guidelines established by government stated in the Summary of Your Costs only when agencies and professional medical societies. For medically necessary. Assistant surgeons are not more information about what services are covered involved in the pre-operative or post-operative care as preventive see Preventive Care. and only assist during a surgical procedure at the direction of the primary surgeon. Benefits allowed Basic Diagnostic Lab, X-ray and Imaging for an assistant surgeon are based on their services includes: participation in this one element of your care and will  Diagnostic imaging and scans such as x-rays be their billed charges or 20% of the primary surgeon’s allowed amount, whichever is less.  Blood and blood services (storage and procurement, including blood banks) when Sometimes more than one procedure is done during medically necessary the same surgery. These may be two separate  Cardiac testing, including pulmonary function procedures or the same procedure on both sides of studies the body. In these cases, benefits for the main procedures will be based on the allowed amount for  Mammograms for a medical condition the first or main procedure. Benefits for the  Bone density screening for osteoporosis secondary procedure will be one half of the allowed  Barium enema amount for the main procedure.  Lab services Covered services include, but not limited to:  Neurological and neuromuscular tests  Anesthesia or sedation and postoperative care, as  Pathology tests medically necessary  Echocardiograms  Cornea transplants and skin grafts  Standard ultrasounds  Cochlear implants, including bilateral implants  Blood transfusion, including blood derivatives

PBCBSAK SCER 01-2017 24 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  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 illnesses such as cold, check-ups, follow-up visits  The use of an anesthesiologist for monitoring and and prescription drug requests. administering general anesthesia for endoscopies, colonoscopies and sigmoidoscopies unless EMERGENCY AMBULANCE SERVICES medically necessary when specific medical This plan covers emergency (ground, water or air) conditions and risk factors are present ambulance services to the nearest facility that can  Routine colonoscopy, sigmoidoscopy and barium treat your condition. The medical care you get enema screening. See Preventive Care for during the trip is also covered. These services are details. covered only when any other type of transport would  Breast reconstruction. See Mastectomy and put your health or safety at risk. Covered services Breast Reconstruction for those covered also include transport from one medical facility to services. another as needed for your condition, or to your home when medically necessary.  Transplant services. See Transplants for details.  Vasectomy. See Preventive Care for details. This plan covers ambulance services from licensed providers only and only for the member who needs EMERGENCY ROOM transport. This plan covers services you get in a hospital Prior authorization is required for non-emergency emergency room for an emergency medical ambulance services. See Prior Authorization for condition. An emergency medical condition includes details. things such as heart attack, stroke, serious burn, chest pain, severe pain or bleeding that does not URGENT CARE CENTERS stop. You should call 911 or the emergency number This plan covers care you get in an urgent care for your local area. You can go to the nearest center. Urgent care centers have extended hours hospital emergency room that can take care of you. and are open to the public. You can go to an urgent If it is possible, call your doctor first and follow their care center for an illness or injury that needs instructions. treatment right away. Examples are minor sprains, You do not need prior authorization for emergency cuts, and ear, nose and throat infections. Covered room services. You must let us know if you are services include the doctor services. admitted as an inpatient from the emergency room You may have to pay a separate copay (if any) or as soon as reasonably possible. See Prior coinsurance for other services you get during a visit. Authorization for details. This includes things such as x-rays, lab work, If you get emergency care from a Non-Participating therapeutic injections and office surgeries. See provider or hospital emergency room, you must pay those covered services for details. for any charges over the allowed amount. HOSPITAL SERVICES Covered services include the following: This plan covers services you get in a hospital.  The emergency room and the emergency room Benefits are limited to the least costly treatment doctor as shown on the Summary of Your Costs setting that is medically necessary for your condition.  Supplies and drugs used in the emergency room If you get services from Non-Preferred or Non- or urgent care center Participating provider at a Preferred INN Provider hospital, you will pay any amounts over the allowed  Services used for emergency medical screening amount. exams and for stabilizing an emergency medical condition Inpatient Care  Outpatient diagnostic tests billed by the All planned (elective) inpatient care requires prior

PBCBSAK SCER 01-2017 25 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska authorization from us before you get treatment. See MENTAL HEALTH, BEHAVIORAL HEALTH Prior Authorization for details. AND SUBSTANCE ABUSE Covered services include: This plan covers mental health care and treatment  Room and board, general duty nursing and for alcohol and drug dependence. A mental health special diets condition is any condition listed in the current Diagnostic and Statistical Manual (DSM),  Doctor services and visits published by the American Psychiatric Association,  Use of an intensive care or special care units excluding diagnosis and treatments for substance  Detoxification abuse. Benefits are limited to the least costly  Operating rooms, surgical supplies, anesthesia, treatment setting that is medically necessary for your drugs, blood and blood derivatives, dressing, condition. This plan complies with federal mental equipment and oxygen health parity requirements.  X-ray, lab and testing All planned inpatient care requires prior authorization from us before you get treatment. See Outpatient Care Prior Authorization for details. Covered services include: Mental Health and Behavioral Health Care  Operating rooms, procedure rooms and recovery This plan covers all of the following services: rooms  Inpatient, residential treatment, partial  Doctor services hospitalization and outpatient therapeutic visits to  Anesthesia manage or reduce the effects of the mental health  Services, medical supplies and drugs, blood and condition blood derivatives, dressings, equipment and  Individual, family or group therapy oxygen that the hospital provides for your use in  Lab and testing the hospital  Take-home drugs you get in a facility  Lab and testing services billed by the hospital and done with other hospital services  Applied behavior analysis (ABA) for the treatment of autism Anesthesia for Dental Services  Physical, speech and occupational therapy In some cases, this plan covers anesthesia services provided to treat a mental health condition, for dental procedures. Covered services include including autism spectrum disorders general anesthesia and fees paid to the  Biofeedback anesthesiologist. Also covered are the related facility charges (inpatient or outpatient) for a hospital  Services received from individuals supervised by or ambulatory surgical center. These services are an autism service provider treating autism covered only when medically necessary for one of spectrum disorders. See Definitions for the reasons: description of autism service providers.  The member is under age 19 or has a disability  Telehealth visits. Covered telehealth visits must and it would not be safe and effective to treat use secure, real-time video or audio services. them in a dental office For this benefit, “outpatient therapeutic visit” means  You have a medical condition (besides the dental a clinical treatment session with a mental health condition) that makes it unsafe to do the dental provider. treatment outside a hospital or ambulatory Substance Abuse surgical center This plan covers all of the following services: This benefit does not cover:  Inpatient, residential treatment, partial  Hospital stays that are only for testing, unless the hospitalization and outpatient visits to manage or tests cannot be done without inpatient hospital reduce the effects of the alcohol or drug facilities, or your condition makes inpatient care dependence medically necessary  Individual, family or group therapy  Any days of inpatient care beyond what is medically necessary to treat the condition  Lab and testing  Dental treatment or procedures  Take-home drugs you get in a facility Please Note: Medically necessary detoxification is covered in any medically necessary setting. Detoxification in the hospital is covered under the

PBCBSAK SCER 01-2017 26 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Emergency Room and Hospital Services –  Supervision of therapy assistants Inpatient Care benefits.  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 does not meet the definition of “Substance Abuse”  Childhood disintegrative disorder as stated in Definitions  Pervasive developmental disorder  Training of therapy assistants/behavioral  Rett’s disorder 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 neurologist (e.g., recreational activities, eating out, shopping, play activities, medical appointments), except  A state-licensed psychiatric nurse practitioner when the member/identified patient has (NP), advanced nurse practitioner (ANP) or demonstrated a pattern of significant behavioral advanced registered nurse practitioner (ARNP) difficulties during specific activities and such  A state-licensed masters-level mental health accompaniment is medically necessary as part of clinician (e.g., licensed clinical social worker, continuing therapy licensed marriage and family counselor, licensed  Transporting the member/identified patient in lieu mental health counselor) of parental/other family member transport  A state-licensed occupational or speech therapist  Assisting the member with academic work or when providing ABA services functioning as a tutor, except when the member  A state-licensed psychologist has demonstrated a pattern of significant  Licensed Community Mental health or Behavioral behavioral difficulties during school work and such Health agency that is also state certified for ABA assistance is medically necessary as part of continuing therapy  Board certified Behavior Analyst, licensed in states with behavior analyst licensure,  Functioning as an educational or other aide for the otherwise, certified by the Behavior Analyst member/identified patient in school Certification Board  Provision of services that are part of an  Other providers, including therapy Individualized Education Program (IEP) and assistants/behavioral technicians/ therefore should be provided by school personnel, paraprofessionals; when services are or other services that schools are obligated to supervised and billed by a licensed provider or provide Board Certified Behavioral Analyst (BCBA)  Provider doing house work or chores, or assisting  Any other provider with appropriate training in the member/identified patient with house work or behavioral analysis, or whose scope of licensure chores, except when the member has includes behavioral analysis demonstrated a pattern of significant behavioral difficulties during specific house work or chores, Covered services include: or acquiring the skills to do specific house work or  Direct treatment or direct therapy services for chores is part of the ABA treatment plan for the identified patients and/or family members when member/identified patient and such assistance is provided by a licensed provider, Board Certified medically necessary as part of continuing therapy Behavioral Analyst (BCBA), or therapy  Babysitting assistants who are supervised by a licensed  Respite for parents/family members provider or BCBA  Provider residing in the member’s home and  Also covered when performed by a licensed functioning as live-in help (e.g., in an au-pair role) provider or BCBA:  Peer-mediated groups or interventions  Initial evaluation/assessment  Training or classes for groups of parents of  Treatment review and planning different patients

PBCBSAK SCER 01-2017 27 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Hippotherapy/equestrian therapy following a cesarean section. A length of stay that  Pet therapy will be longer than these limits must be prior 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  For ABA, any other activity that is not considered includes pediatrician services. Benefits for the to be a behavioral assessment or intervention newborn services are subject to the newborn’s cost- utilizing applied behavioral analysis techniques shares. The hospital stay for the newborn is 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 when provided for an illness or injury treated in an soon as reasonably possible. acute care hospital, or inpatient/residential treatment provided for a mental health condition Newborn children of a covered member are covered from the moment of birth. See the dependent  Neurofeedback and EEG biofeedback eligibility and enrollment guidelines under Eligibility  Family and marriage counseling or therapy, and Enrollment for details. except when it is medically necessary to treat your Covered newborn care services include the mental condition following:  Therapeutic or group homes, foster homes,  Hospital nursery care nursing homes, boarding homes or schools and child welfare facilities  Circumcision  Outward bound, wilderness, camping or tall ship  Newborn hearing screening exams. Your costs programs or activities for these services depend on where the services are received. If the newborn is tested in the  Mental health tests that are not used to assess a hospital, you pay your cost-share for Hospital covered mental health condition or plan of Services. For office visits, you pay the Office and treatment. This plan does not cover tests to Clinic Visits cost-share. For diagnostic services, decide legal competence or for school or job you pay the cost-share for Diagnostic X-ray, Lab placement. and Imaging.  Detoxification services that do not consist of  One screening within 30 days of the date of birth active medical management. See Definitions.  A diagnostic hearing evaluation for children up to  Support groups, such as Alanon or Alcoholics age 24 months if the newborn screening shows an Anonymous impairment  Services that are not medically necessary. This is true even when a court orders them or you must This benefit does not cover routine outpatient well get them to avoid being tried, sentenced or losing baby care. See Preventive Care for those covered the right to drive. services.  Sober living homes, such as halfway houses This benefit does not cover:  Residential treatment programs or facilities that  Complications of pregnancy. These services are are not units of hospitals, or that the state has not covered as other medical conditions and benefits licensed or approved for residential treatment are based on the type of services you get. For example, office visits are covered as shown under  Caffeine dependence Office and Clinic Visits. MATERNITY AND NEWBORN CARE  Outpatient x-ray, lab and imaging. These services Maternity Care are covered under Diagnostic Lab, X-ray and Imaging. This plan covers doctors and facility charges for  Home birth services provided by family members prenatal care, delivery and postnatal care. The or volunteers hospital stay for the mother is covered up to 48 hours for a vaginal delivery or up to 96 hours

PBCBSAK SCER 01-2017 28 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska HOME HEALTH CARE purpose of helping you and your caregivers to adjust to the approaching death Home health care services must be part of a written 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 be for the purpose of occasional respite for your Covered services include: 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 This benefit does not cover: care  Over the counter (OTC) drugs, solutions and  Rehabilitation therapies provided for purposes of nutritional supplements symptom control or to enable you to maintain activities of daily living and basic functional skills  Services provided to someone other than the ill or injured member  Continuous home care during a period of crisis in which you require skilled intervention to achieve  Services provided by family members or palliation or management of acute medical volunteers symptoms  Services, supplies, or providers not in the written This benefit does not cover: plan of care or not named as covered in this benefit  Over the counter (OTC) drugs, solutions and nutritional supplements  Custodial care  Services provided to someone other than the ill or  Nonmedical services, such as housekeeping injured member  Services that provide food, such as Meals on  Services provided by family members or Wheels or advice about food volunteers HOSPICE CARE  Services, supplies or providers not in the written This plan covers hospice care. The benefit limit plan of care or not named as covered in this shown on the Summary of Your Costs may be benefit extended for an extra 6 months when medically  Custodial care, except for hospice care services necessary for your condition.  Nonmedical services, such as housekeeping, All inpatient hospice care requires prior authorization dietary assistance or spiritual bereavement, legal from us before you receive treatment. See Prior or financial counseling Authorization for details.  Services that provide food, such as Meals on Covered services include: Wheels or advice about food  Palliative care for members facing serious, life- REHABILITATION THERAPY threatening conditions, including expanded This plan covers medically necessary inpatient and access to home based care and care outpatient rehabilitation therapies. Rehabilitative coordination. Participation in palliative care is therapy services or devices are provided when usually approved for 12 months at a time and may medically necessary for the restoration of bodily or be extended based on the member’s specific cognitive functions lost due to a medical condition. condition. These services must be provided by a state-licensed  Nursing care provided by or under the supervision or state-certified provider acting within the scope of of a registered nurse their license or certification.  Medical social services provided by a medical Covered services include all of the following: social worker who is working under the direction of a doctor; this may include counseling for the  Physical, speech, and occupational therapies

PBCBSAK SCER 01-2017 29 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Chronic pain care. Chronic pain is pain that is does not apply to chronic conditions such as cancer, hard to control or that will not stop. Treatment for chronic pulmonary or respiratory disease, cardiac chronic pain is not subject to the 24-month limit for disease or other similar chronic conditions or inpatient care. diseases.  Cardiac and pulmonary rehabilitation This benefit does not cover:  Massage therapy. If provided by a massage  Recreational, vocational or educational therapy therapist who is not licensed by the state, the  Exercise programs services must be billed by a supervising doctor to be covered.  Maintenance therapy, therapy performed to maintain a current level of functioning without  Assessments and evaluation related to documentation of significant improvement rehabilitative therapy  Social or cultural therapy  Rehabilitative devices that have been approved by the FDA and prescribed by a qualified provider  Treatment that the ill, injured or impaired member does not actively take part in Inpatient Care  Gym or swim therapy You must get inpatient care in a specialized  Custodial care rehabilitative unit of a hospital or in a separate rehabilitation facility. If you are already in inpatient  Inpatient rehabilitative therapy received more than care, this benefit will start when your care becomes 24 months after the accidental injury, the start of mainly rehabilitative. the illness, or the date of surgery  Neurodevelopmental therapy or treatment of You must get prior authorization from us before you developmental or neurodevelopmental disabilities. get inpatient treatment. See Prior Authorization for See Habilitation Therapy for details. details.  Treatment for mental health, behavioral health or This plan covers inpatient rehabilitative therapy only substance abuse. See Mental Health, when all of the following are true: Behavioral Health and Substance Abuse for  You get the services within 24 months after the those covered services. injury occurred, the date the illness started, or the HABILITATION THERAPY date of the surgery that made you need rehabilitation. This plan covers medically necessary and  You cannot get the services in a less intensive appropriate services and devices for development of setting bodily or cognitive functions to perform activities of daily living that never developed or did not develop  The care is part of a written plan of treatment to appropriately based on the chronological age of the be provided by several specialists. A doctor member. specializing in rehabilitative medicine prescribed this treatment plan and reviews it regularly. Habilitative services include: Outpatient Care  Physical therapy  Neurodevelopmental therapy This plan covers these services only when all of the following are true:  Occupational therapy  You are not staying in a hospital or other medical  Speech language therapy facility.  Massage therapy. If provided by massage  The therapy is a part of a formal written treatment therapist who is not licensed by the state, the plan prescribed by a doctor. services must be billed by a supervising doctor to be covered.  Services are provided and billed by a hospital, a rehabilitation facility approved by us, or another  Habilitative devices that have been approved by licensed provider. FDA and prescribed by a qualified provider. A “visit” is one session of treatment for each type of The outpatient visit limit listed in the Summary of therapy. Each type of therapy counts toward the Your Costs applies to non-chronic conditions. It combined benefit maximum limit listed in the does not apply to chronic conditions such as Summary of Your Costs. If you have two or more cancer, chronic pulmonary or respiratory therapy sessions in one day with the same provider, disease, cardiac disease or other similar chronic it counts as one visit. conditions or diseases. This benefit does not cover: The outpatient visit limit listed in the Summary of  Respite care Your Costs applies to non-chronic conditions. It

PBCBSAK SCER 01-2017 30 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  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  Wheelchairs substance abuse. See Mental Health, 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- approved skilled nursing facility. Sometimes a This plan covers medically necessary supplies patient goes from acute nursing care to skilled ordered by your doctor, including but not limited to nursing care without leaving the hospital. When that the following: happens, this benefit starts on the date that the care  Dressings, braces, splints, rib belts and crutches becomes primarily skilled nursing care.  Ostomy supplies Skilled nursing care is covered only during certain  Blood glucose monitors, insulin pumps and stages of your recovery. It must be a time when accessories inpatient hospital care is no longer medically  Casts, braces and supportive devices when used necessary, but care in a skilled nursing care facility in the treatment of medical or surgical conditions is medically necessary. Your doctor must actively in acute or convalescent stages or as immediate supervise your care while you are in the skilled post-surgical care nursing facility.  Medical devices surgically implanted in a body You must get prior authorization from us before you cavity to replace or aid the function of an internal get treatment. See Prior Authorization for details. organ This benefit does not cover: Medical Foods  Custodial care This plan covers medically necessary medical foods  Care that is mainly for senile deterioration, mental for supplementation or dietary replacement for the deficiency or retardation treatment of an inborn error of metabolism. It must  Treatment for substance abuse be prescribed by a doctor. An example of an inborn error of metabolism is phenylketonuria (PKU). In HOME MEDICAL EQUIPMENT (HME), some cases of severe malabsorption (eosinophilic ORTHOTICS, PROSTHETICS AND SUPPLIES gastrointestinal disease) a medical food called Covered services include home medical equipment, “elemental formula” may be covered. orthotics, prosthetics, certain medical foods, supplies Medical foods are foods that are formulated to be and sales tax for covered items. Some services consumed or administered orally or enterally under require prior authorization. See the Prior strict medical supervision. Medical foods generally Authorization section for details. provide most of a person’s nutrition. Medical foods Medical and Respiratory Equipment are designed to treat a specific problem that can be diagnosed using medical tests. The rental costs for medical and respiratory equipment and the fitting expenses are covered. This benefit does not cover other oral nutrition or Benefits will not be greater than the purchase price supplements not used to treat inborn errors of of the equipment. It must be medically necessary metabolism, even if prescribed by a doctor. This and prescribed by a doctor to treat a covered illness includes but is not limited to specialized infant or injury. formulas and lactose free foods. Benefits may also be provided for the initial Medical Vision Hardware purchase of equipment, in lieu of the rental cost. In Benefits for medical vision hardware, including

PBCBSAK SCER 01-2017 31 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 replace all or part of an absent body limb or to determined otherwise replace all or part of the function of a permanently inoperative or malfunctioning body organ.  Prosthetics, intraocular lenses, appliances or devices requiring surgical implantation. These Covered services include the following: items are covered under surgical benefits. Items  Prosthetic devices such as an artificial limb, provided and billed by a hospital are covered external breast prosthesis following mastectomy, under the Hospital Services benefit for inpatient artificial eye and outpatient care.  Orthotic devices, supports or braces applied to an  Items provided and billed by a hospital. These existing portion of the body for weak or ineffective are covered under Hospital Services. joints or muscles  Over the counter orthotic braces and/or cranial  Maxillofacial prosthetic devices that are required banding for the restoration and management of head and  Non-wearable defibrillator, trusses and ultrasonic facial structures that cannot be replaced by living nebulizers tissue, are defective due to disease, trauma or developmental deformity, to control or eliminate  Blood pressure cuff/monitor (even if prescribed by infection and pain and restore facial configuration a doctor) and function  Enuresis alarm Benefits will only be provided for the initial purchase  Compression stockings which do not require a of a prosthetic device, unless the existing device prescription cannot be repaired. Replacement devices must be OTHER COVERED SERVICES prescribed by a doctor because of a change in your physical condition. Acupuncture Orthopedic Shoes and Shoe Inserts This plan covers acupuncture. Services include treatment to relieve pain, to help with anesthesia for Benefits are provided for medically necessary surgery, or to treat a covered illness, injury, or shoes, inserts or orthopedic shoes for the treatment condition. of diabetes or for other correction purposes. Covered services also include training and fitting. A “visit” is one session of consultation, diagnosis, or treatment with a provider. Two or more visits on the This benefit does not cover: same day with the same provider count as one visit.  Needles, syringes, lancets, test strips, testing Two or more visits on the same day with different agents and alcohol swabs. See Prescription providers count as separate visits. Drugs for covered services. Air or Surface Transportation (Commercial)  Supplies or equipment not primarily intended for medical use This benefit covers transportation via commercial  Special or extra-cost convenience features carrier when you have a serious medical condition that cannot be treated locally. Round trip air or  Fitness items such as exercise equipment and surface transportation by a licensed commercial

PBCBSAK SCER 01-2017 32 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska carrier is provided only for the ill or injured member. Medicare and Medicaid Services, the United States The trip must begin in Alaska where you became ill Department of Defense or the United States or injured and end at the closest in-network provider Department of Veterans Affairs. 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 18, this benefit will also cover a parent or guardian  Palliative care, diagnosis and treatment of the to accompany the child. symptoms of cancer, any complications and the 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  Transportation for routine dental, vision and following: hearing services  Travel between where you are living and the  Transport by taxi, bus, private car or rental car place of the cancer clinical trial  Meals and lodging  Commercial coach (economy) fare for air transportation Allergy Testing and Treatment  Travel for follow-up care that cannot be This plan covers allergy tests and treatments. provided near your home Covered services include testing, shots given at the For ambulance benefits see Emergency doctor’s office, serums, needles and syringes. Ambulance Services. Chemotherapy, Radiation Therapy and This benefit does not cover: Kidney Dialysis  Clinical trials not approved as described above This plan covers services for chemotherapy,  The drug, device or services being tested, except radiation therapy and kidney dialysis. Covered as described under Cancer Clinical Trials services include the following:  Travel costs, except as described under Cancer  Anti-cancer medications used to kill or slow the Clinical Trials growth of cancerous cells  Services required only for the provision or  Outpatient professional services, supplies, drugs monitoring the drug and solutions ordered by your doctor and outpatient facility charges.  Housing, meals, or other nonclinical expenses  Services needed for the prevention, diagnosis or This benefit does not cover prescribed drugs. See treatment of complications of the drug being Prescription Drugs for those covered services. tested, except as described under Cancer Prior authorization is required for radiation therapy Clinical Trials and for some drugs. See Prior Authorization for  Services only for data collection and analysis and details. that are not used directly for your care Clinical Trials  Items or services excluded from coverage under this plan This plan covers the routine costs of a qualified clinical trial. Routine costs mean medically  Services that are free of charge from the sponsor necessary care that is normally covered under this of the clinical trial or the manufacturer, distributor plan outside a clinical trial. Benefits are based on or provider of the drug or device the type of services you get. For example, benefits  Items or services paid for, or usually paid for, of an office visit are covered under Office and through grants or other funding Clinic Visits, and lab tests are covered under  Services that are not routine costs normally Diagnostic X-ray, Lab and Imaging. covered under this plan A qualified clinical trial is a trial that has been We encourage you or your provider to call Customer approved by an institutional review board that Service before you enroll in a clinical trial. We can complies with federal law. It must also be approved help you verify that the clinical trial is a qualified by the National Institutes of Health, the Center for clinical trial. You may also be assigned a Case Disease Control and Prevention, the Agency for Manager to work with you and your provider. See Healthcare Research and Quality, the Centers for Personal Health Support Programs for details.

PBCBSAK SCER 01-2017 33 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Community Wellness and Safety Programs  Bursitis This plan covers programs that promote health and  Hammer toe 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 parenting skills. You pay for the cost of the program  Neuroma 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 Service to request a copy of the reimbursement  Warts, including plantar warts form. Hearing Exams and Hardware Dental Accidents This plan covers hearing exams and hardware. This plan covers accidental injuries to teeth, gums or Before you receive your hearing hardware benefit: 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: Services for those costs.  One otologic (ear) examination by a doctor Services are covered when all of the following are  One audiologic (hearing) examination and hearing true: evaluation by a certified or licensed audiologist,  Treatment is needed because of an accidental including a follow-up consultation injury  Hearing aids (monaural or binaural) prescribed as  The treatment is done within 12 months of the a result of the examinations accidental injury. If the treatment cannot be  Ear molds completed within 12 months, you can ask for an  Hearing aid instruments extension. We must receive your request for an extension no more than 12 months after the injury.  Hearing aid rental while the primary unit is being repaired  The treatment is done on the natural tooth structure and the teeth were free from decay and  Initial batteries, cords, and other necessary functionally sound when the injury happened. ancillary equipment “Functionally sound” means that the teeth do not  A warranty have:  A follow-up consultation within 30 days following  Extensive restoration, veneers, crowns or delivery of the hearing aids with either the splints prescribing doctor or audiologist  Periodontal (gum) disease or any other  Repairs, servicing, and alteration of hearing aid condition that would make them weak equipment This plan does not cover damage from biting or This benefit does not cover: chewing, even when caused by a foreign object in  Replacement of a hearing aid for any reason more food. often than once in a three consecutive calendar We recommend that your provider call Customer year period Service before you get treatment.  Batteries or other ancillary equipment other than that obtained upon purchase of the hearing aids Foot Care  Hearing aids which exceed the specifications This plan covers medically necessary foot care. prescribed for correction of hearing loss Foot care may be considered medically necessary  Expenses incurred after your coverage ends for a member with impaired blood flow to the legs under this plan unless hearing aids were ordered and feet when the complexity of the condition puts prior to that date and were delivered within 90 the member at risk and care requires the services of days after the day your coverage ended a professional.  Hearing aid charges in excess of this benefit are In addition to medical foot care described above, not eligible under this plan’s other benefits benefits for foot care also include:  Hearing aids purchased prior to your effective  Bunion date of coverage on this plan

PBCBSAK SCER 01-2017 34 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 Drugs for those covered services.  Ferry transportation expenses for the member and a companion from the member’s home community Mastectomy and Breast Reconstruction  Lodging expenses at commercial establishments This plan covers a mastectomy needed because of (hotels and motels) for the member and a disease, illness, accidental injury, or a genetic companion while traveling between home and the predisposition to a high risk of breast cancer and medical facility where services will be provided, breast reconstruction. For any member electing based on current IRS guidelines breast reconstruction in connection with a Air travel and lodging arrangements can be made by mastectomy, this benefit covers: Premera’s travel partner or by the member.  Reconstruction of the breast on which mastectomy has been performed including but not Expenses must be incurred while the member is limited to nipple reconstruction, skin grafts and covered under the plan. stippling of the nipple and areola Please Note: Companion travel and lodging  Surgery and reconstruction of the other breast to expenses are only covered if they must, as a matter produce a symmetrical appearance of medical necessity or safety, accompany the  Prostheses member.  Complications of all stages of mastectomy, The full price for these expenses must be paid in including lymphedemas advance, and a claim for reimbursement must be submitted. Please see How To File a Medical  Inpatient care related to the mastectomy and post- Travel Support Claim below for more information. mastectomy services This benefit does not cover: Services are provided in a manner determined by the attending doctor with the patient in accordance  Reimbursement for travel to an in-network facility with state requirements and federal WHCRA 1998 not on the list of eligible providers before requirements. contacting us and receiving approval. If a procedure is performed at a facility that is not on Some services require prior authorization before you the list, travel expenses will not be reimbursed if get treatment. See Prior Authorization for details. the total cost of the procedure, plus travel Medical Travel Support expenses, exceeds the cost of having that procedure performed at a facility in Alaska. This benefit provides travel costs for members who  Travel to providers outside the network reside in Alaska only for specified non-emergent medical procedures performed at certain in-network  International travel providers. Please contact Customer Service for a  Airline charges and fees for booking changes list of eligible procedures and providers. Before you  Reimbursement for mileage rewards or frequent travel to a provider not on the list you must get prior flier coupons approval. Approval is based on the member’s medical condition, and the provider who will be  Travel for ineligible medical procedures performing the services. Please contact Customer  Lodging at any establishment that is not a hotel or

PBCBSAK SCER 01-2017 35 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska motel disabilities. See Habilitation Therapy.  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,  Pet care, except for service animals injury or condition. Related diagnostic laboratory or x-rays services consistent with Current Procedural  Phone service and long distance calls Terminology (CPT) guidelines are covered as How To File a Medical Travel Support Claim: outpatient x-ray and lab services as shown on the 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 duration guidelines. This benefit does not cover: You must also attach the following documents:  X-ray and lab, except when they are consistent with Current Procedural Terminology (CPT)  The boarding pass and a copy of the ticket from guidelines. See Diagnostic Lab, X-ray and the airline or other transportation carrier. The Imaging for covered services tickets must indicate the name(s) of the passenger(s), dates and total cost of travel, and Therapeutic Injections the origination and final destination points; or This plan covers therapeutic injections given at a  A copy of the detailed itinerary as issued by the doctor's office, including serums, needles and airline, transportation carrier, travel agency or syringes. online travel website. The itinerary must identify the name(s) of the passenger(s), the dates of Some injectable medications require prior travel and total cost of travel, and the origination authorization; see Prior Authorization for details. and final destination points. Transplants  Receipts for all covered travel expenses This plan covers transplant services. These  A Utilization Management Authorization number services are covered only when they are provided at for travel to providers not on the list an approved transplant center. An approved Credit card statements or other payment receipts are transplant center is a hospital or other provider that not acceptable forms of documentation. Premera Blue Cross Blue Shield of Alaska has approved for solid organ transplants or bone marrow Psychological and Neuropsychological or stem cell reinfusion. Please call us as soon as Testing you learn you need a transplant. Some services Covered services include interpretation and report require prior authorization from us before you get preparation needed to prescribe an appropriate treatment. See Prior Authorization for details. treatment plan. This includes later re-testing to Covered Transplants make sure the treatment is achieving the desired medical results. This plan covers only transplant procedures that are not considered experimental or investigational for Coverage for autism spectrum disorders includes your condition. Solid organ transplants and bone services received from individuals supervised by an marrow/stem cell reinfusion procedures must meet autism service provider (see Definitions). coverage criteria. We review the medical reasons This benefit does not cover: for the transplant, how effective the procedure is and possible medical alternatives. This plan covers the  Physical, speech or occupational assessments following types of transplants: and evaluations for rehabilitation. See Rehabilitation Therapy or Mental Health,  Heart Behavioral Health and Substance Abuse for  Heart/double lung those covered services.  Single lung  Physical, speech or occupational therapy  Double lung assessments related to neurodevelopmental

PBCBSAK SCER 01-2017 36 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Liver Lodging Allowances: Expenses incurred by a  Kidney transplant patient and companion for hotel lodging away from home is reimbursed based on current IRS  Pancreas guidelines.  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 This benefit does not include cornea transplants or necessity or safety, accompany the member. skin grafts. It also does not include transplants of  Adult Patient – 1 companion is permitted 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; see Surgery Services. This benefit does not cover the following: Recipient Costs  Transplants or related services from a provider not approved by us This plan covers services from an approved transplant center and related professional services.  Services that will be paid by any government, This benefit also provides coverage for anti-rejection foundation, or charitable grant. This includes drugs given by the transplant center. services performed on potential or actual living donors or recipients and on cadavers. Covered services consist of all phases of treatment:  Donor costs for a transplant that is not covered  Evaluation under this benefit or when the recipient is not a  Pre transplant care member  Transplant  Donor costs that may be covered by other group or individual coverage  Follow up treatment  Nonhuman or mechanical organs that are Donor Costs experimental or investigative This plan covers donor or procurement expenses for  Planned blood storage for more than 12 months a covered transplant as shown in the Summary of for possible future use Your Costs. Covered services include:  Alcohol/tobacco  Selection, removal (harvesting) and evaluation of  Car rental the donor organ, bone marrow or stem cell  Entertainment (such as movies, visits to  Transportation of the donor organ, bone marrow museums, additional mileage for sightseeing, etc.) or stem cells, including the surgical and harvesting teams  Meals  Donor acquisition costs such as testing and typing  Personal care items (such as: shampoo, expenses deodorant, etc.)  Storage costs for bone marrow and stem cells for  Souvenirs (such as t-shirts, sweatshirts, toys, etc.) up to 12 months  Telephone calls Transportation and Lodging PRESCRIPTION DRUGS This plan covers costs for transportation and lodging This plan covers prescription drugs. Some for the member getting the transplant (while not prescription drugs require prior authorization. See confined). The member getting the transplant must Prior Authorization for details. live more than 50 miles from the facility, unless treatment protocols require them to remain closer to This plan also covers prescription drugs for “off- the transplant center. label” use, including administration, of prescription drugs for treatment of a covered condition when use Travel Allowances: Travel is reimbursed between of the drug is recognized as effective for treatment of the patient’s home and the facility for round trip (air, such condition by one of the following: train, or bus) transportation costs (coach class only).  One of the following standard reference If traveling by auto to the facility, mileage, parking compendia: and toll costs are reimbursed. Mileage reimbursement will be based on the current IRS  The American Hospital Formulary Service-Drug medical mileage reimbursement. Please refer to the Information IRS website http://www.irs.gov for current rates.  The American Medical Association Drug

PBCBSAK SCER 01-2017 37 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 condition, including a statement that all covered  Other authoritative compendia as identified formulary drugs on any tier will be (or have been) from time to time by the Federal Secretary of ineffective, would not be as effective as the non- Health and Human Services or the Insurance formulary drug, or would have adverse side effects. Commissioner 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 Expedited Exceptions Request for Non- labeling. Formulary Drugs Benefits are not available for any drug when the If exigent circumstances exist, you or your provider U.S. Food and Drug Administration (FDA) has may request that you get a non-formulary drug or a determined its use to be contra-indicated, or for dose that is not on the drug list. Exigent experimental or investigational drugs not otherwise circumstances include when you are suffering from a approved for any indication by the FDA. health condition that may seriously jeopardize your life, health or ability to regain maximum body Prescription Drug Formulary function or when you are undergoing a current This benefit uses a specific list of covered course of treatment using a non-formulary drug. In prescription drugs, sometimes referred to as a addition to your provider’s justification for the non- formulary. Our Pharmacy and Therapeutics formulary drug as described above, your provider Committee, which includes medical practitioners and will need to give us an oral or written statement that pharmacists from the community, frequently reviews confirms that an exigency exists, including the basis current medical studies and pharmaceutical for the exigency (the harm that could reasonably information. The committee then makes come to you if the requested non-formulary drug recommendations on which drugs are included in was not provided within the timeframes of the our drug lists. The drug lists are updated quarterly standard Exceptions Request). based on the committee’s recommendations. External Review for Non-Formulary Drugs The formulary includes preferred generic drugs, If you disagree with our decision, you may ask for an preferred name drugs and non-preferred drugs. additional review by an independent review Consult the Pharmacy Benefit Guide or RX search organization (IRO). We will let you and your tool listed on our website at premera.com. You can provider know the decision within 72 hours (24 hours also call Customer Service for a complete list of this in the case of an expedited exception) of the IRO’s plan’s covered prescription drugs. receipt of the request. See Complaints and Drugs not included in the formulary are not covered Appeals. by this plan. If your provider determines that a generic FDA drug You or your provider may request that you get a approved for female contraception is medically non-formulary drug or a dose that is not on the drug inappropriate for you based upon the provider’s list either in writing, electronically, or by telephone. determination of medical necessity, your cost for a Under some circumstances, such as the ones listed preferred brand name or non-preferred name drug below, a non-formulary drug may be covered if one prescribed in its place will be covered the same as of the following is true: formulary preferred generic drugs.  There is no formulary drug or alternative available If you disagree with our decision you may ask for an appeal. See Complaints and Appeals for details.  You cannot tolerate the formulary drug  The formulary drug or dose is not safe or effective Covered Prescription Drugs for your condition  FDA approved formulary prescription drugs.

PBCBSAK SCER 01-2017 38 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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  Glucagon emergency kits such as rheumatoid arthritis, hepatitis, multiple 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 network specialty pharmacies to arrange ordering  FDA approved oral contraceptive drugs and and delivery of these drugs, however, it is not a devices such as diaphragms and cervical caps requirement. Please note that out-of-network mail-  Oral chemotherapy drugs order Specialty pharmacies are not covered.  Drugs associated with an emergency medical Contact Customer Service for details on which drugs condition (including drugs from a foreign country) are included in the specialty pharmacy program, or Dispensing Limits visit our website at premera.com. Benefits are limited to a certain number of days’ Diabetic Injectable Supplies supply as shown in the Summary of Your Costs. Whether injectable diabetic drug needles and Sometimes a drug maker’s packaging may affect the syringes are purchased along with injectable supply in some other way. We will cover a supply diabetic drugs or separately, the deductible and greater than normally allowed under this plan if the applicable cost-share applies to all items. The packaging does not allow a lesser amount. You deductible and applicable cost-share also applies to must pay your applicable cost-share for each limited purchases of alcohol swabs, test strips, testing days’ supply. agents and lancets. Preventive Drugs Anti-Cancer Medications Benefits for certain preventive care drugs are This benefit covers medications that are injected or covered as shown in the Summary of Your Costs intravenously administered by your doctor and self- when prescribed by your provider. These drugs are administered anti-cancer drugs when the medication limited to those required by federal health care is dispensed by a pharmacy. Anti-cancer reform, such as aspirin, folic acid and certain medication means a drug or biologic used to kill supplements. These drugs require a prescription cancerous cells to slow or prevent the growth of and may be limited to a certain age, condition, cancerous cells or to treat related side effects. dosage or type. You can get a complete list of these These drugs are covered as shown in the Summary drugs by logging into your secure website and of Your Costs. visiting My Plan Information at premera.com. You can also call Customer Service at the number on Drug Discount Programs your ID Card to get a list of these drugs. Premera may receive drug rebates or discounts. Using In-Network Pharmacies  Your benefit programs include per-claim rebates When you use a network pharmacy, always show that Premera receives from its pharmacy benefit your Premera ID Card. As a member, you will not manager or other vendors. We consider these be charged more than the allowed amount for each rebates when we set the subscription charges, or prescription or refill. The pharmacy will also submit we credit them to administrative charges that we your claims to us. You only have to pay the would otherwise pay. These rebates are not deductible, copay (if any) or coinsurance as shown reflected in your allowed amount. in the Summary of Your Costs.  We also may receive discounts from our pharmacy benefit manager. These discounts are If you do not show your Premera ID Card, you will be

PBCBSAK SCER 01-2017 39 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska reflected in your allowed amount. If the allowed you will have lower out-of-pocket costs because the amount for prescription drugs is higher than the double strength tablets are less expensive than the price we pay after our discount, then Premera single-strength medication. does one of two things with this difference: Because the drugs are dispensed at double strength  We keep the difference and apply it to the cost and will be split, they will be dispensed at one-half of our operations and the prescription drug the normal dispensing limits listed above. 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 amount you pay and your account calculations are  Drugs and medicines that you can legally buy based on the allowed amount. over the counter (OTC) without a prescription. OTC drugs are not covered even if you have a Refills prescription. Examples include, but are not Benefits for refills will be provided when the member limited to, nonprescription drugs and vitamins, has used 75% of a supply of a single medication. herbal or naturopathic medicines, and nutritional The 75% is based on all of the following: and dietary supplements such as infant formulas or protein supplements. This exclusion does not  The number of units and days’ supply dispensed apply to OTC drugs that are required to be on the last refill covered by state or federal law.  The total units or days’ supply dispensed for the  Non-formulary generic and brand name drugs same medication in the 180 days immediately preceding the last refill.  Drugs from out-of-network specialty pharmacies  Drugs for cosmetic use such as for wrinkles You may request an early refill for topical eye medication when prescribed for a chronic eye  Drugs to promote or stimulate hair growth condition. Your request must be made no earlier  Biological, blood or blood derivatives than all of the following:  Any prescription refill beyond the number of refills  23 days after a prescription for a 30-day supply is shown on the prescription or any refill after one dispensed year from the original prescription  45 days after a prescription for a 60-day supply is  Lost or stolen medication dispensed  Infusion therapy drugs or solutions, drugs  68 days after a prescription for a 90-day supply is requiring parenteral administration or use, and dispensed injectable medications. Exceptions to this An early refill will be allowed if it does not exceed the exclusion are injectable drugs for self- number of refills prescribed by your doctor and only administration such as insulin and glucagon and once during the approved dosage period. growth hormones. See Infusion Therapy - Outpatient for covered infusion therapy services. Tablet Splitting Program  Drugs dispensed for use in a healthcare facility or The Tablet Splitting Program allows members to provider’s office or take-home medications. have reduced copays on certain prescription Exceptions to this exclusion are injectable drugs medications. for self-administration such as insulin and glucagon and growth hormones. Participation in the program is voluntary. When you participate, selected drugs are dispensed at double  Immunizations. See Preventive Care. strength. The individual tablets are then split by the  Drugs to treat infertility, to enhance fertility or to member into half-tablets for each use. We will treat sexual dysfunction provide you with a tablet splitter. The drugs eligible  Weight management drugs for the program have been selected because they are safe to split without jeopardizing quality or  Therapeutic devices or appliances. See Home effectiveness. Medical Equipment (HME), Orthotics, Prosthetics and Supplies. If you participate in the program, you will pay one- half the copays specified above for retail or mail EXCLUSIONS order drugs included in the program. If your plan This section lists the services that are either limited requires coinsurance rather than copays, the or not covered by this plan. In addition to the coinsurance percentage will remain the same, but services listed as not covered under Covered

PBCBSAK SCER 01-2017 40 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Services, all of the following are excluded from Clinical Trials coverage under this plan.  A drug or device associated with the approved Amounts Over the Allowed Amount clinical trial that has not been approved by the FDA Amounts over the allowed amount, as defined in this plan, are not covered. If you get services from a  Housing, meals, or other nonclinical expenses Non-Participating provider, you will have to pay  Items or services provided to satisfy data charges over the allowed amount. collection and analysis and not used in the clinical management of the patient Assisted Reproduction  An item or service excluded from coverage under This plan does not cover: this plan  Assisted reproduction methods, such as artificial  An item or service paid for or customarily paid for insemination or in-vitro fertilization through grants or other funding  Services to make you more fertile or for multiple Comfort or Convenience births  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 Benefits from Other Sources cover personal services or items like meals for guests, long-distance phone, radio or TV and This plan does not cover services that are covered personal grooming. Please see Transplants for by such types of insurance as: the transportation and lodging expenses  Motor vehicle medical or no-fault coverage exception.  Any type of no-fault coverage, such as Personal  Normal living needs, such as food, clothes, injury protection (PIP), Medical Payment coverage housekeeping and transport. This does not apply or Medical premises coverage to chores done by a home health aide as  Any type of liability insurance, such as home prescribed in your treatment plan. See Home owners’ coverage or commercial liability coverage Health Care and Hospice Care for details.  Any type of excess coverage  Help with meals, diets and nutrition. This includes  Boat coverage Meals on Wheels.  School or athletic coverage Cosmetic Services Benefits That Have Been Exhausted This plan does not cover services, drugs, or supplies for cosmetic purposes, including direct or indirect This plan does not cover benefits that have been complications and aftereffects are also not covered. exhausted Examples of what is not covered are: Biofeedback  Reshaping normal structures of the body in order to improve or change your appearance and self- This plan does not cover biofeedback services that esteem and not primarily to restore an impaired are not medically necessary or determined to be function of the body experimental or investigational, including EEG biofeedback and neurofeedback.  Genital surgery for the purpose of changing genital appearance Broken or Missed Appointments  Breast mastectomy or augmentation for the This plan does not cover charges for broken or purpose of changing the appearance of the missed appointments. breasts, with or without chest reconstruction Charges for Records or Reports The only exceptions to this exclusion are: This plan does not cover separate charges from  Repair of a defect that is the direct result of an providers for supplying records or reports, except injury, but only when the repair was started within those we request for clinical review. 12 months of the date of the event Clinical Trials  Repair of a dependent child’s congenital anomaly (see Definitions) This plan does not cover:  Reconstructive breast surgery in connection with  Clinical trials that are not an approved clinical trial a mastectomy, except as stated under as described in Clinical Trials Mastectomy and Breast Reconstruction  Travel costs, except as described for Cancer  Correction of functional disorders. The plan does

PBCBSAK SCER 01-2017 41 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 Family Members or Volunteers loss drugs. This plan does not cover services that you give to Counseling, Education or Training 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 Government Facilities while committing a felony, an act of terrorism, or an This plan does not cover services provided by a act of riot or revolt. state or federal hospital which is not a participating Custodial Care facility, except for emergency services or other covered services as required by law or regulation. This plan does not cover custodial care. Growth Hormone Dental Care This plan does not cover growth hormones for the This plan does not cover dental services except as following: stated in Pediatric Dental Services (under age 19).  To stimulate growth, except when it meets Dietary Services medical standards Dietary planning or nutritional counseling for the  Treatment of idiopathic short stature without control of dental caries growth-hormone deficiency Donor Breast Milk Hair Analysis This plan does not cover donor breast milk. This plan does not cover hair analysis. Drugs and Food Supplements Hair Loss This plan does not cover the following: This plan does not cover services to replace hair,  Over the counter drugs, solutions, supplies, slow hair loss, or make hair grow. This includes vitamins, food, or nutritional supplements, except wigs, hair weaves, hair transplants and implants, as required by law and drugs or other supplies.  Herbal, naturopathic, or homeopathic medicines Home Medical Equipment and Supplies or devices This plan does not cover: Employee Wellness Services  Supplies or equipment not primarily intended for This plan does not cover employee wellness medical use activities or programs.  Special or extra-cost convenience features Environmental Therapy  Items such as exercise equipment and weights This plan does not cover therapy to provide a  Orthopedic appliances prescribed primarily for use changed or controlled environment. during participation in sports, recreation or similar activities Experimental or Investigational Services  Penile prostheses This plan does not cover any service that is  Whirlpools, whirlpool baths, portable whirlpool experimental or investigational, see Definitions. pumps, sauna baths, and massage devices This plan also does not cover any complications or effects of such services.  Over bed tables, elevators, vision aids and telephone alert systems This does not apply to certain services that are part

PBCBSAK SCER 01-2017 42 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Structural modifications to your home and/or adult family homes. Benefits are provided for personal vehicle medically necessary medical or behavioral health  Hypodermic needles, syringes, lancets, test strips, treatment received in these locations. testing agents and alcohol swabs used for self- Not Medically Necessary administered medications, except as specified in Prescription Drugs This plan does not cover services that are not medically necessary, even if they are court-ordered. Hospital Admission Limitations This rule also applies to the place where you get the This plan does not cover hospital stays solely for services. diagnostic studies, physical examinations, checkups, Orthodontia Services medical evaluations, or observations, unless: This plan does not cover orthodontia services in  The services cannot be provided without the use excess of the Pediatric Dental Services; including of a hospital services for members age 19 and older (see  There is a medical condition that makes hospital Pediatric Care). care medically necessary Orthognathic Surgery Laser Therapy This plan does not cover procedures to make the Benefits are not provided for low-level laser therapy jaw longer or shorter, no matter why they are for any diagnosis, including vitiligo. needed. Military-Related Disabilities Preventive Care This plan does not cover services to which you are This plan does not cover preventive care in excess legally entitled for a military service-connected of the preventive care benefits, including services disability and for which facilities are reasonably that exceed the frequency, age and gender available. guidelines as described under Preventive Care. Military Service and War Private Duty Nursing This plan does not cover illness or injury that is This plan does not cover private duty or 24-hour caused by or arises from: nursing care. See Home Health Care for home  Acts of war, such as armed invasion, no matter if nursing care benefits. war has been declared or not Provider's License or Certification  Services in the armed forces of any country. This This plan does not cover services that the provider's includes the air force, army, coast guard, marines, license or certification does not allow him or her navy or National Guard. It also includes any perform. It also does not cover a provider that does related civilian forces or units. not have the license or certification that the state No Charge or You Do Not Legally Have to Pay requires. This plan does not cover services for which there is Serious Adverse Events and Never Events no charge, or if no charge would have been made if This plan does not cover serious adverse events this plan were not in effect. The plan also does not and never events. These are serious medical errors cover services that you do not legally have to pay, that the U.S. government has identified and except as required by law. published. A “serious adverse event” is an injury Non-Covered Services that is caused by treatment in the hospital and not by a disease. Such events make the hospital stay This plan does not cover services, supplies, drugs, longer or cause another health problem. A “never and medications furnished in connection with or event” should never happen in a hospital. A never directly related to any condition, service, or supply event is when the wrong surgery is done, or a that is not covered under this plan. procedure is done on the wrong person or body part. Non-Treatment Facilities, Institutions or You do not have to pay for services of in-network Programs providers for these events and their follow-up care. Benefits are not provided for institutional care, In-network providers may not bill you or the plan for housing, incarceration or programs from facilities these services. that are not licensed to provide medical or Not all medical errors are serious adverse events or behavioral health treatment for covered conditions. never events. These events are very rare. You can Examples are prisons, nursing homes, juvenile ask us for more details. You can also get more detention facilities, group homes, foster homes and details from the U.S government. You will find them

PBCBSAK SCER 01-2017 43 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska at www.cms.hhs.gov. this plan does not cover Sexual Problems Work-Related Illness or Injury This plan does not cover problems with your sexual This plan does not cover any illness or injury for function or response. It does not matter what the which you can get benefits under: cause is. This includes drugs, implants or any  Separate coverage for injuries on the job, even if complications or effects. you did not have to buy it Temporomandibular Joint (TMJ) Disorders  Worker’s compensation laws This plan does not cover treatment of TMJ disorders.  Any other law that will repay you for an illness or TMJ disorders are problems with the lower jaw joint injury you get from your job that have one or more of the features below: This contract does not replace, change or add to any  Pain in the muscles near the TMJ law that requires worker’s compensation, employer  Internal derangements of the parts of the TMJ liability or other insurance like these. When an employer can buy this kind of coverage and does  Arthritic problems with the TMJ not, this plan will not cover conditions that arise from  The TMJ has a limited range of motion or its your job that would be covered by such insurance. range of motion is not normal OTHER COVERAGE Vision Care for Adults This plan does not cover services to improve visual COORDINATING BENEFITS WITH OTHER sharpness for members age 19 or older. The PLANS following items are not covered: If you have other health plan coverage, this plan will  Routine vision exams work with other group or individual plans so that both  Glasses, frames and contact lenses plans may share a part of the costs.  Vision therapy, eye exercise or training All of the benefits of this plan are subject to coordination of benefits.  Surgeries to improve the refractive character of the cornea and any results of such treatment If you have other coverage besides this plan, we recommend that you submit your claim to the Please see Home Medical Equipment under the primary carrier first, then submit the claim to the Covered Services section for medical eye care secondary carrier with the primary carrier processing covered services. information. In that way, the proper coordinated Voluntary Support Groups benefits may be most quickly determined and paid. This plan does not provide coverage for patient Definitions Applicable To Coordination Of support, consumer or affinity groups such as Benefits diabetic support groups or Alcoholics Anonymous. To understand coordination of benefits, it is Weight Loss (Surgery or Drugs) important to know the meanings of the following This plan does not cover surgery, drugs or terms: supplements for weight loss or weight control. It  Allowable Medical Expense means the usual, also does not cover any complications, follow-up customary and reasonable charge for any services, or effects of those treatments, except medically necessary health care service or supply services defined as Emergency Care. This is true provided by a licensed medical professional when even if you have an illness or injury that might be the service or supply is covered at least in part helped by weight loss surgery or drugs. This plan under this plan. When a plan provides benefits in does not cover removal of extra skin or fat that came the form of services or supplies rather than cash about as a result of weight loss surgery or drugs. payments, the reasonable cash value of each service rendered or supply provided shall be When You Are Not Covered considered an allowable expense. The plan does not cover services that are:  Allowable Dental Expense means the usual,  Received or ordered when this plan is not in force customary and reasonable charge for any dentally  Received or ordered when you are not covered necessary service or supply provided by a under this plan licensed dental professional when the service or supply is covered at least in part under this plan.  Given to someone other than an ill or injured When a plan provides benefits in the form of member services or supplies rather than cash payments,  Directly related to any condition or service that the reasonable cash value of each service

PBCBSAK SCER 01-2017 44 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska rendered or supply provided shall be considered benefits from all dental plans aren’t more than the an allowable expense. 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: We will coordinate benefits when you have other  Group, individual or blanket disability insurance health care coverage that is primary over this plan. policies and health care service contractor and Coordination of benefits applies whether or not a health maintenance organization group or claim is filed with the primary coverage. individual agreements issued by insurers, Here is the order in which the plans should provide health care service contractors, and health benefits: maintenance organizations  Labor-management trusteed plans, labor First: A plan that does not provide for coordination organization plans, employer organization plans of benefits. or employee benefit organization plans Next: A plan that covers you as other than a  Government programs that provide benefits for dependent. their own civilian employees or their Next: A plan that covers you as a dependent. dependents For dependent children, the following rules apply:  Group coverage required or provided by any law, including Medicare. This does not include When the parents are not separated or divorced: workers’ compensation. The plan of the parent whose birthday falls earlier in  Group student coverage that’s sponsored by a the year will be primary, if that’s in accord with the school or other educational institution and coordination of benefits provisions of both plans. includes medical benefits for illness or disease Otherwise, the rule set forth in the plan that does not have this provision shall determine the order of  Dental Plan means all of the following dental care benefits. coverages, even if they do not have their own coordination provisions: When the parents are separated or divorced: If a  Group, individual or blanket disability insurance court decree makes one parent responsible for policies and health care service contractor and paying the child’s health care costs, that parent’s health maintenance organization group or plan will be primary. Otherwise, the plan of the individual agreements issued by insurers, parent with custody will be primary, followed by the health care service contractors, and health plan of the spouse of the parent with custody, maintenance organizations followed by the plan of the parent who does not have custody. If the rules above do not apply, the  Labor-management trusteed plans, labor plan that has covered you for the longest time will be organization plans, employer organization plans primary, except that benefits of a plan that covers or employee benefit organization plans you as a laid-off or retired employee, or as the  Government programs that provide benefits for dependent of such an employee, shall be their own civilian employees or their determined after the benefits of any plan that covers dependents you as other than a laid-off or retired employee, or as the dependent of such an employee. However, Each contract or other arrangement for coverage this applies only when other plans involved have this described above is a separate plan. It is also provision regarding laid-off or retired employees. important to note that for the purpose of this plan, we will coordinate benefits for allowable medical If none of the rules above determine the order of expenses separately from allowable dental benefits, the plan that’s covered the employee or expenses, as separate plans. subscriber for the longest time will be primary. Effect On Benefits Right Of Recovery/Facility Of Payment An important part of coordinating benefits is We have the right to recover any payments we make determining the order in which the plans provide that are greater than those required by the benefits. One plan is responsible for providing coordination of benefits provisions from 1 or more of benefits first. This is called the “primary” plan. The the following: the persons we paid or for whom we primary plan provides its full benefits as if there were have paid, providers of service, insurance no other plans involved. The other plans then companies, service plans or other organizations. If become “secondary.” When this plan is secondary, a payment that should have been made under this it will reduce its benefits for each claim so that the plan was made by another plan, we may also pay benefits from all medical plans aren’t more than the directly to another plan any amount that should have allowable medical expense for that claim and the been paid by us. Our payment will be considered a

PBCBSAK SCER 01-2017 45 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 judgment. Exceptions will be allowed when required This plan has the right to appoint a third party to act by law or regulation. In recovering benefits on its behalf in recovery efforts. 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 your behalf, and you will not be required to pay any If you are also covered under Medicare, federal law portion of the costs incurred by us or on our behalf. determines how we provide the benefits of this plan. 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 any terms or conditions offered in a settlement, and When this plan is not primary, we will coordinate you must notify the third party of our interest in the benefits with Medicare. Benefits will be coordinated settlement established by this provision. You also up to Medicare’s allowed amount, as required by must cooperate with us in recovering amounts paid federal regulations. If the provider does not accept by us on your behalf. If you retain an attorney or Medicare assignment, this allowed amount is the other agent to represent you in the matter, you must Medicare Limiting Charge. require your attorney or agent to reimburse us SUBROGATION AND REIMBURSEMENT directly from the settlement or recovery. If you fail to cooperate fully with us in the recovery of benefits we If we make claims payment on your behalf for injury have paid as described above, you are responsible or illness for which another party is liable, or for for reimbursing us for such benefits. which uninsured/underinsured motorist (UIM) or personal injury protection (PIP) insurance exists, we To the extent that you recover from any available are entitled to be repaid for those payments out of third party source, you agree to hold any recovered any recovery from that liable party. The liable party fund in trust or in a segregated account until our is also known as the “third party” because it is a subrogation and reimbursement rights are fully party other than you or us. This party includes a determined. UIM carrier because it stands in the shoes of a third UNINSURED AND UNDERINSURED party tortfeasor and because we exclude coverage MOTORIST/PERSONAL INJURY for such benefits. PROTECTION COVERAGE Definitions The following terms have specific We have the right to be reimbursed for benefits meanings in this contract: provided, but only to the extent that benefits are also  Subrogation means we may collect directly from paid for such services and supplies under the terms third parties to the extent we have paid on your of a motor vehicle uninsured motorist and/or behalf for illnesses or injury caused by the third underinsured motorist (UIM) policy, personal injury party. protection (PIP) or similar type of insurance or  Reimbursement means that you are obligated contract. under the contract to repay any monies advanced by us from amounts received on your claim. SENDING US A CLAIM  Restitution means all equitable rights of recovery A claim is a request to an insurance company for that we have to the monies advanced under this payment of amount due. Many providers will send plan. Because we have paid for your illness or claims to us directly. When you need to send a injuries, we are entitled to recover those claim to us, follow these simple steps: expenses. Step 1 To the fullest extent permitted by law, we’re entitled Complete a claim form. You can get claim forms by to the proceeds of any settlement or judgment that calling Customer Service or you can print them from results in a recovery from a third party, up to the our website at premera.com. amount of benefits paid by us for the condition. Our right to recover exists regardless of whether it is Be sure to use a separate claim form for each based on subrogation, reimbursement or restitution. member and each provider. We are entitled under our right of recovery to be Step 2 reimbursed for our benefit payments even if you are not “made whole” for all of your damages in the Attach the bill that lists the services you received. recoveries that you receive. Our right of recovery is Your claim must show all of the following not subject to reduction for attorney’s fees and costs information: under the “common fund” or any other doctrine.  Name of the subscriber and the member who

PBCBSAK SCER 01-2017 46 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska received the services Coordination of Prescription Claims  Identification numbers for both the subscriber and If this plan is the secondary plan as described under the Group (these are shown on your identification Other Coverage, you must submit your pharmacy card) receipts attached to a completed claim form for  Name, address, and IRS tax identification number reimbursement. Please send the information to the of the provider address listed under Secondary Prescription Claims  Diagnosis (ICD) code. You must get this from included on the drug claim form. your provider. If you need a supply of envelopes or prescription  Procedure codes (CPT or HCPCS). You must get drug claim forms, contact Customer Service at the these from your provider. number located inside the front cover of this benefit booklet.  Date of service and charges for each service Step 3 Timely Payment of Claim If you are also covered by Medicare, attach a copy You should submit all claims within 365 days of the of the Explanation of Medicare Benefits. date you received services. No payments will be made by us for claims received more than 365 days Step 4 after the date of service. Exceptions will be made if Check to make sure that all the information from we receive documentation of your legal Steps 1, 2, and 3 is complete. Your claim will be incapacitation. Payment of all claims will be made returned if all of this information is not included. within the time limits required. Step 5 Notice Required for Reimbursement and Payment of Claims Sign the claim form. In accordance with federal and state law, we may Step 6 pay the benefits of this plan to the eligible member, Mail your claims to the address located inside the provider, other carrier, or other party legally entitled front cover of this benefit booklet. to such payment under federal or state medical child support laws, or jointly to any of these. Such Prescription Drug Claims payment will discharge our obligation to the extent of To make a claim for covered prescription drugs, the amount paid so that we will not be liable to please follow these steps: anyone aggrieved by our choice of payee. Participating Pharmacies Air or Surface Transportation Claims For retail pharmacy purchases, you do not have to To make a claim for covered air or surface send us a claim. Just show your ID card to the transportation services, please follow these steps: pharmacist, who will bill us directly. If you do not Complete a Member Submitted Claim Form. A show your ID card, you will have to pay the full cost separate Member Submitted Claim Form is of the prescription and submit the claim yourself. necessary for each patient and each carrier or You will need to fill out a prescription drug claim transportation service used. form, attach your prescription drug receipts and submit the information to the address shown on the Attach one of the following forms of documentation: claim form.  A copy of the ticket from the airline or other transportation carrier. The tickets must indicate For mail-order pharmacy purchases, you do not the names of the passenger(s), dates and total have to send us a claim, but you will need to follow cost of travel, and the origination and final the instructions on the mail-order pharmacy order destination points. form and submit it to the address printed on the form. Please allow up to 14 days for delivery.  A copy of the detailed itinerary as issued by the airline, transportation carrier, travel agency or Non-Participating Pharmacies online travel website. The itinerary must identify You will have to pay the full cost for new the name of the passenger(s), the dates of travel prescriptions and refills purchased at these and total cost of travel, and the origination and pharmacies. You will need to fill out a prescription final destination points. drug claim form, attach your prescription drug Please Note: Credit card statements or other receipts and submit the information to the address payment receipts are not acceptable forms of shown on the claim form. documentation. Your claim also must include a statement or letter

PBCBSAK SCER 01-2017 47 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 reached. Claim Procedure for Groups Subject to the 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 cannot complete the review of your claim within this Some services and supplies covered under this plan time period, we will notify you of a 15-day extension require prior authorization. Please see Prior before the 30-day time limit ends. If we need more Authorization for additional information. information from you or your provider to complete Claims for Care Received Outside the United the review of your claim, we will ask for that States information in our notice and allow you 45 days to send us the information. Once we receive the When you submit a claim for care you received information we need, we will review your claim and outside the United States, please include whenever notify you of our decision within 15 days. possible: a detailed description, in English, of the services, drugs, or supplies received; the names and Please Note: If your provider requires a copay credentials of the treating providers, and medical when you receive medical services or supplies, it is records or chart notes. not considered a claim for benefits. However, you always have the right to request and obtain from us To process your foreign claim, we will convert the a paper copy of your explanation of benefits in foreign currency amount on the claim into U.S. connection with such a medical service by calling dollars for claims processing. We use a national Customer Service. The phone number is on the currency converter (available at www.oanda.com) front cover of your booklet and on your Premera ID as follows: card. Or, you can visit our website, premera.com,  For professional outpatient services and other for information and secure online access to claims care with single dates of service, we use the information. To file a claim, please see Sending Us exchange rate on the date of service A Claim for more information. If your claim is denied in whole or in part, you may submit a  For inpatient stays of more than one day, we use complaint or appeal as outlined under Complaints the exchange rate on the date of discharge and Appeals section. COMPLAINTS AND APPEALS If your claim is denied, in whole or in part, our written As a Premera member, you have the right to offer notice (see Notices) will include: your ideas, ask questions, voice complaints and  The reasons for the denial and a reference to the request a formal appeal to reconsider decisions we plan provisions used to decide your claim have made. Our goal is to listen to your concerns  A description of any additional information needed and improve our service to you. to reconsider your claim and why the information If you need an interpreter to help with oral translation is needed services, please call us. Customer Service will be  A statement that you have the right to submit a able to guide you through the service. complaint or appeal WHEN YOU HAVE IDEAS  A description of the plan’s complaint or appeal processes We would like to hear from you. If you have an idea, suggestion, or opinion, please let us know. You can If there were clinical reasons for the denial, you will contact us at the address and telephone number receive a letter from us stating these reasons. found inside the front cover of this benefit booklet. If we do not pay the claim or provide notice within WHEN YOU HAVE QUESTIONS the time frames stated above, interest shall accrue at a rate of 15% annually. Interest will not be paid if You can call us when you have questions about a the amount of interest is $1 or less. benefit or coverage decision, the quality or availability of a health care service or our service. At any time, you have the right to appoint someone We can quickly and informally correct errors, clarify to pursue the claim on your behalf. This can be a

PBCBSAK SCER 01-2017 48 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 coverage decision. There may be times when the same professional license as the treating Customer Service will ask you to submit your provider and has had no prior decisions in your complaint for review through the formal appeals appeal. There will be a meeting during your Level II process outlined below. Appeal for the panel to review. You may participate in the Level II panel meeting in person or by phone When this happens, we will review your complaint to present evidence and testimony. Please contact and notify you of the outcome of our decision in us for additional information about this process. writing. We will provide you with the reasons for our decision as soon as possible, but no later than 30 Once the Level II appeal review is complete, we will days from the date we received your complaint. provide you with a written decision. If you are not satisfied with the final internal appeal decision, you WHEN YOU DO NOT AGREE WITH A may be eligible to request an External Review, as PAYMENT OR BENEFIT DECISION described below. If we declined to provide payment in whole or in part Internal Appeals on a benefit, and you disagree with our decision, you have the right to request we formally review the You or your authorized representative, someone you adverse benefit determination through our internal have named to act on your behalf, may file an appeals process. appeal. To appoint an authorized representative, you must sign an authorization form and mail or fax This plan’s appeal process will comply with any new the signed form to the address or phone number requirements as necessary under state and federal listed below. By completing an authorization form, it laws and regulations. provides us with the authorization for the name Adverse Benefit Determinations person to discuss and represent you in the appeals process and allows us to release your authorized An adverse benefit determination means a denial, information, if any, to them. reduction, termination of, or a failure to provide or make payment, in whole or in part for services based Please call us for an Authorization for Appeals form. on: You can also obtain a copy of this form on our website at premera.com.  An individual's eligibility to participate in a plan or health insurance coverage; Filing An Internal Appeal  A determination that a benefit is not a covered You or your authorized representative may file an benefit; appeal by writing to us at the address listed below.  A limitation on otherwise covered benefits; We must receive your appeal request as follows:  A clinical review determination; or  For a Level I internal appeal, within 180 calendar days of the date you are notified of an adverse  A determination that a service is experimental, benefit determination investigational, or not medically necessary or appropriate.  For a Level II internal appeal, within 60 calendar days of the date you are notified of the Level I WHEN YOU HAVE AN APPEAL determination. If you are hospitalized or traveling; or for other reasonable cause beyond your After you are notified of an adverse benefit control, we may extend this timeline to allow you determination, you can request an internal appeal. to obtain additional medical documentation, doctor This plan includes two levels of internal appeals. consultations or opinions. Your Level I internal appeal will be reviewed by You can mail your written appeal request to: individuals who were not involved in the initial adverse benefit determination. If the adverse benefit Premera Blue Cross Blue Shield of Alaska

PBCBSAK SCER 01-2017 49 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 description of the appeals process by visiting our information about your right to a Level II internal website at premera.com. appeal or your right to an External Review at the end We will acknowledge our receipt of your request in of the internal appeals process. writing within 7 days. Appeals Regarding Ongoing Care Clinically Urgent Situations If you appeal a decision to change, reduce or end If your provider believes that your situation is coverage of ongoing care for a previously approved clinically urgent under law, your appeal will be course of treatment because the service or level of conducted on an expedited basis. A clinically urgent service is no longer medically necessary or situation means one in which your health may be in appropriate, we will suspend our denial of benefits serious jeopardy or, in the opinion of your doctor, during the internal appeal period. Our provision of you may experience pain that cannot be adequately benefits for services received during the internal controlled while you wait for a decision on your appeal period does not, and should not be construed appeal. You may request an expedited internal to, reverse our denial. If our decision is upheld, you appeal by calling Customer Service at the number must repay us all amounts that we paid for such located inside the front cover of this benefit booklet. services. You will also be responsible for any difference between our allowed amount and the If your situation is clinically urgent, you may also provider's billed charge. request an expedited external review at the same time you request an expedited internal appeal. ELIGIBILITY FOR EXTERNAL REVIEW Additional Information For Your Appeal If you are not satisfied with the final internal adverse benefit determination based on medical judgment You may supply new or additional information to (including medical necessity or appropriateness of support your appeal at the time you file an appeal or care, or experimental or investigative care), or a at a later date by mailing or faxing to the address rescission of coverage, you may have the right to and fax number listed above. Please provide us have our decision reviewed by an Independent with this information as soon as possible to give us Review Organization (IRO). You also have the right sufficient time to review. to an external review if we fail to strictly comply with Copies Of Information Relevant To Your Appeal our internal appeals process and with state and federal requirements for internal appeals. An IRO is You can request copies of information relevant to an independent organization of medical reviewers the adverse benefit determination. We will provide who are qualified to review medical and other this information, as well as any new or additional relevant information. There is no cost to you for an information we considered, relied upon or generated external review. in connection to your appeal as soon as possible and free of charge. You will have the opportunity to We will send you an External Review Request form review this information and respond to us before we at the end of the internal appeal process notifying make our decision. you of your rights to an external review. We must receive your written request for an external review What Happens Next within 4 months of the date you received the final We will review your appeal and provide you with a internal adverse benefit determination. Your request written decision as stated below: must include a signed waiver granting the IRO access to medical records and other materials that  Expedited appeals, as soon as possible, but no are relevant to your request. later than 72 hours after we received your request. We will call, fax or email our decision You can request an expedited external review when and will follow-up with a decision in writing. your provider believes that your situation is clinically urgent under law. Please call Customer Service at

PBCBSAK SCER 01-2017 50 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska the number located inside the front cover of this Insurance at any time during this process. If this benefit booklet to request an expedited external plan is governed by the Federal Retirement Income review. Security Act of 1974 (ERISA), you can contact the 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 where additional information may be submitted Alaska Division of Insurance directly to the IRO and when the information must be 550 W 7th Ave., Suite 1560 provided. We will forward your medical records and other relevant materials for your external review to Anchorage, Alaska 99501-3567 the IRO. We will also provide the IRO with any 1-800-INSURAK (467-8725) (within Alaska) additional information they request that is 1-907-269-7900 (outside Alaska) reasonably available to us. Email: [email protected] When The IRO Has Completed The External Online: Review www.commerce.state.ak.us/insurance The IRO will review your request and send you and us a written notification of their decision as stated below: Employee Benefits Security Administration (EBSA)  Expedited external review, as soon as possible, 1-866-444-EBSA (3272) but no later than 72 hours after receiving your request. The IRO will notify you and us immediately by phone, email or fax and will follow up with a written decision by mail. ELIGIBILITY AND ENROLLMENT  All other external review requests, no later than 45 You do not have to be a citizen of or live in the days from the date the IRO receives your request. United States if you are otherwise eligible for coverage. Appeals Of Drug Formulary Decisions This section shows who is eligible for coverage and You also have the right to appeal to the IRO any who can be covered under this plan. Only members decision we have made regarding coverage for enrolled on this plan can receive its benefits. drugs not on the plan’s formulary. To request an IRO review, contact Customer Service at the WHO IS ELIGIBLE FOR COVERAGE telephone number on your Premera ID card. Employee Eligibility What Happens Next Under this small employer health benefit plan, an Premera is bound by the IRO's decision. If the IRO eligible employee is an employee who works on a overturned the final internal appeal adverse benefit full-time basis, with a normal work week of the determination, we will implement their decision in a minimum hours stated on the Group’s application. timely manner. Eligible employee means a sole proprietor, a partner If the IRO upheld our decision, there is no further of a partnership or an independent contractor, review available under this plan's internal appeals or provided the sole proprietor, partner, or contractor is external review process. If you disagree with the included as an employee under a health benefit plan IRO's decision, you may appeal the IRO's decision of a small employer. Eligible employee does not in Superior Court. You must file this request with the include an employee who works on a part-time, Superior Court within 6 months of the date you were temporary, or substitute basis. The employee must notified of the IRO's decision. You may also have also satisfy any probationary period, if one is other remedies available under state or federal law, required by the Group. such a filing a lawsuit. Employees Performing Employment OTHER RESOURCES TO HELP YOU Services in Hawaii If you have questions about understanding a denial For employers other than political subdivisions, such of a claim or your appeal rights, you may contact as state and local governments, and public schools Premera Customer Service for assistance at the and universities, the State of Hawaii requires that number located inside the front cover of this benefit benefits for employees living and working in Hawaii booklet. If you are not satisfied with our decisions (regardless of where the Group is located) be and wish to make a complaint or need help filing an administered according to Hawaii law. If the Group appeal, you can contact the Alaska Division of is not a governmental employer as described in this paragraph, employees who reside and perform any

PBCBSAK SCER 01-2017 51 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 specific date. When the court order terminates Dependent Eligibility 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” the Group who meets the requirements in section below. The term “Grandchildren” in this “Employee Eligibility” earlier in this section, the provision means the natural offspring of spouse can only enroll as a subscriber. dependent children, including dependent children for whom the subscriber, spouse or  The domestic partner of the subscriber. domestic partner has a legal guardianship.  Lives with the subscriber WHEN COVERAGE BEGINS  Is at least 18 years old  Has a close personal relationship with the Enrollment subscriber in which they each take care of the The employee must enroll on forms provided and/or other accepted by us. To obtain coverage, an employee  Shares the costs of basic living, such as food must enroll within 60 days after becoming eligible. and shelter, with the subscriber. The partners When the employee enrolls within 60 days of do not need to pay these expenses equally or becoming eligible, coverage for the employee and jointly as long as they agree that both are enrolled dependents will become effective on the responsible. latest of the applicable dates below:  Is not married to anyone  The employee's date of hire  Is not related to the subscriber by blood more  The date the employee enters a class of closely than Alaska allows a married couple to employees to which the Group offers coverage be under this plan  Is mentally able to agree to a contract when the  The next day following the date the probationary domestic partnership begins period ends, when one is required by the Group  Is the subscriber’s only domestic partner  Another date as designated in the Group Master If all of these statements above are true, the plan Application or Group Contract will give a spouse’s rights and benefits to the When we do not receive the enrollment application domestic partner. Where this benefit booklet within 60 days of the date you became eligible, none refers to marriage, it also means the start of a of the dates above will apply. Please see Open domestic partnership. Where this contract refers Enrollment and Special Enrollment below. to divorce or legal separation, it also means the end of a domestic partnership. Dependents Acquired Through Marriage or  An eligible child under 26 years of age. An Domestic Partnership After The eligible child is one of the following: Subscriber's Effective Date  A biological child of either or both the When we receive the completed enrollment subscriber, spouse or domestic partner application and any required subscription charges  A legally adopted child of either or both the within 60 days after the marriage or domestic subscriber, spouse or domestic partner partnership, coverage will become effective on the first of the month following the date of marriage or  A child placed with the subscriber, spouse or domestic partnership. When the enrollment domestic partner for the purpose of legal application is not received by us within 60 days of adoption in accordance with state law. A child marriage or domestic partnership, refer to Open is placed when the subscriber, spouse or Enrollment later in this section. domestic partner takes the legal duty to support the child. The child must be less than 18 years Newborn And Adoptive Children old when the child was placed. Natural newborn dependent children of the  A minor or foster child for whom the subscriber, subscriber born on or after the subscriber’s effective

PBCBSAK SCER 01-2017 52 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 date of adoption or placement for adoption. dependent children, such charges will begin from the However, if payment of additional subscription dependent’s effective date. charges is required to provide coverage for an Newborn Grandchildren adoptive dependent child, and the subscriber desires coverage of the adoptive child to extend Natural newborn children born on or after the beyond the 31-day period following the dependent subscriber’s effective date to a covered dependent child’s date of adoption or placement for adoption, child (referred to as “grandchildren”) will be covered we must receive a completed enrollment application from their date of birth. The grandchild’s parent and the required additional subscription charges must be covered and remain covered under this plan within the 60-day period following the date of in order for the grandchild to be covered. adoption or placement for adoption. If payment of additional subscription charges is If we do not receive the completed enrollment required to provide coverage for a newborn application and the required additional subscription grandchild, and the subscriber desires coverage of charges within the 60-day period, initial coverage will the newborn grandchild to extend beyond the 31-day be limited to the 31-day period referenced above. period following the newborn grandchild’s date of The child may then be enrolled at a later date, birth, we must receive written notice and any subject to the Open Enrollment provisions required additional subscription charges within the described later in this section. 60-day period following the date of birth. Children Acquired Through Legal If we do not receive the written notice and any Guardianship required additional subscription charges within the 60-day period, initial coverage for the newborn When we receive the completed enrollment grandchild will be limited to the 31-day period application, any required subscription charges, and referenced above. a copy of the guardianship papers within 60 days of the date legal guardianship began with the A newborn grandchild who is not properly enrolled subscriber, coverage for an otherwise eligible child as stated above may not be enrolled at a later date, will begin on the date legal guardianship began. including during Open Enrollment or Special When the enrollment application is not received by Enrollment periods, even if the grandchild’s parent is us within 60 days of the date legal guardianship a covered dependent child under this plan. began, refer to Open Enrollment below. SPECIAL ENROLLMENT Children Covered Under Medical Child Involuntary Loss Of Other Coverage Support Orders If an employee and/or dependent does not enroll in When we receive the completed enrollment this plan or another plan sponsored by the Group application within 60 days of the date of the medical when first eligible because they aren’t required to do child support order, coverage for an otherwise so, that employee and/or dependent may later enroll eligible child that is required under the order will in this plan outside of the annual open enrollment become effective on the date of the order. period if each of the following requirements is met: Otherwise, coverage will become effective on the  The employee and/or dependent were covered date we receive the enrollment application for under group health coverage or a health coverage. The enrollment application may be insurance program at the time coverage under the submitted by the subscriber, the child's custodial Group's plan was offered parent, or a state agency. When subscription charges being paid do not already include coverage  The employee and/or dependent’s coverage for dependent children, such charges will begin from under the other group health coverage or health the child’s effective date. Please contact your Group insurance program ended as a result of one of the

PBCBSAK SCER 01-2017 53 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska following: Subscriber And Dependent Special  Loss of eligibility for Medicaid or a public Enrollment With Medicaid and Children's program providing health benefits Health Insurance Program (CHIP) Premium  Loss of eligibility for coverage (including , but Assistance not limited to, the result of legal separation, You and your dependents may have special divorce, death, termination of employment, or enrollment rights under this plan if you meet the the reduction in the number of hours of eligibility requirements described under When employment) Coverage Begins and:  Termination of employer contributions toward  You qualify for premium assistance for this plan such coverage from Medicaid or CHIP; or  The employee and/or dependent were covered  You no longer qualify for healthcare coverage as required by the federal Consolidated under Medicaid or CHIP. Omnibus Budget Reconciliation Act of 1986 (COBRA) at the time coverage under this plan If you and your dependents are eligible as outlined was previously offered and COBRA coverage above, you qualify for a 60-day special enrollment has been exhausted. period. This means that you must request enrollment in this plan within 60 days of the date you An eligible employee who qualifies as stated above qualify for premium assistance under Medicaid or may also enroll all eligible dependents. When only CHIP or lose your Medicaid or CHIP coverage. an eligible dependent qualifies for special enrollment, but the eligible employee is not enrolled Coverage under this plan for the eligible employee in any of the Group's plans or is enrolled in a and any dependents will start on the first of the different plan sponsored by the Group, the employee month following: is also allowed to enroll in this plan in order for the  The date the eligible employee and any dependent to enroll. dependents qualify for Medicaid or CHIP premium When we receive the employee and/or dependent’s assistance; or completed enrollment application and any required  The date the eligible employee and any subscription charges within 60 days of the date such dependents lose coverage under Medicaid or other coverage ended, coverage under this plan will CHIP. become effective on the first of the month following The eligible employee and any dependents may be the date the other coverage was lost. required to provide proof of eligibility from the state When we do not receive the employee and/or for this special enrollment period. dependent’s completed enrollment application within If we do not receive the enrollment application within 60 days of the date prior coverage ended, refer to the 60-day period as outlined above, you will not be Open Enrollment below. able to enroll until the next open enrollment period. Subscriber And Dependent Special Please refer to Open Enrollment below. Enrollment OPEN ENROLLMENT An eligible employee and otherwise eligible If you are not enrolled when you first become dependents who previously elected not to enroll in eligible, or as allowed under Special Enrollment any of the employer’s group health plans when such above, you cannot be enrolled until the Group's next coverage was previously offered, may enroll in this “open enrollment” period. An open enrollment plan at the same time a newly acquired dependent is period occurs once a year unless otherwise agreed enrolled under “Enrollment” in the case of marriage, upon between the Group and us. During this period, birth, adoption, or placement for adoption. The eligible employees and their dependents can enroll eligible employee may also choose to enroll alone, for coverage under this plan. with some or all eligible dependents or change plans, if applicable. If the Group offers multiple healthcare plans and you are enrolled under one of the Group’s other When we receive the completed enrollment healthcare plans, enrollment for coverage under this application and any required subscription charges plan can only be made during the Group’s open within 60 days of the date of marriage, birth, enrollment period. adoption, or placement for adoption. Coverage under this plan will become effective on the first of Please Note: Grandchildren are not eligible to be the month following the date the other coverage was enrolled during Open Enrollment. Please see lost. Newborn Grandchildren above.

PBCBSAK SCER 01-2017 54 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 will continue to be eligible if all of the following are subscriber is annulled, or when he or she true: becomes legally separated or divorced from the  The child is disabled before reaching 26 years of subscriber age  For a child when he or she no longer meets the  The child is not married requirements for dependent coverage shown in Eligibility And Enrollment  We are notified of the child’s disability within 31 days of the date the child reached age 26  For a grandchild of the subscriber or spouse when the grandchild’s parent is no longer enrolled in the Within 31 days after the child turns age 26, the plan or no longer meets the requirements for subscriber must send us proof that the child meets dependent coverage shown in Eligibility And these conditions. We also have the right to ask for Enrollment proof. We cannot ask for such proof more often than once a year. If the subscriber does not send us  For intentional fraud or intentional satisfactory proof when we ask for it, the child’s misrepresentation of material fact under the terms coverage will not continue after the last date of of the coverage by the subscriber or the eligibility. subscriber’s dependents PLAN TRANSFERS The subscriber must promptly notify the Group when an enrolled family member is no longer eligible to be Subscribers (with their enrolled dependents) may be enrolled as a dependent under this plan. The Group allowed to transfer to this plan from another plan must give us written notice of a member's offered by the Group. Transfers also occur if the termination within 30 days of the date the Group is Group replaces another plan with this plan. All notified of such event. transfers to this plan must occur during “open enrollment” or on another date agreed upon by us CONTINUATION OF COVERAGE and the Group. FOR A DISABLED CHILD When we update the contract for this plan, or you Coverage for a dependent child who cannot support transfer from the Group’s other plan, and there is no himself or herself may continue beyond the lapse in your coverage, the following provisions that dependent age limit if all of the following are true: apply to this plan will be reduced to the extent they were satisfied and/or credited under the prior plan:  The child is not able to earn his or her own living because of a developmental or physical disability  Out-of-pocket maximum  The child became disabled before reaching the  Deductibles. We will credit expenses applied to dependent age limit your prior plan's deductible only when they were incurred in the current calendar year. Expenses  The child mainly depends on the enrolled incurred during October through December of the employee for support and maintenance. prior year are not credited toward this plan's  The enrolled employee continues to be covered deductible for the current year. under this plan TERMINATION OF COVERAGE  The child’s subscription charges, if any, continue to be paid EVENTS THAT END COVERAGE  Within 31 days of the child reaching the Coverage will end without notice on the last day of dependent age limit, the enrolled employee gives

PBCBSAK SCER 01-2017 55 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska us a Request for Certification of Disabled MEMBER IS INPATIENT WHEN COVERAGE Dependent form. We must approve the request ENDS (EXTENDED INPATIENT COVERAGE) for coverage to continue. If coverage ends, the inpatient benefits of this plan  The enrolled employee gives us proof of the will continue if: child’s disability and dependent status when we 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 misrepresentation of material fact under the terms Please Note: This provision does not apply to of the coverage by you or the Group; dependent grandchildren.  Coverage had been in effect for more than 31 FOR GROUPS SUBJECT TO THE FEDERAL days; CONSOLIDATED OMNIBUS BUDGET  You were admitted to a medical facility before the RECONCILIATION ACT OF 1986 (COBRA) date coverage ended; and There are specific requirements, time frames and  You remained as an inpatient in a medical facility conditions which must be followed to be eligible for for the same medical condition for which you were continuation of coverage and which are generally admitted outlined below. Please contact your employer/group as soon as possible for details if you think you may Inpatient coverage will end when the first of the qualify for continuation of coverage. following occurs:  You are covered under another health plan that If you become ineligible you may continue coverage provides benefits for your confinement; or would as required by the federal Consolidated Omnibus provide benefits for your confinement if this plan Budget Reconciliation Act of 1986 (COBRA). did not exist; COBRA is a federal law which requires most employers with 20 or more employees to offer  You are covered under another health plan that continued coverage. You may be eligible to would provide benefits for your confinement if this continue coverage on a self-pay basis for 18 or 36 plan did not exist; months through COBRA. How long you may  You are discharged from the facility or from any continue coverage on COBRA will depend on the other facility to which you were transferred in circumstances which caused you to lose coverage which you are confined; under the group plan.  Inpatient care is no longer medically necessary WHO MAY BE ELIGIBLE (see Definitions) The enrolled employee or enrolled dependent may OTHER PLAN INFORMATION be eligible for COBRA if: This section tells you about how your Group’s  Coverage ends because the employee’s work contract and this plan are administered. It also hours were reduced includes information about federal and state  Coverage ends because the employee’s requirements we must follow and other information employment was terminated. The termination we must provide to you. must not be due to gross misconduct as defined by the group. BENEFITS NOT TRANSFERABLE  Coverage ends because the employee becomes This plan’s benefits are not transferable. This eligible for Medicare means no one except you has the right to receive  Coverage ends because the enrolled employee the benefits of this plan. If you use plan benefits in a dies false or misleading way, we will cancel your plan. We may also take legal action against you.  Coverage ends because the enrolled employee and spouse legally separate or divorce Conformity With The Law  Coverage ends because domestic partnership The Group Contract is issued and delivered in the ends state of Alaska. This plan conforms with the 10  Coverage ends because the enrolled dependent essential health benefits and is consistent with the no longer qualifies as a dependent requirements of the Affordable Care Act (federal healthcare reform). It is governed by the laws of If you are eligible, you must apply for COBRA Alaska, except to the extent preempted by federal coverage within a certain time period. You may also law. If any part of this contract or any endorsement have to pay the subscription charges for it. Please to it is found to be in conflict with applicable state or contact your employer for details. federal laws or regulations, we will administer this

PBCBSAK SCER 01-2017 56 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 created under other provisions of this contract. Entire 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 be entitled to recover these amounts.  This benefit booklet  The Group’s signed application If you make any intentionally false or misleading statements on any application or enrollment form  All attachments, endorsements and options that affects your acceptability for coverage, we may, included or issued hereafter at our option: No change to this contract, including any change  Deny your claim; made by a producer of the Group, will be binding Reduce the amount of benefits provided for your upon us unless it is in writing and approved over the  claim; or signature of an officer of ours.  Void your coverage under this plan (void means to Evidence of Medical Necessity cancel coverage back to its effective date as if it We have the right to require proof of medical had never existed at all.) Your coverage cannot necessity for any services or supplies you receive be voided based on a misrepresentation you before benefits are provided under this plan. made unless you have performed an act or Members or providers must provide evidence of practice that constitutes fraud; or made an medical necessity when requested. If this evidence intentional misrepresentation of material fact that is not provided when required, benefits will not be affects your acceptability for coverage. available. See the Definitions section to learn how Finally, intentionally false or misleading statements the plan defines medically necessity. on any group form required by us, which affect the Group As The Agent acceptability of the Group or the risks to be assumed by us, may cause the voiding of the Group Contract Your Group is your agent for all purposes under this for this plan. Such recoveries will not be sought plan and not the agent of Premera Blue Cross Blue more than 365 days from the date we discovered, or Shield of Alaska. Any action taken by your Group could have reasonably discovered the intentionally will be binding on you. false or misleading statements. Health Care Providers - Independent Contractors Legal Action All health care providers who provide services and No action at law or in equity shall be brought to supplies to a member do so as independent recover under this contract before the expiration of contractors. None of the provisions of this contract 60 days after written proof of loss has been are intended to create, nor shall they be deemed or furnished in accordance with the requirements of construed to create, any employment or agency this contract. No action shall be brought after the relationship between us and the provider of service expiration of three years after the written proof of other than that of independent contractors. We are loss is required to be furnished. not legally responsible for any harm that comes to a member while in a provider’s care. This includes, Limitations of Liability without limitation, any general damages, pain and We’re not legally responsible for any of the following: suffering.  Situations such as epidemics or disasters that INDEPENDENT CORPORATION prevent members from getting the care they need The subscriber hereby expressly acknowledges the  The quality of services or supplies received by understanding that this contract constitutes a members, or the regulation of the amounts contract solely between the subscriber and Premera charged by any provider, since all those who Blue Cross Blue Shield of Alaska. provide care do so as independent contractors The subscriber further acknowledges and agrees  Providing any type of hospital, medical, dental, that he or she has not entered into this contract vision, or similar care based upon representations by any person other  Harm that comes to a member while in a than us, and that no person, entity, or organization provider's care other than us shall be held accountable or liable to  Amounts in excess of the actual cost of services the subscriber for any of our obligations to the and supplies subscriber created under this contract. This

PBCBSAK SCER 01-2017 57 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  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 Member Cooperation modification, including changes in preventive benefits. You must cooperate with us in a timely and appropriate way as we manage and provide Notice of Information Use and Disclosure 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 Newborn’s and Mother’s Health Protection Act (PPI) may include health information, or personal data such as your address, telephone number or Group health plans and health insurance issuers Social Security number. We may receive this generally may not, under federal law, restrict information from, or release it to, healthcare benefits for any hospital length of stay in connection providers, insurance companies, or other sources. with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less This information is collected, used or disclosed for than 96 hours following a cesarean section. conducting routine business operations such as: However, federal law generally does not prohibit the  Determining your eligibility for benefits and paying mother’s or newborn’s attending provider, after claims. (Genetic information is not collected or consulting with the mother, from discharging the used for enrollment purposes.) mother or her newborn earlier than 48 hours (or 96  Coordinating benefits with other healthcare plans hours as applicable). In any case, group health plans and health insurance issuers may not, under  Conducting care management, Personal Health federal law, require that a provider obtain Support Programs, or quality reviews authorization from the plan or the insurance issuer  Fulfilling other legal obligations that are specified for prescribing length of stay not in excess of the 48 under the Group contract hours (or 96 hours). This information may also be collected, used or Not all plans include coverage for dependents and disclosed as required or permitted by law. newborns may not be eligible for coverage. See the To safeguard your privacy, we take care to ensure Eligibility and Enrollment section of this booklet for that your information remains confidential by having details. a company confidentiality policy and by requiring all Non-Transferability of Benefits employees to sign it. No person other than a member is entitled to receive If a disclosure of PPI is not related to a routine benefits under this contract. Such right to benefits is business function, we remove anything that could be nontransferable. used to easily identify you or we obtain your prior written authorization. Nonwaiver You have the right to request inspection and /or No delay or failure when exercising or enforcing any amendment of records retained by us that contain right under this contract shall constitute a waiver or your PPI. Please contact Customer Service and ask relinquishment of that right and no waiver or any a representative to mail a request form to you. default under this contract shall constitute or operate as a waiver of any subsequent default. No waiver of Notice of Other Coverage any provision of this contract shall be deemed to As a condition of receiving benefits under this plan, have been made unless and until such waiver has you must notify us of: been reduced to writing and signed by the party waiving the provision.  Any legal action or claim against another party for a condition or injury for which we provide benefits, Notice and the name and address of that party’s Any notice we are required to submit to the Group or insurance carrier subscriber will be considered to be delivered if  The name and address of any insurance carrier mailed to the Group or subscriber, at the most recent that provides: address appearing on our records. We will use the  Personal injury protection (PIP) date of postmark in determining the date of our notification. If you or your Group is required to  Underinsured motorist coverage submit notice to us, it will be considered delivered on  Uninsured motorist coverage

PBCBSAK SCER 01-2017 58 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska  Any other insurance under which you are or may Severability be entitled to recover compensation Invalidation of any term or provision herein by  The name of any other group or individual judgment or court order shall not affect any other insurance plans that cover you provisions, which shall remain in full force and effect. Premera Blue Cross Blue Shield of Alaska ID Venue Card All suits and legal proceedings, including arbitration The Premera Blue Cross Blue Shield of Alaska ID proceedings, brought against us by you or anyone card is issued by Premera Blue Cross Blue Shield of claiming any right under this plan must be filed: Alaska for member identification purposes only. It  Within 3 years of the date we denied, in writing, does not confer any right to services or other the rights or benefits claimed under this plan, or of benefits under this contract. the completion date of the independent review Recovery of Claims Overpayments process if applicable; and We have the right to recover money we overpay in  In the state of Alaska error. We may recover this money from the member Women’s Health and Cancer Rights Act of 1998 or anyone else that was paid, including a provider. We may deduct the money from future benefits of This plan, as required by the Women’s Health and the employee or any of his or her dependents (even Cancer Rights Act of 1998 (WHCRA), provides if the original payment was not for that member). benefits for mastectomy-related services including We can only do this if we would otherwise pay those all stages of reconstruction and surgery to achieve benefits directly to the subscriber or to a provider symmetry between the breasts, prostheses, and that does not have a contract with us. We will complications resulting from a mastectomy, including provide a minimum of 30 calendar days’ notice of lymphedemas. See Covered Services. the recovery and you will have the right to challenge Workers’ Compensation Insurance the recovery. We will do any recovery no later than 365 days after the original claim is settled. This contract is not in lieu of, and does not affect, any requirement for coverage by Workers’ Right To And Payment Of Benefits Compensation insurance. The benefits of this plan are available only to enrolled members. Except as required by law, we DEFINITIONS will not honor any attempted assignment, Some words we use to describe this plan have garnishment, or attachment of any right of this plan. special meanings in the benefit booklet. The Payment of benefits of this plan are subject to the information here will help you understand what these following provisions: words mean.  Preferred and Non-Preferred Providers: For Accepted Rural Provider covered services from these providers, we pay the A selected provider practicing in a medically under- providers directly. You only have to pay served area of Alaska. These providers are paid at deductibles, copays, coinsurance, and amounts the highest benefit level, however, since we do not for services that are not covered. have a contract with these providers you are  Non-Participating Providers: Except as responsible for amounts above the allowed amount. required by law, we will pay benefits for covered services from providers who are not in our Accidental Injury network to you. Physical harm caused by a sudden, unexpected If we get a request in writing within 30 days of a event at a certain time and place. claim, we will pay the provider directly. You or an Accidental injury does not mean any of the following: individual named in a qualified domestic relations  An illness, except for infection of a cut or wound order may make this request. Once you send us this request, it can only be changed by sending another  Over-exertion or muscle strains written request to us and the provider of services.  Dental injuries caused by biting or chewing  Federal or state laws may require us to pay Affordable Care Act benefits to certain agencies. These may include a state child support enforcement agency, a public The Patient Protection and Affordable Care Act of health program, or other agencies. 2010 (Public Law 111-148) as amended by the Health Care and Education Reconciliation Act of Payment as stated above satisfies our obligation to 2010 (Public Law 111-152). pay benefits.

PBCBSAK SCER 01-2017 59 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Allowed Amount Calendar Year (Year) See Important Plan Information. A 12-month period that starts on January 1 at 12:01 a.m. and ends on December 31 at midnight. Ambulatory Surgical Facility Calendar Year Maximum A healthcare facility where people get surgery without staying overnight. An ambulatory surgical See Important Plan Information. center must be licensed or certified by the state it is Claim in. It also must meet all of these criteria:  It has an organized staff of doctors A request to us for payment of amount due.  It is a permanent facility that is equipped and run Clinical Trials mainly for doing surgical procedures An approved clinical trial means a scientific study  It does not provide inpatient services or rooms using human subjects designed to test and improve Applied Behavior Analysis (ABA) prevention, diagnosis, treatment, or palliative care of cancer, or the safety and effectiveness of a drug, The design, implementation and evaluation of device, or procedure used in the prevention, environmental modifications, using behavioral stimuli diagnosis, treatment, or palliative care, if the study is and consequences, including direct observation, approved by the following: measurement and functional analysis of the  An institutional review board that complies with 45 relationship between environment and behavior to CFR Part 46; and produce socially significant improvement in human behavior or to prevent the loss of an attained skill or  One or more of the following: function.  The United States Department of Health and Human Services, National Institutes of Health, Autism Spectrum Disorders or its institutes or centers Pervasive developmental disorders or a group of  The United States Department of Health and conditions having substantially the same Human Services, United States Food and Drug characteristics as pervasive developmental Administration (FDA) disorders, as defined in the current Diagnostic and Statistical Manual (DSM) published by the  The United States Department of Defense American Psychiatric Association, as amended or  The United States Department of Veterans’ reissued from time to time. Affairs Autism Service Provider  A nongovernmental research entity abiding by current National Institutes of Health guidelines An individual who is licensed, certified, or registered by the applicable state licensing board or by a Coinsurance nationally recognized certifying organization, and See Important Plan Information. who provides direct services to an individual with autism spectrum disorder. Complication of Pregnancy Benefit A medical condition related to pregnancy or childbirth that falls into one of these three What this plan provides for a covered service. The categories: benefits you get are subject to this plan’s cost- shares.  A condition of the fetus that needs surgery while still in the womb (in utero) Benefit Booklet  A disease the mother has during pregnancy that is Benefit booklet describes the benefits, limitations, not caused by the pregnancy. The disease is exclusions, eligibility and other coverage provisions made worse by the pregnancy. included in this plan and are part of the entire  A condition the mother has that is caused by the contract. pregnancy. It is more difficult to treat because of Benefit Waiting Period the pregnancy. These conditions are limited to:  Ectopic pregnancy Means a period during which specified treatment or services are excluded from coverage under this  Hydatidiform mole/molar pregnancy plan. The benefit exclusion periods begins on your  Incompetent cervix that requires treatment effective date of coverage.  Complications of administration of anesthesia or sedation during labor or delivery  Obstetrical trauma, such as uterine rupture

PBCBSAK SCER 01-2017 60 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska before onset or during labor charges, amount over the allowed amount billed by  Hemorrhage before or after delivery that health care providers who are out of the network, or requires medical or surgical treatment the cost of services not covered by this plan. See Summary of Your Costs for your cost-shares.  Placental conditions that require surgical intervention Covered Service  Preterm labor and monitoring A medically necessary service that is eligible for  Toxemia benefits under this plan.  Gestational diabetes Custodial Care  Hyperemesis gravidarum Any part of a covered service that is mainly to:  Spontaneous miscarriage or missed abortion  Maintain your health over time, and not to treat A complication of pregnancy needs services that are specific illness or injury more than the usual maternity services. This  Help you with activities of daily living. Examples includes care before, during, and after birth (normal are help in walking, bathing, dressing, eating, and or cesarean) preparing special food. This also includes supervising the self-administration of medication Comprehensive Oral Evaluation when it does not need the constant attention of Comprehensive oral evaluations include complete trained medical providers. dental/medical history and general health Deductible assessment, complete thorough evaluation of extra- oral and intra-oral hard and soft tissue; the See Important Plan Information. evaluation and recording of dental caries, missing or Dependent unerupted teeth, restoration, occlusal relationships, periodontal conditions (including periodontal The employee’s spouse, domestic partner, children charting), hard and soft tissue anomalies, and oral and any eligible grandchildren who are enrolled on cancer screenings. this plan. Congenital Anomaly Dental Emergency A marked difference from the normal structure of a A condition requiring prompt or urgent attention due body part that is different from the normal structure to trauma and/or pain caused by a sudden at the time of birth. unexpected injury, acute infection or similar occurrence. Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) Dentally Necessary and Dental Necessity COBRA is a federal law which requires most Those covered services which are determined to employers with 20 or more employees to give meet all of the following requirements: employees and their families who lose their health  Essential to, consistent with, and provided for the benefits the right to choose to continue group health diagnosis or the direct care and treatment of a benefits provided by their group health plan for disease, injury, or condition harmful or limited periods of time under certain circumstances threatening to the member’s dental health, unless such as voluntary or involuntary job loss, reduction provided for preventive services when specified in the hours worked, transfer or promotion between as covered under this plan jobs, death, divorce, and other life events.  Appropriate and consistent with authoritative Copay dental or scientific literature See Important Plan Information.  Not primarily for the convenience of the member, the member’s family, the member’s dental care Cosmetic Services provider or another provider Services that are performed to reshape normal Detoxification structures of the body in order to improve your appearance and self-esteem and not primarily to Detoxification is active medical management of restore an impaired function of the body. medical conditions due to substance intoxication or withdrawal, which requires repeated examination Cost-Share appropriate to the substance ingested, and use of The part of healthcare costs that you have to pay. medication. Observation alone is not active medical Examples are deductibles, coinsurance, copays, and management. similar charges. It does not include subscription

PBCBSAK SCER 01-2017 61 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Effective Date marketed without the approval of the U.S. Food and Drug Administration and does not have The date your coverage under this plan begins. 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 assure, within reasonable medical probability that effective than conventional therapies no material deterioration of the condition is likely Reliable evidence means only published reports and to result from or occur during the transfer of the articles in authoritative medical and scientific member from a medical facility. literature, scientific results of the provider of care’s  Ambulance transport as needed in support of the written protocols, or scientific data from another services above. provider studying the same service. Emergency Medical Condition Explanation of Benefits A medical condition that you believe puts your An explanation of benefits is a statement that shows health, a part of your body or the health of an unborn what you will owe and what we will pay for child at risk. Examples are severe pain, a possible healthcare services received. It’s not a bill. heart attack or a broken bone. You need medical Facility (Medical Facility) care right away. Routine care for sore throats or colds, follow-up care and prescription requests are A hospital, skilled nursing facility, state-approved not emergencies. substance abuse treatment program, or hospice. Not all health care facilities are covered under this Endorsement Group contract. A document that is attached to and made a part of Group this contract. An endorsement changes the terms of the contract. A small employer, including a person, firm, corporation, partnership, or political subdivision, that Essential Health Benefits is actively engaged in business and is a party to the Benefits defined by the Secretary of Health and Group Contract. The “Group” is responsible for Human Services that shall include at least the collecting and paying all subscription charges, following general categories: ambulatory patient receiving notice of additions and changes to services, emergency care, hospitalization, maternity employee and dependent eligibility and providing and newborn care, mental health and substance such notice to us, and acting on behalf of its abuse services, including behavioral health employees. treatment, prescription drugs, rehabilitative and Habilitation Therapy habilitative services and devices, laboratory services, preventive and wellness services and Habilitative services or devices are medical services chronic disease management and pediatric services, or devices provided when medically necessary for including oral and vision care. The designation of development of bodily or cognitive functions to health benefits as essential shall be consistent with perform activities of daily living that never developed the requirements and limitations set forth under the or did not develop appropriately based on the Affordable Care Act and applicable regulations as chronological age of the insured. Habilitative determined by the Secretary of Health and Human services include physical therapy, occupational Services. therapy, and speech-language therapy when provided by a state-licensed or state-certified Experimental or Investigational Services provider acting within the scope or his or her license. Services that meet one or more of the following: Therapy to retain skills necessary for activities of daily living and prevent regression to a previous  A drug or device which cannot be lawfully

PBCBSAK SCER 01-2017 62 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska level of function is a habilitative service, if medically contracts with to provide healthcare services. When necessary and appropriate. Habilitative devices you have an in-network healthcare service, you may be limited to those that have FDA approval and usually pay less. are prescribed by a qualified provider. Habilitative Inpatient services do not include respite care, day habilitation services designed to provide training, structured Someone who is admitted to a healthcare facility for activities and specialized assistance for adults, an overnight stay. We also use this word to chore services to assist with basic needs, describe the services you get while you are an educational, vocational, recreational or custodial inpatient. services. Limited Oral Evaluation – Problem Focused Home Health Agency A limited oral evaluation – problem focused is an An organization that provides covered home health evaluation limited to a specific oral health problem or services to a member. complaint and may include evaluation of a specific dental problem or oral health complaint, dental Home Medical Equipment (HME) emergency and referral for other treatment. Equipment ordered by a healthcare provider for Medically Necessary and Medical Necessity everyday or extended use to treat an illness or injury. HME may include: oxygen equipment, Services and supplies that a doctor, exercising wheelchairs or crutches. prudent clinical judgment, would use with a patient to prevent, evaluate, diagnose or treat an illness, Hospice injury, disease or its symptoms. These services A facility or program designed to provide a caring must: environment for supplying the physical and  Agree with generally accepted standards of emotional needs of the terminally ill. medical practice Hospital  Be clinically appropriate in type, frequency, extent, A healthcare facility that meets all of these criteria: site and duration. They must also be considered effective for the patient’s illness, injury or disease  It operates legally as a hospital in the state where it is located  Not be mostly for the convenience of the patient, doctor, or other health care provider. They do not  It has facilities for the diagnosis, treatment and cost more than another service or series of acute care of injured and ill persons as inpatients services that are at least as likely to produce  It has a staff of doctors that provides or equivalent therapeutic or diagnostic results for the supervises the care diagnosis or treatment of that patient’s illness,  It has 24-hour nursing services provided by or injury or disease. supervised by registered nurses For these purposes, “generally accepted standards A facility is not considered a hospital if it operates of medical practice” means standards that are based mainly for any of the purposes below: on credible scientific evidence published in peer reviewed medical literature. This published  As a rest home, nursing home, or convalescent evidence is recognized by the relevant medical home community, doctor specialty society  As a residential treatment center or health resort recommendations and the views of doctors  To provide hospice care for terminally ill patients practicing in relevant clinical areas and any other relevant factors.  To care for the elderly Member  To treat substance abuse or tuberculosis Any person covered under this plan. Illness Mental Health Condition A sickness, disease, medical condition or complication of pregnancy. Any condition listed in the current Diagnostic and Statistical Manual (DSM), published by the Injury American Psychiatric Association, excluding Physical harm caused by a sudden event at a diagnosis and treatments for substance abuse. specific time and place. It is independent of illness, Orthotic except for infection of a cut or wound. A support or brace applied to an existing portion of In-network the body for weak or ineffective joints or muscles, to The specified doctors, hospitals or labs that Premera aid, restore or improve function.

PBCBSAK SCER 01-2017 63 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska Out-of-network  Non-Preferred Providers are providers that have a contract with us, but they are not in your Services from doctors, hospitals, and other provider network. You receive lower benefit healthcare professionals that have not contracted coverage for services provided by Non-Preferred with your plan. Depending on the healthcare providers. Non-Preferred providers will not bill professional, the service could cost more or not be you the amount above the allowed amount for a covered at all by your plan. covered service. Outpatient  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 covered service. Plan For providers of medical care outside the service The benefits, terms, and limitations stated in this area, we use the following terms: Group contract.  In-Network Providers are providers who have Prescription Drug contracts with other Blue Cross and/or Blue Shield Drugs and medications that by law require a Licensees outside the service area. prescription. This includes “biologicals” (medicines  Out-Of-Network Providers are providers who do made from living things or their products) used in not have contracts with other Blue Cross and/or chemotherapy to treat cancer. It also includes Blue Shield Licensees outside the service area. biologicals used to treat people with HIV or AIDS. See BlueCard Program for details. According to the Federal Food, Drug and Cosmetic Act, as amended, the label of a prescription drug For providers of dental care within the service area, must have this statement on it: “Caution: Federal we use the following terms: law prohibits dispensing without a prescription.”  In-Network Providers are contracted providers Primary Care Providers that are in your provider network. You receive the highest benefit level when you use an in-network A doctor (M.D. – Medical Doctor or D.O. – Doctor of provider. In-network providers will not bill you for Osteopathic Medicine), nurse practitioner, clinical the amount above the allowed amount for a nurse specialist or doctor assistant, as allowed covered service. under state law, who provides, coordinates or helps a patient access a range of healthcare services.  Out-Of-Network Providers are providers that are not in your provider network. You receive lower Prior Authorization benefit coverage for services provided by out-of- network dental providers. An out-of-network Planned services that must be reviewed for medical dental provider will bill you the amount over the necessity and approved by us before you receive allowed amount for a covered service. them. See the Prior Authorization section for details. Reconstructive Surgery Provider Reconstructive surgery is surgery: A doctor or other healthcare professional or facility  Which restores features damaged as a result of named in this plan that is licensed or certified as accidental injury (see Definitions) or illness required by the state in which the services were  To correct a congenital deformity or anomaly received to provide a medical service or supply, and who does so within the lawful scope of that license Rehabilitation Therapy or certification. Not all services they provide are Rehabilitative services or devices are medical covered under this plan. See Covered Services services or devices provided when medically and Exclusions for additional information. necessary for restoration of bodily or cognitive For providers of medical care within the service functions lost due to a medical condition. area, we use the following terms. Rehabilitative services include physical therapy,  Preferred INN Providers are contracted occupational therapy, and speech-language therapy providers that are in your provider network. You when provided by a state-licensed or state-certified receive the highest benefit level when you use a provider acting within the scope or his or her license. Preferred INN provider. Preferred INN providers Therapy performed to maintain a current level of will not bill you for the amount above the allowed functioning without documentation of significant amount for a covered service. improvement is considered maintenance therapy

PBCBSAK SCER 01-2017 64 Premera Blue Cross Plus Gold 500 Premera Blue Cross Blue Shield of Alaska 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 Services usually use drugs or alcohol in a frequent or intense pattern that leads to: Procedures, surgeries, consultations, advice, diagnosis, referrals, treatment, supplies, drugs,  Losing control over the amount and devices, technologies or places of service. circumstances of use  Developing a tolerance of the substance, or Skilled Nursing Care having withdrawal symptoms if they reduce or Medical care you get in your home or in a skilled stop the use nursing facility. Care is ordered by a doctor and  Making their health worse or putting it in serious requires the knowledge and training of a licensed danger registered nurse.  Not being able to function well socially or on the Skilled Nursing Facility job A medical facility licensed by the state to provide Substance abuse includes drug psychoses and drug nursing services to patients after an illness or injury. dependence syndromes. A skilled nursing facility must meet all of the following criteria: Urgent Care  Services it provides are directed by a doctor Treatment of unscheduled, drop-in patients who have minor illnesses and injuries. These illnesses or  Nursing care is supervised by a registered nurse injuries need treatment right away but they are not  The facility is approved by Medicare, or would life-threatening. Examples are high fevers, minor qualify for Medicare approval if it were requested sprains and cuts, and ear, nose and throat Small Employer infections. Urgent care is provided at a medical facility that is open to the public and has extended A small employer is an employer who employed an hours. average of at least 1 but not more than 50 common law employees on business days during the Visit preceding calendar year and who employs at least 1 A visit is one session of consultation, diagnosis, or common law employee on the first day of the current treatment with a provider. We count multiple visits plan year. with the same provider on the same day as one visit. In the case of an employer that was not in existence Two or more visits on the same date with different throughout the preceding calendar year, the providers count as separate visits. determination of whether the employer is a small Visual Oral Screenings or Assessments employer be based on the average number of employees that it is reasonably expected the Performed by a licensed dentist or dental hygienist employer will employ on business days in the current under the supervision of a licensed dentist to calendar year. determine the need for sealants, fluoride treatment, and/or when triage services are provided in settings Specialist other than dental offices or dental clinics. A doctor who focuses on a specific area of medicine We, Us and Our or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. Premera Blue Cross Blue Shield of Alaska (“Premera”) in the state of Alaska and Premera Blue Spouse Cross in the state of Washington. Someone who is legally married to the subscriber. A You and Your spouse can also be the subscriber’s domestic partner. Means any member enrolled in this plan. Subscription Charges The monthly rates we establish as consideration for the benefits offered under this contract.

PBCBSAK SCER 01-2017 65 Premera Blue Cross Plus Gold 500 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 38344AK0710001

036463 (10-2016)

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