Benefit Booklet for Booklet Benefit An Independent Licensee of the Blue Cross and Blue Shield Association L1338, 7/13 Blue Options/B0004313 BENEFIT BOOKLET This benefit booklet, along with the GROUP CONTRACT, is the legal contract between your EMPLOYER and Blue Cross and Blue Shield of North Carolina. Please read this benefit booklet carefully. Blue Cross and Blue Shield of North Carolina agrees to provide benefits to the qualified SUBSCRIBERS and eligible DEPENDENTS who are listed on the enrollment application and who are accepted in accordance with the provisions of the GROUP CONTRACT entered into between Blue Cross and Blue Shield of North Carolina and the SUBSCRIBER’S EMPLOYER. A summary of benefits, conditions, limitations, and exclusions is set forth in this Benefit Booklet for easy reference. Blue Cross and Blue Shield of North Carolina has directed that this Benefit Booklet be issued and signed by the President and the Secretary. Attest: President Secretary Important Cancellation Information-Please Read The Provision In This Benefit Booklet Entitled, “When Coverage Begins And Ends.” TABLE OF CONTENTS GETTING STARTED WITH BLUE OPTIONS.............................................................................7 FOR HELP IN READING THIS BENEFIT BOOKLET..............................................................8 WHO TO CONTACT?....................................................................................................................9 TOLL-FREE PHONE NUMBERS, WEBSITE AND ADDRESSES............................................9 VALUE-ADDED PROGRAMS.................................................................................................10 SUMMARY OF BENEFITS..........................................................................................................11 HOW BLUE OPTIONS WORKS..................................................................................................19 OUT-OF-NETWORK BENEFIT EXCEPTIONS.......................................................................21 CARRY YOUR ID CARD.........................................................................................................21 THE ROLE OF A PRIMARY CARE PROVIDER (PCP) OR SPECIALIST..............................22 COVERED SERVICES..................................................................................................................23 OFFICE SERVICES..................................................................................................................23 PREVENTIVE CARE............................................................................................................... 23 FEDERALLY-MANDATED PREVENTIVE CARE SERVICES........................................24 STATE-MANDATED PREVENTIVE CARE SERVICES..................................................25 OBESITY TREATMENT/WEIGHT MANAGEMENT.............................................................27 DIAGNOSTIC SERVICES........................................................................................................27 DIAGNOSTIC SERVICES EXCLUSIONS.........................................................................28 EMERGENCY CARE...............................................................................................................28 WHAT TO DO IN AN EMERGENCY............................................................................... 28 URGENT CARE........................................................................................................................29 FAMILY PLANNING...............................................................................................................29 MATERNITY CARE..........................................................................................................29 COMPLICATIONS OF PREGNANCY...............................................................................30 INFERTILITY SERVICES.................................................................................................30 SEXUAL DYSFUNCTION SERVICES..............................................................................31 FAMILY PLANNING EXCLUSIONS................................................................................31 FACILITY SERVICES..............................................................................................................32 OTHER SERVICES.................................................................................................................. 32 AMBULANCE SERVICES.................................................................................................32 BLOOD...............................................................................................................................33 CERTAIN DRUGS COVERED UNDER YOUR MEDICAL BENEFIT.............................33 CLINICAL TRIALS........................................................................................................... 33 DENTAL TREATMENT COVERED UNDER YOUR MEDICAL BENEFIT....................34 DIABETES-RELATED SERVICES................................................................................... 35 DURABLE MEDICAL EQUIPMENT................................................................................35 HEARING AIDS.................................................................................................................35 SGBOptions , 5/17 i TABLE OF CONTENTS (cont.) HOME HEALTH CARE.....................................................................................................35 HOME INFUSION THERAPY SERVICES........................................................................36 HOSPICE SERVICES.........................................................................................................36 LYMPHEDEMA-RELATED SERVICES...........................................................................36 MEDICAL SUPPLIES........................................................................................................36 ORTHOTIC DEVICES.......................................................................................................36 PEDIATRIC DENTAL SERVICES.................................................................................... 37 PEDIATRIC VISION SERVICES.......................................................................................40 PRIVATE DUTY NURSING..............................................................................................40 PROSTHETIC APPLIANCES.............................................................................................41 SURGICAL BENEFITS............................................................................................................41 ANESTHESIA....................................................................................................................41 MASTECTOMY BENEFITS..............................................................................................42 TEMPOROMANDIBULAR JOINT (TMJ) SERVICES.............................................................42 THERAPIES..............................................................................................................................42 REHABILITATIVE THERAPY AND HABILITATIVE SERVICES..................................42 OTHER THERAPIES.........................................................................................................43 TRANSPLANTS.......................................................................................................................43 TRANSPLANTS EXCLUSIONS........................................................................................44 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES.................................................44 HOW TO ACCESS MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES...........44 PRESCRIPTION DRUG BENEFITS.........................................................................................44 WHAT IS NOT COVERED?.........................................................................................................51 WHEN COVERAGE BEGINS AND ENDS..................................................................................57 ENROLLING IN THIS HEALTH BENEFIT PLAN..................................................................57 ADDING OR REMOVING A DEPENDENT............................................................................58 QUALIFIED MEDICAL CHILD SUPPORT ORDER...............................................................58 TYPE OF COVERAGE............................................................................................................59 REPORTING CHANGES..........................................................................................................59 CONTINUING COVERAGE.....................................................................................................59 MEDICARE........................................................................................................................59 CONTINUATION UNDER FEDERAL LAW.....................................................................59 CONTINUATION UNDER STATE LAW..........................................................................60 WHEN MY COVERAGE UNDER THIS HEALTH BENEFIT PLAN ENDS.....................61 CERTIFICATE OF CREDITABLE COVERAGE...............................................................61 TERMINATION OF MEMBER COVERAGE...........................................................................62 TERMINATION FOR CAUSE...........................................................................................62