Focus on life. Focus on health. Stay focused. BusinessADVANTAGESM 2020 Member Guide Table of Contents Introduction . 1 Health Insurance Portability Your ID Card . 3 And Accountability Act (HIPAA) . 25 Advantages of Your Digital ID Card . 3 Authorization to Disclose to a Third Party Form . 26 How to Access Your Digital ID Card . 3 If You Need To See A Doctor . 27 Your Personal Physician . 27 Accessing the ADVANTAGE Network . 4 Routine Care . 27 ADVANTAGE Network Benefits . 4 Gynecologist (GYN) . 27 Transition of Care . 4 If You Need to See a Specialist . 27 Benefit Basics . 5 Other Health Care Providers . 27 At-a-Glance Charts . 5 If You Need Urgent Care . 28 Plan Overview . 7 Urgent Care . 7 If You Need To Be Admitted To A Hospital . 29 What We Pay For . 7 If You Need Emergency Care . 29 Out-of-Network Benefits . 7 When Is an Emergency Not an Emergency? . 30 What We Do Not Pay For . 8 Services and Supplies We Don’t Cover . 8 If You Need A Prescription Drug . 31 What Is the Covered Drug List? . 31 Preventive Care And How To Stay Healthy . 10 How We Cover Drugs on the Covered Drug List . 31 Coverage for Preventive Exams and Screenings . 10 Preventive Health Guidelines . 10 Can The Covered Drug List Change? . 33 What if My Drug Is Not on the Covered Drug List? . 33 Great Expectations® for health . 11 How to Enroll . 11 Additional Pharmacy Considerations . 33 How the Programs Work . 11 For More Information . 33 Benefits and Services . 13 If You Need Other Services . 33 Adult Vision Care . 13 Lab Work, X-ray Studies and Pathology . 33 Pediatric Vision . 13 Behavioral Health . 33 Dental Care . 14 If You Need Emergency Care Outside Dental Reimbursement Form . 16 Of Your Service Area . 34 Employee Assistance Program (EAP) Services . 18 Within the United States . 34 Counseling Sessions . 18 Around the World . 34 Information On The Web . 19 When You Need To Know What You Will Pay . .35 My Health Toolkit® . 19 What’s Included? . 19 Claims, Coverage And Payment Concerns . .36 Download the My Health Toolkit Mobile App Today . 19 Explanation of Benefits . 36 Submitting Claims . 36 Help Wanted . 20 If You Receive a Bill . 36 FOCUSfwd® Wellness Incentive Program . 21 Coordination of Benefits . 36 Verification of Incapacitated Dependent . 37 FOCUSfwd® Device Integration ......................................22 ® Policies And Procedures . 38 FOCUSfwd GET FIT Challenge ......................................22 Administering Benefits for Appropriate Services . 38 Personal Health Assesment ............................................23 Appeals and External Review Procedures . 38 A Step Toward Beter Health . 23 Covering New Technology . 39 Your Privacy Is Our Priority . 23 Notice Of Our Privacy Policies And Practices . 40 You Matter . ..23 Instant Feedback . 23 Questions And Concerns . 44 How to Access . 23 Rights and Responsibilities . 44 Visit With a Doctor Anytime, Anywhere . 24 Glossary . 45 What Types of Conditions Can Non-Discrimination Statement SM Blue CareOnDemand Doctors Treat? . 24 And Foreign Language Access . 48 When Should You Use Video Visits? . 24 Get Started Now . 24 Get Our Texts . 25 Welcome to BlueChoice HealthPlan This is your BusinessADVANTAGE Member Guide, which outlines your benefits and covered services. Please refer to the Benefits Basics section. It contains important topics for you to know. If you need more detailed information, please read the expanded information in the back of the guide . The ADVANTAGE network from BlueChoice® offers access to quality providers who can minimize costs while administering the highest quality of care . As your health plan, we’re2018 here to helpIcons you . If -you 2018Cumulative need more Icons information, - Cumulative2018 Icons - Cumulative assistance or have other questions, please: icill ases icillPhsicians asesNes icillPhsicians asesNes Phsicians Nes Visit our website: Write to us: Call Monday – Friday Office Manual Office Manual Office Manual www .BlueChoiceSC .com BlueChoice HealthPlan between 8:30 a .m . – 5 p .m .: and send a secure email Member Services 800-868-2528 through My Health Toolkit P .O . Box 6170 TTY Services 711 + 800-868-2528 Columbia, SC 29260-6170 If you need an interpreter, we have free services available for both oral and written assistance . If you have questions about your coverage, please contact Member Services for more information . aorator aorator aorator iometric earning Managementiometric Ecation earning BenefitsManagement Mgmt iometricEcation earning Benefits Management Mgmt Ecation Benefits Mgmt We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, Screening Sstem ScreeningCenter Sstem ScreeningCenter Sstem Center sexual orientation or health status in our health plans, when we enroll members or provide benefits. 1 icEnroll FOCUSficEnroll Great FOCUSfHearing Ais icEnroll Great FOCUSfHearing Ais Great Hearing Ais Emploee leChoice M Health Rears Rears Rears Toacco ToaccoProcers Disconts an ToaccoProcers Disconts an ProcersEmploee Disconts an Emploee leChoice M Health leChoice M Health Epectations Epectations StorefrontEpectations Storefront Assistance Storefront HealthPlan ire Toolit HealthPlan ire Toolit HealthPlan ire Toolit Cessation CessationGie Ae ales CessationGie Ae ales GieAssistance Ae ales Assistance Program Program Program Health Care Vieo Healthle Care sinessVieo AD Healthle Care sinessVieo AD le siness AD les Flash Core Services lesMeical Flash Policies Core Services lesMeical Flash Policies Core Services Meical Policies Moile Fleile Savings Health Fleile Savings Health Fleile Savings Health Avantage Pls Carolina AD AvantageMChoice Pls AD CarolinaPrimar AD Choice AvantageMChoice Pls AD CarolinaPrimar AD Choice MChoice AD Primar Choice Moile Reform Moile ReformOption ReformOption Option App Accont ReimrsementApp Accont ReimrsementApp Accont Reimrsement Accont Accont Accont REV: 11/27/2018 REV: 11/27/2018 REV: 11/27/2018 Other documents referred to in this Member Guide will help you better understand your specific coverage and benefits, such as your copayments for prescription drugs and office visits, exclusions, etc. Here’s how to access these documents: Schedule of Benefits: This is a list of your employer’s unique coverage and benefits. The Schedule of Benefits includes the benefit categories and what you will pay for each service. You can access this through our website, www .BlueChoiceSC .com . From the home page, you can log in to My Health Toolkit . If you don’t have an account, it just takes a few minutes to create one . Be sure to have your member ID card available . Once you have created a profile, you will have access to your Schedule of Benefits. Select the Benefits tab at the top of the page. Then select Health Eligibility and Benefits. Certificate of Coverage: This is an in-depth description of covered services, exclusions, limitations and eligibility requirements. You can find your Certificate of Coverage by logging into your My Health Toolkit account . Once logged in, select the Benefits tab at the top of the page . Then select Health Eligibility and Benefits . Select View Benefit Booklet at the top of the page. You can also request a copy of your Certificate of Coverage from your Human Resources department . One more thing: We know there are a lot of insurance words that may be confusing . Please refer to the glossary on pages 45 – 47 . Thank you for choosing BlueChoice . 2 Your ID Card Keep your BusinessADVANTAGE ID card with you at all times . You will receive your ID card in the mail . If you have single coverage, you will receive one ID card . If you have dependents and/or family coverage, you will receive two cards . The ID cards will only include the primary cardholder’s name, but all covered members can use them . You can also order additional cards if needed. Your ID card is specific to your health plan. Once you receive the card, you can begin using it the first day your plan is effective. Whenever you need medical care, be sure to show your ID card to the health care provider . BusinessADVANTAGE Your ID Card is Digital Too SUBSCRIBER’S FIRST NAME Remember, you can access your digital ID card anytime, SUBSCRIBER’S LAST NAME Member ID anywhere from your computer or mobile device . ZCL000000000 PLAN PPO Health Benets PLAN CODE 380.04 Pediatric Vision RxBIN 021684 Comprehensive Care Advantages of Your Digital ID Card RxGRP CHC Your digital ID card is identical to your physical card . It contains your Member ID number and other coverage details unique to www.BlueChoiceSC.com you . Unlike your physical card, you don’t have to worry about losing it or ordering duplicate copies for your family . You can easily: • View your card on your smartphone, tablet or computer . • Email your card to your spouse, children, doctor’s office or pharmacy. • Print your card at home from your smartphone or computer . Use the printed card just like your physical card . How to Access Your Digital ID Card Visit www BlueChoiceSC. com. and log in to your My Health Toolkit account: • On your computer: Under the “Insurance Card” section on the left, select “View Your Card .” • On your mobile device: Select “Insurance Card” from the main menu . Don’t discard your physical ID card . Some doctors may still want a copy of it for their records . If you have not received a new ID card, the digital card may not be available . Remember, you can also access your ID card via the My Health Toolkit app . Check out page 19 to learn more about the app . 3 Accessing the ADVANTAGE Network Your plan offers a wide and comprehensive network of doctors, hospitals and other health care providers . Your network is the “ADVANTAGE Network .” This means you can receive your health care services from providers in this network . We encourage you to select a primary care physician (PCP) . Once you have selected a PCP from the ADVANTAGE network, call his or her office to schedule an appointment for your routine checkup. Remember to bring your ID card with you each time you visit your PCP .