MyChoice® Health Coverage Plans for Individuals & Families

18610-3-2016

Table of Contents MyChoice Open Access Health Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 MyChoice Value Plans Health Coverage Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Benefit Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-11 Individual and Family Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 How the Family Deductible Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Calculating Family Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Waiting Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Pre-existing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Services and Supplies Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-15 Auto Reject Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Additional Important Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Contact Information for BlueChoice HealthPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Answers to Your Questions About MyChoice Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Peace of Mind and Quality Coverage In today’s world, there is plenty to be said for feeling secure. Knowing you’re protected offers you peace of mind. With MyChoice Health Coverage from BlueChoice®, you can rest easy knowing your health insurance is provided by a company that’s been doing business with South Carolina residents for nearly 30 years. Our commitment to our members has earned us accreditation from the National Committee for Quality Assurance, a national group that reviews health plans. This means we passed the test in critical areas of health plan operations. We value this award and consistently work to improve our service and maintain this status. We’re even more pleased that thousands of South Carolinians select us as their health plan, and we look forward to you joining many of your neighbors as a BlueChoice member!

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MyChoice Open Access Plans … Freedom To Choose The key to maximizing your and your family’s health benefits is having the freedom to choose a physician or specialist, when needed. MyChoice Health Coverage gives you that freedom with open-access plans with a rich level of benefits that include:

• Comprehensive copayments — all services provided in your physician’s office are covered with one low copayment • Mandated preventive services with no copayment • Specialist office visits with no referral needed • Urgent and emergency care • Prescription drug coverage o Value generics* — $8 copayment on any generic drug up to $14.99 o Generic — $15 copayment on any generic drug $15 or higher o $35 brand-name drug o $55 non-preferred brand * Value generic drugs are the lowest-cost generic drugs on the market and also include over-the-counter (OTC) drugs currently covered by prescription • Vision care — free annual exam from Physicians Eyecare Network (PEN) Provider. PEN is an independent company that offers a network of vision care providers on behalf of BlueChoice • Dental care — member reimbursed for the allowed amount • Mental health and substance abuse treatment • Physical, speech and occupational therapy • Durable medical equipment • Hospital services (inpatient and outpatient) • First Sun Individual Assistance Program. Because First Sun is a separate company from BlueChoice HealthPlan, First Sun will be responsible for all services related to the Individual Assistance Program.

As a MyChoice Health Coverage member, you have the freedom to go in or out of network. You can also self-refer to a specialist. Staying in network saves you money and offers advantages such as administrative ease and coverage for preventive care services. Going out of network can mean higher deductibles and coinsurance, and you might have to file some of your own claims. Some benefits, such as routine health screenings, are not covered. For emergency care, members receive in-network benefits regardless of where services are rendered. BlueChoice® HealthPlan is a member of the BlueCard® program. When traveling across the country or around the world, you get the highest level of benefits when you get services from a BlueCard provider. Use our Doctor and Hospital Finder anytime to find a provider near you.

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MyChoice Value Plans … Great Coverage at a Great Price $5 Copayment at Doctor’s Care or CVS Minute Clinic! You want a health plan you can afford, while getting the comprehensive coverage you need. MyChoice Value Plans offer all this and more. With a Value Plan, you not only get many of the same benefits of a MyChoice Open Access Plan, including in- and out-of-network coverage and the BlueCard® program, you have the option of going to any Doctor’s Care office or CVS Minute Clinic in South Carolina for a copayment of just $5! Value Plans offer the following premium-saving differences: Prescription drug coverage – (Generics are the same on all MyChoice products)

• Value generic* — $8 copayment on any generic drug up to $14.99 • Generic — $15 copayment on any generic drug $15 or higher • 30 percent copayment on brand-name drugs; $500 deductible on brand-name only • 60 percent copayment on non-preferred brand Value generic drugs are the lowest-cost generic drugs on the market and also include over-the-counter (OTC) drugs currently covered by prescription. *

• Copayments before inpatient, outpatient and emergency room services For a cost-saving alternative to other individual or family policies, and a $5 copayment at Doctor’s Care or CVS Minute Clinic, sign up for a MyChoice Value Plan today! As a MyChoice Value Plan Open Access member, you have the freedom to go in or out of network. You can also self refer to a specialist. Staying in network saves you money and offers advantages such as administrative ease and coverage for preventive care services. Going out of network can mean higher deductibles and coinsurance, and you might have to file some of your own claims. Some benefits, such as routine health screenings, are not covered. For emergency care, members receive in-network benefits regardless of where services are rendered. BlueChoice is a member of the BlueCard® program. When traveling across the country or around the world, you get the highest level of benefits when you get services from a BlueCard provider. Use our Doctor and Hospital Finder at BlueChoiceSC.com to find a provider near you.

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MyChoice Health Coverage From BlueChoice Open Access Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$500/$1,500 — 80%/60% Plan

$750/$2,250 — 80%/60% Plan

In Network

Out of Network

In Network

Out of Network

$500 – Individual $1,500 – Family

$1,000 – Individual $2,000 – Family

$750 – Individual $2,250 – Family

$1,500 – Individual $3,000 – Family

$2,000 – Individual $4,000 – Family

$4,000 – Individual $8,000 – Family

$2,500 – Individual $5,000 – Family

$5,000 – Individual $10,000 – Family

Primary Care Physician Services

$15 copayment per visit

60% – Subject to deductible

$15 copayment per visit

60% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

Not covered

$0 copayment per visit

Not covered

Specialist Visit

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Inpatient Hospital Services

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Outpatient Hospital Services

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

$35 copayment per visit

60% – Subject to deductible

$35 copayment per visit

60% – Subject to deductible

Emergency Room

80% – Subject to deductible

80% – Subject to deductible

80% – Subject to deductible

80% – Subject to deductible

Ambulance

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Mental Health and Substance Abuse (office services only)

80% – Subject to deductible, up to 20 visits per benefit period

60% – Subject to deductible, up to 20 visits per benefit period

80% – Subject to deductible, up to 20 visits per benefit period

60% – Subject to deductible, up to 20 visits per benefit period

None

None

$500–brand only

None

Prescription Drugs

$8 value/$15 generic $35 brand/$55 non-preferred copayment, then 100%

N/A

$8 value/$15 generic $35 brand/$55 non-preferred copayment, then 100%

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

80% – Subject to deductible

Not covered

80% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

80% – Subject to deductible, up to 20 visits per therapy per benefit period

60% – Subject to deductible, up to 20 visits per therapy per benefit period

80% – Subject to deductible, up to 20 visits per therapy per benefit period

60% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Deductible Coinsurance Maximum

Urgent Care

Prescription Deductible

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MyChoice Health Coverage From BlueChoice Open Access Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$1,000/$3,000 — 80%/60% Plan

$3,250/$9,750 — 80%/60% Plan

In Network

Out of Network

In Network

Out of Network

Deductible

$1,000 – Individual $3,000 – Family

$2,000 – Individual $4,000 – Family

$3,250 – Individual $9,750 – Family

$6,500 – Individual $13,000 – Family

Coinsurance Maximum

$3,000 – Individual $6,000 – Family

$6,000 – Individual $12,000 – Family

$3,250 – Individual $6,500 – Family

$6,500 – Individual $13,000 – Family

Primary Care Physician Services

$20 copayment per visit

60% – Subject to deductible

$35 copayment per visit

60% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

Not covered

$0 copayment per visit

Not covered

Specialist Visit

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Inpatient Hospital Services

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Outpatient Hospital Services

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

$35 copayment per visit

60% – Subject to deductible

$35 copayment per visit

60% – Subject to deductible

Emergency Room

80% – Subject to deductible

80% – Subject to deductible

80% – Subject to deductible

80% – Subject to deductible

Ambulance

80% – Subject to deductible

60% – Subject to deductible

80% – Subject to deductible

60% – Subject to deductible

Mental Health and Substance Abuse (office services only)

80% – Subject to deductible, up to 20 visits per benefit period

60% – Subject to deductible, up to 20 visits per benefit period

80% – Subject to deductible, up to 20 visits per benefit period

60% – Subject to deductible, up to 20 visits per benefit period

None

None

None

None

Prescription Drugs

$8 value/$15 generic $35 brand/$55 non-preferred copayment, then 100%

N/A

80% – Subject to deductible

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

$350 copayment per 31-day supply or per episode

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

80% – Subject to deductible

Not covered

80% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

80% – Subject to deductible, up to 20 visits per therapy per benefit period

60% – Subject to deductible, up to 20 visits per therapy per benefit period

80% – Subject to deductible, up to 20 visits per therapy per benefit period

60% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Urgent Care

Prescription Deductible

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MyChoice Health Coverage From BlueChoice Open Access Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$1,500/$4,500 — 70%/50% Plan

$2,500/$7,500 — 70%/50% Plan

In Network

Out of Network

In Network

Out of Network

Deductible

$1,500 – Individual $4,500 – Family

$3,000 – Individual $6,000 – Family

$2,500 – Individual $7,500 – Family

$5,000 – Individual $10,000 – Family

Coinsurance Maximum

$5,000 – Individual 10,000 – Family

$10,000 – Individual $20,000 – Family

$5,000 – Individual $10,000 – Family

$10,000 – Individual $20,000 – Family

Primary Care Physician Services

$25 copayment per visit

50% – Subject to deductible

$35 copayment per visit

50% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

Not covered

$0 copayment per visit

Not covered

Specialist Visit

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Inpatient Hospital Services

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Outpatient Hospital Services

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

$50 copayment per visit

50% – Subject to deductible

$50 copayment per visit

50% – Subject to deductible

Emergency Room

70% – Subject to deductible

70% – Subject to deductible

70% – Subject to deductible

70% – Subject to deductible

Ambulance

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Mental Health and Substance Abuse (office services only)

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

$500–brand only

None

$500–brand only

None

Prescription Drugs

$8 value/$15 generic $35 brand/$55 non-preferred copayment, then 100%

N/A

$8 value/$15 generic $35 brand/$55 non-preferred copayment, then 100%

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

70% – Subject to deductible

Not covered

70% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Urgent Care

Prescription Deductible

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MyChoice Health Coverage From BlueChoice Open Access Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit Deductible Coinsurance Maximum Primary Care Physician Services Mandated Preventive Services

$3,000/$6,000 HDHP

$5,000/$10,000 HDHP

In Network

Out of Network

In Network

Out of Network

$3,000 – Individual $6,000 – Family

$6,000 – Individual $12,000 – Family

$5,000 – Individual $10,000 – Family

$7,500 – Individual $15,000 – Family

N/A – Individual N/A – Family

$10,000 – Individual $20,000 – Family

N/A – Individual N/A – Family

$10,000 – Individual $20,000 – Family

100% – Subject to deductible

60% – Subject to deductible

100% – Subject to deductible

60% – Subject to deductible

$0 copayment per visit

Not covered

$0 copayment per visit

Not covered

Specialist Visit

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Inpatient Hospital Services

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Outpatient Hospital Services

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Urgent Care

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Emergency Room

100% – Subject to deductible

100% – Subject to deductible

Ambulance

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Mental Health and Substance Abuse (office services only)

100% – Subject to deductible 60% – Subject to deductible

100% – Subject to deductible 60% – Subject to deductible

Prescription Deductible

100% – Subject to deductible

None

100% – Subject to deductible

None

Prescription Drugs

100% – Subject to deductible

N/A

100% – Subject to deductible

N/A

Specialty Pharmaceuticals

100% – Subject to deductible

Not covered

100% – Subject to deductible

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

100% – Subject to deductible

Not covered

100% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

100% – Subject to deductible, 60% – Subject to deductible, 100% – Subject to deductible, 60% – Subject to deductible, up to 20 visits per therapy up to 20 visits per therapy up to 20 visits per therapy up to 20 visits per therapy per benefit period per benefit period per benefit period per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

100% – Subject to deductible

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100% – Subject to deductible

MyChoice Health Coverage From BlueChoice Value Plan Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$1,000/$3,000 — 80%/60% Value Plan

$1,500/$4,500 — 70%/50% Value Plan

In Network

Out of Network

In Network

Out of Network

Deductible

$1,000 – Individual $3,000 – Family

$3,000 – Individual $9,000 – Family

$1,500 – Individual $4,500 – Family

$4,500 – Individual $9,000 – Family

Coinsurance Maximum

$5,000 – Individual $10,000 – Family

$10,000 – Individual $20,000 – Family

$6,000 – Individual $12,000 – Family

$12,000 – Individual $18,000 – Family

Doctor’s Care Physician Services or CVS Minute Clinic

$5 copayment per visit

N/A

$5 copayment per visit

N/A

Primary Care Physician Services

$40 copayment per visit

60% – Subject to deductible

$40 copayment per visit

50% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

N/A

$0 copayment per visit

N/A

Specialist Visit

80% – Subject to deductible

60% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Inpatient Hospital Services

$300 copayment, followed by deductible, then 20%

60% – Subject to deductible

$300 copayment, followed by deductible, then 30%

50% – Subject to deductible

Outpatient Hospital Services

$200 copayment, followed by deductible, then 20%

60% – Subject to deductible

$200 copayment, followed by deductible, then 30%

50% – Subject to deductible

Urgent Care (not Doctor’s Care)

$50 copayment per visit

60% – Subject to deductible

$50 copayment per visit

50% – Subject to deductible

Emergency Room

$100 copayment, followed by deductible, then 20%

$100 copayment, followed by deductible, then 20%

$100 copayment, followed by deductible, then 30%

$100 copayment, followed by deductible, then 30%

Ambulance

80% – Subject to deductible

60% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Mental Health and Substance Abuse (office services only)

80% – Subject to deductible, up to 20 visits per benefit period

60% – Subject to deductible, up to 20 visits per benefit period

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

$500–brand only

None

$500–brand only

None

Prescription Drugs

$8 value generic/$15 generic 30% brand/60% non-preferred copayment, then 100%

N/A

$8 value generic/$15 generic 30% brand/60% non-preferred copayment, then 100%

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

80% – Subject to deductible

Not covered

70% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

80% – Subject to deductible, up to 20 visits per therapy per benefit period

60% – Subject to deductible, up to 20 visits per therapy per benefit period

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Prescription Deductible

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MyChoice Health Coverage From BlueChoice Value Plan Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$2,500/$5,000 — 70%/50% Value Plan

$3,500/$7,000 — 70%/50% Value Plan

In Network

Out of Network

In Network

Out of Network

Deductible

$2,500 – Individual $5,000 – Family

$5,000 – Individual $10,000 – Family

$3,500 – Individual $7,000 – Family

$7,000 – Individual $14,000 – Family

Coinsurance Maximum

$7,500 – Individual $15,000 – Family

$15,000 – Individual $30,000 – Family

$10,500 – Individual $21,000 – Family

$21,000 – Individual $30,000 – Family

Doctor’s Care Physician Services or CVS Minute Clinic

$5 copayment per visit

N/A

$5 copayment per visit

N/A

Primary Care Physician Services

$40 copayment per visit

50% – Subject to deductible

$40 copayment per visit

50% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

N/A

$0 copayment per visit

N/A

Specialist Visit

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Inpatient Hospital Services

$300 copayment, followed by deductible, then 30%

50% – Subject to deductible

$300 copayment, followed by deductible, then 30%

50% – Subject to deductible

Outpatient Hospital Services

$200 copayment, followed by deductible, then 30%

50% – Subject to deductible

$200 copayment, followed by deductible, then 30%

50% – Subject to deductible

Urgent Care (not Doctor’s Care)

$50 copayment per visit

50% – Subject to deductible

$50 copayment per visit

50% – Subject to deductible

Emergency Room

$100 copayment, followed by deductible, then 30%

$100 copayment, followed by deductible, then 30%

$100 copayment, followed by deductible, then 30%

$100 copayment, followed by deductible, then 30%

Ambulance

70% – Subject to deductible

50% – Subject to deductible

70% – Subject to deductible

50% – Subject to deductible

Mental Health and Substance Abuse (office services only)

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

$500–brand only

N/A

$500–brand only

N/A

Prescription Drugs

$8 value generic/$15 generic 30% brand/60% non-preferred copayment, then 100%

N/A

$8 value generic/$15 generic 30% brand/60% non-preferred copayment, then 100%

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

70% – Subject to deductible

Not covered

70% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Blue Distinction Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Prescription Deductible

-9-

MyChoice Health Coverage From BlueChoice Value Plan Benefits

(The benefit period is 12 consecutive months from the effective date of coverage.)

Benefit

$5,000/$10,000 — 70%/50% Value Plan In Network

Out of Network

$5,000 – Individual $10,000 – Family

$10,000 – Individual $20,000 – Family

Unlimited – Individual Unlimited – Family

Unlimited – Individual Unlimited – Family

Doctor’s Care Physician Services or CVS Minute Clinic

$5 copayment per visit

N/A

Primary Care Physician Services

$40 copayment per visit

50% – Subject to deductible

Mandated Preventive Services

$0 copayment per visit

Not covered

Specialist Visit

70% – Subject to deductible

50% – Subject to deductible

Inpatient Hospital Services

$300 copayment, followed by deductible, then 30%

50% – Subject to deductible

Outpatient Hospital Services

$200 copayment, followed by deductible, then 30%

50% – Subject to deductible

Urgent Care (not Doctor’s Care)

$50 copayment per visit

50% – Subject to deductible

Emergency Room

$100 copayment, followed by deductible, then 30%

$100 copayment, followed by deductible, then 30%

Ambulance

70% – Subject to deductible

50% – Subject to deductible

Mental Health and Substance Abuse (office services only)

70% – Subject to deductible, up to 20 visits per benefit period

50% – Subject to deductible, up to 20 visits per benefit period

$500–brand only

N/A

Prescription Drugs

$8 value generic/$15 generic 30% brand/60% non-preferred copayment, then 100%

N/A

Specialty Pharmaceuticals

$80 preferred for a 30-day supply; $125 non-preferred for oral and self-injectibles; $125 per episode for infusion

Not covered

Vision Care

Free annual eye exam from PEN provider

Not covered

Dental Care

Up to $20 for one exam and $30 for one cleaning per benefit period

Up to $20 for one exam and $30 for one cleaning per benefit period

Durable Medical Equipment

70% – Subject to deductible

Not covered

Physical Therapy, Speech Therapy and Occupational Therapy

70% – Subject to deductible, up to 20 visits per therapy per benefit period

50% – Subject to deductible, up to 20 visits per therapy per benefit period

Transplants

Blue Distinction® Centers of Excellence network only

Not covered

Annual Benefit Maximum

$2 million

$2 million

Lifetime Benefit Maximum

Unlimited

Unlimited

Deductible Coinsurance Maximum

Prescription Deductible

- 10 -

MyChoice Open Access Plans Health Coverage Individual (Age 19-64.5) and Family Rates Effective 5-1-2016

Individual/Family Deductible $500/$1,500 80%/60% Plan

Base Rates*

$750/$2,250 80%/60% Plan

$1,000/$3,000 80%/60% Plan

$3,250/$9,750 80%/60% Plan

Age

Male

Female

Male

Female

Male

Female

Male

Female

0-4

$236.18

$236.18

$216.01

$216.01

$220.32

$220.32

$138.19

$138.19

5-18

$185.53

$185.53

$169.69

$169.69

$173.07

$173.07

$108.56

$108.56

19–24

$213.40

$286.76

$195.18

$262.28

$199.07

$267.51

$124.87

$167.79

25–29

$234.20

$351.05

$214.20

$321.07

$218.48

$327.47

$137.03

$205.41

30–34

$283.94

$441.38

$259.69

$403.69

$264.87

$411.74

$166.14

$258.26

35–39

$332.21

$507.73

$303.84

$464.38

$309.90

$473.64

$194.39

$297.09

40–44

$410.99

$594.82

$375.90

$544.02

$383.39

$554.87

$240.48

$348.04

45–49

$523.42

$737.93

$478.71

$674.91

$488.25

$688.37

$306.26

$431.77

50–54

$678.54

$788.26

$620.59

$720.95

$632.96

$735.32

$397.02

$461.23

55–59

$874.71

$860.30

$800.02

$786.84

$815.97

$802.52

$511.82

$503.37

60–64.5

$1,144.81

$976.84

$1,047.05

$893.41

$1,067.93

$911.23

$669.86

$571.57

65+

$1,270.99

$1,064.96

$1,162.44

$974.01

$1,185.62

$993.44

$743.67

$623.13

Individual/Family Deductible Base Rates* Age

$1,500/$4,500 70%/50% Plan

$2,500/$7,500 70%/50% Plan

Male

Male

Female

Female

$3,000/$6,000 100% HDHP Plan Male Individual

$5,000/$10,000 100% HDHP Plan

Female Family

Individual

Family

Male Individual

Female Family

Individual

Family

0-4

$177.95

$177.95

$155.69

$155.69

$136.16

$136.16

$100.13

$100.13

5-18

$139.80

$139.80

$122.30

$122.30

$106.96

$106.96

$78.66

$78.66

19–24

$160.79

$216.07

$140.67

$189.02

$141.58

$123.03

$190.25

$165.32

$108.87

$90.47

$146.29

$121.57

25–29

$176.47

$264.51

$154.37

$231.40

$155.37

$135.01

$232.89

$202.37

$119.48

$99.29

$179.09

$148.83

30–34

$213.94

$332.57

$187.16

$290.96

$188.37

$163.69

$292.83

$254.46

$144.86

$120.38

$225.18

$187.13

35–39

$250.32

$382.56

$218.99

$334.68

$220.40

$191.52

$336.84

$292.70

$169.48

$140.84

$259.02

$215.25

40–44

$309.68

$448.18

$270.91

$392.09

$272.66

$236.93

$394.62

$342.91

$209.67

$174.24

$303.46

$252.18

45–49

$394.38

$556.01

$345.02

$486.42

$347.24

$301.74

$489.56

$425.41

$267.03

$221.91

$376.47

$312.85

50–54

$511.26

$593.93

$447.27

$519.59

$450.15

$391.16

$522.95

$454.43

$346.16

$287.67

$402.14

$334.18

55–59

$659.08

$648.22

$576.59

$567.09

$580.31

$504.27

$570.74

$495.96

$446.25

$370.84

$438.89

$364.73

60–64.5

$862.60

$736.03

$754.64

$643.91

$759.49

$659.97

$648.05

$563.14

$584.04

$485.35

$498.34

$414.13

65+

$957.65

$802.43

$837.80

$702.00

$843.19

$732.71

$706.52

$613.95

$648.40

$538.84

$543.30

$451.50

These base rates are subject to health underwriting. Rates for ages 0–18 are for family plans only.

*

Individuals applying for HDHP coverage must use the individual HDHP rate. HDHP family rates for adults age 19–64.5 include a discount for a family deductible.

Rates can be reduced 2.5 percent with recurring bank draft or credit card payment.

- 11 -

MyChoice Value Plans Health Coverage Individual (Age 19-64.5) and Family Rates Effective 5-1-2016

Individual/Family Deductible Base Rates*

$1,000/$3,000 80%/60% Plan

$1,500/$4,500 70%/50% Plan

$2,500/$5,000 70%/50% Plan

Age

Male

Female

Male

Female

Male

Female

0-4

$191.51

$191.51

$165.36

$165.36

$144.77

$144.77

5-18

$150.44

$150.44

$129.90

$129.90

$113.72

$113.72

19–24

$173.04

$232.52

$149.41

$200.77

$130.80

$175.77

25–29

$189.90

$284.65

$163.97

$245.78

$143.55

$215.17

30–34

$230.23

$357.90

$198.80

$309.03

$174.04

$270.54

35–39

$269.38

$411.69

$232.60

$355.48

$203.63

$311.21

40–44

$333.25

$482.31

$287.75

$416.46

$251.91

$364.59

45–49

$424.41

$598.35

$366.46

$516.65

$320.82

$452.30

50–54

$550.19

$639.16

$475.07

$551.89

$415.90

$483.15

55–59

$709.26

$697.58

$612.43

$602.33

$536.14

$527.31

60–64.5

$928.27

$792.07

$801.53

$683.92

$701.70

$598.74

65+

$1,030.57

$863.53

$889.87

$745.63

$779.03

$652.75

Individual/Family Deductible Base Rates*

$3,500/$7,000 70%/50% Plan

$5,000/$10,000 70%/50% Plan

Age

Male

Female

Male

Female

0-4

$135.28

$135.29

$111.71

$111.71

5-18

$106.27

$106.27

$87.75

$87.75

19–24

$122.23

$164.25

$100.93

$135.63

25–29

$134.14

$201.07

$110.77

$166.03

30–34

$162.64

$252.82

$134.29

$208.76

35–39

$190.29

$290.82

$157.13

$240.14

40–44

$235.41

$340.70

$194.38

$281.33

45–49

$299.80

$422.67

$247.55

$349.01

50–54

$388.65

$451.50

$320.92

$372.81

55–59

$501.02

$492.76

$413.71

$406.89

60–64.5

$655.73

$559.51

$541.45

$462.00

65+

$727.99

$609.99

$601.12

$503.69

These base rates are subject to health underwriting. Rates for ages 0–18 are for family plans only.

*

Rates can be reduced 2.5 percent with recurring bank draft or credit card payment.

- 12 -

Calculating Family Rates — To calculate the family rates for MyChoice, simply add the individual rate for each member of the family. Here are some examples:

Individual Policy Family Policy Male 36 Male 42/Female 39 $1,000 80/60 Plan $1,500 80/60 Family Plan Deductible $309.90 $410.99 – Male Rate + $507.73 – Female Rate $918.72 – Total Family Rate

Family Policy Male 28/Female 29/Child 3 $6,000 HDHP Family Plan Deductible $135.01 – Male Family Rate +$202.37 – Female Family Rate +$136.16 – Child Family Rate $473.54 – Total Family Rate

How the Family Deductible Works When you purchase a family policy, the family deductible is an aggregate deductible for all family members who are on the coverage. For example, if a family of three has a $3,000 80/60 MyChoice Open Access Plan, the family deductible is $3,000. One, two or all three family members can contribute to that deductible amount during the one-year benefit period in any dollar amount for each person until that $3,000 deductible amount is reached.

Conditions Subject to a Six-Month Waiting Period:

Pre-existing Condition Exclusion

After the effective date of your coverage, there are some waiting periods during which no coverage is provided for treatment, including surgery, of certain specified diseases or conditions or losses resulting from them. The waiting periods are:

Pre-existing conditions are those for which medical advice or treatment was received or recommended no more than 12 months prior to the effective date of your coverage.

• • • • • • • • • •

1. Services or supplies for pre-existing conditions are not covered until the earlier of:

Six months for acne treatment Six months for adenoids Six months for allergy testing Six months for gastrointestinal reflux surgery Six months for hemorrhoids Six months for hernia (all types) Six months for disorders of reproductive systems Six months for sinus surgery Six months for strabismus Six months for tonsils



• A period of 12 months without medical care, treatment or supplies related to the pre-existing condition ending after the effective date of coverage • 12 months after the effective date of coverage

Pre-existing exclusions do not apply to dependents under age 19.

These waiting periods do not apply in case of an emergency.

- 13 -

Services and Supplies Not Covered

No benefits are provided for these services and supplies unless otherwise specified in the Schedule of Benefits. Treatment of an injury, which is generally covered by this Certificate, will not be denied if the injury results from being a victim of an act of domestic violence. 1.  Any services or supplies determined to be not medically necessary. 2. Any services or supplies for which the Member is not legally obligated to pay. 3. Any services or supplies for treatment of military servicerelated disabilities when the Member is legally entitled to other coverage. 4.  Any services or supplies for which benefits are paid by Workers’ Compensation, occupational disease law or other similar legislation. 5. Treatment of an illness contracted or injury sustained while engaged in the commission or an attempt to commit an assault or a felony, treatment of an injury or illness incurred while engaged in an illegal act or occupation, treatment of an injury or illness due to voluntary participation in a riot or civil disorder. 6.  Any charges for services provided prior to the Member’s effective date or after the termination of coverage. 7. Custodial care or respite care. 8.  Residential treatment of mental health or substance use disorders, including residential treatment centers, therapeutic schools, wilderness/boot camps, therapeutic boarding homes, halfway houses and therapeutic group homes. 9. Inpatient hospital treatment of mental health or substance use disorders. 10.  Any services or procedures for transsexual surgery or related services provided as a result of complications of such transsexual surgery. 11. All services and supplies related to pregnancy except for life-threatening complications of pregnancy to either the mother or fetus. An elective abortion is not considered to be a complication of pregnancy. 12.  Services, supplies or drugs for the treatment of infertility including, but not limited to, artificial insemination and in-vitro fertilization, fertility drugs, reversal of sterilization procedures and surrogate parenting. 13.  Preconception testing, preconception counseling or preconception genetic testing. 14. Any drugs, services, treatment or supplies determined by the medical staff of the Corporation, with appropriate consultation, to be experimental, investigational or unproven. NOTE: Benefits are provided for off-label uses of pharmaceuticals that have been approved by the FDA (but not approved for the prescribed use), provided that the drug is not contraindicated by the FDA for the off-label use prescribed and that the drug has been proven safe, effective and accepted for the treatment of the specific medical condition for which the drug has been prescribed, as evidenced by the results of good quality-controlled clinical studies published in at least two or more peer-reviewed, full-length articles in respected national professional medical journals. 15. Drugs for which there are over-the-counter equivalents except for over-the-counter drugs considered to be prescription medication. All vitamins, except prenatal vitamins; drugs not approved by the Food and Drug Administration; drugs for the treatment of non-covered therapies, services or conditions

such as drugs prescribed for obesity or weight control, cosmetic purposes, hair growth, fertility or sexual dysfunction. 16. Plastic or cosmetic surgical procedures or services performed to improve appearance or to correct a deformity without restoring a bodily function, unless such services are medically necessary and due to physical trauma, prior surgery or congenital anomaly. 17. Early intensive behavioral interventions for autism spectrum disorders, typified by Applied Behavioral Analysis (ABA) or other behavioral/educational therapies. 18. Services, therapy or medications for the treatment of attention deficit disorder with or without hyperactivity (ADHD). 19.  Psychological or educational testing to determine job or occupational placement, school placement or for other educational purposes or to determine if a learning disability exists. 20. Relationship counseling, including marriage counseling for the treatment of premarital, marital or relationship dysfunction. 21. Counseling and psychotherapy services for these conditions: A. Tic disorders except when related to Tourette’s syndrome B. Elimination disorders C. Mental disorders due to general medical condition D. Sexual function disorders E. Sleep disorders F. Medication-induced movement disorders G. Nicotine dependence, unless listed elsewhere as covered 22.  Medical supplies, services or charges for the diagnosis or treatment of dissociative disorders, sexual and gender identity disorders, personality disorders, learning disorders, developmental speech delay, communication disorders, developmental coordination disorders, mental retardation or vocational rehabilitation. 23. Services for animal assisted therapy; repetitive transcranial magnetic stimulation (rTMS); vagal nerve stimulation for depression and other DSM disorders; eye movement desensitization and reprocessing (EMDR); behavioral therapy for solitary maladaptive habits; or rapid opiate detoxification. 24. Any rehabilitation therapy or services for the treatment of mental retardation or developmental coordination disorder or vocational rehabilitation. 25. Any service or supply for the diagnosis or treatment of sexual dysfunction including, but not limited to, surgery; drugs; laboratory and X-ray tests; counseling; or penile implant necessary due to any medical condition or organic disease. 26. Services or supplies related to dysfunctional conditions of the muscles of mastication, malpositions or deformities of the jaw bone(s), orthognathic deformities or temporomandibular joint (TMJ) disorders including, but not limited to, surgical treatment, appliances and orthodontia. 27.  For dental work or treatment that includes hospital or professional care in connection with: A. An operation or treatment for the fitting or wearing of dentures, regardless if needed due to injury of natural teeth due to an accident B. Orthodontic care or treatment of malocclusion

- 14 -



C. Operations on or treatment of or to the teeth or supporting bones and/or tissues of the teeth except for removal of malignant tumors or cysts D. Any treatment of an injury to natural teeth due to an accident not received within six months of the accident date E. Removal of teeth, whether impacted or not F. Any operation, service, prosthesis, supply or treatment for the preparation for, and the insertion or removal of, a dental implant This exclusion does not apply to facility and anesthesia services that are medically necessary because of a specific organic medical condition including, but not limited to, congestive heart failure, asthma or chronic obstructive pulmonary disease that requires hospital-level monitoring. 28. Hearing aids or examinations for the prescription or fitting of hearing aids. 29. Charges incurred as the result of a missed scheduled appointment and charges for the preparation, reproduction or completion of medical records, itemized bills or claims forms. 30. Services or supplies not specifically listed as a Covered Service or in the Schedule of Benefits. 31.  Transplant services other than those described in Covered Services. 32. Medical and surgical expenses for care and treatment of a living human organ transplant donor. 33. Complications arising during, from or related to the receipt by a Member of non-Covered Services. “Complications,” as used in this exclusion, includes any medically necessary services or supplies which, in the Plan’s judgment, would not have been required by the Member had the Member not received non-Covered Services. This includes complications arising from discount value-added services. 34.  Items that do not provide a direct medical treatment, are generally available without a physician’s prescription and may be useful to a Member in the absence of disease, including, but not limited to, the purchase or rental of air conditioners, home air filtration systems, motorized transportation equipment, escalators or elevators, swimming pools, waterbeds, exercise equipment or other similar items or equipment. 35. Manual or motorized wheelchairs or power-operated vehicles such as scooters for mobility outside of the home setting. Coverage for these devices to assist with mobility in the home setting is subject to the establishment of medical necessity by the Corporation. 36. External infusion insulin pumps and continuous glucose monitoring systems. 37. Bioelectric, computer-programmed prosthetic devices. 38. Services, treatment or medications related to the management of all types of blood clotting or coagulation disorders, such as, but not limited to, hemophilia, unless the member has received treatment at least once in a given benefit year at a hemophilia treatment center (HTC) as designated by the U.S. Centers for Disease Control and Prevention. 39. Any service or supply provided by a member of the patient’s family or by the patient, including the dispensing of drugs. A member of the patient’s family means the patient’s spouse, parent, grandparent, brother, sister, child or spouse’s parent. 40. Charges for acupuncture, hypnotism, biofeedback therapy and TENS units. Services for chronic pain management programs

or any program developed by centers with multidisciplinary staffs intended to provide the interventions necessary to allow the patient to develop pain coping skills and freedom from dependence on analgesic medications. 41. Services, supplies, treatment or medication for the management of morbid obesity, obesity, weight reduction, weight control or dietary control (collectively referred to as “obesity-related treatment”) including, but not limited to, gastric bypass or stapling, intestinal bypass and related procedures or gastric restrictive procedures. Also, the treatment or correction of complications from obesityrelated treatment are non-covered services, regardless of medical necessity, prescription by a physician or the passage of time from a Member’s obesity-related treatment. This includes the reversal of obesity-related treatments and reconstructive procedures necessitated by weight loss. 42. Orthomolecular therapy, including nutrients, vitamins and food supplements. Enteral feedings when not a sole source of nutrition. 43. Nutrition counseling, lifestyle improvements or physical fitness programs. This exclusion does not include diabetic nutrition education. 44. Radial keratotomy, myopic keratomileusis, LASIK surgery, INTACS surgery and any surgery that involves corneal tissue for the purpose of altering, modifying or correcting myopia, hyperopia or stigmatic error. This exclusion does not include the treatment and management of keratoconus unresponsive to contact lens therapy. 45. Treatment of weak, strained or flat feet, including orthopedic shoes or other orthotic supportive devices, for services and supplies for cutting, removal or treatment of corns, calluses or nail care. This exclusion does not include corrective surgery, or treatment for metabolic or peripheral vascular disease. 46. Communications, travel time or transportation, except for use of professional ambulance services as defined in Covered Services under Ambulance Services. 47.  Adjustable cranial orthoses (band or helmet) for positional plagiocephaly or craniosynostoses in the absence of cranial vault remodeling surgery. 48. Services, supplies or treatment for varicose veins, including, but not limited to, endovenous ablation, vein stripping or the injection of sclerosing solutions. 49. Growth hormone therapy. 50. Pulmonary rehabilitation, except in conjunction with a covered lung transplant. 51. Charges for services or supplies from an independent health care professional whose services are normally included in facility charges. 52. Physician charges for virtual office visits including, but not limited to, telephone, Internet, electronic mail or video chat consultations. 53. Preoperative anesthesia assessment. 54. Massage therapy. 55. High Deductible Health Plans (HDHP) only – Services or care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects of such nerve interference, where such interference is the result of or related distortion, misalignment or subluxation of, or in, the vertebral column.

- 15 -

Auto Reject Conditions This is not an all-inclusive list. For conditions with time limits, some applicants may not be approved even after they have satisfied the time limit (depending on the severity of the condition and other health factors).

AIDS, AIDS-Related Complex (ARC), HIV Positive Addison’s Disease Adrenal Disorders Alcohol, Chemical or Drug Dependency (within five years) All Aneurysms, present and untreated Alzheimer’s Disease (all stages) Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig’s Disease) Anemia (moderate to severe, present) Anemia (hemolytic, sickle cell) Aneurysm (present) Angina Pectoris (unstable angina) Ankylosing Spondylitis Anorexia Nervosa and/or Bulimia (within five years) Aortic Stenosis Arterial Occlusion Arteriosclerosis/Atherosclerosis Arteriovenous Malformation (AV Malformation) Arteritis Atrial Septal Defect (present or surgically corrected within one year) Attention Deficit Disorder with or without hyperactivity (ADHD)** Autism Biliary Cirrhosis Bipolar Disorders Bronchiectasis Build/Weight, outside our guidelines Bypass Surgery – cardiovascular Cardiac Defibrillator (implant) Cardiomegaly/Cardiomyopathy Cerebral Palsy Cerebrovascular Accident/Disease (CVA) Chronic Fatigue Syndrome (within five years) Chronic Kidney Disease (stages 2-5) Chronic Obstructive Pulmonary Disease (COPD), moderate to severe Cirrhosis of Liver Coarctation of Aorta Collagen or Connective Tissue Disease, systemic Congestive Heart Failure (CHF)

Coronary Artery/Heart Disease (CAD/CHD) Crohn’s Disease Cushing’s Disease Cystic Fibrosis Cystic Kidney Disease, bilateral Dementia Diabetes, Types 1 and 2 Diverticulitis (within last two years) Down’s Syndrome Embolism, Cerebral Encephalopathy End-stage Renal Disease (whether on dialysis or not) Epilepsy Epstein-Barr Syndrome (within two years) Fibromyalgia Gender Identity Disorder Heart Attack or Heart Disease Heart Valve Replacement Hemiplegia Hemochromatosis Hemophilia, or other coagulation/bleeding disorders Hepatitis (all types) High Blood Pressure (within six months of diagnosis) Hodgkin’s Disease Hydrocephalus Hydronephrosis, bilateral Hyperthyroidism Idiopathic Thrombocytopenia Purpura (ITP), within five years Immune Deficiency Ischemic Colitis Kidney Dialysis Leukemia (all types) Organ Transplant, pending or past Lupus, Discoid (within two years) Lyme Disease (within one year) Lymphoma (all types) Malignant Melanoma Manic Depression Mitral Stenosis Multiple Sclerosis Muscular Dystrophy

Myasthenia Gravis Myocardial Infarction/Ischemia Neurogenic Bladder Neuromuscular Disease Occlusion (any location) Osteoporosis (moderate to severe) Pacemaker Paget’s Disease Pancreatitis, chronic or recurrent Paraplegia Parkinson’s Disease Patent Foramen Ovale (present) Peripheral Arterial/Vascular Disease (PAD/PVD) Peripheral Neuropathy Pneumonitis Polycystic Kidney Disease Prior Open Heart Surgery Psoriatic Arthritis Quadriplegia Reflex Sympathetic Dystrophy Rheumatoid Arthritis Sarcoma Sarcoidosis Schizophrenia Scoliosis (moderate to severe or rod present) Shunt, cardiovascular or cerebral Sickle Cell Anemia Splenomegaly, present Stroke Subarachnoid Hemorrhage (within two years) Suicide Attempt (within five years) Systemic Lupus Erythematosis (SLE) Tetrology of Fallot Transient Ischemic Attack (TIA) Turner’s Syndrome Ulcerative Colitis/Proctitis, without total colectomy Ventricular Fibrillation, within one year Ventricular Septal Defect (present or surgically corrected within one year)

We accept these applicants, but we do not pay any services, therapy or medication for the treatment of this condition.

**

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Additional Important Information If you have questions or concerns about your MyChoice benefits or services or if you want to comment on our coverage, please call our member advocates at 803-786-8476 in Columbia or 800-868-2528 outside of Columbia. Your contract also has details about our formal grievance procedure.

Don’t Forget Us if Your Mailing or Billing Address Changes For a mailing address or billing address change, please go to the Members section of BlueChoiceSC.com and then to the Forms section and open Individual Change Request Form. Complete that form and mail to BlueChoice Billing, Mail Code: AX-430, P.O. Box 6170, Columbia, SC 29260-6170. You can fax it to 803-382-5157. An authorized signature is required to make a billing address change.

Premiums Your premiums are due monthly and must be paid in advance. If you have chosen to pay by automatic bank draft or recurring credit card, this will be done for you. If your payment method is automatic bank draft, please include a copy of a voided check with your request.

To change the way you pay your premium: Go to QuickBillSC.com and select from the available payment methods. You can send a letter to Individual Billing at AX-430 or fax a letter to 803-382-5157. An authorized signature is required to make billing address or payment changes. If you choose to send your request by email, please attach the letter with the authorized signature to the email. Email signatures will not be accepted. Thank you for choosing MyChoice Health Coverage. Membership Address: BlueChoice HealthPlan P.O. Box 6170, AX-425 Columbia, SC 29260-6170

Individual Billing Address: BlueChoice HealthPlan P.O. Box 6170, AX-430 Columbia, SC 29260-6170

BlueChoiceSC.com

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Answers to Your Questions About MyChoice Health Coverage Q Do I have to choose a primary care physician? A.  You are not required to select a primary care physician. We recommend, however, that everyone in your family establish a relationship with a physician. He or she will see you regularly and become most familiar with your medical conditions.

Q. W  hat happens if I have an accident or emergency illness outside the BlueChoice service area and need immediate treatment? A. Go to the nearest physician’s office or hospital emergency room for treatment. Then contact BlueChoice through the toll-free number on your ID card. We’ll coordinate any additional care you may need.

Q. How do I select a physician? A. You select your personal physician from a list of local participating physicians. This list is located in the Doctor and Hospital Finder on our website at BlueChoiceSC.com. Q May I change my physician? A.  Yes, you may change physicians. This can be done quickly and easily on our website at BlueChoiceSC.com. Q. Where will I receive medical care? A. We provide coverage in any setting your physician deems necessary. This can be a doctor’s office, an independent clinical laboratory, a hospital, an ambulatory surgery center, etc.

Q. W  hat happens if I need immediate care and, for some reason, the doctor is unavailable? A.  Your physician has a seven-day-a-week, 24-hour-a-day telephone service. If your regular physician isn’t available, another physician will be “on call” to advise you. Q. A  m I restricted to certain hospitals? A. Yes. Your physician reserves the right to select the hospital based on the type of medical services needed. Q. What if I want to change benefit plans? A.  You can request a change to a plan with equal or lesser benefits anytime by submitting a written request to BlueChoice. Changing to a plan with greater benefits will require a new application and approval (see page 12).

Q. What happens if I have a problem with my physician or specialist? A. If you can’t work out a solution directly with your physician, you can call our member advocates. They’ll help resolve your problem.

Q. When am I no longer eligible for coverage? A. You are no longer eligible for coverage under MyChoice Health Coverage when you reach age 65 or move out of South Carolina.

Q.  What if I need a specialist? A. With MyChoice Health Coverage, you have the freedom to go to a specialist any time you feel it is necessary. You may want to consult with your regular physician, but you do not need to get a referral. Q. What do I do in an emergency? A.  Unless it is a life-threatening emergency, you should call your regular physician. Let the doctor know the exact nature of the problem and that you are a BlueChoice member. The doctor may give you first aid advice, tell you to come to the office or direct you to the hospital.

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Non-Discrimination Statement and Foreign Language Access We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. If you or someone you’re assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice. Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below. If you think we have not provided these services or have discriminated in any way, you can file a grievance online at [email protected] or by calling our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800537-7697 (TDD). Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-3960183. (Spanish)

如果您，或是您正在協助的對象，有關於本健康計畫方面的問題，您有權利免費以您的母語得到幫助和訊 息。洽詢一位翻譯員，請撥電話 [在此插入數字 1-844-396-0188。 (Chinese)

Nếu quý vị, hoặc là người mà quý vị đang giúp đỡ, có những câu hỏi quan tâm về chương trình sức khỏe này, quý vị sẽ được giúp đở với các thông tin bằng ngôn ngữ của quý vị miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-389-4838 (Vietnamese)

이 건보험에 관하여 궁금한 사항 혹은 질문이 있으시면 1-844-396-0187 로 연락주십시오. 귀하의 비용 부담없이 한국어로 도와드립니다. PC 명조 (Korean)

Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa planong pangkalusugang ito, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-844-389-4839 . (Tagalog)

Если у Вас или лица, которому вы помогаете, имеются вопросы по поводу Вашего плана медицинского обслуживания, то Вы имеете право на бесплатное получение помощи и информации на русском языке. Для разговора с переводчиком позвоните по телефону 1-844-389-4840. (Russian)

‫ ﻓﻠدﯾك اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة واﻟﻣﻌﻠوﻣﺎت‬،‫إن ﻛﺎن ﻟدﯾك أو ﻟدى ﺷﺧص ﺗﺳﺎﻋده أﺳﺋﻠﺔ ﺑﺧﺻوص ﺧطﺔ اﻟﺻﺣﺔ ھذه‬ (Arabic) 1-844-396-0189 ‫ﻟﻠﺗﺣدث ﻣﻊ ﻣﺗرﺟم اﺗﺻل ب‬.‫اﻟﺿرورﯾﺔ ﺑﻠﻐﺗك ﻣن دون اﯾﺔ ﺗﻛﻠﻔﺔ‬

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Si ou menm oswa yon moun w ap ede gen kesyon konsènan plan sante sa a, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232. (French/Haitian Creole)

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de ce plan médical, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-396-0190 . (French)

Jeśli Ty lub osoba, której pomagasz, macie pytania odnośnie planu ubezpieczenia zdrowotnego, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-396-0186. (Polish)

Se você, ou alguém a quem você está ajudando, tem perguntas sobre este plano de saúde, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-396-0182. (Portuguese)

Se tu o qualcuno che stai aiutando avete domande su questo piano sanitario, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-844-396-0184. (Italian)

あなた、またはあなたがお世話をされている方が、この健康保険 についてご質問がございましたら、ご 希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳 とお話される場合、1-844-396-0185 までお電話ください。 (Japanese)

Falls Sie oder jemand, dem Sie helfen, Fragen zu diesem Krankenversicherungsplan haben bzw. hat, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-396-0191 an. (German) ‫اﮔﺮ ﺷﻤﺎ ﯾﺎ ﻓﺮدی ﮐﮫ ﺑﮫ او ﮐﻤﮏ ﻣﯽ ﮐﻨﯿﺪ ﺳﺆاﻻﺗﯽ در ﺑﺎرهی اﯾﻦ ﺑﺮﻧﺎﻣﮫی ﺑﮭﺪاﺷﺘﯽ‬ ‫ ﺣﻖ اﯾﻦ را دارﯾﺪ ﮐﮫ ﮐﻤﮏ و اﻃﻼﻋﺎت ﺑﮫ زﺑﺎن ﺧﻮد را ﺑﮫ ﻃﻮر راﯾﮕﺎن‬،‫داﺷﺘﮫ ﺑﺎﺷﯿﺪ‬ ‫ ﺗﻤﺎس ﺣﺎﺻﻞ‬1-844-398-6233 ‫ً ﺑﺎ ﺷﻤﺎرهی‬ ‫ ﻟﻄﻔﺎ‬،‫ ﺑﺮای ﺻﺤﺒﺖ ﮐﺮدن ﺑﺎ ﻣﺘﺮﺟﻢ‬.‫درﯾﺎﻓﺖ ﮐﻨﯿﺪ‬ (Persian-Farsi) .‫ﻧﻤﺎﯾﯿﺪ‬

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