Independence Blue Cross Plan Summary PPO Core Medical Plan

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TO: MLH Medical Plan Participants

FROM: MLH Human Resources – Benefits Team

SUBJECT: Independence Blue Cross Plan Summary – PPO Core Medical Plan

Attached you will find the Independence Blue Cross (IBC) Plan Summary for the PPO Core Medical Plan

effective January 1, 2015. The summary provides information about the coverage the plan offers for

various common medical plan services. It also includes a summary of services not covered by the plan.

This summary represents only a partial listing of the benefits and exclusions of the PPO Core program.

Benefits and exclusions may be further defined by IBC medical policies which are available at the

www.ibxpress.com web portal. This plan may not cover all of your health care expenses. If you have

questions about plan coverage, please contact IBC at 1-800-ASK-BLUE to speak with a customer service

representative.

Definitions for Terms Found on the Plan Summary

Personal Choice Personal Choice refers to IBC’s Preferred Provider Organization (PPO) medical

plan design. The plan gives you the freedom of choice in the providers you

choose for your medical care but your cost of care is lower when you use

providers who participate in Personal Choice network.

PHO A Physician Hospital Organization is a group of physicians and hospitals who

agree to contract together with insurance companies.

JeffPLUS Network This is the network of PHO providers from MLH, Jefferson and Magee Rehab

that is available to employees of the Personal Choice plan. Using these providers

will lower your out-of-pocket cost for care.

Personal Choice

Network

This is the IBC network of physicians and facilities available throughout the

Philadelphia region who participate in the Personal Choice plan.

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07/14 - PA - 51+ JHS-JeffPlus PC PHO - Main Line Health - HCR 131073

www.ibx.com

independent licensees of the Blue Cross and Blue Shield Association.

Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross-

Personal Choice

Main Line Health

PPO PHO

Personal Choice^® , our popular Preferred Provider Organization (PPO), gives you freedom of choice by allowing you to choose your own doctors and hospitals. You can maximize your coverage by accessing your care through Personal Choice's large network of hospitals, doctors and specialists, or by accessing care through preferred providers that participate in the BlueCard^®PPO program. Of course, with Personal Choice, you have the freedom to select providers who do not participate in the Personal Choice network or BlueCard PPO program. However, if you receive services from out-of-network providers, you will have higher out-of-pocket costs and may have to submit your claim for reimbursement.

With Personal Choice...

•You do not need to enroll with a primary care physician

•You never need a referral

In-Network Out-of-Network

Benefits JeffPLUS Network Personal Choice

Network

Out-of-Network^*

DEDUCTIBLE

Individual None $500 $1,000

Family None $1,500 $3,000

BENEFIT PERIOD Calendar Year Calendar Year Calendar Year

COINSURANCE 100% unless otherwise noted 80%, after deductible 60%, after deductible OUT-OF-POCKET MAXIMUM^***

Individual $3,000⁴ $3,000⁴ $5,000

Family $5,000⁴ $5,000⁴ $10,000

LIFETIME MAXIMUM Unlimited Unlimited Unlimited

DOCTOR'S OFFICE VISITS

Primary Care Services $20 Copayment $40 Copayment, NO

deductible

60%, after deductible

Specialist Services $25 Copayment $45 Copayment, NO

deductible

60%, after deductible PREVENTIVE CARE FOR ADULT AND CHILDREN 100% 100%, NO deductible 60%, after deductible

PEDIATRIC IMMUNIZATIONS 100% 100%, NO deductible 60%, NO deductible

ROUTINE GYNECOLOGICAL EXAM/PAP

1 routine exam/pap test per calendar year for women of any age¹

100% 100%, NO deductible 60%, NO deductible

MAMMOGRAM 100% 100%, NO deductible 60%, NO deductible

* Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the actual charge of the provider. This amount may be significant. Claims payments for Non-Preferred Professional Providers (physicians) are based on the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized or reimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actual charge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, payment is 50% of the actual charge of the provider. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge of the provider.

1 Combined all networks

4 Combined JeffPLUS/Personal Choice Network

*** In-network out-of-pocket maximum includes deductible, copays and coinsurance. Out-of-network out-of-pocket maximum includes deductible and coinsurance.

The benefits may be changed by IBC to comply with applicable federal/state laws and regulations.

Note: All JHS Facilities will be considered 'Home' hospital

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Network

Out-of-Network^*

OUTPATIENT DIAGNOSTIC SERVICES

Routine Radiology $15 Copayment (JHS Facility),

$20 Copayment (non-JHS JeffPLUS facility)

$50 Copayment then

70%, after deductible 60%, after deductible

MRI/MRA/CAT/PET $15 Copayment (JHS Facility),

$50 Copayment (non-JHS JeffPLUS facility)

$75 Copayment then 70%, after deductible

Laboratory 100% $20 Copayment per

occurrence, NO deductible

ALLERGY TESTING 100% 80%, after deductible 60%, after deductible

ALLERGY EXTRACT/INJECTIONS 100% 80%, after deductible 60%, after deductible

MATERNITY

First OB Visit $15 Copayment $20 Copayment, NO

deductible

Hospital 100% (JHS facility), $350

Copayment per admission³(non-JHS JeffPLUS facility)

$700 Copayment per admission³ then 80%, after deductible

60%, after deductible²

CONTRACEPTIVES 100% 100%, NO deductible 60%, after deductible

ELECTIVE ABORTION 100% 80%, after deductible 60%, after deductible

INPATIENT HOSPITAL SERVICES

Facility 100% (JHS facility), $350

Physician/Surgeon 100% 80%, after deductible 60%, after deductible

INPATIENT HOSPITAL DAYS¹ 365 365 70²

EMERGENCY CARE $125 Copayment

(Copayment waived if admitted) $125 Copayment, NO deductible

(Copayment waived if admitted)

$125 Copayment, NO deductible

(Copayment waived if admitted)^**

URGENT CARE CENTER $70 Copayment, NO deductible $70 Copayment, NO deductible

60%, after deductible OUTPATIENT SURGERY

Voluntary sterilization procedures included; Reversal of sterilization procedures excluded

Facility 100% (JHS facility), $100

Copayment per occurrence (non-JHS JeffPLUS facility)

$300 Copayment per occurrence then 80%, after deductible

Physician/Surgeon 100% 80%, after deductible 60%, after deductible

AMBULANCE

Emergency 100% 100%, NO deductible 100%, NO deductible

Non-Emergency 100% 80%, after deductible 60%, after deductible

THERAPY SERVICES

Physical, Speech and Occupational

60 visits per calendar year¹ $30 Copayment $40 Copayment, NO

deductible

60%, after deductible Cardiac Rehabilitation

deductible

60%, after deductible Pulmonary Rehabilitation

deductible 60%, after deductible

Respiratory Therapy $30 Copayment $40 Copayment, NO

deductible

60%, after deductible Orthoptic/Pleoptic

8 sessions lifetime¹ $30 Copayment $40 Copayment, NO

HEARING EXAM 100% 100%, NO deductible 60%, after deductible

HEARING AID REIMBURSEMENT

2 hearing aids every 36 months¹ 25% 25%, after deductible 25%, after deductible

2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services 3 Inpatient Copayment waived if readmitted within 10 days of discharge.

** NOTE: for Non-JeffPLUS inpatient hospital admissions through the Emergency Room, the claim is to be processed as a JeffPLUS admission (JeffPLUS admission copay is applied, deductible and coinsurance are waived)

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Network

Out-of-Network^* CRANIAL PROSTHESIS

only covered for members receiving cancer treatment, one per year¹

50% 50%, after deductible 50%, after deductible

RESTORATIVE SERVICES, INCLUDING CHIROPRACTIC CARE

30 visits per calendar year¹

Not available $40 Copayment, NO

CHEMO / RADIATION / DIALYSIS 100% 80%, after deductible 60%, after deductible

OUTPATIENT PRIVATE DUTY NURSING

360 hours per calendar year¹ 100% 80%, after deductible 60%, after deductible

SKILLED NURSING FACILITY

120 days per calendar year¹ 100% (JHS facility), $350

HOME HEALTH CARE 120 days per calendar year¹

100% 80%, after deductilbe 60%, after deductible

HOSPICE 100% (JHS facility), $350

INFUSION THERAPY 100% 80%, after deductible 60%. after deductible

MENTAL HEALTH CARE/SERIOUS MENTAL ILLNESS CARE

Outpatient Services $25 Copayment $40 Copayment, NO

deductible 60%, after deductible Inpatient Facility Services 100% (JHS facility), $350

SUBSTANCE ABUSE TREATMENT

Outpatient/Partial Services $25 Copayment $40 Copayment, NO

deductible 60%, after deductible Inpatient Rehabilitation 100% (JHS facility), $350

Detoxification 100% (JHS facility), $350

DURABLE MEDICAL EQUIPMENT Not Available⁵ 80%, NO deductible 60%, after deductible

PROSTHETICS Not Available 80%, NO deductible 60%, after deductible

OUTPATIENT DIABETIC EDUCATION 100% 100%, NO deductible Not Covered

TRANSPLANT SERVICES 100% 80%, after deductible 60%, after deductible

MEDICAL FOODS AND NUTRITIONAL FORMULAS 100% 80%, after deductible 60%, after deductible

BLOOD 100% 80%, after deductible 60%, after deductible

DIABETIC EQUIPMENT AND SUPPLIES 100% 100%, NO deductible 60%, after deductible

2 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse services 3 Inpatient Copayment waived if readmitted within 10 days of discharge.

What Is Not Covered?

•Services not medically necessary

•Services or supplies which are experimental or investigative except routine costs associated with clinical trials

•Reversal of voluntary sterilization

•Expenses related to organ donation for non-member recipients

•Alternative therapies/complementary medicine

•Dental care, including dental implants, and non-surgical treatment of temporomandibular joint syndrome (TMJ)

•Music therapy, equestrian therapy and hippotherapy

•Treatment of sexual dysfunction not related to organic disease except for sexual dysfunction resulting from injury

•Routine foot care, unless medically necessary or associated with the treatment of diabetes

•Foot orthotics, except for orthotics and podiatric appliances required for the prevention of complications associated with diabetes

•Routine physical exams for non-preventive purposes such as insurance or employment applications, college, or premarital examinations

•Immunizations for travel or employment

•Service or supplies payable under Workers' Compensation, Motor Vehicle Insurance, or other legislation of similar purpose

•Cosmetic services/supplies

•Vision care (except as specified on a group contract)

•Infertility

•Self-injectable drugs

This summary represents only a partial listing of the benefits and exclusions of the Personal Choice Program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract/member handbook carefully for a complete listing of the terms, limitations and exclusions of the program. If you need more information, please call 1-800-626-8144 (outside Philadelphia) or 215-557-7577 (if calling within the Philadelphia area).

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Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorization, please log on to http://www.ibx.com/preapproval or call the phone number that is listed on the back of your identification card.