IBC Individual Health Plans 2010

Health Plans for Individuals and Families

The benefits you need...

at the price you can afford...

from the name you know and trust

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Why choose Blue?Because we’re dedicated to improving the health and wellness of the communities we serve in Philadelphia, Montgomery, Bucks, Delaware, and Chester counties. In fact, we’re the region’s #1 HMO and PPO provider*. With an expansive network of more than 55,000 doctors and 100 hospitals to choose from, you can always find the care you need.

For more than 70 years, we’ve provided the best in quality, reliability, and service to Philadelphians. Choose Independence Blue Cross, the name you know and trust.

Think a Blue plan is too expensive?

Think again. You have a wide variety of medically underwritten plans** to choose from at various prices. You’re bound to find a plan that meets your needs without breaking the bank. That means you still have money left to catch a Phillies game, visit the zoo, or spend the weekend at the shore.

Plus, all of our plans include value-added extras such as reimbursements for gym fees and weight management

programs, discounts on health and wellness products, and 24/7 access to a Health Coach. You also get tools and resources to manage your benefits and make informed decisions about your health through our member website, ibxpress.com.

Need help choosing? We can help.We offer three different types of plans – copay, deductible, and health savings account (HSA). All of our plans offer comprehensive coverage, but what you pay each month depends on what you want to spend when you see the doctor or go to the hospital. With our copay plans, you pay a set dollar amount for most services while our deductible and HSA plans help reduce monthly costs by requiring a deductible and coinsurance for certain services. Use the chart below to figure out what type of plan works best for you. Still not sure? Contact your broker for more information.

Copay plans . . . . . . . . . . . . . . . . . . 2It’s all about predictability. Almost all of the in-network services you use are covered by a fixed dollar amount, known as a copay. Visiting your doctor for a check-up? Pay a copay. Need physical therapy? Pay a copay, and we take care of the rest.

Deductible plans . . . . . . . . . . . . . . . 6It’s all about affordability. With these plans, you still have copays or 100% coverage for the services you use most often, such as doctor visits, screenings, and immunizations. The in-network deductible, an amount you pay before insurance kicks in, applies only to services such as hospital and emergency care. After you pay your deductible, you’re responsible for coinsurance, a percentage of the provider’s charge.

HSA plans . . . . . . . . . . . . . . . . . . . . 10It’s all about savings. With our health saving account (HSA) plans, you have two ways to save. First, you save money by paying lower premiums each month. Then, you can invest your money in a tax-advantaged HSA to save for deductibles and coinsurance. Plus, if you don’t use all of your HSA dollars, the money is yours and can be rolled over year to year to pay for future expenses.

Value-added programs . . . . . . . . . .14There are a lot of advantages to being an Independence Blue Cross member. We want to make it easier for you to save money and make healthy choices. That’s why we offer the programs, tools, and resources members need to get engaged in their health and make informed health care decisions.

Glossary . . . . . . . . . . . . . . . . . . . . . 18Choosing a health plan doesn’t have to be difficult. Learn more about some of the common terms and definitions, such as coinsurance, deductible, and referral.

Important information . . . . . . . . . . 20Get a better understanding of our policies and guidelines and the steps we take to help you receive appropriate care.

Contents

Cost-sharing included in the chart above applies to in-network coverage only. For PPO out-of-network cost-sharing, refer to the benefits summary charts in this brochure. *According to a leading independent consumer magazine.**Final rate quote and approval of coverage is dependent on medical underwriting. Approval is not guaranteed, and some applications may not be approved based on medical conditions.

Here’s an overview of the types of plans we offer

Copay Deductible HSAOffice visits Copay Copay Coinsurance after deductible

Preventive care Covered 100% Covered 100% Covered 100%

Emergency care HMO options: CopayPC options: Coinsurance Coinsurance after deductible Coinsurance after deductible

Inpatient hospital HMO options: CopayPC options: Coinsurance Coinsurance after deductible Coinsurance after deductible

X-ray HMO options: CopayPC options: Coinsurance

HMO: CopayPC: Coinsurance after deductible Coinsurance after deductible

Laboratory HMO options: Covered 100%PC options: Coinsurance

HMO: Covered 100%PC: Coinsurance after deductible options Coinsurance after deductible

Prescription drugs Yes Yes Yes

Pair with a tax-free health savings account (HSA) N/A N/A Yes

$$$ $Monthly Rate

It’s all about predictability.Whether paying for utilities, your phone bill, or groceries, it can be hard to predict how much you’ll need to pay each month. But our copay plans offer the predictability you need to control your budget so that you aren’t surprised when your bill arrives.

Almost all of the services you use are covered by a fixed copay if you use in-network providers. Visiting your doctor? Pay a copay. Need physical therapy? Pay a copay. We’ll take care of the rest.

Here’s a look at what our copay plans include:

office visits•preventive care•prescription drugs•hospital stays•emergency/urgent care•X-rays•laboratory services•routine eye care (HMO plans only)•

maternity (HMO plans only)•

Need help choosing between our Keystone HMO and Personal Choice® PPO plans?There are several key differences between our HMO and Personal Choice plans. With our HMO plans from Keystone Health Plan East, you select a primary care physician to coordinate all of your health care needs and provide you with referrals to network specialists.

In comparison, our Personal Choice plans give you the flexibility to receive care from doctors both in and out of network. There’s no need to pick a primary care physician and you never need a referral. Our Personal Choice plans also provide in-network coverage coast-to-coast when you use BlueCard® PPO providers. While our Personal Choice plans offer you freedom to access care directly, they do not provide coverage for maternity and routine eye care, which are included in our HMO options.

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City skyline from steps of the Philadelphia Museum of Art, Philadelphia County.

Our copay plans have predictable, set costs for most services. This makes it easier for you to budget so that you can add in trips to the

movies, art museum, or any of the attractions that Philly has to offer.

Copay plans

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Copay plansHMO 20 Copay HMO 15 Copay HMO 10 Copay Personal Choice PPO 30 Copay

Benefits per calendar year You pay You pay You pay You pay in-network You pay out-of-network**Deductible, individual/family

None None None

None $5,000/$10,000

Coinsurance, after deductible 20% 50%

Out-of-pocket maximum, individual/family $5,000/$10,000 Includes coinsurance only

$10,000/$20,000 Includes coinsurance only

Preventive services

Mammogram (no referral required)

$0 $0 $0

$050%, no deductible

Pediatric immunizations (subject to office visit copay) $0

Nutrition counseling (6 visits per year‡) $0 50%, after deductible

Physician services

Primary care office visit $20 $15 $10 $3050%, after deductible

Specialist office visit

$30 $25 $20

$50

Routine gynecological exam/Pap test (no referral required, 1 per year) $30 50%, no deductible

Routine eye exam (once every two years) Not covered Not covered

Eyeglasses or contact lenses (once every two years) $35 benefit* $35 benefit* $35 benefit* Not covered Not covered

Spinal manipulations (20 visits per year‡)$30 $25 $20

$5050%, after deductible

Physical/occupational therapy (30 visits per year‡) $50

Hospital/other medical services

Inpatient hospital services $400† $200† $100†

20%/unlimited days 50%, after deductible/70 days

Maternity hospitalization Not covered Not covered

Emergency room (not waived if admitted) $100 $100$100

20% 20%, after in-network deductible

Outpatient surgery $400 $200

20% 50%, after deductible

Ambulance$0 $0 $0

Outpatient lab/pathology

Routine radiology/diagnostic $30 $25 $20

MRI/MRA, CT/CTA scan, PET scan $60 $50 $40

Biotech/specialty injectables $100 $75 $50

Durable medical equipment (HMO: up to $1,000 per year; PC: up to $2,000 per year, which includes up to $1,000 for diabetic equiptment and supplies) 50% 50% 50%

Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered Not covered

Prescription drug

Prescription deductible, individual/family $250/$750 $100/$300 $100/$300 None None

Generic formulary copay $15, after prescription deductible $15, after prescription deductible $15, after prescription deductible $10

50%, no deductibleBrand formulary copay $25, after prescription deductible $25, after prescription deductible $25, after prescription deductible $30

Non-formulary copay $35, after prescription deductible $35, after prescription deductible $35, after prescription deductible $50

Prescription mail order Available Available Available Available Available

Maximum prescription drug benefit, individual/family Up to $2,500/$5,000 per year Up to $2,500/$5,000 per year Up to $2,500/$5,000 per year Up to $2,500 per person per year ‡

*Paid-in-full benefit available with select group of frames at Davis Vision participating providers. ** It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, hospitals, and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. † Amount shown reflects the copayment per day. There is a maximum of five copayments per admission. ‡ For PPO plans, maximums shown are combined for in- and out-of-network care.Certain plan benefits may be enhanced in order to comply with health care reform legislation.

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Deductible plans

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Linvilla Orchards, Delaware County.

With a deductible plan, you get lower monthly rates and you don’t have to pay for benefits you don’t use. That makes it

easier to enjoy hayrides through the fields, fishing in Orchard Lake, and picking fresh fruit at Linvilla Orchards.

It’s all about affordability.Our deductible plans are a great way to lower your monthly costs. Better yet, the in-network deductible applies only to services such as hospital and emergency care. You still have copays or 100% coverage for services such as doctor visits, screenings, and immunizations.

Here’s a look at what our deductible plans include:

office visits•preventive care•prescription drugs•hospital stays•emergency/urgent care•X-rays•laboratory services•routine eye care (HMO plans only)•maternity (HMO plans only)•

Why have insurance if I have to pay a deductible?A deductible may seem like a lot of money to pay, but keep in mind, it doesn’t apply to all services. Think of the cost if you don’t have insurance. An unexpected accident or illness could result in medical bills up to $50,000 or more. A deductible is much less, and probably much easier to pay off.

Plus, when you show your card to a participating provider, your deductible is based on our discounted rates. It’s typically a fraction of what people without insurance pay. Once you reach the deductible, you’re responsible for a percentage of the cost and we’ll take care of the rest.

Need help choosing between HMO and Personal Choice? Turn to page 3.

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Deductible plansHMO 5000 HMO 2500 HMO 1500 Personal Choice PPO 5000 Personal Choice PPO 2500

Benefits per calendar year You pay You pay You pay You pay in-networkYou pay

out-of-network* You pay in-networkYou pay

out-of-network*Deductible, individual/family $5,000/$10,000 $2,500/$5,000 $1,500/$3,000 $5,000/$10,000 $10,000/$20,000 $2,500/$5,000 $5,000/$10,000

Coinsurance, after deductible 30%, unless otherwise noted 30%, unless otherwise noted 30%, unless otherwise noted 20% 50% 20% 50%

Out-of-pocket maximum, individual/family $7,500/$15,000 $5,000/$10,000 $5,000/$10,000 $10,000/$20,000 $20,000/$40,000 $5,000/$10,000 Includes coinsurance only

$10,000/$20,000 Includes coinsurance only

Preventive services

Mammogram (no referral required)

$0, no deductible $0, no deductible $0, no deductible$0, no deductible 50%, no deductible $0, no deductible 50%, no deductible

Pediatric immunizations (subject to office visit copay)

Nutrition counseling (6 visits per year†) $0, no deductible 50%, after deductible $0, no deductible 50%, after deductible

Physician services

Primary care office visit $30, no deductible $30, no deductible $30, no deductible $30, no deductible50%, after deductible

$30, no deductible50%, after deductible

Specialist office visit $50, no deductible $50, no deductible $50, no deductible $50, no deductible $50, no deductible

Routine gynecological exam/Pap test (no referral required, 1 per year) $30, no deductible $30, no deductible $30, no deductible $30, no deductible 50%, no deductible $30, no deductible 50%, no deductible

Routine eye exam (once every two years) $50, no deductible $50, no deductible $50, no deductible Not covered Not covered Not covered Not covered

Eyeglasses or contact lenses (once every two years) $35 benefit* $35 benefit* $35 benefit* Not covered Not covered Not covered Not covered

Spinal manipulations (20 visits per year†)$50, no deductible $50, no deductible $50, no deductible $50, no deductible 50%, after deductible $50, no deductible 50%, after deductible

Physical/occupational therapy (30 visits per year†)

Hospital/other medical services

Inpatient hospital services/days

30%, after deductible/unlimited 30%, after deductible/unlimited 30%, after deductible/unlimited

20%, after deductible/unlimited 50%, after deductible/70 20%, after deductible/unlimited 50%, after deductible/70

Maternity hospitalization Not covered Not covered Not covered Not covered

Emergency room (not waived if admitted) 20%, after deductible 20%, after in-networkdeductible 20%, after deductible 20%, after in-network

deductible

Outpatient surgery

20%, after deductible 50%, after deductible 20%, after deductible 50%, after deductible

Ambulance

Outpatient lab/pathology $0, no deductible $0, no deductible $0, no deductible

Routine radiology/diagnostic $50, no deductible $50, no deductible $50, no deductible

MRI/MRA, CT/CTA scan, PET scan$100, no deductible $100, no deductible $100, no deductible

Biotech/specialty injectables

Durable medical equipment (HMO: up to $1,000 per year; PC: up to $2,000 per year, which includes up to $1,000 for diabetic equiptment and supplies) 50%, after deductible 50%, after deductible 50%, after deductible

Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered Not covered Not covered Not covered

Prescription drug

Prescription deductible, individual/family None None None None None None None

Generic formulary copay $10 $10 $10 $10

50%, no deductible

$10

50%, no deductibleBrand formulary copay $30 $30 $30 $30 $30

Non-formulary copay $50 $50 $50 $50 $50

Prescription mail order Available Available Available Available Available Available Available

Maximum prescription drug benefit, individual/family Each year you have coverage up to $2,500/$5,000

Each year you have coverage up to $2,500/$5,000

Each year you have coverage up to $2,500/$5,000 Up to $2,500 per person, per year† Up to $2,500 per person, per year†

*Paid-in-full benefit available with select group of frames at Davis Vision participating providers. ** It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, hospitals, and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. † For PPO plans, maximums shown are combined for in- and out-of-network care.Certain plan benefits may be enhanced in order to comply with health care reform legislation.

It’s all about savings.Finally, there’s a way to make the most of your health care dollars.

When you have one of our Personal Choice® HSA-qualified medical plans, the savings are twofold. First, you save money by paying lower premiums each month. Then, you can invest your money in a tax-advantaged health savings account (HSA) to save for deductibles and coinsurance. Plus, if you don’t use all of your HSA dollars, the money is yours and can be rolled over year to year to pay for future expenses.

Here’s a look at what our HSA-qualified medical plans cover, both in and out of network:

office visits•preventive care•prescription drugs•hospital stays•emergency/urgent care•X-rays•laboratory services•

Want to open a health savings account?You can use our preferred vendor, The Bancorp Bank, an independent company, to set up an HSA or you can pick any bank you like. To set up a Bancorp HSA, simply check the box in Section A of the application that reads: “Yes, I’d like an HSA account set up with Bancorp.” Bancorp HSA features include:

no application or account set up fees;•no monthly maintenance fees• 1;ability to earn interest with first deposit• 2;free no-annual-fee Visa® Check Card;•toll-free 24/7 customer service and online access;• ability to invest HSA funds through National Financial Services •once balance reaches $2,500.

To learn more, visit the Bancorp website at www.mybancorphsa.com. 1 Standard banking fees apply, e.g. insufficient funds 2 Interest paid on balances over $1

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HSA plans

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Downtown West Chester, Chester County.

Our HSA plans help you save money, so you can spend it on what you love most: grabbing a bite to eat with

friends or browsing local stores for that next great find.

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Personal Choice PPO 5000 HSA Personal Choice PPO 3000 HSA

Benefits per calendar yearYou pay in-

networkYou pay

out-of-network* You pay in-networkYou pay

out-of-network*Deductible, individual/family $5,000/$10,000 $10,000/$20,000 $3,000/$6,000 $6,000/$12,000

Coinsurance, after deductible N/A 50% 20% 50%

Out-of-pocket maximum, individual/family (includes deductibles, copays, and coinsurance) $5,000/$10,000 $20,000/$40,000 $5,000/$10,000 $10,000/$20,000

Preventive services

Mammogram

$0, no deductible50%, no deductible

$0, no deductible50% , no deductible

Pediatric immunizations (subject to office visit copay)

Nutrition counseling (6 visits per year†) 50%, after deductible 50%, after deductible

Physician services

Primary care office visit$0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible

Specialist office visit

Routine gynecological exam/Pap test (1 per year) $0, no deductible 50%, no deductible $20, no deductible 50% , no deductible

Routine eye care Not covered Not covered Not covered Not covered

Spinal manipulations (20 visits per year†)$0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible

Physical/occupational therapy (20 visits per year†)

Hospital/other medical services

Inpatient hospital services/days $0, after deductible/ unlimited days

50%, after deductible/ 70 days

20%, after deductible/ unlimited days

50%, after deductible/ 70 days

Maternity hospitalization Not covered Not covered Not covered Not covered

Emergency room (not waived if admitted) $0, after deductible $0, after in-network deductible 20%, after deductible 20%, after in-network

deductible

Outpatient surgery

$0, after deductible 50%, after deductible 20%, after deductible 50%, after deductible

Ambulance

Outpatient lab/pathology

Routine radiology/diagnostic

MRI/MRA, CT/CTA scan, PET scan

Biotech/specialty injectables

Durable medical equipment (up to $1,000 per year)

Mental health/substance abuse/serious mental illness treatment Not covered Not covered Not covered Not covered

Prescription drug

Prescription deductible, individual/family Integrated with medical

Integrated with medical Integrated with medical Integrated with medical

Generic formulary copay

$0, after deductible 50%, after deductible

$10, after deductible

50%, after deductibleBrand formulary copay $30, after deductible

Non-formulary copay $50, after deductible

Prescription mail order Available Available Available Available

Maximum prescription drug benefit†, individual/family None None None None

Want to see just how much you can save with an HSA?Let’s say each year you contribute $1,500 to your HSA and withdraw, on average, $500 for health care expenses. With an interest rate of 3.5%, your savings will grow each year! Depending on how you invest your money in the account, your savings can be even greater.

HSA plans

The above chart is for illustrative purposes only. With an annual deposit of $1,500 on the first day of each year, an annual percentage yield of 3.5% with all earnings reinvested in the account, and $500 withdrawn for eligible medical expenses on the first day of each year.

The chart is not intended to be used as legal and/or tax advice. Please consult with your tax advisor and/or attorney for your particular situation.

Want to make the most of your HSA plan?Take the savings you get with your monthly premiums and open a health savings account (HSA). You can use the money in your HSA to pay for deductibles and coinsurance. If you have money left over at the end of the year, it carries over into your account for next year.

* It is important to note that all percentages are percentages of the plan allowance, not the provider’s actual charge. Out-of-network, non-participating providers may bill you for differences between the plan allowance, which is the amount paid by Personal Choice, and the provider’s actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on Independence Blue Cross’s (IBC’s) own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under IBC contracts with providers, hospitals, and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. † Maximums shown are combined for in- and out-of-network care.Certain plan benefits may be enhanced in order to comply with health care reform legislation.

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$14,000

$12,000

$10,000

$8,000

$6,000

$4,000

$2,000

$02 3 4 5 6 7 8 9 10

Monthly premium

Premium savings put into HSA

Balance at end of year 10 $11,731.39

Tax savings$5,314.02

Value-added programs

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A plan for better health We care about you and your health. We want to make it easier for you to save money and make healthy choices. That’s why we offer the programs, tools, and resources members need to get engaged in their health and make informed health care decisions.

Enjoy big rewards with Healthy LifestylesSM

Our unique Healthy Lifestyles programs offer cash rewards, discounts, and reminders designed to help you and your family lead healthier lives.

Cash rewards – We believe you should be rewarded for taking action to maintain and improve your health. Exercise regularly? We’ll give you up to $150 back on your fitness center fees. Quit smoking or lost weight? We’ll reimburse you up to $200 on your program fees. We’ll even give you money back when you buy a bike helmet, complete a CPR class, or go to a parenting class.

Valuable discounts – How about a discount on a massage or fitness gear? Just show your card and you’ll earn a discount at participating providers. From alternative health services like acupuncture to yoga books and DVDs, you’ll enjoy the discounts that come with an Independence Blue Cross membership. Our members also get exclusive discounts on CorCell®, a program that preserves your child’s umbilical cord blood - a resource that may help combat a variety of life-threatening diseases.*

Important reminders – We’ll help you remember to schedule those routine tests and screenings that always seem to slip your mind. We’ll send you educational reminders for mammograms, Pap tests, and colorectal screenings. You’ll also get special reminders and resource mailings to keep the whole family up to date on immunizations and vaccinations.

Healthy Lifestyles programs are value-added programs and services – they are not benefits under the health care plan that you purchased and are therefore subject to change without notice.

*CorCell is an independent company offering a discount on cord blood preservation services to Independence Blue Cross members. CorCell does not offer Blue Cross and/or Blue Shield products or services. CorCell is solely responsible for its products and services.

Valley Forge National Historical Park, Montgomery County.

Our wellness programs offer cash rewards and valuable discounts. It’s just the motivation you need to go for a run, ride your bike, or

take a walking tour on the expansive grounds of this historical site.

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Value-added programs

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Make informed decisions Our member website, ibxpess.com, provides tools and resources to help you make informed health care decisions. We’ve partnered with WebMD® to provide you with personalized tools and reliable information to help you make health decisions that are right for you.

• Provider Finder and Hospital Finder help you find the participating doctors and hospitals that are best equipped to handle your needs. You can learn about where your doctors went to medical school, their board certification, languages spoken, and more. You can also compare hospitals based on their experience, cost, patient satisfaction, and other factors you find important.

• Symptom Checker provides a head-to-toe tool to help you evaluate how serious your symptoms are – and what you should do about them.

Health Encyclopedia• provides information on more than 160 health topics and the latest news on common conditions.

• Treatment Cost Estimator helps you estimate your costs for hundreds of common conditions – including tests, procedures, and health care visits – so you can plan and budget for your expenses.

Take control of your health ibxpress.com also provides the tools you need to make lifestyle changes – like losing weight or quitting smoking – by helping you get started, set reachable goals, and track your progress.

• Personal Health Profile (PHP) – This powerful health assessment tool will give you a clear picture of what you are doing right and suggest ways to stay healthy. After you complete the PHP, you’ll receive an accurate, confidential, and personalized action plan.

Lifestyle Improvement Programs• – These personalized, self-paced, step-by-step programs will help you improve your health. You’ll find several different programs, such as exercise, weight management, nutrition and smoking cessation, designed to inspire and support your positive health changes. These online programs combine proven tactics with the ultimate in privacy, security, and convenience.

Health Trackers • – Chart your progress over time to help you stay motivated. Track blood pressure, cholesterol, body fat, and other health factors. Or, customize the tool by adding a new health tracker for additional data you want to track – like test results, number of push-ups, etc.

• Personal Health Record – Use your Personal Health Record to store, maintain, track, and manage your health information in one centralized, private, and secure location. We’ll even update your Personal Health Record for you each time we process one of your claims.

Receive personalized supportYou don’t have to be alone when making important decisions regarding your health. Our ConnectionsSM Health Management Programs give you the one-on-one support you need when facing significant treatment decisions or everyday health concerns. Your personal Health Coach is available 24/7 to answer your questions and to help you make knowledgeable, confident decisions regarding your health care. Your Health Coach can provide:

• information on everyday health concerns, such as headaches and joint pain;

help if you are facing a significant •medical decision, such as treatment options for back pain, breast or prostate cancer, or surgery:

personalized calls about your •chronic condition or health concerns;

information about what types of •questions to ask your doctor.

1WebMD is an independent company offering online health information and wellness education to Independence Blue

Cross members.

Health information at your fingertips

No matter where you take your laptop, ibxpress.com makes it easy for you to stay on top of your health.

Take a tour of our member website on www.ibxpress.com.

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Glossary

Choosing a health plan doesn’t have to be difficult. Learn more

about some of the common terms and definitions before you

make a decision.

Copay - It’s a set dollar amount you pay for a covered health

service. If you have a $10 copay for a doctor’s visit, you simply

pay $10 and we cover the rest.

Coinsurance - Some plans require you to pay a percentage

of your medical costs. If you use a participating provider, your

costs are based on our discounted rate.

Deductible – This is a fixed dollar amount that you must

pay before your insurance kicks in. If you use a participating

provider, your costs are based on our discounted rate.

HMO - This stands for health maintenance organization. If

you pick an HMO plan, you’ll need to select a family doctor who

can help you with general health concerns, or refer you to a

network specialist for care.

Health savings account (HSA) - A tax-advantaged savings

account that can be used to save for health care expenses. You

must be enrolled in an HSA-qualified high-deductible health

plan to be eligible to open an HSA. There is a maximum amount

that you can contribute to an HSA each year but if you don’t

use all of the money within your benefit period, it rolls over to

the next year.

Medically underwritten plan - All of the plans in this

brochure are medically underwritten. Your health history and

current health will be reviewed to determine whether you

qualify for enrollment. If approved, some health conditions may

require you to pay a higher premium.

Out-of-pocket maximum – This is the maximum amount

that you will have to pay under your plan. Once you hit your

out-of-pocket maximum, we’ll cover services requiring a

deductible or coinsurance 100% for the remainder of the

benefit period. Check plan details to see what’s included in the

out-of-pocket maximum calculation. Please note that none of

the plans include balance billing by out-of-network providers in

the out-of-pocket maximum calculation.

PPO - This stands for preferred provider organization. With a

PPO plan, there’s no need to select a primary care physician.

You can visit any doctor or specialist in the network, without a

referral. You also have the freedom to choose doctors outside

the network if you’re willing to pay more for their services.

Preexisting condition - It’s a health condition you received

medical care or advice for before applying for insurance.

All of our medically underwritten plans have exclusions for

preexisting conditions for the first 12 months of coverage,

meaning that some conditions may not be covered for the first

year. Under our HMO plans, we will look at any conditions that

you received services or advice for in the 90 days preceding

your enrollment. For our PPO plans, the look back period is 12

months. There are two ways that you can waive or reduce the

preexisting condition exclusion period.

Blue-to-Blue transfer• – If you’ve had active health

coverage with a Blue Cross® or Blue Shield® plan for up

to 12 months without a break in coverage prior to your

requested effective date, you can receive credit for each

month of prior coverage up to the entire exclusion period

of 12 months.

Creditable Coverage• – If you had active coverage with

another insurance carrier for at least 18 months without

a break in coverage of more than 63 days prior to your

current application, you can receive credit for the entire

exclusion period of 12 months.

If you qualify for a preexisting condition waiver, be sure to complete Section G of the application and provide any required documentation.

Premium - This is the amount you pay for your health insurance coverage. This is separate from costs you pay when you use your benefits to get care, such as copays, deductibles, and coinsurance.

Primary care physician (PCP) – This is just another term

for your family doctor. HMO plans require you to pick a PCP to

coordinate your health care and refer you to a specialist if needed.

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Precertification – This may also be called

preapproval or prior authorization. Basically,

you may need additional approval from

your health plan before you receive certain

tests, procedures, or medications. It’s a way

to make sure the services you’re getting

are effective.

Rate guarantee - All of the plans in

this brochure come with a six-month rate

guarantee. This means that your final rate

will remain the same for the first six months

of coverage. You will be notified in advance

of any rate increases approved by the

Pennsylvania Insurance Department.

Referral – If you have an HMO plan, your

family doctor (or PCP) will need to write

you a referral before you see other network

providers, such as a dermatologist. No need

to pick up a piece of paper, our referrals are

done electronically.

Frankenfield Covered Bridge, Bucks County.

Riding your bike is a great way to get your health in gear – and admire the foliage and covered bridges of Bucks County.

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Important information

Benefits that require preapprovalWhen you need services that require preapproval, your physician or provider contacts the Care Management and Coordination (CMC) team and provides information to support the request for services. For PPO members using a BlueCard® PPO or out-of-network provider, the member is responsible for contacting CMC directly for any required approvals. The CMC team, made up of physicians and nurses, evaluates the proposed plan of care for payment of benefits. The CMC team notifies your physician/provider if the services are approved for coverage. If the CMC team does not have sufficient information or the information evaluated does not support coverage, you and your physician/provider are notified in writing of the decision. Members and providers acting on behalf of a member may appeal the decision. At any time during the evaluation process or the appeal, the provider or member may provide additional information to support the request.

For a list of services that require preapproval, visit www.ibx4you.com/importantinfo.

Inpatient hospital staysDuring and after an approved hospital stay, Independence Blue Cross’s (IBC) Care Management and Coordination team monitors your stay. The team reviews whether you are receiving medically appropriate care, sees that a plan for your discharge is in place, and coordinates services that may be needed following discharge.

Utilization reviewTo assist IBC in making coverage determinations regarding the medical necessity and appropriateness of requested services, IBC uses medical guidelines based on clinically credible evidence. This is called utilization review. Utilization review can be done before a service is performed (prenotification/precertification/preservice); during a hospital stay (concurrent review); or after services have been performed (retrospective/post-service review). IBC follows applicable state/federal standards pertaining to how and when these reviews are performed.

Continuity of care (Continuity of care policy applies to HMO plans only)

Terminated providersIBC offers members continuation of coverage for an ongoing course of treatment with a terminated provider (for reasons other than cause) for up to 90 days from the date that IBC notified the member of the provider termination. IBC will cover such continuing treatment under the same terms and conditions as if the treatment was being received from participating providers.

If a member is in her second or third trimester of pregnancy at the time of the termination, the transitional period of authorization shall extend through post-partum care related to the delivery. All authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers. The nonparticipating provider must agree that all authorized health care services provided during this transitional period would be covered by IBC under the same terms and conditions applicable for participating health care providers. The plan is not required to provide health care services that are not covered benefits.

In order to initiate continuity of care, members must complete a Continuity of Care form and submit it to IBC’s Care Management and Coordination department. The form is available through Customer Service.

Emergency servicesAn emergency is defined as the sudden and unexpected onset of a medical condition manifesting itself in acute symptoms of sufficient severity or severe pain that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:

placing the member’s health or, in the case of a pregnant member, •the health of the unborn child in jeopardy;serious impairment to bodily functions;•dysfunction of any bodily organ or part.•

Emergency care includes covered services provided to a member in an emergency, including emergency transportation and related emergency services provided by a licensed ambulance service.

Complaints and grievancesYou have a right to appeal any adverse decision through the Complaint and Grievance Process. Instructions for the appeal will be described in the denial notifications and in the contract.

Privacy policyAt IBC, protecting your privacy is very important to us. That is why we have taken numerous steps to see that your Protected Health Information (PHI) is kept confidential. Protected health information is individually identifiable health information about you. This information may be in oral, written, or electronic form. IBC may obtain or create your PHI while conducting our business of providing you with health care benefits.

IBC has implemented policies and procedures regarding the collection, use, and release or disclosure of PHI by and within our organization. We continually review our policies and monitor our business processes to make sure that your information is protected while assuring that the information is available as needed for the provision of health care services. For detailed information on our privacy policy, visit www.ibx4you.com/importantinfo.

Procedures that support safe prescribingIndependence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, FutureScripts®, to manage the administration of its commercial prescription drug programs. As our PBM, FutureScripts is responsible for providing a network of participating pharmacies, administering pharmacy benefits, and providing customer service to our members and providers. We support a number of procedures to support safe prescribing, including:

Prior authorization – This means that you may need additional approval from your health plan for a certain medication. Certain covered drugs require prior authorization to ensure that the drug prescribed is medically necessary and appropriate and is being prescribed according to the U.S. Food and Drug Administration’s (FDA) guidelines.

Age and gender limits – The FDA has established specific procedures that govern prescription prescribing practices. These rules are designed to prevent potential harm to patients and ensure that the medication is being prescribed according to FDA guidelines. For example, some drugs are approved by the FDA only for individuals age 14 and older, or are prescribed only for females.

Quantity level limits – These are designed to allow a sufficient supply of medication based upon FDA-approved maximum daily doses and length of therapy of a particular drug. There are several different types of quantity level limits, such as rolling 30-day period, refill too soon, and therapeutic drug class.

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If you want to learn more about how health care reform may affect you,

visit www.ibx.com.

96-hour temporary supply program – Under this program, if a member’s doctor writes a prescription for a drug that requires prior authorization, has an age limit, or exceeds the quantity level limit for a medication, and prior authorization has not been obtained by the doctor, a 96-hour supply of the drug will be made available while the request is being reviewed. Obtaining a 96-hour temporary supply does not guarantee that the prior authorization request will be approved.

To learn more about safe prescribing procedures, see a list of drugs requiring prior authorization, or find out how to file a request or appeal, visit www.ibx4you.com/importantinfo.

Prescription Drug Program provider payment informationA pharmacy benefits management (PBM) company administers our prescription drug benefits and is responsible for providing a network of participating pharmacies and processing pharmacy claims. The PBM also negotiates price discounts with pharmaceutical manufacturers and provides drug utilization and quality reviews. Price discounts may include rebates from a drug manufacturer based on the volume purchased. Independence Blue Cross anticipates that it will pass on a high percentage of the expected rebates it receives from its PBM through reductions in the overall cost of pharmacy benefits. Under most benefit plans, prescription drugs are subject to a member copayment.

Benefits exclusionsThe benefits summaries in this brochure represent only a partial listing of benefits and exclusions of the plans. Benefits and exclusions may be further defined by medical policy. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. If you need more information, please call 1-800-263-1410.

What’s not covered?services not medically necessary;•

any treatment of substance abuse or mental illness, including •serious mental illness;

services or supplies that are experimental or investigative, except •routine costs associated with qualifying clinical trials;

hearing aids, hearing examinations/tests for the prescription/fitting of •hearing aids, and cochlear electromagnetic hearing devices;

assisted fertilization techniques, such as in vitro fertilization, •GIFT, and ZIFT;

reversal of voluntary sterilization;•

alternative therapies, such as acupuncture;•

dental care, including dental implants or dentures, and nonsurgical •treatment of temporomandibular joint syndrome (TMJ);

treatment of obesity, except for surgical treatment of morbid obesity •when medically necessary;

routine foot care, except for medically necessary treatment of •peripheral vascular disease and/or peripheral neuropathic disease including, but not limited to, diabetes;

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

routine physical exams for nonpreventive purposes, such as insurance •or employment applications, college, or premarital examinations;

contraceptive devices;•

immunizations for travel or employment;•

services or supplies payable under Workers’ compensation, motor •vehicle insurance, or other legislation of similar purpose;

cosmetic services/supplies;•

outpatient services that are not performed by your primary care •physician’s designated provider;

private duty nursing;•

charges related to any medical condition or illness for which medical •advice or treatment was recommended or received during a certain amount of time (90 days for HMO, 12 months for PPO) preceding the effective date of your plan policy is excluded for the first 12 months. If you have been continuously insured for 12 months by a participating Blue Cross® or Blue Shield® plan, or the past 18 months by another plan (without a break in coverage of more than 63 days prior to the current application), you may be able to receive credit for all or part of the 12 month exclusion. To learn more about preexisting condition exclusions and how they can be reduced through creditable coverage, visit www.ibx4you.com/importantinfo.

In addition, the following benefits are not covered for PPO plans:

maternity care•

routine eye care•

NOTE: Eligible unmarried dependent children are generally covered to age 19 or age 23 (if full-time student). See contract for additional details. To obtain complete copies of these policies by mail, please contact your broker.

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For questions or to apply, contact your broker!

www.ibx4you.com

2010-0053 (05/10) HMO products underwritten and administered by Keystone Health Plan East. Personal Choice PPO products underwritten and administered by QCC Insurance Company, subsidiaries of Independence Blue Cross – independent licensees of the Blue Cross and Blue Shield Association.