Business Blue ExclusiveSM Upstate IGROUP INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

Business Blue ExclusiveSM

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

WITH THE CARD THAT OPENS DOORS IN 50 STATES

Table of Contents

Overview

Essentials

Plan Networks

Services

Value Adds

Tools

Plan Benefits

Exclusions

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6-7

5

8-9

10-11

12-13

14-16

17

4

Overview

Think Blue®TRUST

BlueCross BlueShield of South Carolina has earned the trust of South Carolinians for nearly 70 years, offering solutions for business owners throughout the state. Ensuring access to quality health coverage is vital to the health and well-being of every community in our state. We’re more than a recognized member of the community — we’re a strong and stable partner you can count on.

CHOICE

Our goal is simple: to provide the highest quality coverage at a reasonable price. Since there’s no such thing as one size fits all, we offer numerous choices to make sure you have the right plan for you and your business. Let us help you find the right plan for your company.

COMMUNITY OUTREACH

Supporting our local community — your working families living in your community — is important to us. That’s why the BlueCross BlueShield of South Carolina Foundation supports workplace giving programs, health care-related research, education and service throughout the state. We also encourage our employees to volunteer their time and talents to non-profit organizations. By supporting projects that directly benefit South Carolina’s most vulnerable populations, we are helping to create a strong community for everyone.

AWARD-WINNING CUSTOMER SERVICE

Year after year, independent companies recognize our Customer Service team for pro-viding excellent service to our members. In 2014, in fact, 35 BlueCross customer service advocates (CSAs) were recognized for providing superior service to our members. The recognition came from a leading research firm called Service Quality Management Group for the CSAs’ ability to resolve member issues during the first call, as well as callers’ overall service experience.

Our world-class Customer Service team is always here to help you and your employees!

The BlueCross BlueShield of South Carolina Foundation is an independent licensee of the Blue Cross and Blue Shield Association

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Plan Networks

Think NetworksPROVIDER NETWORK

The network for our Business Blue Exclusive Upstate I plans is an Exclusive Provider Organization (EPO). BlueCross has partnered with MyHealth First Network (MyHFN) to offer exclusive savings on services offered by select doctors and hospitals within Abbeville, Greenville, Greenwood, Laurens, Oconee, and Pickens counties. With four different plans to choose from, you can select the plan structure and benefit level that best meets your company’s needs, as well as the needs of your employees.

Because the plan is an EPO, if a member visits a doctor, clinic or hospital outside the EPO network for a non-emergency, the member will be responsible for paying the full bill. However, CVS Minute Clinics throughout the state are in network for members and their covered dependents. In addition, Doctors Care clinics in South Carolina are in network, except for locations inside the EPO’s six counties and Newberry County. This offers members convenient choices for non-emergencies that occur while they are traveling.

In the event of a medical emergency, a visit or treatment in an emergency room anywhere in the state is covered as in network. If members are traveling outside South Carolina, they are eligible for the BlueCard® program, which covers emergency medical treatment for plan members in an emergency room setting only.

WHAT IS MyHealth First Network?

MyHealth First Network (MyHFN) is a select, clinically-integrated group of health care providers in the Upstate who collaborate to deliver comprehensive, consistent, coordinated health care. Together, BlueCross and MyHFN aim to improve health outcomes while reducing costs for members and delivering an exceptional patient experience.

OCONEE

PICKENS

ANSERSON

ABBEVILLE

MCCORMICK

GREENWOOD

NEWBERRY

UNION

CHEROKEE

YORK

CHESTER

FAIRFIELD

LANCASTER

KERSHAW

RICHLAND

CLARENDONCALHOUN

LEXINGTON

ORANGEBURG

AIKEN

EDGEFIELD

SALUDA

GEO

RGETOWN

LEE

CHESTERFIELD

DARLINGTONDILLON

FLORENCE

WILLIAMSBURG

BERKELEY

CHARLESTON

BEAUFORT

JASPER

HAMPTON

ALLENDALE

BARNWELL BAMBERG

COLLETON

DORCHESTER

SUMTER

MARION

HORRY

MARLBORO

LAURENS

SPARTANBURG

GREEN

VILLE

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Think Basics BLUE CROSS HEALTH PLAN BASICS

Here are some key things to know before you shop for a plan. Business Blue Exclusive Upstate I plans often are referred to as “metallic plans” (Gold and Silver) to illustrate the value of benefits in each plan.

DEFINING GOLD AND SILVER PLANS

Each plan must cover the same set of minimum essential health benefits. While the range of benefits is the same among the plans, the value of the benefits will vary. This means the amounts members pay — such as copayments, coinsurance or deductibles — are different. These metal levels can help you compare plans, monthly premiums and costs for services, such as doctor or hospital visits.

ESSENTIAL HEALTH BENEFITS

All of our Affordable Care Act (ACA) health plans include these essential health benefits:

■ Ambulatory patient services: services that can be completed during a single day and don’t require a patient to be admitted to the hospital

■ Emergency services: care that is given in a hospital emergency room

■ Hospitalization: hospital stays

■ Maternity and newborn care: care for pregnant women and newborn babies

■ Mental health and substance dependency services

■ Prescription drugs: medications your doctor prescribes

■ Rehabilitative and habilitative services and devices: services that help you recover lost abilities or services that help you gain functions so you can participate in daily life

■ Routine wellness and preventive services and chronic disease management services

Essentials

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Essentials

SUSTAINED HEALTH

Each of our Business Blue Exclusive Upstate I plans covers many important preventive benefits the ACA recommends. (Note: some plans may have different levels of preventive benefits.) The PPACA doesn’t cover some common procedures, however, including:

■ Electrocardiograms (EKGs)■ Chest X-rays

■ Blood work (except lipid screenings)■ Urinalysis

Our Sustained Health Benefit is an optional program with all of our Business Blue Exclusive Upstate I plans. Sustained Health provides $300 toward allowable expenses for preventive services the member’s plan may not cover when provided or directed by an in-network primary care physician (PCP). And Sustained Health offers BlueCross’ one-of-a-kind discounted pricing on these preventive services. Consider the benefits of Sustained Health for you and your employees.

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Services

Think Services PREVENTIVE SERVICES

Services such as preventive screenings for children, women and men, including prostate screenings according to the American Cancer Society guidelines, are provided at 100 percent.

The American Cancer Society (ACS) is an independent organization that provides health information on behalf of BlueCross BlueShield of South Carolina.

For a complete list of covered preventive services, please visit www.uspreventive servicestaskforce.org. (This link leads to a third party website. That company is solely responsible for the contents and privacy policies on its site.)

PHARMACY SERVICES

RETAIL To receive the highest level of benefits for prescription drugs, you must get them through our network. You can find a list of pharmacies on our website at www.SouthCarolinaBlues.com. When you buy drugs from a network pharmacy, you must show your BlueCross ID card. Prescription drugs filled at an out-of-network pharmacy are covered at 50 percent, and the cost does not apply to your deductible or maximum out of pocket.

Up to 31-day supply

RETAIL 90 Retail 90 is a pharmacy program that allows Business BlueExclusive Upstate I members to purchase up to a three-month supply of maintenance prescription medications at local retail pharmacies at the lower mail-order copayment amount. The Retail 90 Pharmacy Network includes more than 62,000 pharmacies across the country, including the largest retail chains. A complete list of the Retail 90 Pharmacy Network is available on the Prescription Drug Information page on our website.

Up to 90-day supply

MAIL ORDER Members also can get their medications at discounted rates with our mail-order program. Information about the mail-order program is located on our website under Prescription Drug Information.

Up to 90-day supply

SPECIALTY DRUG Drugs designated as specialty medications must be filled at a Caremark Specialty Pharmacy. Caremark Specialty Pharmacy is an independent company that provides pharmacy services on behalf of BlueCross. You’ll find the list of drugs that must be filled at Caremark on the Business Covered Drug List.

Up to 31-day supply

TIERS

Tier 1 Drugs: Usually

generic and will generally

cost you the least amount

of money out of your

pocket.

Tier 2 Drugs: Most often

brand drugs, sometimes

referred to as “Preferred”

Drugs, because they

usually cost you less

than other brand drugs.

Tier 3 Drugs: Most often

brand drugs, sometimes

referred to as “Non-Preferred”

Drugs, because they usually

cost you more than other

brand drugs. They may

have generic equivalents.

Tier 4 Drugs: Drugs that

treat complex conditions

and are usually very

expensive. You will

usually pay more for

drugs in this tier.

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Services

Your NavigatorSM for Health ManagementAt BlueCross, we take extra steps toward improving the health of your workforce through our comprehensive health management programs. Using a 360° approach, we offer wellness, prevention and treatment programs to your employees dealing with an array of chronic conditions. All of these programs are offered under the name Your Navigator for Health Management.

There are programs for all members that focus on the early detection of illness and the prevention of disease. Members with chronic conditions also receive more targeted educational information and contact with our highly trained health specialists. Our members with intensive needs receive care coordination and the support of our team of caring nurses.

Members are automatically enrolled in the appropriate programs based on claims history, pharmacy spending and physician referral. Members can self-refer to any of these programs at any time.

Through Your Navigator for Health Management, we offer programs that cover the spectrum of health and disease in four categories:

PREVENTION AND WELLNESS

Children’s HealthCholesterol Improvement Men’s Health Pre-Hypertension Tobacco CessationWeight Management Women’s HealthWalkingWorksSM for South

Carolina Schools

CONDITION MANAGEMENT

Alcohol Management Back Care Healthy and Active Kids

(childhood obesity)High Cholesterol High Blood Pressure

(hypertension)Irritable Bowel Syndrome Maternity Migraine (adult and

pediatric)Metabolic Health

(pre-diabetes)Neonatal Intensive Care

Unit (NICU) Case Management

DISEASE MANAGEMENT

Asthma Chronic Obstructive

Pulmonary Disease (COPD)

Depression Diabetes Heart Disease Heart Failure

CRITICAL HEALTH MANAGEMENT

Care Calls (hospital- to-home transition)

Case Management (for conditions including cancer, severe trauma, multiple chronic condi-tions, complex wounds, weight-loss surgery, Hepatitis C, traumatic brain injury, rheumatoid arthritis, transplants and neuro-muscular diseases)

Care Guardian (emergency room diversion management)

Chronic Kidney Disease

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Think ValueDISCOUNT AND VALUE-ADDED PROGRAMS

Sometimes all you need to feel great is a little sprucing up. And saving money in the process makes it even more rewarding. That’s why our members enjoy our discounts and value-added programs. With no claims to file and no annual limits, members pay the discounted rate directly to participating providers.

FITNESS AND WELLNESS

Fitness Center Memberships Getting in shape is now more affordable than ever! We make it easy for our mem-bers to save on memberships to local fitness facilities and other exercise centers.

Children’s Fitness With My Gym Children’s Fitness Center, choose from a variety of structured, age- appropriate classes that use music, dance, relays, games and more.

Weight Management Enjoy discounts on weight-loss programs and services, including Jenny Craig. Plus, get one-on-one support to help you lead a healthy lifestyle.

Allergy Relief You’ll breathe easier thanks to special prices on products designed to reduce exposure to indoor allergens.

Alternative Health Care Where does it hurt? With Natural BlueSM you can tap into an extensive network of credentialed acupuncturists, massage therapists, chiropractors, plus diet advisers — all offering extensive discounts. Members also can get information about vitamins and natural supplements, as well as purchase items, such as home fitness equipment, at a discount.

Healthy Reading Stay health conscious and informed with access to a wide variety of articles and information online. Members also can purchase books, DVDs and CDs at discounted rates.

Value Adds

For more information, visit www.SouthCarolinaBlues.com/links/discounts

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Value Adds

BLUE365®

BlueCross members have access to Blue365, a daily deal website with discounts on everyday products that can help families live healthier, happier lives. Members can enjoy discounts on personal care products, fitness, wellness and lifestyle products and healthy eating, as well as financial services. Blue365 complements a member’s health coverage by making it easier and more affordable to make healthy choices.

Visit: Blue365deals.com/BCBSSC for the deal of the day!

HEARING AND VISION

Laser Vision Correction Our members receive exclusive discounts on Lasik vision correction services, including exams, surgery, and preoperative and postoperative care.

Eye Care Open your eyes to special savings from Vision One — eye exams, designer frames, lenses and contacts.

Hearing Care Hear that? With Blue, get great savings from TruHearing — a leader in digital hearing aids and ranked No.1 in customer service. Save on hearing exams and follow-up care, too.

COSMETIC

Cosmetic Surgery Lift your spirits with preferred rates on face lifts; breast lifts; breast augmenta-tion and reduction; tummy tucks; nose reshaping; ear pinning; even cheek and chin augmentation. Save on nonsurgical procedures, too.

Hair Restoration Suffering from hair loss? You have every-thing to gain. As a member, you’ll save 20 percent on a hair transplantation procedure.

Teeth Whitening Purchase professional teeth whitening services at a special discounted rate.

Dental Services Through Companion Global Dental, our members can receive dental work over-seas at a fraction of what you would pay in the United States. Global dental services are offered by Companion Global Dental. Because Companion Global Den-tal is a separate company from BlueCross, Companion Global Dental will be respon-sible for all services related to global dental services.

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Go to www.SouthCarolinaBlues.com.

On the home page, find the Member Login: My Health Toolkit box and click Register.

Create your profile by entering your member information found on your insurance card. Follow the remaining steps to complete your profile.

Tools

Think Smart BLUES ENROLLSM AND BLUE E-BILLSM

We offer two great online tools to manage your company’s benefits. This means you will have more time to focus on YOUR business.

With BluesEnroll, it’s never been easier to add or delete employees and/or dependents, order new ID cards, pay your bill and much more.

Blue e-Bill is another online service that gives you the ability to access and manage your account 24 hours a day, seven days a week.

MY HEALTH TOOLKIT®

We understand the importance of making the right health care decisions. My Health Toolkit helps you and your employees make smart decisions and manage your health plan.

My Health Toolkit is the BlueCross information and customer service center. With My Health Toolkit, members can take control of their health care from the comfort of their own homes. Whether you need to locate an in-network doctor or want to research the cost of a specific surgery, My Health Toolkit has resources that can help you make sound decisions on future treatments.

As more power is placed in your hands to manage your health care benefits, we are here to help you every step of the way.

TO SET UP AN ACCOUNT:

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Tools

Think Control MY HEALTH TOOLKIT OFFERS WAYS TO MAKE INFORMED HEALTH CARE DECISIONS:

■Claims Summary — View claims status and an Explanation of Benefits (EOB).

■Eligibility and Benefits — Read about your benefits and coverage information and check your eligibility.

■Ask Customer Service — Send a secure message directly to the customer service area for fast answers to your questions.

■Authorization Status — Verify your autho-rization status for inpatient and outpatient visits.

■Deductible and Out-of-Pocket Statuses — See how close you are to meeting your deductible and maximum out of pocket.

■Request a New ID Card.

■Compare Hospital Quality — Choose the hospital that is right for you by comparing up to 10 facilities on the number of pa-tients treated, complication rates, average lengths of stay for certain conditions and procedures, and more.

■Estimate Treatment Costs — Research average costs and days of treatment for specific medical conditions or procedures.

■Compare Drug Costs — Look up cost and consumer information about prescription drugs.

■Find a Doctor — Find a network doctor or hospital across the country and around the world.

IMPROVE YOUR WELLNESS

■Personal Health Record — A confidential online tool providing a summary of all your health information, including doctors’ visits, prescriptions, lab results and much more. You also can keep track of upcoming medical appointments and print a copy of your medical history. Additional features are available, based on your benefit plan.

■Personal Health Assessment — An online survey that helps identify risk factors and offers ways to improve your health based on your answers.

■Health Library — This feature offers medical information, health calculators, self-care channels and nutrition guides to help improve and protect your health.

Benefits

Benefits 15

UPSTATE I GOLD 1UPSTATE I HEALTH REIMBURSEMENT

ACCOUNT (HRA) GOLD 2

Deductible Individual: $400 Family: $800

Individual: $3,000 Family: $6,000

Coinsurance 50% 0%

Out-of-Pocket Maximum Individual: $4,000 Family: $8,000

Individual: $3,000 Family: $6,000

Primary Care Physician (PCP) $0 on first four visits, then $25 $0 on first four visits, then $25

Specialist Copayment $50 copayment $50 copayment

Urgent Care $50 copayment $50 copayment

Emergency Room Services Deductible and Coinsurance Deductible

Inpatient Hospitalization Deductible and Coinsurance Deductible

PHARMACY BENEFITS

Prescription Drugs Generic (Tier 1): $10 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $80 Specialty (Tier 4): $250

Generic (Tier 1): $10 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $80 Specialty (Tier 4): $250

Mail Order (90 Day) Generic (Tier 1): $14 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $216

Generic (Tier 1): $14 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $216

Benefits 16

UPSTATE I SILVER 1 UPSTATE I SILVER 2

Deductible Individual: $5,500 Family: $11,000

Individual: $3,350 Family: $6,700

Coinsurance 40% 30%

Out-of-Pocket Maximum Individual: $6,850 Family: $13,700

Individual: $6,850 Family: $13,700

PCP $0 on first four visits, then $25 $35 copayment

Specialist Copayment $50 copayment $60 copayment

Urgent Care $50 copayment $60 copayment

Emergency Room Services Deductible and Coinsurance $300 copayment, then Deductible and Coinsurance

Inpatient Hospitalization Deductible and Coinsurance Deductible and Coinsurance

PHARMACY BENEFITS

Prescription Drugs Generic (Tier 1): $10 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $80 Specialty (Tier 4): $250

Generic (Tier 1): $15 Preferred (Tier 2): $40 Non-Preferred (Tier 3): $100 Specialty (Tier 4): 30%

Mail Order (90 Day) Generic (Tier 1): $14 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $216

Generic (Tier 1): $21 Preferred (Tier 2): $108 Non-Preferred (Tier 3): $270

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Exclusions

EXCLUDED SERVICES

We Will Not Pay Benefits For:

■ Any services or benefits not specifically covered under the terms of this policy, which were received before this policy went into effect or after it terminates, or claims submitted after the time limit for filing claims has been exceeded.

■ Services or charges for which the member is entitled to payment or benefits from other sources (e.g., workers’ compensation), for which the provider does not charge, or for which the member is not legally obligated to pay, including treatment provided in a government hospital or benefits provided under Medicare or other government programs (except Medicaid).

■ Cosmetic surgery, or surgery or treatment for the purpose of weight reduction, including any complications from or reversal of these procedures, or reconstructive procedures made necessary by weight loss.

■ Refractive care, such as radial keratotomy, laser eye surgery or Lasik.

■ Services for the detection and correction of structural imbalance, distortion or subluxation (spinal subluxation) to remove nerve interference.

■ Treatment, services or supplies received because of suicide, attempted suicide or intentionally self-inflicted injuries unless it results from a medical (physical or mental) condition, even if the condition is not diagnosed prior to the injury.

■ Treatment resulting from war or acts of war (whether declared or undeclared), while participating in a riot or uprising, or while in the military service or its auxiliary units.

■ An illness you get or injury you receive while committing or attempting to commit a crime, felony or misdemeanor or while engaging or attempting to engage in an illegal act or occupation.

Other Services This Policy Does Not Cover

■ Non-emergency services when received at or from out-of-network provider or hospitals, except true emergency services when received in emergency rooms of out-of-network hospitals.

■ Hospital or skilled nursing facility charges when preauthorization is not received. Please see preauthorization in your policy found in My Health Toolkit.

■ Services and supplies not medically necessary, investigational/experimental in nature, not needed for the diagnosis or treatment of an illness or injury, or not specifically listed in Covered Services.

■ Any service or supply provided by a member of the patient’s family or by the patient, including the dispensing of drugs. This means the spouse, parent, grandparent, brother, sister, child or spouse’s parent.

■ Charges for a missed appointment or for filling out claim forms.

■ Any loss resulting from a member being legally intoxicated or impaired, by being under the influ-ence of alcohol, any narcotic or drug, unless taken on the advice of a physician. The member or member’s representative must provide any available test result, upon our request, showing blood alcohol or drug levels. If the member refuses to provide these test results, we will not provide benefits.

■Services or supplies related to chewing or bite problems, pain in the face, ears, jaws or neck resulting from problems of the jaw joint(s), also known as temporomandibular joint disorders (TMJ).

This is a partial list of some of our exclusions. For a full list of excluded services and supplies, or for all limitations, please refer to your policy in My Health Toolkit.

BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.

BCBSSC BCBSSC www.SouthCarolinaBlues.com

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Contact your agent or broker today.

18662-4-2016