triton college 2014 ppo insurance booklet

Benef ts Information iTriton College PPO 01/01/2014

Nearly one in every three Americans has a Blue Cross and Blue Shield product.

ExperiencePreventive care is essential to maintaining a healthier life, and no one understands this better than Blue Cross and Blue Shield of Illinois (BCBSIL). For more than 75 years, BCBSIL has provided quality health care benefits and services to its members and communities. BCBSIL provides members with programs and support to create customized wellness action plans, make smarter health care choices and help manage their health care.

Your Journey to WellnessWellness is defined as the state of being healthy in body and mind, especially as the result of deliberate effort. The choices you make each day can affect your health now and in the future. Deciding on the best approach for a healthier lifestyle can be challenging, but it may be easier than you think.

BCBSIL offers access to convenient online tools and resources to help you plan and manage your health care. BCBSIL health care plans include flexible options with the right combination of benefits, choice of providers and access to a wide variety of educational resources. Whether you are trying to improve your health or reach the next level of wellness, BCBSIL is here to help.

Take time to explore what Blue Cross and Blue Shield of Illinois has to offer. The coverage options, tools and resources can help you on your journey to wellness.

In This GuideThe following pages include a description of the medical plan and other features and services available to you. In some cases, your employer may be offering you more than one medical plan to choose from. Think carefully about how you and your family will use these benefits. Before you make a decision, consider the services that are covered, provider network, potential out-of-pocket costs and other options.

If you have questions, your employer can provide additional information or direct you to other resources for assistance.

The Choicefor Nearly 1 in 3 Americans

Blue Cross and Blue Shield of Illinois is a leader in health care benefits.

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Triton College: PPO Plan Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL | Plan Type: PPO

Questions: Call 1-800-327-8497 or visit us at www.bcbsil.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-855-756-4448 to request a copy.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcbsil.com or by calling 1-800-327-8497.

Important Questions Answers Why this Matters:

What is the overall deductible?

$ 100 Individual/ $300 Family

Does not apply to preventative care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific services?

No. You don’t have to meet deductibles for specific, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. PPO

$350 Individual/ $1,050 Family

Non-PPO

$600 Individual/ $1,800 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in

the out–of–pocket limit?

Prescription copay, premiums, balanced-billed charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Does this plan use a network of providers?

Yes. Visit www.bcbsil.com or call 1-800-327-8497 for a list of Participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use PPO providers by charging you lower deductibles, copayments and coinsurance amounts.

Common

Medical Event Services You May Need

Your Cost If You Use an

PPO Provider

Your Cost If You Use an Non-PPO Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 10% coinsurance 20% coinsurance ---none---

Specialist visit 10% coinsurance 20% coinsurance ---none---

Other practitioner office visit 10% coinsurance 20% coinsurance ---none---

Preventive care/screening/immunization No Charge 20% coinsurance ---none---

If you have a test Diagnostic test (x-ray, blood work) 10% coinsurance 20% coinsurance Covered at 100% up to $100 per

calendar year then covered at 90% for PPO, and 80% Non-PPO. Imaging (CT/PET scans, MRIs) 10% coinsurance 20% coinsurance

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Common



PPO Provider



If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com.

Generic drugs $6 copay/ prescription

$6 copay/ prescription plus 25% coinsurance

34 day retail / 90 day mail For Out-of-Network drug provider, you are responsible for 25% of the eligible amount after the copay. Certain women’s preventative services will be covered with no cost to the member. For a full list of these prescriptions and/or services, please contact Customer Service.

Preferred brand drugs $10 copay/ prescription


Non-preferred brand drugs $12 copay/ prescription


Specialty drugs Covered Not Covered Retail 34 day supply.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 10% coinsurance 20% coinsurance Covered at 100% up to $100 per calendar year then covered at 90% for PPO, and 80% Non-PPO.

Physician/surgeon fees 10% coinsurance 20% coinsurance

If you need immediate medical attention

Emergency room services 10% coinsurance 20% coinsurance

Supplemental accident covered at 100% up to $300 per accident no deductible then 90% for PPO and 80% for Non-PPO.

Emergency medical transportation 10% coinsurance 10% coinsurance ---none---

Urgent care 10% coinsurance 20% coinsurance ---none---

If you have a hospital stay

Facility fee (e.g., hospital room) 10% coinsurance 20% coinsurance Covered at 100% up to $150 per day then covered at 90% for PPO and 80% Non-PPO.

Physician/surgeon fee 10% coinsurance 20% coinsurance ---none---

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Common



PPO Provider



If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services 10% coinsurance 20% coinsurance Covered at 100% up to $100 per calendar year then 90% PPO and 80% Non-PPO.

Mental/Behavioral health inpatient services 10% coinsurance 20% coinsurance Covered at 100% up to $150 per day then covered at 90% for PPO and 80% Non-PPO.

Substance use disorder outpatient services 10% coinsurance 20% coinsurance Covered at 100% up to $100 per calendar year then 90% PPO and 80% Non-PPO.

Substance use disorder inpatient services 10% coinsurance 20% coinsurance Covered at 100% up to $150 per day then covered at 90% for PPO and 80% Non-PPO.

If you are pregnant Prenatal and postnatal care 10% coinsurance 20% coinsurance ---none---

Delivery and all inpatient services 10% coinsurance 20% coinsurance ---none---

If you need help recovering or have other special health needs

Home health care 10% coinsurance 20% coinsurance

Limited to 60 visits per benefit period. Covered at 100% up to $150 per day then covered at 90% for in-network, and 80% out-of-network.

Rehabilitation services 10% coinsurance 20% coinsurance ---none---

Habilitation services 10% coinsurance 20% coinsurance ---none---

Skilled nursing care 10% coinsurance 20% coinsurance Covered at 100% up to $150 per day then covered at 90% for in-network, and 80% out-of-network.

Durable medical equipment 10% coinsurance 20% coinsurance

Benefits are limited to item used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price).

Hospice service 10% coinsurance 20% coinsurance Covered at 100% up to $150 per day then covered at 90% for PPO, and 80% Non-PPO

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Common



PPO Provider



If your child needs dental or eye care

Eye exam Not Covered Not Covered ---none---

Glasses Not Covered Not Covered ---none---

Dental check-up Not Covered Not Covered ---none---

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Bariatric Surgery

Cosmetic Surgery

Dental Care (Adult and Children)

Hearing Aids

Infertility Treatment

Long-Term Care

Routine Eye Care (Adults and Children)

Routine Foot Care (with the exception of person with diagnosis of diabetes)

Weight Loss Programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Chiropractic Care

Most coverage provided outside the United States. See www.bcbsil.com

Non-Emergency Care When Traveling Outside the U.S.

Private Duty Nursing (with the exception of inpatient private duty nursing)

http://www.bcbsil.com/

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Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-327-8497. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross Blue Shield of Illinois at 1-800-327-8497 or visit www.bcbsil.com, or contact the U.S Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) 527-9431 or visit http://insurance.illinois.gov.

Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This

health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-327-8497. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-327-8497.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-327-8497.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-327-8497.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.cciio.cms.gov/

http://www.dol.gov/ebsa/healthreform

http://insurance.illinois.gov/

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Triton College: PPO Plan Coverage Period: 01/01/2014 - 12/31/2014 Coverage Examples: Coverage for: ALL | Plan Type: PPO


Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays $7,040 Patient pays $500

Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $100

Copays $0

Coinsurance $250

Limits or exclusions $150

Total $500

Amount owed to providers: $5,400 Plan pays $4,970 Patient pays $430

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $100

Copays $120

Coinsurance $130

Limits or exclusions $80

Total $430

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Note: These examples are based on individual

coverage only.

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Triton College: PPO Plan Coverage Period: 01/01/2014 - 12/31/2014 Coverage Examples: Coverage for: ALL | Plan Type: PPO


Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded or preexisting condition.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Freedom PPO - Passive

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

TRITON COLLEGE- EFFECTIVE 01/01/2014

The following is a listing of common services available through your BlueCare Dental PPO network. The member’s share of the cost is determined by whether care is received from a contracting or non-contracting provider.

This information only provides highlights of this program. Please refer to the BlueCare Dental Certificate for additional benefit information.

B E N E F I T H I G H L I G H T S

P r o g r a m B a s i c s C o n t r a c t i n g P r o v i d e r *

N o n - C o n t r a c t i n g P r o v i d e r *

Benefit Period Maximum $1,500 per calendar year

Deductible $50 per person per benefit period

$150 maximum per family Dependent Coverage Spouse and unmarried dependent up to age 26

S e r v i c e s

Diagnostic & Preventive Services Dental exams

Cleanings X-rays Fluoride treatment

100% of Maximum Allowance

100% of Usual and Customary

Miscellaneous Services Sealants Space maintainers Labs & tests



Emergency Care Treatment for the relief of pain



Restorative Services Routine fillings (amalgams and resins)

Pin retention Simple extractions

80% of Maximum Allowance after deductible

80% of Usual and Customary after deductible

General Services Intravenous sedation

General anesthesia Stainless steel crowns



Endodontic Services Root canals

Pulp caps Apicoectomy / apexification



Periodontic Services Scaling & root planing

Gingivectomy / gingivoplasty Osseous surgery



Oral Surgery Services

Surgical extractions Alveoloplasty Vestibuloplasty



Crowns, Inlays / Onlays Services Crowns

Inlays / onlays Prefabricated posts and cores Repair and recementation of crown, inlays / onlays



Prosthodontic Services Bridges and dentures

Reline / rebase of dentures Addition of tooth or clasp Repair of bridges and dentures



Orthodontics Not Covered Not Covered

Not Covered

* Schedule of Maximum Allowances Contracting providers have agreed to accept the Schedule of Maximum Allowances as payment in full for covered services. Non-contracting providers do not accept the Schedule of Maximum Allowances as payment in full. For services received from a non-contracting provider, member will be liable for the difference between the dentist’s charge and covered benefits.

Rev. 01/2014

Preventive CareYour coverage may include preventive care benefits for children and adults, including physical exams, diagnostic tests and immunizations. Check your group plan for the specific coverage.

Emergency CareIf you, as a prudent layperson (with an average knowledge of health and medicine) need to go to the emergency room of any hospital, your care will be covered subject to your plan’s deductible and any applicable copayments or coinsurance. In an emergency, you should seek care from an emergency room or other similar facility. Call 911 or other community emergency resources to obtain assistance in life-threatening situations. Your group plan may require that you, a family member or friend contact BCBSIL if you are admitted to the hospital.

You have nationwide access to contracting providers in networks linked through the BlueCard® program when you or your covered dependents live, work or travel anywhere in the country. The national network includes more than 85 percent of all physicians and hospitals in the country. Be sure to use a BlueCard network provider to receive the highest level of benefits.

With the BlueCard program, there are two ways to locate contracting doctors and hospitals:

• Visit the Web site at www.bcbsil.com to find provider names and locations using the Provider Finder. Maps and driving directions are also available.

• Call the toll-free customer service number on the back of your ID card.

Other Benefits for non-HMO plans

Your health care benefit plan travels with you wherever you go –

across the country or around the world.

National Coverage

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Reconstructive Surgery Following MastectomyFederal and State of Illinois legislation require group health plans and health insurers to provide coverage for reconstructive surgery following a mastectomy. Specifically, these laws state that health plans that cover mastectomies must also provide coverage in a manner determined in consultation with the attending physician and patient for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of

physical complications for all stages of mastectomy, including lymphedemas.

Your coverage may also include benefits for baseline and annual mammograms. Check your group plan documents for details.

Illinois Dependent Eligibility Mandate Under new, Federal law, your dependents are eligible for health and/or dental coverage up to the dependent limiting age and may not be denied coverage due to marital, student or employment status before age 26. Check with your employer for additional details regarding eligibility requirements. In addition, eligible military personnel may not be denied coverage before age 30 under Illinois law. If you elect BlueChoice Select coverage, your dependents must live within the defined service area.

This Illinois law applies to all individual plans and insured group medical and/or dental plans, as well as self-insured municipalities, counties and schools. The law does not apply to self-funded national account groups or local non-municipal self-funded groups. If you have questions about this law, contact your benefits administrator.

When you travel outside the United States and need medical assistance services, call 800-810-BLUE (800-810-2583) or call collect to 804-673-1177 for information. Blue Cross and Blue Shield has contracts with doctors and hospitals in more than 200 countries. An assistance coordinator, in conjunction with a medical professional, can arrange your doctor’s appointment or hospitalization, if necessary.

Providers that participate in the BlueCard Worldwide® program, in most cases, will not require you to pay up front for inpatient care. You are responsible for the out-of-pocket expenses such as a deductible, copayment, coinsurance and non-covered services. The doctor or hospital should submit your claim.

You also have coverage at non-contracting hospitals, but you will have to pay the doctor or hospital for care at the time of service, then submit an international claim form with original bills. Call the toll-free customer service number on your ID card for the address to send the claim. You can get a claim form from your employer, customer service or online at www.bcbsil.com.

International Coverage

Prescription Drug Card ProgramYour benefi ts include prescription drug coverage through BCBSIL. You have access to a national network of contracting pharmacies, which includes most national chain as well as independent pharmacies across the country. When you visit a contracting pharmacy and show your BCBSIL card, the claim is processed immediately at the time of purchase based on your medical plan deductible, coinsurance and out-of-pocket limitations. You are only responsible for your share of the discounted price of the medication.

Mail ServiceYou can receive up to a 90-day supply of maintenance medication delivered directly to you. Mail service claims are processed based on your medical plan deductible, coinsurance and out-of-pocket limitations, and you are only responsible for your share of the discounted price of the medication. You can print registration and order forms, request prescription refi lls and see the status of orders you’ve placed, as well as learn more about generic drugs and more when you visit the Web site at www.bcbsil.com and log in to Blue Access® for Members.

Prescription Drugs

The prescription drug mail service can help you save money on your maintenance medications.

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Use BAM while you’re on the go. Register or log in by going to bcbsil.com from your mobile device Web browser for secure and convenient access.

It’s easy to get started

1. Go to bcbsil.com.

2. Click the Already a Member? tab. Then click the Register Now button in the BAM section.

3. Use the information on your BCBSIL ID card to complete the registration process.

Log in to Blue Access for MembersSM (BAM)

Your Online Resource

Would you like to know when your medical claims are paid and the payment amounts? Do you need to confirm who in your family is included under your coverage? BAM, the secure member portal from Blue Cross and Blue Shield of Illinois (BCBSIL), can help. Get immediate online access to health and wellness information, and:

• Check the status of a claim and your claims history

• Confirm the family members who are covered under your plan

• View and print an Explanation of Benefits (EOB) statement for a claim

• Select an option to stop receiving EOBs by mail

• Set your preferences to receive notifications for claims status and wellness updates through emails or text alerts.

• Locate a doctor or hospital in the network

• Request a new or replacement member ID card or print a temporary member ID card

• Join My Blue Community®, a social network for BAM members

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Find what you need at Blue Access for MembersSM (BAM)

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1. My Coverage: Review benefit details for you and the family members covered under your plan.

2. Claims Center: View and organize details such as payments, dates of service, provider names, claims status and more.

3. My Health: Make more informed health care decisions by reading about health and wellness topics and researching specific conditions.

4. Doctors & Hospitals: Use Provider Finder® to locate a network doctor, hospital or other health care provider, and get driving directions.

5. Forms & Documents: Use the form finder to get claim and other forms quickly and easily.

6. Message Center: Learn about updates to your benefit plan, and receive notification of pending and finalized claims via secure messaging.

7. Quick Links: Go directly to some of the most popular pages for information, such as medical coverage, replacement ID cards, manage preferences and more.

8. Settings: Set up notifications and alerts to receive updates via text messaging and email, review your member information, and change your secure password at anytime.

9. Help: Look up definitions of health insurance terms, get answers to frequently asked questions and find Health Care School articles and videos.

10. Contact Us: Submit a question and a Customer Service Advocate will respond by phone or through the message center.

Frequently Asked Questions

Q: Whom do I call with questions about my benefi ts?A: Call customer service at the toll-free number on the back of your member ID card.

Q: How do I fi nd a contracting network doctor or hospital?A: Go to www.bcbsil.com and use the Provider Finder® or call customer service at the toll-free number on the back of your

member ID card.

Q: What should I bring to my fi rst appointment?A: Your fi rst appointment is an opportunity to share information about your health with your new doctor, so bring as much

medical information as possible, including:

• Medical records and insurance card – If you are undergoing treatment when you change doctors, your medical records are especially important to your new doctor. Your BCBSIL member ID card provides information about copayments, billing and customer service phone numbers.

• Medications – Give your new doctor information on prescription and over-the-counter medications, including any herbal medications you take. Be sure to include the name of the medication, the dosage, how often you take it and why.

• Special needs – Make a list of medical equipment and devices you use, including wheelchairs, oxygen, glucose monitors and glucose strips. Be prepared to explain how you use them, not only to make sure you have the equipment you need, but also to avoid any disruption in your care.

Q: Are my medical records kept confi dential?A: Yes. Blue Cross and Blue Shield of Illinois is committed to keeping specifi c member information confi dential. Anyone

who may need to review your records is required to keep your information confi dential. BCBSIL may need to review your medical record or claims data (for example, as part of an appeal that you request). If so, precautions are taken to keep your information confi dential. In many cases, your identity will not be associated with this information.

• What is the doctor’s experience in treating patients with the same health problems I have?

• Where is the doctor’s offi ce? Is there ample parking or is it close to public transportation?

• What are the regular offi ce hours? Does the offi ce have drop-in hours for urgent problems?

• How long should I expect to wait to see the doctor when I’m in the waiting room?

• Are routine lab tests and X-rays performed in the offi ce, or will I have to go elsewhere?

• Which hospitals does the doctor use?

• If this is a group practice, will I always see my chosen doctor?

• How long does it usually take to get an appointment?

• How do I get in touch with the doctor after offi ce hours?

• Can I get advice about routine medical problems over the phone or by e-mail?

• Does the offi ce send reminders for routine preventive tests, like cholesterol checks?

Q: What questions should I ask when selecting a doctor?A: In addition to preliminary questions you’d ask a new doctor—such as “Are you accepting new patients?”—the following questions will help you evaluate whether a doctor is right for you:

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Highlights of the site include:

• Simple steps you can take to live healthier

• Links to useful resources

• Information provided by medical professionals

• Timely newsfeeds from national media

Numerous health and safety topics including mental health, childhood obesity, drug safety and caregiving are presented on the site. New topics are continually added.

Be Smart. Be Well. is sponsored by Health Care Service Corporation, the largest customer-owned health insurer in the United States, with more than 12 million members in its Blue Cross and Blue Shield Plans in Illinois, New Mexico, Oklahoma and Texas.

Be sure to join the daily discussion on Twitter at twitter.com/bsbw and visit us on You Tube at www.youtube.com/besmartbewell.

Be Smart. Be Well. Know the facts. Visit www.besmartbewell.com today.

Be Smart. Be Well.®

Divisions of Health Care Service Corporation,a Mutual Legal Reserve Company, an Independent Licenseeof the Blue Cross and Blue Shield Association.

This information is not intended to be a substitute for professional medical advice. If you are under the care of a doctor and receive advice contrary to this information, follow the doctor’s advice. See your doctor if you are experiencing any symptoms or health problems.

You can increase your odds of living better and living longer by making smart health and safety choices. Be Smart. Be Well. is a unique Web site dedicated to helping you be safe and healthy. Be Smart. Be Well. features engaging video documentaries of the personal lessons learned by real people. The goal of Be Smart. Be Well. is simple: to give you the information and resources you need to make an immediate and positive impact on your everyday life.

Caregiving Childhood Obesity Drug Safety

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Health Insurance FraudWhat You Should Know

Don’t Be a VictimIn addition to losing money through fraud, members may also experience physical and mental harm as a result of health care fraud schemes in which a provider performs unnecessary or dangerous procedures.

Identifying FraudCommonly identifi ed schemesinvolving providers include:• Misrepresenting Services – Intentionally billing procedures

under different names or codes to obtain coverage for services that aren’t included in a member’s plan.

• Upcoding – Deliberately charging for more complex or more expensive services than those actually provided.

• Non-rendered and/or “Free” Services – Some providers intentionally bill for tests or services never provided. This can also mean that the provider offered “free” services to bill the insurance company for services not performed or needed.

• Kickbacks, Bribes or Rebates – Referring patients to a provider or facility where the referring provider has a fi nancial interest.

Commonly identifi ed member schemes include:• Identity Swapping – Allowing an uninsured individual to

use your insurance card.

• Identity Theft – Using false identifi cation to gain employment and the health insurance benefi ts that come with it.

• Non-eligible Members – Adding someone to a policy who is not eligible or failing to remove someone when that person becomes ineligible.

• Prescription Medicine Abuse and Diversion – Controlled substances can be obtained through deception or dishonesty for personal use or sale “on the street.” Prescription medications can be obtained through doctor shopping, visiting several emergency rooms or stealing doctors’ prescription pads.

Health Insurance FraudWhat You Should Know

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Fraud Affects Everyone Fraud may cost the health care industry (public and private payers) more than $200 billion each year. As a member of Blue Cross and Blue Shield of Illinois (BCBSIL ), this fraud may cause you to face rising premiums, increased copayments and deductibles, and the elimination of certain benefi ts.

Fraud increases costs and decreases benefi ts.

• Know your own benefi ts and scope of coverage.

• Review all Explanation of Benefi ts (EOB) forms. Make sure the exams, procedures and tests billed were the ones you actually had with the provider who treated you.

• Understand your responsibility to pay deductibles and copayments, and what you can and cannot be balance-billed for once your claim has been processed.

• Guard your health insurance card and personal insurance information. Notify BCBSIL immediately if your card or insurance information is lost or stolen.

• Sign and date only one claim form per offi ce visit.

• Never lend your member ID card to another person.

• Don’t give out insurance or personal information if services are offered as “free.” Be sure you understand what is “free” and what you or your employer will be charged for.

• Ask your doctors exactly what tests or procedures they want you to have and why. Ask why the tests or procedures are necessary before you have them.

• Be sure any referrals you receive from your network provider are to other network doctors or facilities. If you’re not sure, ask.

• Monitor your prescription utilization via the BCBSIL website or your Pharmacy Benefi t Manager (PBM). Make sure the medications billed to your insurance are accurate.

Fighting FraudBCBSIL offers these tips:

• Review all Explanation of Benefi ts (EOB) forms. Make sure the exams, procedures and tests billed were the ones you actually had with the provider

• Understand your responsibility to pay deductibles and copayments, and what you can and cannot be balance-billed for once your claim has been

• Guard your health insurance card and personal insurance information. Notify BCBSIL immediately if your card or insurance information is lost or stolen.

• Don’t give out insurance or personal information if services are offered as “free.” Be sure you understand what is “free” and what you or your employer

• Ask your doctors exactly what tests or procedures they want you to have and why. Ask why the tests or procedures are necessary before you have them.

• Be sure any referrals you receive from your network provider are to other

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Preventing Health Care Fraud BCBSIL created the Special Investigations Department (SID) to fi ght fraud and help lower health care costs. The staff includes individuals with medical, insurance and law enforcement backgrounds as well as data analysts experienced in detecting fraudulent billing schemes. The SID aggressively investigates allegations of fraud and refers appropriate cases for criminal prosecution.

Fraud Isn’t Fair. Help Us Fight It. Reducing health care fraud is a collaborative effort between BCBSIL, its providers and its members. Additional information and a fraud awareness training program are available through the SID website at bcbsil.com/sid.

We also encourage you to report any suspected incidence of fraud by calling our Health Care Fraud Hotline, completing a form online or sending us a note in the mail. Suspicions of fraud can be reported to the SID anonymously.

Three Ways To Report Fraud To BCBSIL The SID is here to help you. You can contact the SID in any of the following ways:

1. 800-543-0867The toll-free Fraud Hotline operates 24 hours a day, seven days a week. You can remain anonymous or provide information if you want to be contacted by a member of the SID.

2. bcbsil.com/sid/reportingThis website address links to an online fraud reporting form that can be completed and sent to the SID electronically.

3. U.S. MailYou can write the SID at:Blue Cross and Blue Shield of IllinoisSpecial Investigations Department300 E Randolph StreetChicago, Illinois 60601

Our Special Investigations Department is one of the most effective in the industry.

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Understanding Your EOB

An Explanation of Benefi ts (EOB) Statement is a notifi cation form provided to members when a health care benefi ts claim is processed by Blue Cross and Blue Shield of Illinois (BCBSIL). The EOB displays the expenses submitted by the provider and shows how the claim was processed.

The EOB has four major sections:• Claim Information includes the member

and patient name, the member’s group and ID numbers, and the claim number.

• Summary highlights the fi nancial information – the amount billed, total benefi ts approved and the amount you may owe the provider.

• Service Information identifi es the health care facility or physician, dates of service and charges.

• Coverage Information shows what was paid to whom, what discounts and deductions apply, and what part of the total expense was not covered.

The EOB may includeadditional information. • Information About Amounts Not Covered

will show what benefi t limitations or exclusions apply.

• Information About Out-Of-Pocket Expenses will show an amount when a claim applies toward your deductible or counts toward your out-of-pocket expenses.

• Information About Appeals explains your rights regarding review of claim denials.

• Fraud Hotline is a toll-free number you can call if you think you are being charged for services you did not receive or if you suspect any fraudulent activity.

A Guide to Reading Your Explanation of Benefi ts Statement

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Your EOBs are Always Available Online!Sign up for Blue Access® for Members (BAM) at www.bcbsil.com for quick, convenient and confi dential access to your claim information and history. To support our commitment to eco-friendly business practices, you can choose to opt out of receiving EOBs by mail. This saves resources and offers you additional confi dentiality. Just go to BAM, click on User Profi le and change your User Preferences.

Sample EOB

18

19

20

21

22

12

17

13 14 15 16

11

66

77

899

10

1

2

34

5

Sample EOBAccount name (member’s company or organization)

Date claim was fi nalized

Toll-free number to call for additional information

Member’s name and mailing address

BCBSIL messages

Member’s name

Employer or group identifi cation number*

Member number that appears on the ID card*

Claim number*

Person who received the services*

Summary box, including the total amount billed by the provider for the services, the benefi ts approved and paid by BCBSIL, and the remainder you may owe.(See also 14, 20 and 21).

Provider name (top line) and description of service (below)

Beginning and end service dates

Amount billed by the provider for each service

Portion of the billed amount not covered by the plan(a footnote explains the reason)

Amount covered by the plan*

Total charges included on this claim

Plan reductions subtracted from billed amount, such as PPO allowances

Deductible and copayment or coinsurance amounts

Payment approved before benefi ts are coordinated with other insurers, such as Medicare

Amount the member may be responsible for paying

Total benefi t approved for provider

18

19

20

21

22

12

17

13

14

15

16

11

6

7

8

9

10

1

2

3

4

5

* Please provide this information when contacting us about a claim.

Not all EOBs are the same. The format and content of your EOB depends on your benefi t plan and the services provided. Deductible and copayment amounts vary.

Blue Distinction is a designation awarded by the Blue Cross and Blue Shield companies to hospitals that have demonstrated expertise in delivering clinically proven specialty health care. Its goal is to help consumers fi nd specialty care on a consistent basis, while enabling and encouraging health care professionals to improve the overall quality and delivery of care nationwide.

Blue Distinction Centers for Bariatric Surgery® Provides a full range of bariatric surgical care services, including inpatient care, post-operative care, follow-up and patient education.

Blue Distinction Centers for Cardiac Care® Provides a full range of cardiac care services, including inpatient cardiac care, cardiac rehabilitation, cardiac catheterization and cardiac surgery.

Blue Distinction Centers for Transplants® Transplant program that provides services, such as global pricing, fi nancial savings analysis, and global claims administration and support services.

Blue Distinction Centers for Complex and Rare Cancers® Inpatient cancer care programs for adults, including those treating complex and rare subtypes of cancer, delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise, focus on treatment planning and complex, major surgical treatments.

Blue Distinction Centers for Knee and Hip ReplacementSM Provides inpatient knee and hip replacement services,including total knee and total hip replacement surgeries.

Blue Distinction Centers for Spine Surgery® Inpatient spine surgery services, including discectomy,fusion and decompression procedures.

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Use the Blue Distinction Center Finder.

• Go to bcbsil.com

• Select the Provider Finder® tool and search for hospitals

• To fi nd a Blue Distinction center near you, search by designated area of specialty and state

Blue Distinction® For hospitals with expertise in specialty care

Blue Access Mobile brings convenient, secure access to your mobile phone.

Blue Access MobileSM

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From your mobile phone Web browser, you can:SM

coverage details, access or request identification (ID) cards, check claims status, manage

There is no registration required to access the mobile site. However, BCBSIL members must enter their user name and password to log in to Blue Access for Members.

bcbsil.com/mobile

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Integrated Provider Finder from Blue Cross and Blue Shield of Illinois (BCBSIL), is an innovative way to help you estimate health care costs and select providers with independent, third-party quality ratings and meaningful patient reviews.

You can use the Integrated Provider Finder tool to: • Find a network primary care physician, specialist or hospital.

• Filter search results by doctor, specialty, ZIP code, language and gender – even get directions from Google Maps™.

• Make an appointment to consult with a provider in select geographic areas.

• Determine if a Blue Distinction Center for Specialty Care® is an option for treatment.

• View patient feedback or add your review for a provider.

• View quality, certifications and recognitions for doctors.

• Estimate the cost of a provider’s procedures, treatments and tests.

It’s easy, immediate, secure – and available at bcbsil.com.

Integrated Provider Finder shares information that puts you in charge.

• Do you want to know more about the providers who take care of you or your family?

• Do you need to know the estimated cost of a medical service?

• How do you choose where to go for medical services?

Integrated Provider FinderQuick and Easy Ways to Find Providers and Treatment Costs

Integrated Provider Finder without Benefit Accumulator

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It’s easy to get started with the Integrated Provider Finder by registering for Blue Access for MembersSM (BAM):1. Go to bcbsil.com.

2. Click the Log In tab, and then click the Register Now link.

3. Use the information on your BCBSIL ID card to complete the registration process.

4. Once you are registered, log in to BAM. The Integrated Provider Finder tool is located under the Doctors & Hospitals tab.

Get assistance while you’re away from home. Go to bcbsil.com and register or log in to BAM. You can stay connected to your claims activity, ID card information, coverage information, prescription reminders, and health tips via text messages.

You can also call a BCBSIL Customer Service Advocate at the toll-free telephone number on the back of your member ID card for help in locating a provider.

Screen shots are for illustrative purpose only.

Integrated Provider Finder helps you make important health care decisions

Q&A Prescription Drug Formulary What is a formulary?The Blue Cross and Blue Shield of Illinois formulary, which your prescription drug benefit plan is based on, is a regularly updated list of preferred drugs selected based on the recommendations of a committee comprised of individuals from throughout the country who hold a medical or pharmacy degree. U.S. Food and Drug Administration (FDA)-approved drugs are chosen based on efficacy, safety, uniqueness and cost-effectiveness. The formulary includes all generic drugs and a select group of brand drugs.

What are the advantages of using the formulary?Your copayment/coinsurance amount for covered formulary drugs is usually lower than for non-formulary drugs. You have benefits for most covered medications that are not on the formulary, but you may pay more out-of-pocket. The formulary is a reference for your doctor when prescribing medications. However, it is solely up to you and your physician to determine the medication that is best for you.

What are the advantages of using generic drugs?Generics are recognized as safe and effective medications. Generics cost less because manufacturers do not have to recover an investment in research and development. Therefore, you usually pay less for a generic drug than for a brand medication. A generic can usually be substituted for a brand drug if it contains the same active ingredients, the same strength and dosage form and produces the same results. Only your doctor can make prescribing decisions for you. Talk to your doctor or pharmacist to find out if a generic drug is available and right for you.

How do I know if a drug is on the formulary and what my cost will be?On the following pages are some commonly prescribed generic and formulary brand medications. If a drug you are looking for is not on the list, search the formulary at bcbsil.com or call the Pharmacy Program number on the back of your ID card.

Your particular prescription drug benefit plan and whether or not the drug is on the formulary will determine the amount you pay. To find out what you will pay, visit our website at bcbsil.com or call the Pharmacy Program number on the back of your ID card.

What are drug dispensing limits?Based on FDA-approved dosage regimens and manufacturer’s product packaging, certain medications have dispensing limits. This means that only a specific quantity of medication is covered per prescription or in a given time period. For example, coverage for the osteoporosis drug Actonel® (risedronate) is limited to 30 tablets per 30 days because the FDA-approved labeling states that the recommended dose is one 5 mg oral tablet taken daily.

What if I have questions? Call the Pharmacy Program number on the back of your ID card, 24 hours a day, 7 days a week, or visit bcbsil.com. Drug safety information is also available at besmartbewell.com/drugsafety.

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October 2013Commonly Prescribed Formulary MedicationsThis list is a sample of commonly prescribed generic and formulary brand drugs. Refer to the Blue Cross and Blue Shield of Illinois Prescription Drug Formulary at bcbsil.com for a more comprehensive and up-to-date list. The online formulary is updated after new generic drugs become available and also on a regular basis. The formulary may contain medications not covered under your prescription drug benefit plan. In addition, prescription versions of over-the-counter (OTC) medications may not be covered based on your prescription drug benefit plan. If you have questions about your prescription drug benefit, call the Pharmacy Program number on the back of your ID card.

CARDIOVASCULARACE Inhibitors/Combinationsamlodipine/benazeprilbenazepril/benazepril HCTcaptopril/captopril HCTenalapril/enalapril HCTfosinopril/fosinopril HCTirbesartan/irbesartan HCTlisinopril/lisinopril HCTquinapril/quinapril HCTramipril trandolapril

Angiotensin II Receptor Blockerscandesartanlosartan/losartan HCTvalsartan HCTBENICAR/BENICAR HCT

Beta-Blockersacebutolol atenolol bisprolol/bisprolol HCTcarvedilol labetalolmetoprolol/metoprolol ERpropranololINNOPRAN XL

Calcium Channel Blockersamlodipinediltiazem/XR/SRnifedipine ERverapamil/SR/ER

Cholesterol Lowering Drugsatorvastatincholestyraminecolestipol pktfenofibrategemfibrozillovastatinpravastatinsimvastatinCRESTORNIASPAN TRILIPIXWELCHOL

DEPRESSIONSSRIscitalopram

escitalopramfluoxetineparoxetinesertraline

Other Antidepressantsamitriptylinebupropion/SR/XLbupropion ext-release 24 hr mirtazapine/ODTnefazodonetrazodonevenlafaxine/XR

DIABETESacarbosemetformin/XRmetformin/glyburiderepaglinidePRANDIN VICTOZA

Dipeptidyl Peptidase 4 InhibitorsJANUMET/JANUMET XR JANUVIA JUVISYNCKOMBIGLYZE XRONGLYZA

Sulfonylureas glimepirideglipizide/XLglyburide/glyburide micronized

Insulin ProductsHUMALOG/HUMULINLANTUS LEVEMIRNOVOLIN/NOVOLOG

Monitoring Kits/Strips & SyringesACCU-CHEK STRIPS & KITSACCU-CHEK LANCETSBAYER BREEZE STRIPSBAYER CONTOUR STRIPSBAYER MICROLET LANCETSBD NEEDLES/SYRINGESCHEMSTRIP BG STRIPS & KITS

GASTROINTESTINALH2 Receptor Antagonistscimetidinefamotidineranitidine

Proton Pump Inhibitorslansoprazole/ODTomeprazole/ omeprazole- sodium bicarbonate pantoprazoleNEXIUM

ANTI-INFECTIVE AGENTSAntibacterialsamoxicillinamoxicillin/clavulanateampicillinazithromycin tabs/suspcefaclorcefadroxilcefdinircefprozilcefuroximecephalexinciprofloxacindoxycyclineEES/sulfisoxazoleerythromycinlevofloxacinpenicillin VKtetracyclinetmp-smz DS

Antifungals/Onychomycosisterbinafinevoriconazole

Antivirals/Herpesacyclovirvalacyclovir

LOW MOLECULAR WEIGHT HEPARINenoxaparin

MIGRAINETriptansnaratriptanrizatriptansumatriptanzolmitriptan

OPHTHALMICAntibacterialofloxacin ophth solnpolymyxin B/trimethoprimtobramycinVIGAMOX

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Formulary brand drugs are noted with names in UPPERCASE. Certain generic drug products are listed by their proprietary name, and are indicated with an asterisk (*). EE = ethinyl estradiol Drug trademarks and servicemarks are the property of their respective third-party owners.

October 2013Commonly Prescribed Formulary Medications

Glaucomabrimonidine 0.15%, 0.2%dorzolamide solnlatanoprosttimolol maleate solnALPHAGAN P 0.1%AZOPT LUMIGANTRAVATAN Z

Other Eye Productsazelastine solndiclofenac solnketorolac soln 0.4%, 0.5%tobramycin/dexamethasone suspPATADAYTOBRADEX OINTZYLET

PAIN/ARTHRITISAnti-inflammatory AgentsdiclofenacetodolacibuprofenindomethacinmeloxicamnabumetonenaproxenoxaprozinsulindacCELEBREXHUMIRA

RESPIRATORYAllergy DrugsAll generically available antihistamine/decongestant combinations that require a prescription are on the formulary.

azelastinefexofenadinefluticasonelevocetirizinetriamcinoloneASTEPRONASONEX

Asthma DrugsmontelukastzafirlukastADVAIR DISKUS/ADVAIR HFAASMANEXDULERAFLOVENT DISKUS/FLOVENT HFA

FORADIL AEROLIZERPROAIR HFA QVARSYMBICORTVENTOLIN HFA

Cough and ColdAll generically available cough/cold medications that require a prescription are on the formulary.

MiscellaneousATROVENT HFACOMBIVENTCOMBIVENT RESPIMATipratropium/albuterol sulfateSPIRIVA HANDIHALER

SLEEP AIDSzaleplonzolpidem/ER

THYROID REPLACEMENTlevothyroxine – includes Levoxyl*

UROLOGIC DISORDERSBenign Prostatic Hypertrophydoxazosintamsulosinterazosin

Urinary Incontinenceoxybutynin/ext-releasetolterodineDETROL LAVESICARE

OthersfinasterideAVODART

WOMEN’S HEALTHContraceptivesMonophasicEE/desogestrel (Apri*)EE/drospirenone (Gianvi*, Ocella*, Zarah*)EE/levonorgestrel (Aviane*, Levora*)EE/norethindrone (Necon*, Necon 1/35*, Nortrel*, Nortrel 1/35*)EE/norgestimate (Mononessa*, Sprintec*)EE/norgestrel (Low-Ogestrel*)

BiphasicEE/desogestrel (Kariva*)EE/norethindrone (Necon 10/11*)

TriphasicEE/desogestrel (Velivet*)EE/levonorgestrel (Trivora*)EE/norethindrone (Necon 7/7/7*, Nortrel 7/7/7*)EE/norgestimate (Tri-Sprintec*, Trinessa*)

Progestin Onlynorethindrone (Errin*, Jolivette*)

Otherslevonorgestrel 0.75 mgNUVARINGORTHO EVRA

Hormone Therapyestradiolestradiol/norethindrone acetateestropipatemedoxyprogesteronenorethindrone progesterone micronizedESTRADERMVIVELLE DOT

MiscellaneousalendronateibandronateACTONELEVISTAZEMPLAR

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Health concerns don’t always follow a 9-to-5 schedule. Fortunately, registered nurses are on call at (800) 299-0274 to answer your health questions, wherever you may be, 24 hours a day, seven days a week.

The 24/7 Nurseline’s registered nurses can understand your health concerns and give general health tips. Get trusted guidance on possible emergency care, urgent care, family care and more.

When should you call?The toll-free Nurseline can help you or a covered family member get answers to health problem questions, such as:

• Asthma, back pain or chronic health issues

• Dizziness or severe headaches

• High fever

• A baby’s nonstop crying

• Cuts or burns

• Sore throat

Plus, when you call, you can access an audio library of more than 1,000 health topics—from allergies to women’s health—with more than 600 topics available in Spanish.

24/7 Nurseline* – Around-the-Clock, Toll-Free Support

20750.0710

The 24/7 Nurseline can help you figure out if you should call your doctor, go to the ER or treat the problem yourself.

Get the information you need, just when you need it.

Note: For medical emergencies, call 911 or your local emergency services first. This program is not a substitute for a doctor’s care. Talk to your doctor about any health questions or concerns.

*The 24/7 Nurseline is not available to HMO members.

As an HMO member, you should always try to see your PCP fi rst (the doctor who knows you and your health history best) to receive services covered by HMO benefi ts and to ensure continuity of care. If you cannot get a timely offi ce visit with your doctor, Take Care Clinics may offer an alternative to visiting an emergency room.

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Walgreens’ Take Care Clinics– an alternative to urgent care

New discount program for Illinois HMO Members

Illinois HMO members will receive a discount on a variety of health care services at Walgreens’ Take Care Clinics. Simply show your Blue Cross and Blue Shield of Illinois (BCBSIL) HMO identifi cation card at the time of service for the discount. Payment will be expected at time of service.

Convenient Care for You and Your FamilyTake Care Clinics are staff ed by nationally certifi ed family nurse practitioners who diagnose and treat minor illnesses and injuries. A few examples of Take Care Clinics’ health care services include:

• Treating respiratory illnesses, skin conditions and minor injuries

• Giving physicals and health evaluations • Providing immunizations

Accessible Services When and Where You Need ThemTake Care Clinics are open seven days a week and appointments are not needed. To fi nd a Take Care Clinic near you, visit www.TakeCareHealth.com.

It is important to inform your PCP as soon as possible about any treatment or services you receive at a Take Care Clinic to help ensure your records are always up to date.

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Well onTarget is designed to give you the support you need to make healthy choices. All while rewarding you for your hard work. Well onTarget Member Wellness PortalThe heart of Well onTarget is the member portal, available at wellontar-get.com. It uses the latest technology to offer you an enhanced online experience. This engaging portal links you to a suite of innovative programs and tools.

• onmytime Self-directed Courses Online courses let you work at your own pace to reach your health goals. Learn more on nutrition, fitness, weight management, tobacco cessation and stress. Track your progress as you make your way through each lesson. Reach your milestones and earn Life Points.

• Health and Wellness Content Health library teaches and empowers through evidence-based, user-friendly articles.

• Tools and Trackers Interactive tools help keep you on course while making wellness fun. Use a food and exercise diary, symptom checker and health trackers.

onmyteam Wellness CoachingCertified wellness coaches offer you guidance in nutrition, fitness and stress management. You can interact with your coach by phone or send a secured message through the portal.

Wellness is more than healthy eating and working out. It involves making healthy choices that enrich your mind, body and spirit.

A New Way to Experience WellnessWell onTarget offers personalized tools and resources to help all members— no matter where you may be on the path to health and wellness.

Well onTarget is a registered mark of Health Care Service Corporation, a Mutual Legal Reserve Company.

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Onlife Health is an independent company that provides wellness services for the Well onTarget program.

* onmyway is registered mark of Onlife Health.

** Life Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal for further information. Your company may have additional reward programs in place to encourage you to take advantage of certain preventive care and wellness activities or for making healthy changes. Check your employee benefits.

*** The Fitness Program is provided by Healthways, Inc., an independent contractor which administers the Prime Network of fitness centers. The Prime Network is made up of independently-owned and managed fitness centers.

onmywayTM* Health Assessment (HA) The HA features adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. This private record offers tips for living your healthiest life. Your answers will be used to tailor the Well onTarget portal with the programs that can help you reach your goals.

Life Points** ProgramLife Points will help motivate you to maintain a healthy lifestyle. Earn points by taking part in wellness activities. Points can be redeemed in the new online shopping mall. Real-time granting of points lets you instantly use your points. To earn a larger reward, you can add to your point total at checkout.

Online Workplace CompetitionsIndividual daily missions encourage you to take small wellness steps. Challenge yourself with stress management, fitness and nutrition missions. Team missions let you join forces with co-workers to compete in physical activity contests.

Fitness Program***Fitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of fitness centers. With more than 8,000 participating gyms on hand, you can work out at any place or at any time. Choose a gym close to home and one near your office. Other program perks are:

• No long-term contract required. Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25.

• Automatic withdrawal of monthly fee.

• Online tools for locating gyms and tracking visits.

• Earn 2,500 bonus Life Points for joining the Fitness Program. Earn up to 500 points with weekly visits.

• Access to discounts through a nationwide Complementary and Alternative Medicine (CAM) network of 40,000 health and well-being providers such as massage therapists, personal trainers and nutrition counselors.

Sign up for the Fitness Program today! Call toll-free at 888-762-BLUE (2583), Monday through Friday, 8 a.m. – 9 p.m. in any continental U.S. time zone.

Start experiencing the new wellness today by logging on to wellontarget.com. If you have any questions about the Well onTarget program, call Customer Service at 877-806-9380.

Blue365 is just one more advantage of being a Blue Cross and Blue Shield of Illinois (BCBSIL) member. With this program, you can save money on health care products and services that are most often not covered by your benefit plan. There are no claims to file and no referrals or pre-authorizations.

Blue365 has a range of new features and greater discounts from top national and local retailers on fitness gear, gym memberships, family activities, healthy eating options and much more. Once you register on the Blue365 website at blue365deals.com/BCBSIL, you will receive weekly “Featured Deals,” which offer additional discounts from leading health companies and online retailers that are available for a short period of time.

Davis VisionSM’ TruVision877-393-8844 877-882-2020Save on eyeglasses as well as contact lenses, laser vision correction services, examinations and accessories. For a list of Davis Vision providers near you, go to bcbsil.com, click Find a Doctor then select Find a Vision Provider. The Davis Vision network consists of major national and regional retail locations as well as independent ophthalmologists and optometrists. You and your eligible dependents can receive discounts on laser vision correction services through the TLC/TruVision network.

Jenny Craig®’877-JENNY70 (877-536-6970)Let Jenny Craig help you reach your weight-loss goals. Your consultant will help you find the program that fits your life. Experience the Jenny difference with discounts to the Jenny As You Go monthly program or the Jenny All Access yearly membership program.

Procter & Gamble (P&G) Dental ProductsGet savings on dental packages containing the latest in Oral B®’ power toothbrushes and Crest®’ products. The dental packages from P&G can help you improve the health of your teeth and gums. Packages may contain items such as an electric toothbrush, mouth rinse, floss and more.

TruHearing®’800-687-4617TruHearing customers save on average $890 per hearing aid compared to national retail prices. Each purchase comes with a 45-day money-back guarantee, a three-year warranty and 48 free batteries per hearing aid. Plus, get personal service when you visit one of TruHearing’s professional hearing care providers near you.

Blue365®

A Discount Program for Members

21274.0913

Our HMOs have been awarded an Excellent Accreditation from the National Committee for Quality Assurance (NCQA). This accreditation level is awarded to plans that demonstrate levels of service and clinical quality that meet or exceed NCQA’s rigorous requirements for consumer protection and quality improvement. The NCQA results are publicly reported in five categories:

• Access and Service • Qualified Providers • Staying Healthy • Getting Better • Living with Illness

Seattle Sutton’s Healthy Eating®’800-442-DIET (800-442-3438)Save on these freshly prepared, calorie-controlled meals designed to help with weight loss and managing certain health problems. Depending on your location, you can have Seattle Sutton’s Healthy Eating deliver your food or you can pick up your meals at a neighborhood location. Bon appetit!

ReebokA trusted brand for more than 100 years, Reebok develops top athletic equipment for people everywhere, from professional athletes to kids playing soccer. Its wide selection of training equipment, workout apparel, fan gear and more makes it easy to look good and feel great knowing you’re using some of the best shoes, apparel and accessories in the world. Enjoy 20 percent off plus free shipping on your entire Reebok.com order.

SeniorLink Care™’It’s important to find skilled, compassionate care for the elderly individuals we love – but it’s not always easy. With SeniorLink Care you’ll find just the right level of expert support to help your aging family members or friends lead fulfilling and comfortable lives. From coordinating care to assisting caregivers, SeniorLink connects seniors and their families to the programs and services they need most. Save on a three- or 12-month membership.

BodyMedia®’Enjoy 21 percent off a BodyMedia armband in order to automatically and accurately track your calories around the clock, helping you lose weight, stay active and lead a healthier life. The armband collects 5,000 data points per minute from four different sensors. Using a computer, you can upload the data and log your food for a complete picture of calories, activity, steps and sleep.

Life Time Fitness®’Life Time Fitness offers a total health fitness experience no matter your fitness level, interests, schedule or budget. For new members, Life Time Fitness offers a $0 enrollment fee when you sign up online.*

The relationship between these vendors and Blue Cross and Blue Shield of Illinois (BCBSIL) is that of independent contractors. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by the above-mentioned vendors.

* Proof of Blue Cross and Blue Shield of Illinois coverage is needed. The $0 enrollment fee offer is only for new members who enroll online at blue365deals.com/BCBSIL. A $35 administrative fee applies to all memberships. Monthly dues and taxes may also apply. Members’ prices, dues and fees may change at any time. Other rules may apply. Always check with the Life Time Fitness club in your area for the most up-to-date offer.

Blue365 is a discount program only for BCBSIL members. This is NOT insurance. Some of the services offered through this program may be covered under your health plan. Please check your benefit booklet or call the customer service number on the back of your ID card for specific benefit facts. Use of Blue365 does not change your monthly payment, nor do costs of the services or products count toward any maximums and/or plan deductibles. Discounts are only given through vendors who take part in this program. BCBSIL does not guarantee or make any claims or recommendations about the program’s services or products. You may want to talk to your doctor before using these services and products. BCBSIL reserves the right to stop or change this program at any time without notice.

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The Fitness Program opens the door to a network of more than 8,000 fitness centers for only $25 per month!

Make Your Fitness Program Membership Work for You!Fitness can be easy, fun and affordable. Well onTarget makes it possible with the Fitness Program.


Available exclusively to members and their covered dependents (age 18 and older), the Fitness Program provides:

• Flexible membership, no long-term contract required. Enroll for a one-time fee of $25 and $25 per member per month.*

• Unlimited access to a nationwide network of more than 8,000 participating fitness centers.

• Online fitness center locator and views of your fitness center visits online.

• Easy online enrollment; automatic monthly payment withdrawal.

• Access to discounts through a nationwide Complementary and Alternative Medicine (CAM) network of 40,000 health and well-being providers such as massage therapists, personal trainers and nutrition counselors.

Are you ready for fitness? Enroll today online by logging in to Blue Access for MembersSM (BAM) at bcbsil.com. Prefer to sign up by phone? Call 888-762-BLUE (2583) toll-free, Monday through Friday, 8 a.m. – 9 p.m., in any continental U.S. time zone.

* The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes.

The Fitness Program is provided by Healthways, Inc., an independent contractor which administers the Prime Network of fitness centers. The Prime Network is made up of independently-owned and managed fitness centers.

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Make new friends, take a class and try something new! Join the Fitness Program today. Log into Blue Access for Members or call 888-762-BLUE (2583) toll-free, Monday through Friday, 8 a.m. – 9 p.m., in any continental U.S. time zone.

It’s easy to sign up.

1. Go to bcbsil.com and log in to BAM.

2. Under Quick Links, choose Fitness Program. On this page you can enroll, search for fitness centers near you by zip code and learn more about the program.

3. Click Begin Enrollment, then search and select the fitness center that is best for you. Remember, you can visit any participating fitness center after you sign up.

4. Verify your personal information and method of payment. Print your temporary Fitness Program membership card. You will receive your official card by mail in a few weeks.

5. Visit a facility today!

What do you take personally in life? Your family? Your work? Sports? A hobby? Add your health to the list by taking the Well onTarget Health Assessment (HA). Just a few minutes and a few personal details—how you eat, how you sleep, how you live your life—can give you a personalized map to your best health. You can know your risks and your best options to avoid them. Your customized Personal Wellness Report can tell you how to go from good to better.

The new Health Assessment consists of nine modules that can be completed all at once or by section. These modules include questions regarding your:

• Diet

• Tobacco use

• Physical activity

• Emotional health

• Health at work and on the road

It would be helpful—but not a must—to have a few more personal details on hand when you begin the HA:

• Current height and weight

• Systolic (top number) and Diastolic (bottom number) of your blood pressure reading

• Total cholesterol level

• HDL cholesterol level

• Triglyceride level

• Blood sugar level

• Waist measurement in inches

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The new onmywayTM*

Health Assessment is available

at wellontarget.com.

Log in today and earn

2,500 Life Points for taking

your HA.

Take Your Health Personally. Take the Health Assessment!

* onmyway is registered mark of Onlife Health.

Registered mark of Health Care Service Corporation, a Mutual Legal Reserve Company

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What Will I Need?It would be helpful—but not a must—to have a few more personal details on hand when you begin the HA:

• Current height and weight

• Systolic (top number) and Diastolic (bottom number) of your blood pressure reading

• Total cholesterol level

• HDL cholesterol level

• Triglyceride level

• Blood sugar level

• Waist measurement in inches

How Will the HA Be Personalized?You will begin by answering a set of basic questions. Then, the HA asks more detailed questions based on your first answers. Your health status and lifestyle control which questions you answer, customizing your assessment to your individual needs. Your answers will help tailor the Liveon portal for you with programs that will help you reach your health goals. You can check your progress and earn Life Points twice a year.

What Should I Do with My Results?After completing the HA, you will receive a confidential Personal Wellness Report. It will help take the guess work out of wellness. The report will show you how you are doing and give you healthy tips. You can also print a Provider Report to share with your doctor.

When you know your risks, you can choose your best options to avoid them. When you know your strengths, you can decide to build on them.

Take Your HA TodayFollow these simple steps to find the new HA:

1. Go to wellontarget.com and log in. If you have an existing Blue Access for MembersSM (BAM) account, use the same username and password. If you are not yet a registered user, click “Register Now” to create a new account.

2. Once you’re logged in, click on My Dashboard. Under Program Steps, click Take Health Assessment.

Have questions about the Health Assessment or Well onTarget program? Call 877-806-9380.


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It’s no secret that the best teams look to their coaches for help in reaching the top. Now you can, too. With Well onTarget’s onmyteam Wellness Coaching, you can find the support you need to be your best.Our Wellness Coaching is based on evidence-based guidelines and proven techniques of motivation and goal setting.

Your Trusted AllyA wellness coach works with you to design a plan to help you determine your wellness goals. First, your coach will take a look at your lifestyle and habits. Your coach can help you figure out what’s most important to you and what you need to be successful. Best of all, your coach can offer you inspiration and ideas.

Reaching OutThrough the new Well onTarget Member Wellness Portal, you can send and receive messages with your coach. By calling the phone number on your dashboard, you can speak directly with your coach or request a callback. These convenient options make it easy for you to keep in regular contact with your coach.

With Well onTarget’s Wellness Coaching, you can form trusted relationships that give you the added support you need to take action.

Wellness Coaching Provides Personalized Guidance and Support


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Our team is made up of credentialed and certified health experts, including dietitians, nurses, personal trainers and other clinical specialists. Coaches can work one-on-one with you to discuss three core areas—nutrition, physical activity and stress. You can sign up for one program at a time.

Stress Management ProgramFind out how to look at the stress in your life and learn what’s causing it. Your coach can share creative steps for dealing with stress by finding healthy ways of thinking and acting. Learn relaxation techniques you can use. Online trackers let you record and chart your daily stress levels that you can share with your coach.

Physical Activity ProgramSometimes the hardest thing about exercising is making working out a key part of your day. Your coach will help you make a plan that’s right for your fitness level and lifestyle. This plan consists of a mix of cardio, strength training, and flexibility and stretching exercises. Trackers can help you log your progress and share with your coach.

Nutrition ProgramWe can put you in touch with a registered dietitian who can help you understand your relationship with food. Your coach can share ideas for making healthy eating choices. A set of online trackers let you to log the food you eat, learn the nutritional value of your meals and share the data with your coach.

Prioritize your coaching. Take the Health Assessment today to find out which program is right for you.

Program Descriptions

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Well onTarget understands how hard it can be to main-tain a healthy lifestyle. Sometimes you may need a little motivation. That’s why we offer Life Points1 to keep you climbing toward your wellness goals. With the Life Points program, you will be able to earn points by regularly participating in a range of healthy activities. You can then redeem your points for popular health and wellness merchandise and services.

Life Points offers you many new features:

Instant recognition of points Real-time granting of points2 gives you with instant notice of your healthy efforts.

Easily manage your points The interactive portal makes it easier to understand how many points are available to be earned. You can also track the total number of points earned year-to-date. All of your point data will be displayed on one screen.

Get more Life Points The Life Points program gives you the option to supplement your Life Points balance using a credit card to redeem your points for a larger reward.

Expanded selection of rewards Redeem your hard-earned points in an expanded online Shopping Mall. Reward categories include Apparel, Books, Health & Personal Care, Jewelry, Electronics, Music and Sporting Goods. In addition, check out the “Rewards on Sale” section for discounted merchandise including electronics, games, luggage and more.

Life Points and Well onTarget feature convenient online tools and personalized services that help support, inform and motivate you on a journey to wellness.

Life Points Rewards for Healthy Living

1 Life Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal for further information. Your company may have additional reward programs in place to encourage you to take advantage of certain preventive care and wellness activities or for making healthy changes. Check your employee benefits.


2 Does not include Life Points earned from the Fitness Program and Biometric Screenings activities.

3 onmyway is registered mark of Onlife Health.

4 The Fitness Program is provided by Healthways, Inc., an independent contractor which administers the Prime Network of fitness centers. The Prime Network is made up of independently-owned and managed fitness centers.


Look how quickly your Life Points can add up! Sample activities that help you earn Life Points include:

Completing the onmywayTM3 Health Assessment (once every six months) 2,500 points every 6 months

Taking all 12 lessons of a Self-directed Course 1,000 points per quarter

Tracking progress in the online tools on the Well onTarget Member Wellness Portal 10 points

Enrolling in the Fitness Program4 2,500 points

Adding weekly Fitness Program visits to your routine up to 500 points each week

Completing any Self-directed Course Milestone Assessment up to 300 points per month

Participating in a Biometric Screening through the Well onTarget program 2,500 points per year

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Log on to wellontarget.com to access all the interactive tools and programs you need to start racking up Life Points. Check out the online Shopping Mall with an expanded array of rewards to help motivate you to earn more points.

Rewarding Healthy Behavior

It’s All About Diabetes

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Living with diabetes can be a challenge. But maintaining close-to-normal levels of blood sugar has been shown to reduce the risk of diabetes-related problems. Therefore, monitoring your blood sugar levels with a blood glucose meter is important in managing diabetes.

Choosing a Blood Glucose MeterWhen choosing a meter, it often comes down to the features you’re looking for. Here are a few things to consider when making your choice:

• How does the meter score for accuracy? Does it come with a control solution or test strip to check for accuracy?

• Does the meter fit in your backpack, supplies kit or purse?

• How skillful are you at handling those test strips? You might want to try a meter that uses cartridges instead of individual strips.

• How much blood does the meter require? Less is better.

• Do you want to download results to a computer, or email them to your doctor’s office?

• Interested in alternative site testing? There are meters that can test samples from various places on the body.

Checking Your Blood GlucoseRegular blood glucose checks and consistent record-keeping give you a good picture of where you are in your diabetes care.

Checks tell you how often your blood glucose levels are in your target range. Your target range is a personalized blood glucose range that you set with your doctor. Once you know how often and when to check, stick to the schedule and check at those times each day.

Keep a daily log recording your levels. Then take your log with you when you visit your doctor or other members of your diabetes care team. The information in the log will help them answer your questions.

For more information about diabetes, go to bcbsil.com, log in to Blue Access for MembersSM and click the “My Health” tab.

Blue Cross and Blue Shield of Illinois (BCBSIL) offers certain blood glucose meters to members with diabetes at no additional charge. See next page for details.

Glucose Meters Are Available to YouBCBSIL is offering you a choice of the blood glucose meters below at no additional charge for a limited time to help you manage your condition. This offer is available through December 31, 2013.

Test strips for the Roche and Bayer meters are on the Standard formulary. Please note that only test strips for the Bayer meters are on the Generics Plus formulary. Coverage and payment levels for test strips may vary depending on your plan.

Please review these options and ask your doctor which meter best fits your needs.

† The ACCU-CHEK Nano SmartView and ACCU-CHEK Aviva Plus systems are compatible with all ACCU-CHEK data management tools, including the ACCU-CHEK 360˚ diabetes management system. You also may download data to your PC with the ACCU-CHEK Smart Pix Device Reader; no additional software required.

1 Using U.S. and imported materials.2 Ranked first most often versus leading competitors. Data on file.

Disclaimer: This information is not intended to be a substitute for professional medical advice. If you are under the care of a doctor and receive advice different from the information contained in this flier, follow the doctor’s advice. See your doctor if you are experiencing any diabetes symptoms or health problems.

Roche, the Makers of ACCU-CHEK®’ ProductsTo order an ACCU-CHEK meter, you will need a prescription for a meter from your doctor. Call 888-355-4242 or go online at meters.accu-chek.com (use order code BCBSIL12) for your voucher that you can take to a major retail pharmacy to get your meter.

ACCU-CHEK Nano SmartView System†

• Advanced accuracy with ACCU-CHEK SmartView test strips

• Small, sleek design to fit in the palm of your hand

• Brilliant backlit display makes reading your numbers easy anytime, anywhere

• No coding

• Meter and strips manufactured in the U.S.A.1

ACCU-CHEK Aviva Plus System†

• Advanced accuracy with ACCU-CHEK Aviva Plus test strips

• Easy to use right out of the box

• Includes ACCU-CHEK FastClix lancing device – proven least painful and overall easiest to use2

• Meter and strips manufactured in the U.S.A.1

Bayer’s Blood Glucose Monitoring SystemsTo order a Bayer meter to be shipped directly to you, call 877-229-3777 and identify yourself as a BCBSIL member. For more detailed descriptions, visit bayercontour.com.

CONTOUR®“ NEXT EZ blood glucose monitoring system

• The easy-to-use features you want with the proven accuracy you expect

• Ready to test, right out of the box

• Easy-to-read display

• No CodingTM” technology makes testing easy by automatically setting the correct code each time a test strip is inserted into the meter

• Proven accuracy: next-generation CONTOUR NEXT test strips deliver results close to those obtained in a professional lab

CONTOUR NEXT blood glucose monitoring system

• Use AutoLog to see the effect of food choices on your blood sugar levels with pre-meal, post-meal and fasting markers

• Set audible reminders to help you remember to test after eating

• Personalize high/low target settings to identify trouble spots and get clear summaries and patterns

• View 7-, 14-, 30- and 90-day trends to get more tracking knowledge and an overview of averages

• Set your meter to English, Spanish or any of 12 other languages

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Health Care Service Corporation, A Mutual Legal Reserve CompanyFort Dearborn Life Insurance Company, A Stock Life Insurance CompanyNotice of Information PracticesThis description of the Information Practices of Health Care Service Corporation (HCSC) a Mutual Legal Reserve Company and FortDearborn Life Insurance Company (FDL), a Stock Life Insurance Company, (collectively referred to herein as “we,” “our” or “us”),is provided to you in accordance with the requirements of the Illinois Insurance Information and Privacy Protection Law.

Collection of InformationIn order to properly underwrite and administer your insurance coverage, we must collect a certain amount of necessary and helpfulinformation. The amount and type of information may vary depending on the amount and type of coverage applied for, but in generalwe will be seeking information about your age, occupation, physical condition and health history.

You are our most important source of information, but we may also collect or verify information by contacting medical professionals andinstitutions which have provided care to you or members of your family proposed for coverage, employers and business associates, friendsand neighbors, and other insurance companies you have applied to. We may collect information by exchanges of correspondence, by phoneor by personal contact.

Circumstances of DisclosureIn some circumstances, we may make disclosures of personal or privileged information to third parties without your authorization.Following is a description of the types of persons who may receive such information without your authorization and some of the circumstances that might give rise to such disclosures.

• We might use an unaffiliated organization or person to perform a professional, business or insurance function for us. If, for example, wehired an independent organization to assist in the administration of a group insurance plan of which you are a participant, informationrelating to your insurance coverage would be disclosed to that organization in order for it to adequately perform its function. This wouldalso be the case with respect to any organization or person, which performs a professional, business or insurance function for us.

• We may disclose information concerning your coverage to our agents and producers in order to provide you with adequate service,including the updating and improvement of your insurance program.

• We may disclose information to other insurance institutions, agents, insurance-support organizations or self-insurers, which is necessary(a) to prevent criminal activity, fraud, material misrepresentation or material non-disclosure in connection with insurance transactions, or(b) for either of us or such company to perform its function in connection with an insurance transaction involving you or a member ofyour family insured under your coverage. For example, if you are a participant in an HCSC or FDL group insurance plan, and if you,your spouse or dependents are insured under other group plans, the companies involved may be required to share claims informationpursuant to coordination of benefits provisions in their respective policies. The object, of course, is to make sure that you receive totalbenefits from all companies no greater than the cost of health care received.

• We may disclose information to the Illinois Insurance regulatory authority in connection with its regulation of our business.• We may disclose information to a law enforcement or governmental authority to protect our interest in preventing or prosecuting the

perpetration of fraud upon us, or if we reasonably believe that illegal activities have been conducted we will also disclose informationwhen permitted or required by law to do so.

• Various industry and professional organizations conduct scientific and actuarial research studies to learn more about the risk experience ofour insureds. Other organizations conduct studies relating to medical research. These studies are purely scientific in nature, never identifyindividuals in their reports, and always maintain information provided in a highly confidential manner. When asked to provide informationto such organizations, we ordinarily will do so because the results of such studies are of benefit to our customers and the public at large.You will not be individually identified in any report that results from the research, and material that we give to the person or organizationperforming the research will be returned to us or destroyed when it is no longer needed.

• If you are covered under an HCSC and/or FDL group policy, we may disclose information as is reasonably necessary to the group for purposes of administration of the group policy and to permit the group to audit, review and evaluate the performance of HCSC and FDLunder the group policy.

• We are sometimes approached by persons or organizations that are interested in the opportunity to market products or services to our customers. When this happens, we may provide some limited information. However, if we want to give information to persons not affiliated with us, we will give you an opportunity to indicate to us that you do want information to be disclosed for this purpose. We willgive information to our affiliates so that our customers may be aware of the insurance products and services offered by our affiliates.

Please understand that the above is intended to describe some of the disclosures which might be made, not disclosures which are always or even often made, in any event, the information disclosed without your authorization will be only as much as reasonably necessary toaccomplish the intended purpose.

22492.0210 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Your Right to Access Personal InformationAs an individual, you have certain rights in regards to access to recorded personal information, which is reasonably locatable and retrievable.In order to maintain the security of that information, access will be permitted only after proper identification has been submitted to us.

1. If you have any question about what information we may have on file about you, please write us at the address indicated at the end ofthis notice. We will need your complete name, address, date of birth and all policy numbers under which you are insured. Tell us whatinformation you would like to receive. Within 30 days of our receipt of your written request, we will:

a) Inform you of the nature and substance of the recorded personal information in writing, by telephone or by other communication;b) Permit you to see and copy, in person (by appointment only,) the recorded personal information which applies to you or provide

you with copies of this information by mail;c) Any insurance-support organization that furnished the personal information that has been corrected, amended or deleted.

2. If you disagree with a refusal to correct, amend or delete recorded personal information, you may file a:a) Concise document setting forth what you think is the correct, relevant or fair information, and a b) Concise statement of the reasons why you disagree with the refusal to correct, amend or delete recorded personal information.

3. If you file either of the statements described above, we will:a) File the statement with the disputed personal information and provide a means by which anyone reviewing the disputed personal

information will be made aware of the statement and have access to it;b) In any subsequent disclosure of the recorded personal information that is the subject of disagreement, clearly identify the

information in dispute and provide the statements along with the recorded personal information being disclosed;c) Furnish the statement to any of the three categories of persons and organizations covered in the preceding point “2.”

4. Your rights to correct, amend or delete recorded personal information exist to the extent that the information is collected and maintainedin connection with an insurance transaction. These rights do not extend to information about you that relates to and is collected in connection with or in reasonable anticipation of a claim or civil or criminal processing.

Please understand that the above is intended to describe some of the disclosures which might be made, not disclosures which are always oreven often made. In any event, the information disclosed without your authorization will only be as much as reasonably necessary to accom-plish the intended purpose.

Your Privacy Is Our ConcernShould you have any questions about our procedures or information maintained about you, please contact us at the following address:

Health Care Service Corporation, (A Mutual Legal Reserve Company)300 East RandolphChicago, IL 60601Attn: SSD – Privacy Act Information

This Important Notice is for coverages provided by Fort Dearborn Life Insurance Company

Fort Dearborn’s underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and to providea mechanism by which policyholders and certificate holders pay their fair share of the cost. In considering your application, Fort Dearbornconsiders information from various sources, including your own statements, the results of your physical examination (if required), and anyobtained from doctors or medical facilities where you have been treated.

Information regarding your insurability will be treated as confidential. Fort Dearborn, or its reinsurer(s), may, however, make a brief reportthereon to the Medical Information Bureau, Inc. a nonprofit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another Bureau Member Company for life or health insurance coverage,or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such a company with the information it mayhave in its file.

Upon receipt of a request from you, the Bureau will arrange a disclosure of any information it may have in your file. If you question theaccuracy of the information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with procedures set forthin the Federal Fair Credit Reporting Act. The address of the Bureau’s information office is Post Office Box 105, Essex Station, Boston,Massachusetts 02112, telephone number (617) 426-3660.

Fort Dearborn, or its reinsurer(s) may also release information in their file to other life insurance companies to whom you may apply for lifeor health insurance, or to whom a claim for benefits may be submitted.

The purpose of the Bureau is to protect its member and their policyholders from the extra expense created by those who omit or concealinformation relevant to their insurability. Information furnished by the Bureau may serve to alert the company to a need for further investigation but under Bureau rules cannot be used either wholly or partly as the basis for increasing the charge for or denying the issuanceof insurance. Information in the Bureau gives no indication regarding the action taken on an application (i.e., whether accepted standard,accepted with increase premium or declined).

22492.0210

Important Notices

I. Initial Notice About Special Enrollment Rights and Pre-existing

Condition Exclusion Rules in Your Group Health Plan A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about

two very important provisions in the plan. The first is your right to enroll in the plan under its “special enrollment provision” without being considered a late applicant if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Second, this notice advises you of the plan’s pre-existing condition exclusion rules that may temporarily exclude coverage for certain pre-existing conditions that you or a member of your family may have. Section I of this notice may not apply to certain self-insured, non-federal governmental plans. Contact your employer or plan administrator for more information.

A. SPECIAL ENROLLMENT PROVISIONS

Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program) If you are declining enrollment for yourself or your eligible dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if you move out of an HMO service area, or the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or move out of the prior plan’s HMO service area, or after the employer stops contributing toward the other coverage).

Loss of Coverage For Medicaid or a State Children’s Health Insurance Program If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.

New Dependent by Marriage, Birth, Adoption, or Placement for Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

Eligibility for State Premium Assistance for Enrollees of Medicaid or a State Children’s Health Insurance Program If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.

You or your spouse or dependents may also have special enrollment rights in another group health plan at the time a claim is denied as a result of a lifetime limit on all benefits, if you request enrollment within 30 days after the claim has been denied.

To request special enrollment or obtain more information, call Customer Service at the phone number on

the back of your Blue Cross and Blue Shield ID card.

B. PRE-EXISTING CONDITION EXCLUSION RULES

Pre-existing condition exclusion rules do not apply to group health plans with effective dates on or after

January 1, 2014.

Most health plans impose pre-existing condition exclusions. This means that if you have a medical condition before coming to our plan you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the six- month period before your enrollment date. Generally, this six-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. “Waiting period” generally refers to a delay between the first day of employment and the first day of coverage under the plan. The pre-existing condition exclusion does not apply to pregnancy or to an individual under the age of 19.

This pre-existing condition exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days you had prior “creditable coverage.” Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, you have a right to request one from your prior plan or issuers. We will help you obtain one from your prior plan or issuer, if necessary. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.

For more information about the pre-existing condition exclusion and creditable coverage rules affecting

your plan, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.

II. Additional NoticesOther federal laws require we notify you of additional provisions of your plan.

NOTICES OF RIGHT TO DESIGNATE A PRIMARY CARE PROVIDER (FOR NON-GRANDFATHERED HEALTH

PLANS ONLY)

For plans that require or allow for the designation of primary care providers by participants or beneficiaries: If the plan generally requires or allows the designation of a primary care provider, you have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, call Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.

For plans that require or allow for the designation of a primary care provider for a child: For children, you may designate a pediatrician as the primary care provider.

For plans that provide coverage for obstetric or gynecological care and require the designation by a

participant or beneficiary of a primary care provider: You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain ser-vices, following a pre-approved treatment plan, or procedures for making referrals.

For a list of participating health care professionals who specialize in pediatrics, obstetrics or gynecology, call

Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.

Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

225425.0913

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

Rev. 9/23/13 an Independent Licensee of the Blue Cross and Blue Shield Association Page | 1

___________________________________________________________________________________________

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This notice describes how Blue Cross and Blue Shield of Illinois can use or disclose your medical information

and how you can get access to this information. Our contact information can be found at the end of the notice.

Please review this notice carefully.

___________________________________________________________________________________________

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This section explains your rights and some of our responsibilities to help you.

___________________________________________________________________________________________

Get a copy of your * You can ask to see or get a copy of your health and claims records and other

health and claims records health information we have about you. Ask us how to do this by using the contact

information at the end of this notice.

* We will provide a copy or a summary of your health and claims records usually

within 30 days of the request. We may charge a reasonable, cost-based fee.

___________________________________________________________________________________________

Ask us to correct health * You can ask us to correct your health and claims records if you think

and claims records they are incorrect or incomplete. Ask us how to do this by using the contact


* We may say “no” to your request. We’ll tell you why in writing within 60 days.

___________________________________________________________________________________________

Request confidential * You can ask us to contact you in a specific way or to send mail to a different

communications address Ask us how to do this by using the contact information at the end

of this notice.

* We will consider all reasonable requests, and must say “yes” if you tell us you

would be in danger if we do not.

___________________________________________________________________________________________

Ask us to limit what * You can ask us not to share or use certain health information for

we use or share treatment, payment or our operations. Ask how to do this by using the contact


* We are not required to agree to your request, and we may say “no” if it

would affect your care.

___________________________________________________________________________________________

Get a list of those with * You can ask for a list (accounting) for six years prior to your request date of

whom we’ve shared when we shared your information, who we shared it with and why. Ask us how

information to do this by using the contact information at the end of this notice.

* We will include all the disclosures except for those about treatment, payment,

and our operations, and certain other disclosures (such as any you asked us

to make). We will provide one accounting a year for free but we may charge a

reasonable, cost-based fee if you ask for another one within 12 months.

___________________________________________________________________________________________

Get a copy of this notice * You can ask for a paper copy of this notice at any time, even if you have

agreed to receive the notice electronically. To request a copy of this notice,

use the contact information at the end of this notice and we will send you

one promptly.

___________________________________________________________________________________________

Choose someone to act * If you have given someone medical power of attorney or if someone is your legal

for you guardian, that person can exercise your rights and make choices about your health

information. Ask us how to do this by using the contact information at the end of

this notice.

* We confirm the person has the authority and can act for you before we share

your information.



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___________________________________________________________________________________________

File a complaint if * You can complain if you feel we have violated your privacy rights by using the

you feel your rights contact information at the end of this notice.

are violated * You can also file a complaint with the U.S. Department of Health and Human

Services Office for Civil Rights by calling 1-877-696-6775; or by visiting

www.hhs.gov/ocr/privacy/hipaa/complaints/ or by sending a letter to them at:

200 Independence Ave., SW, Washington, D.C. 20201.

* We will not retaliate against you for filing a complaint.

___________________________________________________________________________________________

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If you have a clear preference on how you want us to share your information in the situations described below,

tell us and we will follow your instructions. Use the contact information at the end of this notice.

___________________________________________________________________________________________

In these cases, you have * Share information with your family, close friends, or others involved in

both the right and choice payment for your care

to tell us to: * Share information in a disaster or relief situation

* Contact you for fundraising efforts

If you cannot share your preference, for example, if you are unconscious, we can share your information if we

think it is in your best interest. We may share information when needed to lessen a serious or imminent threat to

health or safety.

___________________________________________________________________________________________

We never share your * Marketing purposes

your information in these * Sale of your information

situations unless you give

us written permission

___________________________________________________________________________________________

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We typically use or share your health information in the following ways.

___________________________________________________________________________________________

Help manage * We can use your health information * Example: A doctor sends us

the health care and share it with professionals who are information about our diagnosis

treatment you receive are treating you. and treatment plan so we can

arrange additional services.

___________________________________________________________________________________________

Run our * We can use and disclose your * Example: We use health

organization information to run our organization information to develop better

and contact you when necessary. services for you.

We are not allowed to use genetic information to decide whether we will give you coverage and the price of

that coverage. This does not apply to long-term care plans.

___________________________________________________________________________________________

Pay for your * We can use and disclose your health * Example: We share information

health services information since we pay for your health about you with your dental plan

services. to coordinate payment for your

dental work.



___________________________________________________________________________________________

Administer * We may disclose your health information *Example: If your company

your plan to your health plan sponsor for plan contracts with us to provide a

administration purposes. health plan, we may provide

them certain statistics to explain

the premiums we charge.

___________________________________________________________________________________________

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We are allowed or required to share your information in other ways, usually in ways that contribute to the public

good, such as public health and research. We have to meet many conditions in the law before we can share your

information for these purposes. For more information go to:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

___________________________________________________________________________________________

Help with public health * We can share your health information for certain situations such as:

and safety issues * Preventing disease

* Helping with product recalls

* Reporting adverse reactions to medications

* Reporting suspected abuse, neglect or domestic violence

* Preventing or reducing a serious threat to anyone’s health or safety

___________________________________________________________________________________________

Do research * We can use or share your information for health research.

___________________________________________________________________________________________

Comply with the law * We will share information about you when state or federal law requires it,

including the Department of Health and Human Services if they want to determine

that we are complying with federal privacy laws.

___________________________________________________________________________________________

Respond to organ/tissue * We can share health information about you with an organ procurement

donation requests and work organization.

with certain professionals * We can share information with a medical examiner, coroner or funeral director.

___________________________________________________________________________________________

Address workers’ * We can use or share health information about you:

compensation, law * For workers’ compensation claims

enforcement, and other * For law enforcement purposes or with a law enforcement official

government requests * With health oversight agencies for activities authorized by law

* For special government functions such as military, national security, and

presidential protective services or with prisons regarding inmates.

___________________________________________________________________________________________

Respond to lawsuits and * We can share health information about you in response to an administrative or

legal actions court order, or in response to a subpoena.

___________________________________________________________________________________________

Certain health * State law may provide additional protection on some specific medical

information conditions or health information. For example, these laws may prohibit us from

disclosing or using information related to HIV/AIDS, mental health, alcohol or

substance abuse and genetic information without your authorization. In these

situations, we will follow the requirements of the state law.



___________________________________________________________________________________________

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___________________________________________________________________________________________

* We are required by law to maintain the privacy and security of your protected health information.

* We will let you know promptly if a breach occurs that compromises the privacy or security of your information.

* We must follow the duties and privacy practices described in this notice and give you a copy of it.

* We will not use or share your information other than as described here unless you tell us we can in writing.

You may change your mind at any time. Let us know in writing if you change your mind.

For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

___________________________________________________________________________________________

+��+��

We can change the terms of this notice, and the changes we make will apply to all information we have about you.

The new notice will be available upon request or from our website. We will also mail a copy of the new notice to

you if there are material changes to our privacy practices.

___________________________________________________________________________________________

+��+��

If you would like general information about your privacy rights or would like a copy of this notice, go to:

http://www.bcbsil.com/important_info/index.html. If you have specific questions about your rights or about this

notice, you may contact us in one of the following ways:

* Call us at the toll-free number on the back of your member identification card.

* Call us at 1-877-361-7594.

* Write us at:

Divisional Vice President, Privacy Office

Blue Cross and Blue Shield of Illinois

P.O. Box 804836

Chicago, IL 60680-4110

___________________________________________________________________________________________

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September 23, 2013

___________________________________________________________________________________________

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