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USC PPO PlanEffective January 1, 2022Welcome1HealthComp Administrators2Understanding Your Plan ID Card3How to Read Your Explanation of Benefits (EOB)5Using Your Prescription Drug Benefits7Livongo for Diabetes Program8LiveHealth Online9Lyra Health9HealthComp Online10Published By:U S C H E A LT H P L A N Shealthplans@usc.edu(213) 740-0035employees.usc.edu/ppoUSCHP210818W 2022 PPO Welcome Brochure M.indd 1-212/8/21 3:55 PM

US C P P O P L A N2Welcome to the USC PPO PlanThe USC PPO Plan is a self-funded medical benefit programprovided by the University of Southern California. As a Participant/Covered Person of the USC PPO Plan, benefits are administeredby the university with HealthComp, Anthem Blue Cross andNavitus, each providing certain administrative services.The USC PPO Plan is a Preferred Provider Organization (PPO)that includes two tiers of In-Network providers (Tier 1 andTier 2) and Non-Network providers (Tier 3).While you don’t have to choose a primary care physician (PCP),your PCP office visit copay with Tiers 1 and 2 providers will bereduced by 10 after you do designate one. To designate a PCPfor you and your covered dependents, register at hconline.healthcomp.com/usc. Changes made on or before the 15th dayof the month will be effective on the 1st of the following month.T I E R 1 P R OV I D E R STo ensure you receive the highest level of benefits, access Tier1 providers—USC Care Medical Group, Keck Hospital of USC,USC Norris Cancer Hospital and USC Verdugo Hills Hospital.The USC PPO Plan pays Tier 1 benefits to Tier 2 providers whenservices are rendered to Covered Persons under age 19.To find Tier 1 (Keck Medicine) providers call Keck at(833) KECK-USC/(833) 532-5872 or visit keckmedicine.org.T I E R 2 P R OV I D E R SAnthem Blue Cross maintains the Tier 2 provider network(Anthem Blue Cross Prudent Buyer providers in California andBlueCard program providers outside of California).To find Tier 2 providers anywhere in the U.S., call (800) 888-8288or visit anthem.com/ca. To find participating providersoutside of the U.S., contact Blue Cross Blue Shield Global Core at (800) 810-2583 or visit bcbsglobalcore.com.You can also access Tier 2 primary care providers from thecomfort of your home via your own computer or mobiledevice. LiveHealth Online physicians are available year round,seven days a week, 24 hours a day. Please refer to page 9 foradditional details about LiveHealth Online.P R I O R AU T H O R I Z AT I O N SAnthem Blue Cross provides Prior Authorization for allscheduled hospitalizations, outpatient surgical proceduresand certain medical health services. Physical andoccupational therapy require Prior Authorization after the first12 visits of the calendar year.HealthComp AdministratorsHealthComp is a Third Party Administrator (TPA) responsiblefor processing all medical claims, maintaining eligibility,generating Plan ID cards, and providing customer service formembers of the USC PPO Plan.Contact information for HealthComp is shown below and isalso printed on the front of your Plan ID card. Information onwhere to submit medical claims is printed on the back of yourPlan ID card.Present your ID card each time you receive medical care orpurchase prescription drugs to ensure all claims are filedcorrectly. See pages 3 and 4 in this brochure for a description ofthe information included on the front and back of your ID Card.For questions about benefits, eligibility or claims, or torequest additional or replacement plan ID cards, contact:H E A LT H C O M P C U S T O M E R S E R V I C ETelephone (toll free): (855) SC-PLANS/(855) 727-5267Monday-Friday, 6:00 a.m. to 5:00 p.m. (PST)HCONLINEYou can also access HCOnline (HealthComp’s secure webportal) to access claims history, view electronic Explanationof Benefits (EOBs), review benefits and eligibility informationand more. See Page 10 for information on how to accessHCOnline and set up a member account.T I E R 3 P R OV I D E R SYou may also access Non-Network Tier 3 providers for medicallynecessary covered services. You’ll receive the lowest level ofbenefits and your out-of-pocket costs will be higher than if youaccessed care through Tier 1 or Tier 2 In-Network providers.USCHP210818W 2022 PPO Welcome Brochure M.indd 3-412/8/21 3:55 PM

US C P P O P L A N4Understanding Your Plan ID CardAll Participants enrolled in the USC PPO Plan receive an ID card.Understanding Your Plan ID Card—Reference1 Anthem Blue Cross logo identifies USC’s contracted TierYou can also receive a digital ID card that can be viewed onyour computer or any mobile device. To access the digitalID card, set up your member account on the HealthCompwebsite at hconline.healthcomp.com/usc. If you needassistance, please contact HealthComp’s member serviceteam at (855) 727-5267.2 provider network.2 This is the name of the primary subscriber (employee).3 S ubscriber ID is the number which should be used foridentifying the subscriber eligibility record.4 This is the name of the subscriber’s dependent (if any isbeing covered).5 Anthem Group Number is the Anthem Blue Cross assignedgroup number.6 Plan Code 040 is a code used by Anthem Blue Cross toidentify the USC plan.I D C A R D — FR O N T71 ealthComp Group Number is used by HealthCompHto identify the USC account. You may be asked for thisnumber when contacting HealthComp.8 HealthComp is USC’s Third Party Administrator (TPA).Contact HealthComp with member service, eligibility andbenefit-related questions.2834679 Navitus is your prescription benefits manager. Contact95Navitus if you have prescription related questions. TheRx Bin, Rx PCN and Rx Group numbers are used by yourpharmacy when processing your prescription drug claim. Prudent Buyer Plan and PPO suitcase logo identify the10Anthem Blue Cross PPO provider network. 11 Most common prior authorization requirements are listedhere. It is important to adhere to all prior authorizationrequirements.I D C A R D — B AC K Mailing address for all medical claims incurred in California,if not submitting electronically to or-authorization: To obtain prior authorization, call 800-274-7767.Prior-authorization is required for scheduled hospitalizations, outpatient surgical procedures andcertain mental health services. Physical & occupational therapy require prior-authorization after thefirst 12 visits of the calendar year. Notification of an emergency admission must be made within 48hours.Submit California medical claims to:Prudent Buyer Plan PO Box 60007 Los Angeles, CA 90060-0007Medical claims outside of CA:Anthem Blue Cross PrudentBuyer Providers OnlyFor claim inquiries, call:800-688-3828Submit to your local Blue Cross and/or Blue Shield plan in the state where services are rendered. Toensure prompt claims processing, include the 3 digit alpha prefix (TRJ) that precedes the patient’sID numberHOW TO LOCATE A NETWORK PROVIDERTier 1 (USC Providers):www.keckmedicine.org Or call (833) KECK-USC (833-532-5872)Tier 2 (Anthem Providers): www.anthem.com/ca - Choose: Blue Cross PPO (Prudent Buyer) - Large GroupAnthem Blue Cross Life & Health Insurance Company provides administrative services only and does not assume any financial risk or obligationwith respect to claims. Blue Cross of California, using the trade name Anthem Blue Cross, administers claims on behalf of An them Blue CrossLife and Health Insurance Company and is not liable for benefits payable. Independent licensees of the Blue Cross Association. lue Cross/Blue Shield note to providers, reminding them toBuse the TRJ prefix when submitting claims incurred outsideof California to their local Blue Cross/Blue Shield plan. Web addresses used to locate Tier 1 (Keck Medicine) andTier 2 (Anthem) providers. Phone number to call when requiring medical priorauthorization. Phone number Anthem Blue Cross Prudent Buyer providersuse for claims inquiries. Anthem Blue Cross is legally required to include thisdisclaimer on ID cards accessing their names and logos.USCHP210818W 2022 PPO Welcome Brochure M.indd 5-612/8/21 3:55 PM

USCHP210818W 2022 PPO Welcome Brochure M.indd 7-8How to Read YourExplanation of Benefits(EOB)An Explanation of Benefits (EOB) isimportant because it verifies that aclaim was received by your insurance,documents payment and/or reason(s) fordenial and patient responsibility. It alsoprovides the “Covered Amount” Tier 1 andTier 2 providers have agreed to accept asplan payment and clearly specifies yourpatient responsibility.AClaim #:Patient:Member ID:BCD36670368-01Amanda Forester461611EService DetailsFPlan RateGPlan PaidSFIELD DESCRIPTIONS INCLUDED ON AN EOBA Claim #: The claim number that was assigned byHealthComp.B Patient: The plan member who received the services.C ember ID: Your member ID number that is on your PlanMID card as Subscriber ID number. Service Details: A description of the service that wasreceived and the date that it was received. Total Charge: The amount that the provider chargedfor the service received. Plan Rate: The allowable charges under the Plan or theamount your provider has agreed to accept for servicesrendered. Plan Paid: The amount paid by the Plan.G12/8/21 3:55 PMH Paid by Other Insurance: A portion of the Total Chargemay have been covered by another source (e.g. otherhealth insurance, automobile insurance).JFor odesServiceCodes 151.73 131.73 0.00 0.00 0.00 20.00 0.00 20.00100JA, 02410Date: 1/10/2018A) Surgical Services 337.00 151.50 68.50 0.00 0.00 83.00 0.00 0.00 83.00100JA412 617.00 303.23 200.23 0.00 0.00 83.00 20.00 103.00Provider:PDr. Joseph ForbesABC Medical GroupReason Code DescriptionOther Credits or Adjustments:QYour Total Responsibility: 0.00 103.00TPayment DistributionCode:A)Claim #36670368-01Paid To:ABC Medical GroupCheck No.01053445Amount 200.23MessagesClaim #36670368-01FNotCovered260 Main Street, Suite 300Cityville, CA 10000UEI 280.00JA-Discount. Patient not liable.02-Copayment was taken on this serviceDYour ResponsibilityPaid byOtherInsuranceHDate: 1/10/2018A) Physician - Office VisitTotalsRCovered by Your PlanTotalChargeMessage:Payment will be remitted by local carrier. Not Covered: The amount that was not covered bythe Plan, such as “over usual and customary fees” orexclusions by the Plan. J For Your Deductible: The amount you must pay forservices before the Plan will pay.IKLMN o-pay: The set amount that you pay for certain servicesC(such as office visits). You may have already paid for yourco-pay at the provider’s office. o-insurance: The percentage amount you pay forCcertain services (such as labs and x-rays). Total: The total amount you owe to the provider for theservice received. (%) Percentage: The percentage of the coveredamount that was paid by the Plan, after any applicabledeductible and/or co-pays. Reason Codes: HealthComp’s reason code for chargesthat were not covered or require further explanation.OPQRSTU Service Codes: HealthComp’s code for the servicethat was received. Other Credits or Adjustments: Any final adjustmentsthat were made to the amount that you owe. Your Total Responsibility: The total amount that youowe for all services listed in the claim. This may includeco-pays that you already paid at the provider’s office. Provider: The provider/facility that rendered theservice(s). Reason Code Description: A description of theReason Codes in section N. Payment Distribution: Identifies the name of the payee,payment amount and check number of each payment thatHealthComp issued for services listed in the EOB. Messages: Shows additional information related tothe EOB.