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CITY OF CLOVISJanuary 1, 2022ANTHEM HDHPPrudent Buyer PlanHealth Savings AccountBenefit BookletSPD175075-73 2022 PB HSA 3000/0/50
Dear Plan Member:This Benefit Booklet (“benefit booklet”) provides a complete explanationof your benefits, limitations and other plan provisions which apply to you.Subscribers and covered dependents (“members”) are referred to as“you” and “your”. The plan administrator is referred to as “we”, “us” and“our”.All italicized words have specific definitions. These definitions can befound either in the specific section or in the DEFINITIONS section of thisbenefit booklet.Please read this Benefit Booklet (“benefit booklet”) carefully so that youunderstand all the benefits your plan offers. Keep this Benefit Booklethandy in case you have any questions about your coverage.Important: This is not an insured benefit plan. The benefits described inthis Benefit Booklet or any rider or amendments hereto are funded by theplan administrator who is responsible for their payment. Anthem BlueCross Life and Health Insurance Company provides administrativeclaims payment services only and does not assume any financial risk orobligation with respect to claims.Anthem Blue Cross Life and Health Insurance Company is anindependent licensee of the Blue Cross Association.
COMPLAINT NOTICEAll complaints and disputes relating to coverage under this planmust be resolved in accordance with the plan’s grievanceprocedures. Grievances may be made by telephone (please call thenumber described on your Identification Card) or in writing (write toAnthem Blue Cross Life and Health Insurance Company, 21215Burbank Blvd., Woodland Hills, CA 91367 marked to the attention ofthe Member Services Department named on your identificationcard).If you wish, the Claims Administrator will provide aComplaint Form which you may use to explain the matter.All grievances received under the plan will be acknowledged inwriting, together with a description of how the plan proposes toresolve the grievance. Grievances that cannot be resolved by thisprocedure shall be submitted to arbitration.
TABLE OF CONTENTSCONSOLIDATED APPROPRIATIONS ACT OF 2021 NOTICE . 1Consolidated Appropriations Act of 2021 (CAA) . 1Surprise Billing Claims . 1No Surprises Billing Act Requirements . 1Transparency Requirements . 3TYPES OF PROVIDERS . 6TIMELY ACCESS TO CARE . 12SUMMARY OF BENEFITS . 14MEDICAL AND PRESCRIPTION DRUG BENEFITS . 15Preferred Generic Program . 20Special Programs . 20Half-tab Program . 21Therapeutic Substitution . 22Retail 90 for Maintenance Drugs . 22YOUR MEDICAL BENEFITS. 28MAXIMUM ALLOWED AMOUNT. 28MEDICAL AND PRESCRIPTION DRUG DEDUCTIBLE . 32MEDICALANDPRESCRIPTIONDRUGOUT-OF-POCKETAMOUNTS . 34CO-PAYMENTS AND MEDICAL BENEFIT MAXIMUMS . 35CREDITING PRIOR PLAN COVERAGE . 35CONDITIONS OF COVERAGE . 36MEDICAL CARE THAT IS COVERED . 37Preventive Care for Chronic Conditions (per IRS guidelines). 56MEDICAL CARE THAT IS NOT COVERED . 67BENEFITS FOR MENTAL HEALTH AND SUBSTANCE USEDISORDERS . 78BENEFITS FOR OR AUTISM SPECTRUM DISORDERS . 82SUBROGATION AND REIMBURSEMENT . 86SPD175075-73 2022 PB HSA 3000/0/50
YOUR PRESCRIPTION DRUG BENEFITS . 90PRESCRIPTION DRUG COVERED EXPENSE. 90PRESCRIPTION DRUG CO-PAYMENTS . 90HOW TO USE YOUR PRESCRIPTION DRUG BENEFITS . 91PRESCRIPTION DRUG FORMULARY . 94PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS . 99PRESCRIPTION DRUG CONDITIONS OF SERVICE . 100PRESCRIPTION DRUG SERVICES AND SUPPLIES THAT ARECOVERED. 103PRESCRIPTION DRUG SERVICES AND SUPPLIES THAT ARENOT COVERED . 105COORDINATION OF BENEFITS . 110BENEFITS FOR MEDICARE ELIGIBLE MEMBERS . 114UTILIZATION REVIEW PROGRAM . 116DECISION AND NOTICE REQUIREMENTS . 123HEALTH PLAN INDIVIDUAL CASE MANAGEMENT . 125EXCEPTIONS TO THE UTILIZATION REVIEW PROGRAM . 126HOW COVERAGE BEGINS AND ENDS . 127HOW COVERAGE BEGINS . 127HOW COVERAGE ENDS . 134CONTINUATION OF COVERAGE . 136EXTENSION OF BENEFITS. 140GENERAL PROVISIONS . 141COMPLAINTS AND APPEALS. 159BINDING ARBITRATION . 159DEFINITIONS. 160YOUR RIGHT TO APPEALS . 176FOR YOUR INFORMATION . 182IDENTITY PROTECTION SERVICES . 182GENERAL PLAN INFORMATION . 185GET HELP IN YOUR LANGUAGE. 192SPD175075-73 2022 PB HSA 3000/0/50
SPD175075-73 2022 PB HSA 3000/0/50
Consolidated Appropriations Act of 2021 NoticeConsolidated Appropriations Act of 2021 (CAA)The Consolidated Appropriations Act of 2021 (CAA) is a federal law thatincludes the No Surprises Billing Act as well as the provider transparencyrequirements that are described below.The CAA provisions within this plan apply unless state law or any otherprovisions within this plan are more advantageous to you.Surprise Billing ClaimsSurprise Billing Claims are claims that are subject to the No SurprisesBilling Act requirements: Emergency services provided by non-participating providers; Covered services provided by an non-participating provider at aparticipating provider facility; and Non-participating providers air ambulance services.No Surprises Billing Act RequirementsEmergency ServicesAs required by the CAA, emergency medical conditions are coveredunder your plan: Without the need for pre-certification; Whether the provider is a participating provider or non-participatingprovider;If the emergency medical conditions you receive are provided by a nonparticipating provider, Covered services will be processed at theparticipating provider benefit level.Note that if you receive emergency services from a non-participatingprovider, your out-of-pocket costs will be limited to amounts that wouldapply if the covered services had been furnished by a participatingprovider. However, non-participating provider cost-shares (i.e.,Copayments, Deductibles and/or Coinsurance) will apply to your claim ifthe treating non-participating provider determines you are stable,meaning you have been provided necessary emergency care such thatyour condition will not materially worsen and the non-participatingprovider determines: (i) that you are able to travel to a participating1
provider facility by non-emergency transport; (ii) the non-participatingprovider complies with the notice and consent requirement; and (iii) youare in condition to receive the information and provide informed consent.If you continue to receive services from the non-participating providerafter you are stabilized, you will be responsible for the non-participatingprovider cost-shares, and the non-participating provider will also be ableto charge you any difference between the maximum allowable amountand the non-participating provider’s billed charges. This notice andconsent exception does not apply if the covered services furnished by anon-participating provider result from unforeseen and urgent medicalneeds arising at the time of service.Non-Participating Services Provided at a Participating Provider FacilityWhen you receive covered services from a non-participating provider ata participating provider facility, your claims will be paid at the nonparticipating provider benefit level if the non-participating provider givesyou proper notice of its charges, and you give written consent to suchcharges. This means you will be responsible for out-of-network costshares for those services and the non-participating provider can alsocharge you any difference between the maximum allowable amount andthe non-participating provider’s billed charges. This requirement doesnot apply to ancillary services. Ancillary services are one of the followingservices: (A) emergency care; (B) anesthesiology; (C) pathology; (D)radiology; (E) neonatology; (F) diagnostic services; (G) assistantsurgeons; (I) hospitalists; (J) intensivists; and (K) any services set out bythe U.S. Department of Health & Human Services. In addition, Anthemwill not apply this notice and consent process to you if Anthem does nothave a participating provider in your area who can perform the servicesyou require.Non-participating providers satisfy the notice and consent requirement asfollows:1. By obtaining your written consent not later than 72 hours prior to thedelivery of services; or2. If the notice and consent is given on the date of the service, if youmake an appointment within 72 hours of the services beingdelivered.Anthem is required to confirm the list of participating providers in itsprovider directory every 90 days. If you can show that you receivedinaccurate information from Anthem that a provider was in-network on aparticular claim, then you will only be liable for the participating providercost shares (i.e., Copayments, Deductibles, and/or Coinsurance) for thatclaim. Your participating provider cost-shares will be calculated based2
upon the maximum allowed amount. In addition to your participatingprovider cost-shares, the non-participating provider can also charge youfor the difference between the maximum allowed amount and their billedcharges.How Cost-Shares Are CalculatedYour cost shares for emergency care services or for covered servicesreceived by a non-participating provider at a participating provider facility,will be calculated using the median plan a participating provider contractrate that we pay participating providers for the geographic area wherethe covered service is provided. Any out-of-pocket cost shares you payto a non-participating provider for either emergency services or forcovered services provided by a non-participating provider at aparticipating provider facility will be applied to your Participating ProviderOut-of-Pocket Limit.AppealsIf you receive emergency care services from a non-participating provideror covered services from a non-participating provider at a participatingprovider facility and believe those services are covered by the NoSurprise Billing Act, you have the right to appeal that claim. If yourappeal of a Surprise Billing Claim is denied, then you have a right toappeal the adverse decision to an Independent Review Organization asset out in the “Grievance Procedures” section of this Benefit Book.Transparency RequirementsAnthem provides the following information on its website (i.e.,www.anthem.com): Protections with respect to Surprise Billing Claims by providers; Estimates on what non-participating providers may charge for aparticular service; Information on contacting state and federal agencies in case youbelieve a provider has violated the No Surprise Billing Act’srequirements.Upon request, Anthem will provide you with a paper copy of the type ofinformation you request from the above list.Anthem, either through its price comparison tool on [anthem.com] orthrough Member Services at the phone number on the back of you IDcard, will allow you to get:3
Cost sharing information that you would be responsible for, for aservice from a specific participating provider; A list of all participating providers; Cost sharing information on a non-participating provider‘s servicesbased on Anthem’s reasonable estimate based on what Anthemwould pay a non-participating provider for the service.In addition, Anthem will provide access through its website to thefollowing information: Participating provider negotiated rates; Historical non-participating provider rates; and Drug pricing information.4
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TYPES OF PROVIDERSPLEASE READ THE FOLLOWING INFORMATION SO YOU WILLKNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTHCARE MAY BE OBTAINED. THE MEANINGS OF WORDS ANDPHRASES IN ITALICS ARE DESCRIBED IN THE SECTION OF THISBOOKLET ENTITLED DEFINITIONS.Participating Providers in California. The claims administrator hasmade available to the members a network of various types of"Participating Providers". These providers are called "participating"because they have agreed to participate in the claims administrator’spreferred provider organization program (PPO), called the Prudent BuyerPlan. Participating providers have agreed to a rate they will accept asreimbursement for covered services. The amount of benefits payableunder this plan will be different for non-participating providers than forparticipating providers. See the definition of "Participating Providers" inthe DEFINITIONS section for a complete list of the types of providers whichmay be participating providers.A directory of participating providers is available upon request. Thedirectory lists all participating providers in your area, including healthcare facilities such as hospitals and skilled nursing facilities, physicians,laboratories, and diagnostic x-ray and imaging providers. You may callthe Member Services number listed on your ID card and request for adirectory to be sent to you. You may also search for a participatingprovider using the “Find a Doctor” function on the claims administrator’swebsite at www.anthem.com/ca. The listings include the credentials ofparticipating providers such as specialty designations and boardcertification.If you need details about a provider’s license or training, or help choosinga physician who is right for you, call the Member Services number on theback of your ID card.If you receive covered services from a non-participating provider after wefailed to provide you with accurate information in our provider directory,or after we failed to respond to your telephone or web-based inquirywithin the time required by federal law, covered services will be coveredat the participating provider level.Connect with Us Using Our Mobile App. As soon as you enroll in thisplan, you should download our mobile app. You can find details on howto do this on our website, www.anthem.com.Our goal is to make it easy for you to find answers to your questions.You can chat with us live in the app, or contact us on our website,www.anthem.com.6
How to Access Primary and Specialty Care ServicesYour health plan covers care provided by primary care physicians andspecialty care providers. To see a primary care physician, simply visitany participating provider physician who is a general or familypractitioner, internist or pediatrician. Your health plan also covers careprovided by any participating provider specialty care provider you choose(certain providers’ services are covered only upon referral of an M.D.(medical doctor) or D.O. (doctor of osteopathy), see “Physician,” below).Referrals are never needed to visit any participating provider specialtycare provider including a behavioral health care provider.To make an appointment call your physician’s office: Tell them you are a Prudent Buyer Plan member. Have your Member ID card handy. They may ask you for your groupnumber, member ID number, or office visit co-payment. Tell them the reason for your visit.When you go for your appointment, bring your Member ID card.After hours care is provided by your physician who may have a variety ofways of addressing your needs. Call your physician for instructions onhow to receive medical care after their normal business hours, onweekends and holidays. This includes information about how to receivenon-emergency care and non-urgent care within the service area for acondition that is not life threatening, but that requires prompt medicalattention. If you have an emergency, call 911 or go to the nearestemergency room.Participating Providers Outside of CaliforniaIf you are outside of the California service areas, please call the tollfree BlueCard Provider Access number on your ID card to find aparticipating provider in the area you are in. A directory of PPOProviders for outside of California is available upon request.Non-Participating Providers. Non-participating providers are providerswhich have not agreed to participate in the Prudent Buyer Plan network.They have not agreed to the reimbursement rates and other provisions ofa Prudent Buyer Plan contract.The claims administrator has processes to review claims before and afterpayment to detect fraud, waste, abuse and other inappropriate activity.Members seeking services from non-participating providers could bebalance billed by the non-participating provider for those services thatare determined to be not payable as a result of these review processesand meets the criteria set forth in any applicable state regulations7
adopted pursuant to state law. A claim may also be determined to be notpayable due to a provider's failure to submit medical records with theclaims that are under review in these processes.Contracting and Non-Contracting Hospitals. Another type of provideris the "contracting hospital." This is different from a hospital which is aparticipating provider. As a health care service plan, the claimsadministrator has traditionally contracted with most hospitals to obtaincertain advantages for patients covered by the plan. While only somehospitals are participating providers, all eligible California hospitals areinvited to be contracting hospitals and most--over 90%--accept.Physicians. "Physician" means more than an M.D. Certain otherpractitioners are included in this term as it is used throughout the plan.This doesn't mean they can provide every service that a medical doctorcould; it just means that the plan will cover expense you incur from themwhen they're practicing within their specialty the same as if the care wereprovided by a medical doctor. As with the other terms, be sure to readthe definition of "Physician" to determine which providers' services arecovered.Only providers listed in the definition are covered asphysicians. Please note also that certain providers’ services are coveredonly upon referral of an M.D. (medical doctor) or D.O. (doctor ofosteopathy). Providers for whom referral is required are indicated in thedefinition of “physician” by an asterisk (*).Other Health Care Providers. "Other Health Care Providers" areneither physicians nor hospitals. They are mostly free-standing facilitiesor service organizations. See the definition of "Other Health CareProviders" in the DEFINITIONS section for a complete list of thoseproviders. Other health care providers are not part of the Prudent BuyerPlan provider network.Reproductive Health Care Services. Some hospitals and otherproviders do not provide one or more of the following services that maybe covered under your plan and that you or your family member mightneed: family planning; contraceptive services, including emergencycontraception; sterilization, including tubal ligation at the time of laborand delivery; infertility treatments; or abortion. You should obtain moreinformation before you enroll. Call your prospective physician or clinic,or call the Member Services telephone number listed on your ID card toensure that you can obtain the health care services that you need.Participating and Non-Participating Pharmacies."ParticipatingPharmacies" agree to charge only the prescription drug maximumallowed amount to fill the prescription. After you have met your CalendarYear Deductible, you pay only your co-payment amount.8
"Non-Participating Pharmacies" have not agreed to the prescription drugmaximum allowed amount. The amount that will be covered asprescription drug covered expense is significantly lower than what theseproviders customarily charge.Centers of Medical Excellence. The claims administrator is providingaccess to the following separate Centers of Medical Excellence (CME)networks. The facilities included in each of these CME networks areselected to provide the following specified medical services: Transplant Facilities. Transplant facilities have been organized toprovide services for the following specified transplants: heart, liver,lung, combination heart-lung, kidney, pancreas, simultaneouspancreas-kidney, or bone marrow/stem cell and similar procedures.Subject to any applicable co-payments or deductibles, CME haveagreed to a rate they will accept as payment in full for coveredservices. These procedures are covered only when performed ata CME. Bariatric Facilities. Hospital facilities have been organized toprovide services for bariatric surgical procedures, such as gastricbypass and other surgical procedures for weight loss programs.These procedures are covered only when performed at a CME.A participating provider in the Prudent Buyer Plan network is notnecessarily a CME facility.Care Outside the United States—BlueCross BlueShield Global CorePrior to travel outside the United States, call the Member Servicestelephone number listed on your ID card to find out if your plan hasBlueCross BlueShield Global Core benefits. Your coverage outside theUnited States is limited and the claims administrator recommends: Before you leave home, call the Member Services number on yourID card for coverage details. You have coverage for services andsupplies furnished in connection only with urgent care or anemergency when travelling outside the United States. Always carry your current ID card. In an emergency, seek medical treatment immediately. The BlueCross BlueShield Global Core Service Center isavailable 24 hours a day, seven days a week toll-free at (800)810-BLUE (2583) or by calling collect at (804) 673-1177. Anassistance coordinator, along with a medical professional, willarrange a physician appointment or hospitalization, if needed.9
Payment Information Participating BlueCross BlueShield Global Core hospitals. Inmost cases, you should not have to pay upfront for inpatient care atparticipating BlueCross BlueShield Global Core hospitals except forthe out-of-pocket costs you normally pay (non-covered services,deductible, co-payments, and coinsurance). The hospital shouldsubmit your claim on your behalf. Doctors and/or non-participating hospitals. You will have to payupfront for outpatient services, care received from a physician, andinpatient care from a hospital that is not a participating BlueCrossBlueShield Global Core hospital.Then you can complete aBlueCross BlueShield Global Core claim form and send it with theoriginal bill(s) to the BlueCross BlueShield Global Core ServiceCenter (the address is on the form).Claim Filing Participating BlueCross BlueShield Global Core hospitals willfile your claim on your behalf. You will have to pay the hospital forthe out-of-pocket costs you normally pay. You must file the claim for outpatient and physician care, orinpatient hospital care not provided by a participating BlueCrossBlueShield Global Core hospital. You will need to pay the healthcare provider and subsequently send an international claim form withthe original bills to the claims administrator.10
Additional Information About BlueCross BlueShield Global Core Claims. You are responsible, at your expense, for obtaining an Englishlanguage translation of foreign country provider claims and medicalrecords. Exchange rates are determined as follows:-For inpatient hospital care, the rate is based on the date ofadmission.-For outpatient and professional services, the rate is based on thedate the service is provided.Claim Forms International claim forms are available from the claims administrator,from the BlueCross BlueShield Global Core Service Center, or onlineat:www.bcbsglobalcore.comThe address for submitting claims is on the form.11
TIMELY ACCESS TO CAREAnthem has contracted with health care service providers to providecovered services in a manner appropriate for your condition,consistent with good professional practice. Anthem ensures that itscontracted provider networks have the capacity and availability tooffer appointments within the following timeframes: Urgent Care appointments for services that do not requireprior authorization: within forty-eight (48) hours of the requestfor an appointment; Urgent Care appointments for services that require priorauthorization: within ninety-six (96) hours of the request for anappointment; Non-Urgent appointments for primary care: within ten (10)business days of the request for an appointment; Non-Urgent appointments with specialists: within fifteen (15)business days of the request for an appointment; Appointments for ancillary services (diagnosis or treatmentof an injury, illness or other health condition) that are noturgent care: within fifteen (15) business days of the request foran appointment.For Mental Health Conditions and Substance Use disorder care: Urgent Care appointments for services that do not requireprior authorization: within forty-eight (48) hours of the requestfor an appointment; Urgent Care appointments for services that require priorauthorization: within ninety-six (96) hours of the request for anappointment; Non-Urgent appointments with mental health and substanceuse disorder providers who are not psychiatrists: within ten(10) business days of the request for an appointment; Non-Urgent appointments with mental health and substanceuse disorder providers who are psychiatrists: within fifteen(15) business days of the request for an appointment. Due toaccreditation standards, the date will be ten (10) business daysfor the initial appointment only.For Vision care:12
Urgent Care appointments: within seventy-two (72) hours ofthe request for an appointment; Non-Urgent appointments: within thirty-six (36) business daysof the request for an appointment; Preventive vision care appointments: within forty (40)business days of the request for an appointment; After-hours care (when a vision provider’s office is closed):In-Network Providers are required to have an answering serviceor a telephone answering machine during non-business hours,which will provide instructions on how you can obtain Urgent orEmergency Care including, when applicable, how to contactanother vision provider who has agreed to be on-call to triage orscreen by phone, or if needed, deliver Urgent or EmergencyCare; Question for Anthem’s Member Services by telephone onhow to get care or solve a problem: ten (10) minutes to reacha live person by phone during normal business hours.For Medical and Vision care:If you need the services of an interpreter, the services will becoordinated with scheduled appointments and will not result in adelay of an In-Network appointment.If a provider determines that the waiting time for anappointment can be extended without a detrimental impact onyour health, the provider may schedule an appointment for alater time than noted above.Anthem arranges for telephone triage or screening services for youtwenty-four (24) hours per day, seven (7) days per week with awaiting time of no more than thirty (30) minutes. If Anthem contractswith a provider for telephone triage or screening services, theprovider will utilize a telephone answering machine and/or ananswering service and/or office staff, during and after businesshours, to inform you of the wait time for a return call from theprovider or how the member may obtain urgent care or emergencyservices or how to contact another provider who is on-call fortelephone triage or screening services.If you need the services of an interpreter, the services will becoordinated with scheduled appointments and will not result in adelay of an appointment with a participating provider.13
SUMMARY OF BENEFITSYOUR EMPLOYER HAS AGREED TO BE SUBJECT TO THE TERMSAND CONDITIONS OF ANTHEM’S PROVIDER AGREEMEN
covered. Only providers listed in the definition are covered as physicians. Please note also that certain providers' services are covered only upon referral of an M.D. (medical doctor) or D.O. (doctor of osteopathy). Providers for whom referral is required are indicated in the definition of "physician" by an asterisk (*).
