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CALIFORNIA INSTITUTE OFTECHNOLOGYJanuary 1, 2020Prudent Buyer HSA PlanBenefit BookletSPD175104-4 2020 (non-std.)
Dear Plan Member:This Benefit Booklet (“benefit booklet”) provides a complete explanation ofyour 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 administrative claimspayment services only and does not assume any financial risk or obligationwith respect to claims.Anthem Blue Cross Life and Health Insurance Company is an independentlicensee 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 ID card) or in writing (write to Anthem BlueCross Life and Health Insurance Company, 21215 Burbank Blvd.,Woodland Hills, CA 91367 marked to the attention of the MemberServices Department named on your ID card). If you wish, the ClaimsAdministrator will provide a Complaint Form which you may use toexplain 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.
Claims Administered by:ANTHEM BLUE CROSSon behalf ofANTHEM BLUE CROSS LIFE AND HEALTH INSURANCECOMPANY
TABLE OF CONTENTSTYPES OF PROVIDERS . 1HOW COVERAGE BEGINS AND ENDS . 6HOW COVERAGE BEGINS . 6HOW COVERAGE ENDS . 11SUMMARY OF BENEFITS . 14MEDICAL BENEFITS . 15PreventiveRx Program . 19Preferred Generic Program . 21Special Programs . 21Half-tab Program . 22Day Supply and Refill Limits . 22Therapeutic Substitution . 23YOUR MEDICAL BENEFITS. 27MAXIMUM ALLOWED AMOUNT. 27MEDICAL AND PRESCRIPTION DRUG DEDUCTIBLE . 32MEDICALANDPRESCRIPTIONDRUGOUT-OF-POCKETAMOUNTS . 32CO-PAYMENTS AND MEDICAL BENEFIT MAXIMUMS . 34CREDITING PRIOR PLAN COVERAGE . 35CONDITIONS OF COVERAGE . 36MEDICAL CARE THAT IS COVERED . 37MEDICAL CARE THAT IS NOT COVERED . 63BENEFITS FOR PERVASIVE DEVELOPMENTAL DISORDER ORAUTISM . 74SUBROGATION AND REIMBURSEMENT . 77YOUR PRESCRIPTION DRUG BENEFITS . 81PRESCRIPTION DRUG COVERED EXPENSE . 81PRESCRIPTION DRUG CO-PAYMENTS . 81HOW TO USE YOUR PRESCRIPTION DRUG BENEFITS . 82PRESCRIPTION DRUG UTILIZATION REVIEW . 85SPD175104-4 2020
PREFERRED DRUG PROGRAM . 85PREVENTIVE PRESCRIPTION DRUGS AND OTHER ITEMS . 89PRESCRIPTION DRUG CONDITIONS OF SERVICE . 90PRESCRIPTION DRUG SERVICES AND SUPPLIES THAT ARECOVERED. 93PRESCRIPTION DRUG SERVICES AND SUPPLIES THAT ARENOT COVERED . 94COORDINATION OF BENEFITS . 99BENEFITS FOR MEDICARE ELIGIBLE MEMBERS . 103UTILIZATION REVIEW PROGRAM . 105DECISION AND NOTICE REQUIREMENTS . 111HEALTH PLAN INDIVIDUAL CASE MANAGEMENT . 112EXCEPTIONS TO THE UTILIZATION REVIEW PROGRAM . 113CONTINUATION OF COVERAGE . 115EXTENSION OF BENEFITS. 121GENERAL PROVISIONS . 122BINDING ARBITRATION . 137DEFINITIONS. 138YOUR RIGHT TO APPEALS. 154FOR YOUR INFORMATION . 160SPD175104-4 2020
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 THISBENEFIT BOOKLET ENTITLED DEFINITIONS.Participating Providers in CaliforniaThe claims administrator has made available to the members a network ofvarious types of "Participating Providers". These providers are called"participating" because they have agreed to participate in the claimsadministrator’s preferred provider organization program (PPO), called thePrudent Buyer Plan. Participating providers have agreed to a rate theywill accept as reimbursement for covered services. The amount ofbenefits payable under this plan will be different for non-participatingproviders than for participating providers.A directory of participating providers is available upon request. Thedirectory lists all participating providers in your area, including health carefacilities 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.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 visit anyparticipating provider physician who is a general or family practitioner,internist or pediatrician. Your health plan also covers care provided byany participating provider specialty care provider you choose (certainproviders’ services are covered only upon referral of an M.D. (medicaldoctor) or D.O. (doctor of osteopathy), see “Physician,” below). Referralsare never needed to visit any participating provider specialty care providerincluding a behavioral health care provider.To make an appointment call your physician’s office:1
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-payments. 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 CaliforniaThe Blue Cross and Blue Shield Association, of which the claimsadministrator is a member, has a program (called the “BlueCard Program”)which allows members to have the reciprocal use of participating providerscontracted under other states’ Blue Cross and/or Blue Shield Licensees(the Blue Cross and/or Blue Shield Plan).If 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 orthe Blue Cross and/or Blue Shield Plan. They have not agreed to thereimbursement rates and other provisions of a Prudent Buyer Plancontract nor the Blue Cross and/or Blue Shield Plan.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 that aredetermined to be not payable as a result of these review processes andmeets the criteria set forth in any applicable state regulations adoptedpursuant to state law. A claim may also be determined to be not payabledue to a provider's failure to submit medical records with the claims thatare 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 a2
participating 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 expenses you incur from themwhen they're practicing within their specialty the same as would becovered if the care were provided by a medical doctor. As with the otherterms, be sure to read the definition of "Physician" to determine whichproviders' services are covered. Only providers listed in the definition arecovered as physicians. Please note also that certain providers’ servicesare covered only upon referral of an M.D. (medical doctor) or D.O. (doctorof osteopathy). Providers for whom referral is required are indicated in thedefinition of “physician” by an asterisk (*).Other Health Care Providers. "Other Health Care Providers" are neitherphysicians nor hospitals. They are mostly free-standing facilities orservice organizations. See the definition of "Other Health Care Providers"in the DEFINITIONS section for a complete list of those providers. Otherhealth care providers are not part of the Prudent Buyer Plan providernetwork or the Blue Cross and/or Blue Shield Plan.Reproductive Health Care Services. Some hospitals and otherproviders do not provide one or more of the following services that may becovered under your plan and that you or your family member might need:family planning; contraceptive services, including emergencycontraception; sterilization, including tubal ligation at the time of labor anddelivery; infertility treatments; or abortion. You should obtain moreinformation before you enroll. Call your prospective physician or clinic, orcall 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 maximum allowedamount to fill the prescription. You pay only your co-payment amount."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.3
Centers of Medical Excellence. The claims administrator is providingaccess to Centers of Medical Excellence (CME) networks. The facilitiesincluded in each of these networks are selected to provide the followingspecified 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 to provideservices for bariatric surgical procedures, such as gastric bypass andother surgical procedures for weight loss programs.Theseprocedures are covered only when performed at a CME.A participating provider in the Prudent Buyer Plan or the Blue Cross and/orBlue Shield Plan network is not necessarily a CME facility.Care Outside the United States—Blue Cross Blue Shield Global CorePrior to travel outside the United States, call the Member Servicestelephone number listed on your ID card to find out if your plan has BlueCross Blue Shield Global Core benefits. Your coverage outside the UnitedStates is limited and the claims administrator recommends: Before you leave home, call the Member Services number on your IDcard 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 Blue Cross Blue Shield Global Core Service Center isavailable 24 hours a day, seven days a week toll-free at (800) 810BLUE (2583) or by calling collect at (804) 673-1177. An assistancecoordinator, along with a medical professional, will arrange aphysician appointment or hospitalization, if needed.4
Payment Information Participating Blue Cross Blue Shield Global Core hospitals. Inmost cases, you should not have to pay upfront for inpatient care atparticipating Blue Cross Blue Shield Global Core hospitals except forthe out-of-pocket costs you normally pay (non-covered services,deductible, co-payments, and co-insurance). 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 Blue CrossBlue Shield Global Core hospital. Then you can complete a BlueCross Blue Shield Global Core claim form and send it with the originalbill(s) to the Blue Cross Blue Shield Global Core Service Center (theaddress is on the form).Claim Filing Participating Blue Cross Blue Shield 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, or inpatienthospital care not provided by a participating Blue Cross Blue ShieldGlobal Core hospital. You will need to pay the health care providerand subsequently send an international claim form with the originalbills to the claims administrator.Additional Information About Blue Cross Blue Shield 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 Blue Cross Blue Shield Global Core Service Center, or onlineat:www.bcbsglobalcore.comThe address for submitting claims is on the form.5
HOW COVERAGE BEGINS AND ENDSHOW COVERAGE BEGINSELIGIBLE STATUS1. Subscribers. Eligibility is based on the group’s determination thatemployees meet basic service and hourly requirements. In addition,eligibility may be based on employment agreements with specifiedemployees where coverage may be offered by applying alternativeservice and/or hourly requirements.2. Dependents. The following are eligible to enroll as dependents: (a)Either the subscriber’s spouse or domestic partner; and (b) A child.Definition of Dependent1. Spouse is the subscriber’s spouse under a legally valid marriage.Spouse does not include any person who is in active service in thearmed forces. A person may be covered as both an employee and afamily member, if eligible as both. However, the total amount ofbenefits we would then pay shall not exceed the amount of themaximum allowed amount.2. Domestic partner is the subscriber’s domestic partner under a legallyregistered and valid domestic partnership. Domestic partner does notinclude any person who is in active service in the armed forces. Aperson may be covered as both an employee and a family member, ifeligible as both. However, the total amount of benefits we would thenpay shall not exceed the amount of the maximum allowed amount.3. Child is the subscriber's or spouse’s or domestic partner’s naturalchild, stepchild, legally adopted child, or a child for whom thesubscriber, spouse or domestic partner has been appointed legalguardian by a court of law, subject to the following:a. The child is under 26 years of age.b. The unmarried child is 26 years of age, or older and: (i) is chieflydependent on the subscriber, spouse or domestic partner forsupport and maintenance, and (ii) is incapable of self-sustainingemployment due to a physical or mental condition. A physicianmust certify in writing that the child is incapable of self-sustainingemployment due to a physical or mental condition. We mustreceive the certification, at no expense to us, within 60-days of thedate the subscriber receives our request. We may request proofof continuing dependency and that a physical or mental condition6
still exists, but not more often than once each year after the initialcertification. This exception will last until the child is no longerchiefly dependent on the subscriber, spouse or domestic partnerfor support and maintenance due to a continuing physical ormental condition. A child is considered chiefly dependent forsupport and maintenance if he or she qualifies as a dependent forfederal income tax purposes.c.A child who is in the process of being adopted is considered alegally adopted child if we receive legal evidence of both: (i) theintent to adopt; and (ii) that the subscriber, spouse or domesticpartner have either: (a) the right to control the health care of thechild; or (b) assumed a legal obligation for full or partial financialresponsibility for the child in anticipation of the child’s adoption.Legal evidence to control the health care of the child means awritten document, including, but not limited to, a health facilityminor release report, a medical authorization form, orrelinquishment form, signed by the child’s birth parent, or otherappropriate authority, or in the absence of a written document,other evidence of the subscriber’s, the spouse’s or domesticpartner’s right to control the health care of the child.d. A child for whom the subscriber, spouse or domestic partner is alegal guardian is considered eligible on the date of the courtdecree (the “eligibility date”). We must receive legal evidence ofthe decree.e. If both parents are covered as employees, their children may becovered as the family members of both. However, the totalamount of benefits we would then pay shall not exceed themaximum allowed amount.ELIGIBILITY DATE1. For subscribers, you become eligible for coverage in accordance withrules established by your employer. For specific information aboutyour employer’s eligibility rules for coverage, please contact yourHuman Resources or Benefits Department.2. For dependents, you become eligible for coverage on the later of: (a)the date the subscriber becomes eligible for coverage; or, (b) the dateyou meet the dependent definition.If, after you become covered under this plan, you cease to be eligibledue to termination of employment, and you return to an eligible statusbased on your employer’s eligibility rules, you will become eligible to7
re-enroll for coverage on the first day of the month following the dateyou IBILITYENROLLMENTTo enroll as a subscriber, or to enroll dependents, the subscriber mustproperly file an application. An application is considered properly filed,only if it is personally signed, dated, and given to the plan administratorwithin 31 days from your eligibility date. If any of these steps are notfollowed, your coverage may be denied.EFFECTIVE DATEYour effective date of coverage is subject to the timely payment of requiredmonthly contributions. The date you become covered is determined asfollows:1. Timely Enrollment: If you enroll for coverage before, on, or within 31days after your eligibility date, then your coverage will begin as follows:(a) for subscribers, on your eligibility date; and (b) for dependents, onthe later of (i) the date the subscriber’s coverage begins, or (ii) the firstday of the month after the dependent becomes eligible. If you becomeeligible before the plan takes effect, coverage begins on the effectivedate of the plan, provided the enrollment application is on time and inorder.2. Late Enrollment: If you enroll more than 31 days after your eligibilitydate, you must wait until the next Open Enrollment Period to enroll.3. Disenrollment: If you voluntarily choose to disenroll from coverageunder this plan, you will be eligible to reapply for coverage as set forthin the “Enrollment” provision above, during the next Open Enrollmentperiod (see OPEN ENROLLMENT PERIOD).For late enrollees and disenrollees: You may enroll earlier than the nextOpen Enrollment Period if you meet any of the conditions listed underSPECIAL ENROLLMENT GIBILITYImportant Note for Newborn and Newly-Adopted Children. If thesubscriber (or spouse or domestic partner, if the spouse or domesticpartner is enrolled) is already covered: (1) any child born to thesubscriber, spouse or domestic partner will be enrolled from the momentof birth; and (2) any child being adopted by the subscriber, spouse ordomestic partner will be enrolled from the date on which either: (a) the8
adoptive child’s birth parent, or other appropriate legal authority, signs awritten document granting the subscriber, spouse or domestic partner theright to control the health care of the child (in the absence of a writtendocument, other evidence of the subscriber’s, spouse’s or domesticpartner’s right to control the health care of the child may be used); or (b)the subscriber, spouse or domestic partner assumed a legal obligation forfull or partial financial responsibility for the child in anticipation of the child’sadoption. The “written document” referred to above includes, but is notlimited to, a health facility minor release report, a medical authorizationform, or relinquishment form.In both cases, coverage will be in effect for 31 days. For coverage tocontinue beyond this 31-day period, the subscriber must submit amembership change form to the plan administrator within the 31-dayperiod.Special Enrollment PeriodsYou may enroll without waiting for the plan administrator’s next openenrollment period if you are otherwise eligible under any one of thecircumstances set forth below:1. You have met all of the following requirements:a. You were covered as an individual or dependent under either:i.Another employer group health plan or health insurancecoverage, including coverage under a COBRA continuation;orii.A state Medicaid plan or under a state child health insuranceprogram (SCHIP), including the Healthy Families Program orthe Access for Infants and Mothers (AIM) Program.b. You certified in writing at the time you became eligible forcoverage under this plan that you were declining coverage underthis plan or disenrolling because you were covered under anotherhealth plan as stated above and you were given written notice thatif you choose to enroll later, you may be required to wait until theplan administrator’s next open enrollment period to do so.c.Your coverage under the other health plan wherein you werecovered as an individual or dependent ended as follows:9
i.If the other health plan was another employer group healthplan or health insurance coverage, including coverage undera COBRA continuation, coverage ended because you losteligibility under the other plan, your coverage under a COBRAcontinuation was exhausted, or employer contributions towardcoverage under the other plan terminated. You must properlyfile an application with the plan administrator within 31 daysafter the date your coverage ends or the date employercontributions toward coverage under the other plan terminate.Loss of eligibility for coverage under an employer group healthplan or health insurance includes loss of eligibility due totermination of employment or change in employment status,reduction in the number of hours worked, loss of dependentstatus under the terms of the plan, termination of the otherplan, legal separation, divorce, death of the person throughwhom you were covered, and any loss of eligibility forcoverage after a period of time that is measured by referenceto any of the foregoing.ii.If the other health plan was a state Medicaid plan or a statechild health insurance program (SCHIP), including theHealthy Families Program or the Access for Infants andMothers (AIM) Program, coverage ended because you losteligibility under the program. You must properly file anapplication with the plan administrator within 60 days after thedate your coverage ended.2. A court has ordered coverage be provided for a spouse, domesticpartner or dependent child under your employee health plan and anapplication is filed within 31 days from the date the court order isissued.3. You have a change in family status through either marriage ordomestic partnership, or the birth, adoption, or placement for adoptionof a child:a. If you are enrolling following marriage or domestic partnership,you and your new spouse or domestic partner must enroll within31 days of the date of marriage or domestic partnership. Yournew spouse or domestic partner’s children may also enroll at thattime.b. If you are enrolling following the birth, adoption, or placement foradoption of a child, your spouse (if you are already married) ordomestic partner or other dependents, who are eligible but notenrolled, may also enroll at that time. Application must be madewithin 31 days of the birth or date of adoption or placement foradoption.10
4. You meet or exceed a lifetime limit on all benefits under another healthplan. Application must be made within 31 days of the date a claim ora portion of a claim is denied due to your meeting or exceeding thelifetime limit on all benefits under the other plan.5. You become eligible for assistance, with respect to the cost ofcoverage under the employer’s group plan, under a state Medicaid orSCHIP health plan, including any waiver or demonstration projectconducted under or in relation to these plans. You must properly filean application with the plan administrator within 60 days after the dateyou are determined to be eligible for this assistance.Effective date of coverage. For enrollments during a special enrollmentperiod as described above, coverage will be effective on the first day ofthe month following the date you file the enrollment application, except asspecified below:1. If a court has ordered that coverage be provided for a dependent child,coverage will become effective for that child on the earlier of (a) thefirst day of the month following the date you file the enrollmentapplication or (b) within 30 days after a copy of the court order isr
Blue Shield Plan network is not necessarily a CME facility. Care Outside the United States—Blue Cross Blue Shield Global Core Prior to travel outside the United States, call the Member Services telephone number listed on your ID card to find out if your plan has Blue Cross Blue Shield Global Core benefits. Your coverage outside the United
