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Published ByUSC Health PlansUSC PPO Plan1150 S. Olive Street, Suite 2150 Los Angeles, CA 90089213.740.0035Self-Insured PlanEffective January 1, 2020https://employees.usc.edu/ppo
FOREWORDThe plan described on the following pages provides benefits for a wide range of services and supplies for medicalcare.Your medical benefit plan is a self-funded program provided by the University of Southern California (the“University”). Benefits are administered by the University with HealthComp, Anthem Blue Cross, and MedImpact,each providing certain administrative services.The USC Group Health Plan provides self-insured medical benefits under the USC PPO Plan. This bookletconstitutes the portion of the plan document that describes the USC PPO Plan.The University of Southern California reserves the right to amend or terminate the USC PPO Plan at any time, orterminate any benefit under the Plan.Plan Administrator’s Decision Final. The administration of the Plan shall be under the supervision of the PlanAdministrator, which is the University and the University’s delegate, USC Health Plans (hereafter, collectively, the“Plan Administrator”). To the fullest extent permitted by law, the Plan Administrator shall have the discretion todetermine all matters relating to eligibility, coverage and benefits under the Plan, and the Plan Administrator shallhave the discretion to determine all matters relating to the interpretation and operation of the Plan. Anydetermination by the Plan Administrator shall be final and binding, in the absence of clear and convincing evidencethat the Plan Administrator acted arbitrarily and capriciously.THIS BOOKLET, TOGETHER WITH THE INFORMATION CONTAINED ON THE USC EMPLOYEEGATEWAY WEBSITE, https://employees.usc.edu/ppo, RELATING TO THE PLAN CONSTITUTES THESUMMARY PLAN DESCRIPTION REQUIRED BY THE EMPLOYEE RETIREMENT INCOME SECURITYACT OF 1974, (ERISA). IMPORTANT ERISA INFORMATION AND A STATEMENT OF YOUR ERISA RIGHTSCAN BE FOUND AT THE USC EMPLOYEE GATEWAY WEBSITE https://employees.usc.edu/ppo.–1–
IMPORTANT CONTACTSPrior AuthorizationsAnthem Blue Cross(800) 274-7767Plan Coverage QuestionsHealthComp(855) SC-PLANS(855) 727-5267hconline.healthcomp.com/uscClaim QuestionsHealthComp(855) SC-PLANS(855) 727-5267hconline.healthcomp.com/uscTier 1 Providers:Keck Medicine of USC(833) KECK-USC (833-532-5872)www.keckmedicine.orgTier 2 Providers:Anthem Blue Cross PrudentBuyer and BlueCard (800) 888-8288www.anthem.com/caFind a ParticipatingNetwork Provider(800) 810-2583www.bcbsglobalcore.comBlue Cross Blue ShieldGlobal CoreContracted Pharmacies:MedImpact(844) 401-2054mp.medimpact.com/uscKeck Medicine of USC(833) KECK-USC act(844) 401-2054mp.medimpact.com/uscKeck Medicine at UPCKeck Medicine ofUSC – UPC Clinic(833) KECK-USC (833-532-5872)For help scheduling anappointment with a KeckMedicine providerYou can also visit the USC PPO Plan’s website for otherimportant information and links:https://employees.usc.edu/ppo–2–
TABLE OF CONTENTSPageFOREWORD . 1IMPORTANT CONTACTS . 2PROVISIONS APPLYING TO THE PLAN . 5Important Note About Your Medical Plan . 5USC’s Preferred Provider Organization Program . 5Designating a Primary Care Physician (PCP) . 5Rate of Payment Adjustment . 6Special Benefit for Covered Persons Under Age 19 . 6The Deductible . 6Carryover of Expenses Year-to-Year . 7Out-Of-Pocket Limits . 7DEFINITIONS FOR THE PURPOSE OF THE PLAN. 9ELIGIBILITY AND ENROLLMENT . 16Eligible Employees . 16Eligible Dependents . 16Enrolling New Dependents . 17Change in Family Status . 17Special Enrollment Rules . 17Right to Receive and Release Information . 17Eligibility Under the Hawaii Prepaid Health Care Law . 17PRIOR AUTHORIZATION PROGRAM . 18Non-Emergency Inpatient Admission . 18Emergency Hospital Admission . 18Extension of Length of Inpatient Confinement . 18Outpatient Services And Supplies . 18Effect On Eligible Expenses When A Request For Prior Authorization IsNot Made On Time. 19COVERED SERVICES . 20Acupuncture . 20Ambulance Services / Emergency Medical Transportation . 20Bariatric Surgery . 21Breast Pumps. 23Chiropractic / Acupuncture Services . 24Cochlear Implants . 25Dental Coverage . 25Diabetic Equipment and Supplies . 26Disposable Medical Supplies . 26Durable Medical Equipment, Prosthetic and Orthotic Devices . 27Emergency Services . 28Gender Reassignment Surgery . 29Hearing Aids For Dependent Children Under Age 26 . 30Home Health Care . 31Home Infusion Therapy . 32Hospice Care . 32Hospital Services. 33Infusion Therapy . 33Laboratory Services . 34LiveHealth Online Consultation . 34Maternity Care . 35Mental Health and Substance Abuse Program . 35Nutritional Services . 37Outpatient Surgery – Hospital-Based or Freestanding Facility . 37Physical and Occupational Therapies. 38Physician Visits . 38–3–
TABLE OF CONTENTS — ContinuedPagePrescription Drug Program . 39Preventive Care . 42Reconstructive Surgery . 46Skilled Nursing Facility Care . 47Smoking Cessation . 47Speech Therapy . 48Transplants – Organ and Tissue . 49Urgent Care Center . 52Well Child Care . 52X-Ray / Radiology Services . 53EXCLUSIONS . 54HOW TO USE THE PLAN . 57Network Participating Providers . 57Making Appointments . 57If You Or A Covered Dependent Is To Be Hospitalized. 57Claim Payments. 57Patient Responsibility For Payment . 57How To Present A Claim . 58When You Have A Claim . 58GENERAL INFORMATION. 60Coordination Of Benefits . 60Special Coordination of Benefits Rule for Non-Group Insurance and TravelHealth Insurance . 61Modification of Benefits . 61Subrogation . 61Medicare Program . 63Termination of Coverage . 64Q & A . 65NOTICE OF NON-DISCRIMINATION . 67–4–
PROVISIONS APPLYING TO THE PLANIMPORTANT NOTE ABOUT YOUR MEDICAL PLANYOUR MEDICAL PLAN CONTAINS A PRIOR AUTHORIZATION PROGRAM, AS DESCRIBED ON PAGES18-19.Failure to follow the Prior Authorization Program may result in a reduction or denial of benefits, which may mean agreater expense to you.TO ARRANGE FOR A PRIOR AUTHORIZATION, PLEASE CONTACT ANTHEM BLUE CROSS AT (800)274-7767.USC's Preferred Provider Organization ProgramUSC Network Providers are comprised of two tiers of Participating Providers, Tier 1 and Tier 2. Tier 1 consists ofKeck Medicine of USC Physicians, Keck Hospital of USC, USC Norris Cancer Hospital, and USC Verdugo HillsHospital. Tier 2 consists of all Anthem Blue Cross Prudent Buyer providers in California, participating BlueCard providers in other parts of the United States (with the exception of vision and dental providers) and participatingBlue Cross Blue Shield Global Core providers outside of the United States. You may also obtain MedicallyNecessary Covered Services from Non-Network (Tier 3) providers; however, the rate of Plan payment under yourmedical expense benefit is much greater for services furnished by USC Network Providers.If your Network Physician refers you to another Physician or provider, it is your responsibility to verify that thePhysician/provider is also a Participating Network Provider. If the Physician/provider is not a ParticipatingNetwork Provider, Benefits will be paid at the out-of-Network rate and you will be responsible for the remainderof the charges.If you seek treatment at a Network facility (e.g., hospital or outpatient surgery center) and a Non-Networkprovider (e.g., a Non-Network Physician, anesthesiologist, radiologist, respiratory therapist) participates in yourtreatment, the Non-Network provider’s claim will be paid at 80% of Usual, Customary and Reasonable (UCR)Charges, the Tier 2 deductible will apply and the Tier 3 annual out-of-pocket maximum will apply in accordancewith applicable law, except where noted under Covered Services section for specific services. You will always beresponsible for all billed charges which exceed the Usual, Customary and Reasonable (UCR) charges, in additionto your responsibility for any applicable copayments and coinsurance amounts.USC is not responsible for the quality and extent of care you may receive at any of the Network Hospitals or fromany specific Network Pro
The USC Group Health Plan provides self-insured medical benefits under the USC Plan. This booklet PPO constitutes the portion of the plan document that describes the USC PPO Plan. The University of Southern California reserves the right to amend or terminate the USC Plan
