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USC Trojan Care EPO PlanEffective January 1, 2021Welcome1Finding an EPO Plan Provider1HealthComp 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 S1150 S. Olive St., Suite 2150, Los Angeles, CA 90089(213) 740.0035 employees.usc.edu/epoUSCHP200818CC 2021 EPO Welcome Brochure M.indd 1-212/11/20 1:00 PM

US C T ROJA N CAR E EPO PLAN2Welcome to the USC Trojan Care EPO PlanThe USC Trojan Care EPO Plan is a self-funded medical benefitprogram provided by the University of Southern California. Asa Participant/Covered Person of the USC Trojan Care EPO Plan,benefits are administered by the university with HealthComp,Anthem Blue Cross and Navitus, each providing certainadministrative services.The USC Trojan Care EPO Plan is an Exclusive ProviderOrganization that provides convenient access to a full range ofhigh quality providers near where you live or work. Included inthe EPO provider network are Keck Medicine of USC providers,as well as other selected Anthem providers within six SouthernCalifornia counties.It is important to know that you must use USC Trojan CareEPO Plan network providers to receive plan benefits; there isno out-of-network coverage except in an emergency orurgent care services.While you don’t have to choose a primary care physician (PCP),your network PCP office visit copay will be 10 instead of 20after you do designate one. To designate a PCP for you andyour covered dependents, register at hconline.healthcomp.com/usc. Changes made on or before the 15th day of themonth will be effective on the 1st of the following month.Finding an EPO Plan ProviderTo find USC Trojan Care EPO Plan providers, go tohconline.healthcomp.com/usc and select “Find a Provider”.You can filter your search.You can also visit keckmedicine.org to search for a KeckMedicine provider or call (833) KECK.USC/(833) 532.5872.USCHP200818CC 2021 EPO Welcome Brochure M.indd 3-4P 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 procedures,and 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 Trojan Care EPO Plan.Contact information for HealthComp is shown below and is alsoprinted on the front of your Plan ID card. Information on where tosubmit medical claims is printed on the back of your Plan 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.12/11/20 1:00 PM

US C T ROJA N CAR E EPO PLAN4Understanding Your Plan ID CardAll Participants enrolled in the USC Trojan Care EPO Planreceive an ID card. Present your ID card each time you receivemedical care or purchase prescription drugs.Understanding Your Plan ID Card—Reference1 Anthem Blue Cross logo identifies USC’s contractedprovider network.2 This is the name of the primary subscriber (employee).You 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) 727.5267.3 Subscriber 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 Crossassigned group number.6 Plan Code 040 is a code used by Anthem Blue Cross toidentify the USC plan.7 HealthComp Group Number is used by HealthCompI D C A R D — FR O N Tto identify the USC account. You may be asked for thisnumber when contacting HealthComp.18 HealthComp is USC’s Third Party Administrator (TPA).Contact HealthComp with member service, eligibilityand benefit-related questions.USC TROJAN CARE EPO PLAN2Subscriber Name:John DoeSubscriber ID:MEDICALEligibility Claims Customer ServiceHealthComp (TPA)855-SC-PLANS (855-727-5267)hconline.healthcomp.com/usc3JEX NP1234567Dependent Name:JaneDoeAnthem Group Number: 276727M003Plan Code: 040HealthComp Group Number: SC14567THIS CARD IS FOR IDENTIFICATION ONLY.POSSESSION CONFERS NO RIGHT TOBENEFITS OR GUARANTEE OF COVERAGE.9 Navitus is your prescription benefits manager. Contact8PRESCRIPTION DRUGSRx Bin: 610602Rx PCN: NVTRx Group: Fr PRUDENT BUYER PLAN109Navitus 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 is the AnthemBlue Cross PPO provider network.11 Most common prior authorization requirementsare listed here. It is important to adhere to all priorauthorization requirements.I D C A R D — B AC K Mailing address for all medical claims incurred inCalifornia, 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 90060-0007Claims for emergency services 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 (JEX) that precedes the patient’sID number.HOW TO LOCATE A NETWORK PROVIDERUSC Providers: keckmedicine.orgOr call (833) KECK-USC (833-532-5872)All Other EPO Providers: hconline.healthcomp.com/uscprovidersearchAnthem 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 Anthem Blue CrossLife and Health Insurance Company and is not liable for benefits payable. Independent licensees of the Blue Cross Association.USCHP200818CC 2021 EPO Welcome Brochure M.indd 5-6 Blue Cross/Blue Shield note to providers, reminding them touse the JEX prefix when submitting claims incurred outsideof California to their local Blue Cross/Blue Shield plan. Web addresses used to locate EPO providers. Phone number to call when requiring medical priorauthorization. Phone number Anthem Blue Cross Prudent Buyerproviders use for claims inquiries. Anthem Blue Cross is legally required to include thisdisclaimer on ID cards accessing their names and logos.12/11/20 1:00 PM

USCHP200818CC 2021 EPO Welcome Brochure M.indd 7-8How to Read Your Explanationof Benefits (EOB)An Explanation of Benefits (EOB) is importantbecause it verifies that a claim was receivedby your insurance, documents paymentand/or reason(s) for denial and patientresponsibility. It also provides the “CoveredAmount” providers have agreed to acceptas plan payment and clearly specifies yourpatient responsibility.AClaim #:Patient:Member ID:BCD36670368-01Amanda Forester461611EService DetailsFPlan RateGPlan PaidYour ResponsibilityPaid byOtherInsuranceHINotCoveredJFor odesServiceCodesDate: 1/10/2018A) Physician - Office Visit 280.00 151.73 131.73 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 20.00 103.00TotalsRCovered by Your PlanTotalChargeProvider:PDr. Joseph ForbesABC Medical GroupOther Credits or Adjustments:QYour Total Responsibility: 0.00 103.00260 Main Street, Suite 300Cityville, CA 10000SReason Code DescriptionJA-Discount. Patient not liable.02-Copayment was taken on this serviceUA 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.DEFG12/11/20 1:00 PMH Paid by Other Insurance: A portion of the Total Chargemay have been covered by another source (e.g. otherhealth insurance, automobile insurance).Payment DistributionCode:A)Claim #36670368-01Paid To:ABC Medical GroupCheck No.01053445Amount 200.23MessagesClaim #36670368-01FIELD DESCRIPTIONS INCLUDED ON AN EOBTMessage: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. Co-insurance: The percentage amount you pay forcertain 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.