guide to your healthcare benefits 2017 - Board of Pensions

Benefits through the stages of your life.

GUIDE TO YOUR HEALTHCARE BENEFITS 2017 For Active Medical Plan Members

TABLE OF CONTENTS 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 A Network-Driven Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 PPO Medical Option . . . . . . . . . . . . . . . . . . . . . . . . . 2 EPO Medical Option . . . . . . . . . . . . . . . . . . . . . . . . . 2 Non-network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Your service providers . . . . . . . . . . . . . . . . . . . . . . . 3 Emergency and urgent care services . . . . . . . . . . . . . . . . 4 Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Alternatives to the ER . . . . . . . . . . . . . . . . . . . . . . . . 4 2. Eligibility and Coverage Contributions . . . . . . . . . . . . . 6 Installed Pastors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Other Teaching Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Other Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Medical Continuation Coverage . . . . . . . . . . . . . . . . . . . . 8 3. Your Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Carry Your ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Get Advance Approval When Required . . . . . . . . . . . . . 9 Report Qualifying Life Events . . . . . . . . . . . . . . . . . . . . . . 10 Understand Your Share of the Costs . . . . . . . . . . . . . . . . 10 Protect Plan Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 4. Medical Plan Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medical Necessity Standard . . . . . . . . . . . . . . . . . . . . . . . 12 What’s Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Limits to coverage . . . . . . . . . . . . . . . . . . . . . . . . . 13 Women’s health protection . . . . . . . . . . . . . . . . . 13 Behavioral health services . . . . . . . . . . . . . . . . . . 15 Routine eye exam coverage . . . . . . . . . . . . . . . . 16 Specialized therapies . . . . . . . . . . . . . . . . . . . . . . 16 Organ transplants . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Habilitative services for developmental disabilities . . . . . . . . . . . . . . . 17 Pre-Certification Requirements . . . . . . . . . . . . . . . . . . . . 18 Emergency admission . . . . . . . . . . . . . . . . . . . . . . 18 If you don’t obtain advance approval . . . . . . . 18 What’s Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5. Your Medical Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Your Share of the Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Preventive care benefit . . . . . . . . . . . . . . . . . . . . . 21 Routine medical costs . . . . . . . . . . . . . . . . . . . . . . 22 Routine vision exam . . . . . . . . . . . . . . . . . . . . . . . . 24 Hospital and emergency room visits . . . . . . . . 24 How To Get Reimbursed . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Medical and Hospital Services . . . . . . . . . . . . . . . . . . . . . 25 Claims Summaries and Explanation of Benefits Statements . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Online claims seminars . . . . . . . . . . . . . . . . . . . . . 25 Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . 25 Reviewing your claims . . . . . . . . . . . . . . . . . . . . . . 25 6. Your Prescription Drug Benefits . . . . . . . . . . . . . . . . . 27 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Deciding on the Right Prescription for You . . . . . . . . . 27 Brand vs. generic drugs . . . . . . . . . . . . . . . . . . . . . 27 Listing of covered drugs . . . . . . . . . . . . . . . . . . . . 28 Costs for formulary and non-formulary drugs . . . . . . . . . . . . . . . . . . . . . 28 Annual family copayment maximum . . . . . . . . 29 How To Get Prescriptions Filled . . . . . . . . . . . . . . . . . . . . 29 At your local participating pharmacy . . . . . . . . 29 Through mail order . . . . . . . . . . . . . . . . . . . . . . . . . 29 Special Programs To Limit Costs . . . . . . . . . . . . . . . . . . . . 30 Step therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Prior authorization . . . . . . . . . . . . . . . . . . . . . . . . . 30 Quantity limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Specialty medications . . . . . . . . . . . . . . . . . . . . . . 30 Drugs Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Excluded drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Questions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

7. Other Wellness Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 32 Employee Assistance Program . . . . . . . . . . . . . . . . . . . . . 32 Health and Wholeness: Call to Health . . . . . . . . . . . . . . 33 Your Well-Being Assessment . . . . . . . . . . . . . . . 33 Tobacco-Free Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Your Personal Health Record . . . . . . . . . . . . . . . . . . . . . . . 33 Your Well-Being Assessment . . . . . . . . . . . . . . . . . . . . . . . 33 24-Hour Nurse Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

10. Administrative and Miscellaneous Provisions . . . 42 Confidentiality and Privacy Practices . . . . . . . . . . . . . . . 42 Plan’s Right to Recoupment, Subrogation & Reimbursement for Medical Costs Recovered from Third Parties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Fraud and/or Misrepresentation . . . . . . . . . . . . . . . . . . . 43 Limitation of Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

8. Coverage for Special Circumstances . . . . . . . . . . . . . 35 Children Residing Away from Home . . . . . . . . . . . . . . . 35 Travel within the United States . . . . . . . . . . . . . . . . . . . . 35 International Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 BCBS Global . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 International SOS . . . . . . . . . . . . . . . . . . . . . . . . . . 36 After Termination of Eligibility . . . . . . . . . . . . . . . . . . . . . 36 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Employment termination . . . . . . . . . . . . . . . . . . . 38 Death of member . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Divorce or dissolution . . . . . . . . . . . . . . . . . . . . . . 38 Transitional participation coverage . . . . . . . . . 38 Employer Withdrawal . . . . . . . . . . . . . . . . . . . . . . . 38 9. Claims and Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Claims Filing Deadline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Claims Payment with Dual Coverage . . . . . . . . . . . . . . . 39 Maintenance of benefits . . . . . . . . . . . . . . . . . . . 39 Member couple coverage . . . . . . . . . . . . . . . . . . 39 Child and divorce, dissolution, or separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Appeals Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Copays, Deductibles, and Copayment Maximums . . 46 Plan Maximum Reimbursement Limits . . . . . . . . . . . . . 48 2017 Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 2017 Preventive Schedule . . . . . . . . . . . . . . . . . . . . . . . . . 58 Privacy Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Help Accessing Healthcare Information Available for Those with Disabilities or Limited English Proficiency The Board of Pensions does not discriminate on the basis of race, color, national origin, age, disability, or sex. If, because of a disability or limited English proficiency, you need auxiliary aids or language assistance to understand the information in this guide, the Board of Pensions will provide the necessary services at no cost to you. Go to pensions.org or call 800-773-7752 (800-PRESPLAN) for more information. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1- 800-773-7752 (800-PRESPLAN). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1- 800-773-7752 (800-PRESPLAN) 번으로 전화해 주십시오.

Members’ rights under the Benefits Plan are governed by the official Benefits Plan document. If this guide is inconsistent with the plan document in any way, the plan document governs. The guide addresses highlights of our Medical Plan, principally administered by Highmark Blue Cross Blue Shield, OptumRx, and Cigna Behavioral Health. Triple-S and GeoBlue enrollees should consult their plans’ provisions for information about covered services.

Dear Member, The Medical Plan of the Presbyterian Church (U.S.A.) is one of the most comprehensive healthcare plans in the church benefits community. This Guide to Your Healthcare Benefits can help you understand — and get the most out of — your healthcare coverage. Available on the Board’s website, pensions.org, or by calling the Board to request a printed copy, this guide provides essential information on • eligibility for coverage; • covered services; • potential costs; and • your rights and responsibilities under the plan. If you need detailed information on specific plan provisions, please refer to The Benefits Plan of the Presbyterian Church (U.S.A.), the official document of the Benefits Plan. The Board of Pensions has three goals in its role overseeing this plan for you, your family, and other members: (1) encourage you to take care of your health; (2) support your efforts to be a wise consumer of healthcare services; and (3) steward plan resources for the benefit of all those who serve the Church. We hope you’ll take advantage of the preventive care, medical screenings, and wellness benefits available through the plan, as these can help identify health risks, limit complications, and improve your health and well-being. I invite you to participate in Call to Health, which promotes all aspects of well-being: spiritual, health, financial, and vocational. Participating in Call to Health from October 1, 2016, through November 10, 2017, also enables you to lower your individual and family deductibles for 2018. Look for information about Call to Health on pensions.org and at calltohealth.org. If you have questions about your coverage after reading this guide, visit pensions.org for further information, call 800-773-7752 (800-PRESPLAN) to speak with a service representative, or contact one of the service providers listed in the Contact Information section of this guide. We wish you the very best of health! Sincerely,

Patricia M. Haines Executive Vice President, Benefits

1.

OVERVIEW

The Medical Plan, a key component of the Benefits Plan of the Presbyterian Church (U.S.A.), is a self-funded church plan designed to care for and protect a community of members. These members are church workers like you, who are employed by churches and other employers of the Presbyterian Church (U.S.A.), and their families. The Medical Plan plays a key role in the care of this community, encouraging both community and member responsibility for healthcare costs — and your health. Your employer may offer you one or both of two medical coverage options through the Medical Plan: a preferred provider organization (PPO) option and/ or an exclusive provider organization (EPO) option. The types of services that are covered under each of the options are largely the same, although the costsharing provisions differ.

PPO or EPO? Unless otherwise specified, the benefits described in this guide are available under both the PPO and EPO medical options.

Under both medical coverage options, you’ll have comprehensive healthcare coverage, which includes • preventive care; • hospital and medical/surgical coverage; • behavioral health benefits; • prescription drug coverage; and • resources to improve your health and well-being. While the Board of Pensions of the Presbyterian Church (U.S.A.), an agency of the Church, administers the Medical Plan, it contracts with companies that specialize in health and wellness benefits to provide claims processing and other support services: Highmark Blue Cross Blue Shield, one of the largest BCBS organizations in the United States, is responsible for processing medical claims, and OptumRx, one of the leading pharmacy benefits managers, is responsible for processing prescription drug claims. (For a complete listing of service providers, see Contact Information.) This booklet summarizes these benefits and explains how to access them. It also provides general information about cost and eligibility.

About the Plan The Benefits Plan, a church plan under §414(e) of the Internal Revenue Code, is not subject to the Employee Retirement Income Security Act of 1974 (ERISA). Under the Church Plan Parity and Entanglement Prevention Act of 1999, it is exempt from state insurance licensing, solvency, and funding requirements. The Medical Plan of the Presbyterian Church (U.S.A.) is self-funded, which means its benefits are not provided through an insurance company. The plan’s ability to pay claims depends on continued contributions, claims experience, and market performance.

Page 1

The terms out of network and non-network refer to healthcare providers that do not participate in the PPO or EPO.

A NETWORKDRIVEN PLAN The Medical Plan provides access to a broad Blue Cross Blue Shield (BCBS) network of physicians, hospitals, and other medical facilities with which the plan has a contractual relationship; these are called network providers. All members are encouraged to use network providers: The contracted rates established with network providers result in savings to both you and the plan, and you can receive services from any network provider without coordinating your care through a primary care physician.

PPO Medical Option Under the PPO option, you may receive treatment from a provider who is in network or out of network; however, seeing an out-of-network provider will cost you more unless you live in an area not served by the network (see Non-Network). Emergency services provided at a non-network provider are the only exception. See Emergency and Urgent Care Services.

EPO Medical Option Under the EPO option, you must use network providers (the same BCBS network as the PPO). Costs for services from out-of-network providers are not covered unless you live in an area not served by the network (see Non-Network). If you visit an outof-network provider when you have access to a provider that participates in the network, you are responsible for all costs incurred.

Non-Network If you reside in an area not served by the network — a non-network area — and therefore cannot access a provider that participates in the network, your medical costs under the plan will be the same as if you were using a network provider. When you see a non-network provider, you’ll need to submit your own claims for reimbursement by the plan. Whether you reside in a network or nonnetwork area is determined by whether network providers are available within a certain travel distance. In the rare instance where a particular specialty is not available in your area through the network, out-of-network expenses may be approved for reimbursement at the network rate. You must get the Board’s approval in advance to qualify for this exception.

Page 2

Your Service Providers

Routine Vision Services

Be familiar with the service providers that administer benefits on behalf of the Board of Pensions for both the PPO and EPO medical options. (See the Appendix for a list of the plan’s service providers and their contact information.)

The Medical Plan participates in the VSP Choice network, a broad network of optometrists and ophthalmologists administered by VSP, for routine annual eye exams. (The VSP Choice network is distinct from the BlueCard PPO network of physicians.)

Medical and Behavioral Health Services

You don’t need an ID card to access VSP services under the Medical Plan. (See Routine Eye Exam Coverage in Medical Plan Basics.)

Highmark oversees most of your healthcare benefits. Call them to pre-certify the medical, surgical, and behavioral health services specified on the back of your Highmark ID card or to reach the 24-Hour Nurse Line. Many of Highmark’s services are described in Other Wellness Benefits. Cigna administers the Employee Assistance Program (EAP). You don’t need an ID card to access EAP services under the Medical Plan. (See the section Other Wellness Benefits for information on the EAP.)

Prescription Drug Program Services As part of your healthcare coverage, you have access to prescription drug benefits, both at participating local retail pharmacies and through mail order. These benefits are administered by OptumRx, the plan’s service provider for prescription drugs. See the section Your Prescription Drug Benefits.

To find out if a certain provider participates in the Highmark network, visit highmarkbcbs.com and select Find a Doctor or Rx, then click on Find a Doctor, Hospital or other Medical Provider.

Show this card at your medical care provider or hospital admissions office. On the front, it reflects your $0 copay for covered preventive care services. On the back, your ID card lists services that require advance approval, or pre-certification. The back of the card also lists the numbers to call for EAP services, provided by Cigna Behavioral Health, and for the 24Hour Nurse Line, provided by Highmark. Whenever you receive a new ID card, shred the old one.

Telemedicine You also have access to a telemedicine benefit with Teladoc through the Medical Plan. (See Use the telemedicine option.) Use your OptumRx card when you fill prescriptions at a participating pharmacy, or order directly from OptumRx for delivery by mail. You can also use this card to get routine vaccines, such as flu shots, at a participating pharmacy at no cost to you.

Page 3

When You Need Help Now ... The phone numbers and Web addresses of the Board of Pensions and its service providers are listed in the Contact Information section, in the back of this guide.

EMERGENCY AND URGENT CARE SERVICES If you need emergency care, call 911 and seek care from the nearest provider or hospital emergency room (ER), regardless of network participation. ERs are the most prepared and best equipped facilities to handle serious, potentially life-threatening medical needs. The services provided in an ER are subject to the plan’s deductible and copayment provisions.

Notification To maximize your benefits, you must notify Highmark within 48 hours of an inpatient emergency admission for: • physical illness or injury

Alternatives to the ER If unsure whether you really need emergency care when your symptoms are not life-threatening, consider these alternatives: • Contact your primary care physician. Your primary care physician is generally best suited to treat non-life-threatening conditions and manage your care over time. • Call the 24‑Hour Nurse Line, provided by Highmark, at 888-8352959. Always available, including weekends and holidays, the Nurse Line is staffed by an experienced nurse, who will help you to assess the problem and consider the most appropriate place for treatment. (See 24-Hour Nurse Line in Other Wellness Benefits.)

• mental health or substance use disorder treatment If you go to an ER and are admitted to an out-of-network hospital or other facility, once the emergency is addressed, you may need to transfer to a network provider. A visit to an ER without admission does not have to be certified — that is, you do not have to notify Highmark.

Ways To Contact the Board • L og on to Benefits Connect for medical coverage information (including coverage levels), resources, and support • Call 800-773-7752 (800-PRESPLAN) Monday - Friday, 8:30 a.m. to 5:00 p.m. ET • Email [email protected]

Page 4

Copays and Copayments Yo u r c o p a y s a n d c o p a y m e n t responsibilities depend on whether you are covered under the PPO or EPO and the type of service you receive. See the 2017 Provisions: Key PPO & EPO chart in the Appendix or on pensions.org.

• Go to an urgent care center. A freestanding healthcare clinic, an urgent care center generally is staffed by physicians who can treat serious but non-lifethreatening accidents and injuries, such as burns, cuts, and sprains, or common illnesses like the flu, allergic reactions, and infections. No appointment is necessary. Your visit is subject to an urgent care center visit copay (same as a specialist copay), but is not subject to a deductible or copayment unless higher-level services, such as laboratory or X-ray services, are also used. • Visit a retail medical clinic (typically in a pharmacy). Use a pharmacy medical clinic — generally staffed by certified registered nurse practitioners — for more minor ailments in after-hours situations. This visit is subject to a primary care visit copay and not subject to a deductible or copayment.

The Board of Pensions is here to help you understand — and make the best use of — your benefits. The Board provides several key resources to help you with all of your benefits under the Benefits Plan and the Medical Plan in particular: • Pensions.org: Features benefit overviews, plan and program bulletins, and other important information. Visit pensions.org often to see what’s new! • Benefits Connect: Provides secure, online access to your personalized benefits information. Available 24/7 from the home page of pensions.org, this site lets you • enroll in and review your key coverage, including medical coverage, and certain optional benefits online; • view contact and dependent information; and • simplify logins to the websites of many of the Board’s service providers, including Highmark and OptumRx, among others. • Board of Pensions Service Representative: Helps you with your questions about plan benefits and is focused on ensuring you receive excellent service, tailored to your needs. Speak with a service representative when you have • eligibility, dues, or payment questions; • a family status, work situation, address, or salary change; or • concerns that arise with a service provider.

• Use the telemedicine option, provided by Teladoc through Highmark, at 800-835-2362. Preregister with Teladoc so you and your family’s health histories are on file. Then, for a modest copay, you can get a consult with a physician — and even get a prescription — 24/7 for common, acute issues, such as your child’s ear infection or your sinusitis.

Page 5

2.COVERAGE ELIGIBILITY AND CONTRIBUTIONS Eligibility for Medical Plan coverage and any coverage contributions are determined by your employer following the broad parameters of the plan.

INSTALLED PASTORS Installed pastors must be enrolled in Pastor’s Participation, regardless of the number of hours the pastor is regularly scheduled to work. Benefits for installed pastors in Pastor’s Participation include full family medical coverage in the preferred provider organization (PPO) option on a non-contributory basis. In addition to the pastor, the following family members are eligible for full family medical coverage: • spouses • children younger than 26, regardless of their financial dependency, marital status, or residency • dependent, totally disabled children who are covered under the plan before they reach age 26 If you are enrolled in Pastor’s Participation, you may not waive medical coverage for yourself but may waive coverage for your spouse and/or other eligible family member. If you waive coverage for family members, your employer is still responsible for paying the full dues amount; family member participation does not affect dues.

Page 6

OTHER TEACHING ELDERS Teaching elders who are not in an installed pastoral relationship are considered to be other teaching elders. If you are regularly scheduled to work at least 20 hours a week, your employer may offer you either Pastor’s Participation or menu options. If you are enrolled in Pastor’s Participation, you’ll have full family medical coverage in the preferred provider organization (PPO) option on a non-contributory basis. There is no minimum-hours requirement for other teaching elders to enroll in medical coverage in menu options. If you are enrolled in menu options, you will have the same comprehensive medical coverage as is offered under Pastor’s Participation, but your employer may ask you to contribute toward the cost of coverage.

OTHER EMPLOYEES Employees other than teaching elders who are regularly scheduled to work 20 or more hours per week may be enrolled in menu options only. Employees who decide to enroll in medical coverage under menu options may also enroll their eligible family members, subject to any contributions required by their employers. Eligible family members are • spouses; • children younger than 26, regardless of their financial dependency, marital status, or residency; and • dependent, totally disabled children who are covered under the plan before they reach age 26. If you are in menu options, you may waive medical coverage for yourself and any family members. If you are considering waiving medical coverage, see Waiving Medical Coverage Offered through Menu Options.

Note: If you waive medical coverage for yourself and/or your eligible family members, you will not be able to elect Medical Plan coverage until the next annual enrollment (unless you have a qualifying life event). A change in status may not be a qualifying life event.

Contributions Employer-specific coverage -level rates apply to coverage through menu options for the Preferred Provider Organization (PPO) and/ or Exclusive Provider Organization (EPO). Employers must pay at least 50 percent of Member-only coverage for the lowest-priced medical option they offer, and employees may be required to contribute the balance of the cost of their coverage.

All members must report any change in marital or eligible dependent status to the Board of Pensions within 60 days of the event. To report a life event, download the Life Event Change form from pensions.org or call 800‑773‑7752 (800-PRESPLAN) to request the form; complete it and return it via mail or fax.

Employees may also be required to pay up to the full cost of coverage for family members.

Page 7

Waiving Medical Coverage Offered through Menu Options If you are considering waiving medical coverage offered through menu options, you should carefully consider the following: • Some employers limit spousal medical coverage to spouses whose own employers do not offer medical coverage. In that case, if you are offered coverage through the Medical Plan, you may not be eligible for coverage under your spouse’s employer plan. In addition, some employers impose an additional charge for spouses enrolled in their plan if they have coverage available to them elsewhere. Before waiving Medical Plan coverage, you should confirm your eligibility for and the costs of your spouse’s plan. • If you waive Medical Plan coverage, you may be assessed shared responsibility payments under the Affordable Care Act if you do not obtain coverage elsewhere. Potential coverage sources include a spouse or parent’s employer; government programs such as Medicare, Medicaid, and TRICARE; and health insurance exchanges. • If you are offered coverage through the Medical Plan, you cannot qualify for a subsidy for coverage obtained through a health insurance exchange. If you waive medical coverage for yourself and/or your family members, you will not be able to elect Medical Plan coverage until the next annual enrollment period (unless you have a qualifying life event). A change in status may not be a qualifying life event.

Page 8

MEDICAL CONTINUATION COVERAGE Eligible members whose active coverage under the Medical Plan is ending may extend their medical coverage on a self-pay basis by enrolling in medical continuation coverage or, if ending Pastor’s Participation and otherwise eligible, by enrolling in transitional participation coverage. Information on these programs, including eligibility rules, is available in the Medical Continuation Benefits Overview and Continuing Coverage at Termination of Eligible Service. Both publications are available on pensions.org or by request from the Board of Pensions at 800-773-7752 (800-PRESPLAN).

3. YOUR RESPONSIBILITIES The Board of Pensions has certain obligations to you as a Medical Plan member, and you have certain responsibilities in return. By all parties fulfilling their responsibilities, the entire community of members covered by the plan receives a benefit. Together, we can ensure smart, safe, and efficient use of a critically important resource — our Medical Plan.

CARRY YOUR ID CARDS Your Highmark ID card shows that you are covered by the Medical Plan; your OptumRx ID card, by the Prescription Drug Program. Carry both cards so that you have them available for emergency and routine use. You do not need special ID cards to access your EAP benefits with Cigna or vision benefits with VSP.

You may request additional or replacement cards at any time by contacting Highmark or OptumRx. Be sure to shred the old cards whenever you receive new ID cards.

GET ADVANCE APPROVAL WHEN REQUIRED For certain tests and procedures, you must receive approval before having them performed — that is, you must get them pre-certified or you may be responsible for their cost. The tests and procedures that require advance approval are listed on the back of your medical ID card, along with the phone numbers to call. You also must pre-certify non-urgent hospital admissions. In many cases, your provider’s office will coordinate the precertification process for you to ensure pre-certification has been obtained. In an emergency, seek out the care you need from the nearest provider. Notify Highmark within 48 hours of an inpatient emergency admission.

Page 9

For detailed pre-certification requirements, how-to information, and more, see Pre-Certification Requirements in Medical Plan Basics.

To pre-certify a non-urgent hospital admission, procedure, test, or facilitybased behavioral health treatment, you or your provider should immediately call Highmark, using the phone number listed on the back of your medical ID card.

REPORT QUALIFYING LIFE EVENTS Certain events or changes in your life can affect your benefits status or coverage. For this reason, you must inform the Board of Pensions within 60 days of any qualifying life event, such as welcoming a child, getting married, losing a covered family member, or losing other medical coverage. Reporting these changes accurately and on a timely basis ensures your benefits are in place when and where you need them and allows the Board of Pensions to better communicate with and serve you. You can notify the Board of Pensions of a qualifying life event by doing one of the following: • Go to pensions.org and select Available Resources. Click on Forms, then scroll to the relevant form. Download the form and complete and mail or fax it to the Board at the address or fax number indicated on the form. • Call the Board to request the appropriate notification form, and complete and submit the form by mail or fax.

Page 10

UNDERSTAND YOUR SHARE OF THE COSTS The following Summary of Coverage chart helps you determine the types of charges for which you are responsible. Your costs largely depend on whether your providers are in the network or not. Additional cost details are provided in the next two sections: Medical Plan Basics and Your Medical Benefits.

PROTECT PLAN RESOURCES The Medical Plan has finite resources. Its financial viability depends largely on current dues and claims experience. The health of its members, in part, determines the claims experience. As steward of the Medical Plan, the Board of Pensions encourages you to pursue every opportunity to improve your health and well-being — for your sake as well as the plan’s. Eat healthy foods, get plenty of exercise, and take advantage of the preventive care and wellness resources provided by the plan. Participate in and complete Call to Health each year. Also, seek care from the right providers in the appropriate settings. See Emergency and Urgent Care Services in the Overview section of this guide. Protect your medical and prescription ID cards so that no one other than you and your eligible family members accesses your Medical Plan benefits. It is in everyone’s interest not to permit expenses to be incurred by individuals who are not eligible for coverage.

And finally, please review the online claims summaries or Explanation of Benefits statements provided by Highmark Blue Cross Blue Shield on its website or in print. Check that any claims paid are for services received by you or your eligible family members.

This helps to minimize inappropriate and mistaken charges to the plan. If, for any reason, you believe your Medical Plan benefits have been accessed inappropriately, please call the Board of Pensions immediately.

S U M M A R Y YO U SE EK SE R V I CES IN A:

THE PROVIDER IS A:

Network area

Network provider

O F

C O V E R A G E

B E N E F I T

L E V E L

1

Office visits: For office visits when you are sick, you pay a fixed copay amount; the amount depends on whether the visit is to a primary physician or a specialist; for preventive care visits, there is no copay.2 Copays do not count toward the plan’s annual deductible and copayment maximum. Other services during sick visits (such as blood tests) may be subject to other copays, network deductibles, or copayment requirements, depending on whether you participate in the PPO or EPO; tests and screenings listed in the 2017 Preventive Schedule and performed in connection with preventive care visits are provided at no charge to you. Hospital inpatient and outpatient services: You pay annual network deductible(s) and network copayments of 20% (after deductible) up to a maximum. The plan pays a percentage of contracted rate (100% after annual copayment maximum, if applicable, is reached). Provider may not bill you for the balance of charges. Routine eye exam: You pay a fixed copay, without deductible, for a routine annual eye exam with a VSP provider.

Out-of-network provider

Office visits (PPO only): You pay a percentage of the plan allowance for all office visits, including preventive care visits, to out-of-network providers.2 Inpatient and outpatient services (PPO only): You pay annual out-of-network deductible(s) and copayments of 40% (after deductible) up to a maximum. The plan pays a percentage of plan allowance (100% after annual outof-network copayment maximum is reached). Provider may bill you for the balance of charges over the allowance established by the plan. Routine eye exam: At time of visit, you pay the full amount owed for the routine annual eye exam. Upon making a claim, you will be reimbursed up to a limit after your fixed copay is deducted.

Non-network area

Mix of network and out-of-network providers

Inpatient and outpatient services when: • The hospital, outpatient facility, and attending physician3 are network providers: All claims are paid at the network rate, subject to deductibles and copayment maximum. • The hospital, outpatient facility, or attending physician is out of network: Network providers are paid at the network rate; all others are paid at the out-of-network rate (PPO only). • The hospital and attending physician are network providers: Ancillary services that may be provided by out-of-network providers (anesthesiologists, radiologists, and others) are reimbursed at the network rate, subject to the plan allowance.

Out-of-network and network providers

All claims from non-network area providers are paid at network rates, subject to the plan allowance. The plan allowance is up to 120% of the Blue Cross Blue Shield participating provider rate in the area. You may be subject to balance billing if your provider charges fees in excess of the plan allowance.

See the 2017 Key Provisions: PPO & EPO chart and 2017 PPO Deductibles and Copayment Maximums chart (Appendix) to determine your office copay amounts, deductibles, and family copayment maximum.

1

For details and limitations of preventive care coverage, see Preventive Care Benefit in Your Medical Benefits.

2

Attending physician means the physician who is the primary treating physician for an inpatient — e.g., the surgeon when a patient is admitted for surgery.

3

Page 11

4. MEDICAL PLAN BASICS With the cost of healthcare continuing to rise, you’ll want to make sure a particular treatment is covered before incurring the expense. This section can help you do that by highlighting what’s covered and what’s not, and by explaining the rules and limitations of coverage under the Medical Plan.

• not custodial or for the convenience of the patient or provider; • not educational, experimental, or investigative in nature; • of demonstrated medical value to the member (that is, the member is capable of benefiting from the proposed care); and • the most appropriate standard or level of services.

MEDICAL NECESSITY WHAT’S COVERED The Medical Plan covers the medically necessary services STANDARD and supplies shown in the following chart. Coverage is

The Medical Plan pays its share of covered costs when the services are medically necessary. Medically necessary healthcare services and supplies are • provided or prescribed by an accredited hospital or a licensed physician; • appropriate to the symptom and diagnosis or treatment plan;

Page 12

for amounts up to the plan allowance and subject to the applicable deductibles and copayments. Although this chart lists most of the services and supplies covered by the plan, it is not necessarily all-inclusive. (Prescription coverage under the plan is described in Your Prescription Drug Benefits.) If you are unsure whether a service or supply is covered, contact Highmark, as appropriate, before incurring the expense. If still in doubt, call the Board of Pensions at 800‑773-7752 (800-PRESPLAN) and speak with a service representative.

Limits to Coverage The Medical Plan has maximum reimbursement limits on cer tain services and an annual maximum benefit limit per individual. (For a list of these limits, see the Appendix.)

Women’s Health Protection Reproductive Health Coverage Prescribed birth control is 100 percent covered if the prescription is for a generic contraceptive or one listed on the formulary. If so, no copayment is required. PPO: Medically necessary in vitro fertilization procedures are covered services, subject to plan limits, which include a lifetime maximum. (See the Appendix.) EPO: Fertility services are not covered under the EPO. Consistent with the Presbyterian Church (U.S.A.)’s affirmation of the ability and responsibility of a woman to make good moral choices regarding problem pregnancies, the Medical Plan reimburses medical costs for abortion procedures, subject to plan limits. The Presbyterian Church (U.S.A.) further affirms that abortion should not be used as a method of birth control, for gender selection only, or solely to obtain fetal parts for transplantation.

COVERED MEDICAL SERVICES1 P R E V E N T I V E

C A R E

S E R V I C E S

2

Immunizations Routine child, routine adult, and routine gynecological P R O F E S S I O N A L

S E R V I C E S

Primary care and specialist physician fees for office visits, allergy shots, therapeutic injections, surgery, and second opinions before a non-urgent surgical or diagnostic procedure is performed; telemedicine (through Teladoc) Diagnostic laboratory tests (whether outpatient, independent lab, or physician’s office) Outpatient imaging services, including MRI, CT scan, and PET scans (with pre-certification), and ultrasounds and X-rays (without pre-certification) Nuclear stress tests (with pre-certification) Hearing aids and fittings (PPO only)3 Advanced reproductive technology procedures (up to three attempts)4 Behavioral health (outpatient therapy, including marriage counseling via EAP) Outpatient rehab, including physical, occupational, and speech therapy5 Routine eye exam6 Chiropractic Acupuncture H O S P I TA L

S E R V I C E S

Inpatient stay (with pre-certification), including related services (imaging, testing, etc.) and surgery Inpatient rehab (with pre-certification) Outpatient procedures (with pre-certification for designated procedures) Skilled nursing facility Mastectomy-related benefits, including reconstruction, surgery, prostheses, and treatment of physical complications (Women’s Health and Cancer Rights Act) Emergency room care for medical emergency Organ transplants7 Behavioral health (inpatient care)(with pre-certification) OT H E R

S E R V I C E S

A N D

S U P P L I E S

Ambulance or certain commercial transportation

8

Urgent facility care Subject to plan’s managed care and exclusion and Private duty nursing in a hospital (if intensive care unit available) limitation provisions. 2  For a detailed list, see the 2017 Preventive Home health and hospice care (with precertification) Schedule in the Appendix. 3  The plan pays for hearing aids and fittings once Durable medical equipment and supplies every three years, up to a certain limit. See the Medical Plan Reimbursement Limits chart in the Appendix. 4  See the Medical Plan Reimbursement Limits chart in the Appendix. 5 See Specialized Therapies in this section. 6 See Vision Costs chart in the Appendix. 7 See Organ Transplants in this section. 8 To nearest facility equipped to furnish treatment only. 1 

Page 13

Be sure to add your baby — your new dependent — to your coverage within 60 days of birth or adoption by notifying the Board. To do so, download a Life Event Change form from pensions.org, or call the Board to obtain this form. (You will need to include a copy of the birth certificate to add your baby to the plan.) If you do not enroll your newborn within this time frame, you will need to wait until annual enrollment.

For details of the PC(USA) affirmation, see Minutes, 204th General Assembly (1992), available upon request from the Board of Pensions. Churches and other employing organizations that object, as a matter of conscience, to the use of their dues for abortion procedure costs may apply for relief of conscience. Monies offset from Medical Plan dues of employers that have applied for and received relief of conscience are deposited in the Board’s Assistance Program and used to help provide Adoption Assistance Grants to plan members. For more information regarding this administrative policy and Adoption Assistance Grants, contact the Board of Pensions and speak with a service representative.

Pregnancy Highmark’s Baby BluePrints maternity program offers tools, educational resources, and ongoing suppor t throughout your pregnancy. Upon enrolling in Baby BluePrints, you will receive an enrollment confirmation mailing with helpful pregnancy tips. In addition, online resources are available and include topics such as the proper use of medications, avoiding alcohol and tobacco, working, travel considerations, nutrition and weight gain, exercise, and body changes. Enrolled participants will also have access to a personal nurse health coach throughout their pregnancy. Baby BluePrints is included in your healthcare benefits. To enroll, call 866918-5267 or call Highmark at 888-8352959 and ask to be directed to Baby BluePrints. Page 14

Maternity Care In conformity with federal law, the plan covers maternity expenses, including a hospital stay of not less than • 48 hours following a normal vaginal delivery; or • 96 hours following a delivery by caesarean section. The mother may be discharged sooner, but only if the decision is made by the attending physician in consultation with the mother. The plan covers medical expenses for services provided in a hospital or in a birthing facility by a midwife, if the midwife is state-licensed.

Breast Reconstruction Also in conformity with federal law, the plan provides breast reconstruction benefits to members and dependents who are receiving care in connection with a mastectomy. These benefits will be provided in a manner determined in consultation with the attending physician and the patient. The plan provides coverage for the following: • all stages of reconstruction of the breast on which the mastectomy was performed • surgery and reconstruction of the other breast to produce a symmetrical appearance • prostheses and treatment for physical complications, including lymphedemas, at all stages of the mastectomy These services are subject to the plan’s deductible and copayment requirements.

Behavioral Health Services The Board urges you to contact Highmark before beginning treatment with a therapist, although this is not a requirement. Highmark can help match you with a provider who has the appropriate background and experience to address your concerns. Highmark network providers all are properly credentialed and licensed. PPO: If you choose a provider who is not part of the network and Highmark certifies that the treatment is medically necessary, you receive benefits on the out-of-network basis and so pay a percentage of the plan allowance. (For copayment information, see the Appendix.) EPO: To access your benefits, you must use a network provider. If you choose a provider who is not part of the network, you will be responsible for 100 percent of the costs. If you or any eligible family member calls Highmark when experiencing what you believe is a behavioral health crisis (mental health or substance use disorder), you will immediately be connected to one of Highmark’s licensed mental health professionals, who will help you determine the best next steps for your situation. In any crisis situation, however, it is usually better to seek crisis services directly from a behavioral health professional or emergency room.

If you require inpatient, par tial hospitalization, intensive outpatient, or residential treatment center care, Highmark will review your treatment with your provider and authorize continued stays in the program based on medical necessity guidelines. Depending on the type of service you receive, you may be contacted by a Highmark case manager by phone (and sometimes by letter if the case manager can’t reach you). The Board strongly encourages you to accept the call and speak directly to the case manager. This individual is a licensed behavioral health professional who can help you in a variety of ways, including helping you obtain the right services at the right time for your situation, coordinating your care and advocating for you with your providers or program, helping you to develop realistic and attainable short- and long-term goals, helping you learn about community resources, and sometimes just provide a listening ear. Case management provides an important service to support overall success in treatment. Remember that inpatient mental health or substance use disorder treatment must be medically necessary. If you are admitted for inpatient treatment without first contacting Highmark, be sure to certify your admission. Either you or someone acting on your behalf must notify Highmark within 48 hours of your admission so the treatment plan can be reviewed with your doctor and a determination made regarding the medical necessity of the admission and any continued inpatient care.

Page 15

Blue Distinction Centers for Specialty Care The Blue Cross Blue Shield Association has awarded the designation Blue Distinction to certain medical facilities that have demonstrated expertise in delivering high-quality healthcare. The association provides this information to encourage providers to improve the overall quality and delivery of healthcare, and to help patients identify medical facilities that best meet their needs for certain conditions and procedures. There are specialty care centers for the following: • bariatric surgery • cardiac care • complex and rare cancers • knee and hip replacement • spine surgery • transplants For members who receive any of the above-listed services at a Blue Distinction facility 100 miles or more from their home, a travel and lodging benefit for the covered patient and a companion is provided. The Blue Cross Blue Shield website identifies the selection criteria for and names of hundreds of Blue Distinction facilities across the country.

VSP Out-of-Network Claims You can limit your costs if you see a VSP-participating provider for your routine eye exam. If your optometrist or ophthalmologist is out of network, however, you can submit your claim to VSP and you’ll be reimbursed up to a certain dollar amount after your copay is deducted.

Page 16

Routine Eye Exam Coverage The Medical Plan covers routine annual eye exams with VSP-participating optometrists and ophthalmologists, subject to a copay with no deductible, under both the PPO and EPO. Comprehensive eye exams can lead to the early detection of serious eye conditions and early signs of other chronic health conditions. And, getting a documented vision exam counts toward your Call to Health point total. (For copay amounts, see the Vision Costs chart in the Appendix.) The cost of prescribed glasses and contact lenses is not covered under this benefit; however, discounts for these items are available at participating providers. You don’t need a special ID card to use your vision benefit. When you visit a participating provider, simply give your name and the last four digits of your Social Security number to confirm your coverage. For a list of VSP-participating providers, go to vsp.com/choice.

Specialized Therapies The Medical Plan covers medically necessar y visits for physical, occupational, and speech therapy. Speech therapy, however, is covered only when prescribed by a physician for correction of a speech impairment resulting from disease or trauma. Therapy services that are primarily developmental are not covered under the plan, except through the habilitative services benefit for children with certain congenital developmental disabilities. If you and your therapist expect you will need more than 25 sessions, contact Highmark to initiate such a review by your 20th session. By allowing adequate time for the review process, you can avoid interrupting your therapy.

Organ Transplants For organ transplants, you and your eligible dependents have access to Blue Distinction facilities throughout the country. These facilities, deemed among the best in the country, are rigorously evaluated for quality of care. All transplant patients are enrolled in Highmark’s Case Management Program. Special transplant benefit: For a covered transplant at any location (not necessarily a Blue Distinction facility), if the surgery occurs 100 or more miles from home, a travel and lodging benefit for the covered patient and a companion is provided. (See the Appendix.)

Habilitative Services for Developmental Disabilities The plan covers the habilitative services described here for eligible children who have any of the following developmental disabilities: • autism spectrum disorder • cerebral palsy • Down syndrome • intellectual disability (mental retardation) • spina bifida The services covered are intended to improve the level of the child’s physical, mental, and social development, and assist the child in acquiring and maintaining life skills to cope more effectively with the demands of his or her condition and environment. Covered habilitative services are subject to the plan allowance, deductible, and copayment provisions of the plan.

Applied Behavior Therapy To be eligible for applied behavior therapy — i.e., the design, implementation, and evaluation of environmental modifications — the child must participate in Highmark’s Case Management Program. Through this program, Highmark assigns a nurse case manager with expertise in pediatric developmental issues to coordinate all available resources for the child, including medical and school services and any other community agency services.

Specialized Therapies Specialized therapies, including speech, occupational, and vocational therapies, are covered, subject to a standard of medical necessity defined below, up to an annual maximum number of visits per therapy type. After an initial number of visits in a given therapy, the child must participate in the Case Management Program with Highmark to continue coverage.

Different provisions and limitations apply to specialized therapies when provided outside of the habilitative services benefit, as described in Specialized Therapies.

Habilitative Services and Medical Necessity For purposes of the habilitative services benefit described in this section, medically necessary means the covered therapy, subject to plan limits, is reasonably expected to accomplish (or will accomplish) one or more of the following: • arrive at a correct medical diagnosis • prevent the onset of an illness, condition, injury, or disability • reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury, or disability • assist in the achievement or maintenance of sufficient functional capacity to perform ageappropriate or developmentally appropriate daily activities

Page 17

Pre-Certify with Highmark: • hospital admission for nonemergency medical or surgical treatment, including maternity • bariatric or other weight-loss surgery • scheduled outpatient imaging, excluding X-rays and ultrasounds • scheduled nuclear stress tests • all facility-based treatment for mental health or substance use disorders • biofeedback and electroshock therapies • prescriptions for medical injectable drugs

Pre-certification is required for inpatient hospital admissions outside of the United States. (See International Travel.)

PRE-CERTIFICATION REQUIREMENTS Yo u m u s t g e t a p p rova l b e fo re having certain tests and procedures performed; if you do not pre-certify the specified tests and procedures, you may be responsible for their cost. Most tests and procedures that require advance approval are listed on the back of your medical ID card, along with the phone numbers to call. If your provider recommends a non-urgent hospital admission or a procedure or test that requires precertification, your provider should immediately call Highmark, using the phone number on the back of your medical ID card. The approval process takes up to 10 days, so it’s important your doctor ’s office request precertification as soon as you’re aware that the test or procedure needs to be performed; otherwise, the medical service may be delayed. Certain specialized procedures — bariatric surgery, for example — may require additional time.

Page 18

Emergency Admission In an emergency, seek the care you need from the nearest provider. Certification of your admission must occur within 48 hours of an inpatient emergency admission to maximize your benefits. Call Highmark in a medical or surgical emergency or for a mental health or substance use disorder emergency. Pre-certification requirements are the same regardless of whether you live in a network or non-network area. In many instances, your provider’s office will coordinate the pre-certification process for you. However, it’s your responsibility to verify that precertification has been obtained. If you are unsure whether a test or procedure needs advance approval, call the Board of Pensions at 800‑7737752 (800-PRESPLAN) before having it performed.

If You Don’t Obtain Advance Approval The pre-certification process helps to manage costs for you and the plan by ensuring members receive medically necessary and appropriate care. If you fail to pre-certify services when necessary, benefits may be denied. Highmark will retroactively review the appropriateness and medical necessity for the services.

If the services . . .

W H AT ’ S N O T C O V E R E D B Y Y O U R M E D I C A L P L A N

• would have been precertified had they been submitted as required, the claim is processed as usual.

E X P E R I M E N TA L O R I N V E S T I G AT I O N A L M E D I C A L T R E AT M E N T Any experimental or investigational medical treatment, as determined by Highmark D E N TA L 1

• do not qualify for certification as appropriate and medically necessary, no benefits are payable, including all related charges.

Dentures Dental X-rays (An optional dental program is available on a self-pay basis.) Dental services (including orthodontic services that are related to a covered medical cost), except for services related to the removal of bony impacted wisdom teeth, injury to sound natural teeth, and treatment for TMJ2 HEARING

WHAT’S NOT COVERED

Hearing aids and fittings (EPO only) VISION

The Medical Plan does not cover certain expenses. The What’s Not Covered by Your Medical Plan chart lists most of the services and supplies excluded from coverage under the plan; however, it does not include every item that is not covered. (Excluded drugs are not included, for example — see Your Prescription Drug Benefits.)

Eyeglasses (Discounts are available through VSP providers.) Vision surgery to alter the refractive character of the eye (Discounts are available through VSP providers.) FOOT ORTHOTICS3 If prescribed for: • weak, strained, flat, unstable, or unbalanced feet, metatarsalgia or bunions, corns, calluses, or toenails • nonsurgical treatment of fractures • replacement of existing orthotics designed to treat a covered condition, unless they are irreparably damaged due to normal wear and tear or a change in the patient’s condition or size OTHER PROFESSIONAL SERVICES AND SUPPLIES Cosmetic surgery, treatment, or supplies Services provided by a person who ordinarily resides in a member’s home or is related to the patient Custodial care

If you are unsure whether a service or supply is covered, contact Highmark or the Board of Pensions before incurring the expense.

Group homes, educational programs (except the educational benefit for diabetics), wilderness/boot camps, and educational testing Medical reports or charges Services payable under any workers’ compensation law or similar legislation Medical services provided by a U.S. government facility or received elsewhere for which the member is not legally obligated to pay Reversal of a previous sterilization procedure The Medical Plan does provide limited coverage for dental reconstruction resulting from trauma or injury. Benefits for TMJ-related services have a lifetime limit. See the Medical Plan Reimbursement Limits chart in the Appendix. 3 Foot orthotics are covered if prescribed by a physician for treatment of metabolic, peripheral vascular disease, or other medical conditions if not specifically excluded above. 1 2

Page 19

5. YOUR MEDICAL BENEFITS Your medical coverage is designed to promote your health and well-being and give you significant financial protection. It includes preventive, routine, and catastrophic coverage by a network of providers with a proven record of delivering high-quality care. This section discusses your share of the costs for medically necessary medical, surgical, and behavioral health treatment through the plan, and outlines reimbursement procedures for out-of-network care, if applicable. (Prescription drug coverage is discussed in the next section.)

P R E V E N T I V E

1

YOUR SHARE OF THE COSTS The Medical Plan promotes shared responsibility for healthcare costs by requiring plan members to pay copays, deductibles, and copayments for certain services. Your share of the costs for medical expenses depends on • the type of coverage you have (PPO or EPO) — depending on whether you’re covered under the PPO or the EPO, you are responsible for different deductibles, copays for office visits, costs for specific outpatient services, and copayment maximums.

C A R E

C O V E R A G E

ELIGIBLE MEMBER

SERVICES

PROVIDER

Adults and children ages 3 and older

Annual general wellness exam and specified screenings, immunizations, and blood tests

Primary care provider

Females

Annual gynecological wellness exam and specified screenings, immunizations, and blood tests; contraceptives; breastfeeding counseling, support, and supplies; HIV counseling and screening; and more1

Gynecologist or nurse practitioner

Babies up to 30 months of age

Specified well-baby visits and specified immunizations

Pediatrician

Internationally adopted children through age 18

Additional specified screenings and immunizations

Primary care provider

For a complete list of covered services, screenings, and procedures, see the 2017 Preventive Schedule in the Appendix.

Page 20

• the type of service you need — when you visit the doctor, the amount you pay first depends on whether you are getting preventive care or seeking treatment for an illness, injury, or condition. Second, the cost structure for certain outpatient services differs depending on whether you are in the PPO or the EPO. • your choice of provider — under the PPO, if you use a network provider you pay less than if you see an out-of-network provider; under the EPO, you must see a network provider or you’ll pay the full cost for the service. For cost-sharing details, see the chart 2017 Key Provisions: PPO & EPO in the Appendix.

Preventive Care Benefit The plan provides annual preventive care for you and your eligible family members, at no cost to you, to promote wellness and early detection of disease. Under both the PPO and EPO, when you visit a network provider, the plan covers 100 percent of the plan allowance, with no deductible, for • annual wellness exams with a primary care provider according to the Preventive Schedule (see the Preventive Care Coverage chart); • eligible preventive screening and immunization procedures; and • eligible preventive blood tests. You have a $0 copay when you use a network provider for these services.

PPO: When you visit an out-of-network provider for preventive care services, the plan covers 50 percent of the plan allowance, with no deductible, and you pay the remaining 50 percent and any charges above the allowed amounts. EPO: You must visit a network provider to access the preventive care benefit; otherwise, you pay the full cost for these services. Prescribed contraceptives that are generic or listed on the formulary also are 100 percent covered under both the PPO and EPO (you have a $0 copay). Eligibility for covered preventive screenings, immunizations, and tests is based on age and gender. Refer to the 2017 Preventive Schedule, a chart listing covered screenings, immunizations, and tests — including children’s — in the Appendix. (A schedule for members whose challenges include obesity prevention also is included.) Bring it with you to your annual exam so that your doctor will know which screenings you are eligible for at no cost to you.

Plan allowance — the maximum amount payable by the plan (including the member’s copayments) to the provider for a given procedure or service based on the Blue Cross Blue Shield PPO contracted rate in the area. PPO only: The plan allowance for a given procedure or service differs depending on whether it is performed by a network, non-network, or out-of-network provider.

Special screenings, immunizations, and tests for internationally adopted children, through age 18, are covered at 100 percent of the plan allowance. For details, see the Preventive Health Recommendations for Internationally Adopted Children Benefits Overview on pensions.org or call the Board at 800-773-7752 (800-PRESPLAN) to request a copy.

Preventive Care Office Visits If you use a network provider in a network area, you pay no copay for annual preventive care office visits with primary care physicians, pediatricians, and gynecologists. Blood work, screenings, and tests listed on the 2017 Preventive Schedule (for your age and gender) are covered at no cost to you.* If you live in a non-network area, you pay no copay for annual preventive care office visits with primary care physicians and gynecologists. Allowed blood work and tests are covered at no cost to you.* PPO only: If you use an out-of-network provider in a network area, you pay a percentage of the plan allowance for preventive care office visits (see the Appendix). Blood work, screenings, and tests listed on the 2017 Preventive Schedule (for your age and gender) are covered at 100 percent of the plan allowance.* You may be billed for the balance of charges over the plan allowance. *See schedules of covered preventive services in the Appendix.

Page 21

Medical expenses not covered by the plan do not count toward either your deductible or copayment maximum, if applicable. Expenses may be excluded from consideration for reimbursement because they exceed the plan allowance, are not covered services, or were incurred for services, products, or medications that were not medically necessary.

If a health condition is discovered or diagnosed during your exam, as long as no signs or symptoms of illness are apparent, your visit will still be 100 percent covered under the preventive care benefit, and your provider should code the visit as preventive. (Subsequent tests related to a detected health condition are subject to normal plan provisions.)

Routine Medical Costs Expenses That Do Not Count Toward the Medical Deductible The following expenses do not count toward meeting your annual deductible (or the plan’s copayment maximum, if applicable): • office copays • expenses that exceed the plan allowance, as determined by the service provider • copays for prescription drugs covered by OptumRx • ineligible expenses, such as cosmetic surgery or experimental procedures

If you are treated for an illness, injury, or condition, you pay a portion of the costs you incur for medical services. Your out-of-pocket costs include the following: • copays • deductibles • copayments (up to certain maximums) Your out-of-pocket medical costs also will include any ineligible medical expenses, such as those listed in the Expenses That Do Not Count Toward the Medical Deductible box.

Copays Except for preventive care, whenever you visit a Blue Cross Blue Shield network doctor’s office you will be charged a copay — one amount for primary care and behavioral health providers and a higher amount for specialists. You also pay a copay when you use your telemedicine benefit with Teladoc or seek care at an urgent care center. Members in the EPO also pay flat dollar copays, rather than percentage copayments, for diagnostic services (basic and advanced); physical, speech, and occupational therapy; and spinal manipulations. Page 22

Copays do not count toward the plan deductible or copayment maximum under either the PPO or the EPO. For copay amounts, see the 2017 Key Provisions: PPO & EPO chart in the Appendix.

Deductibles Your deductible is the annual amount you pay before the plan pays its portion for certain services. Members with covered spouses and/or children are responsible for two medical deductibles, one for themselves and one for all other family members combined. PPO: Under this medical option, deductibles are based on a percentage of your effective salary (determined by salary range and subject to the medical participation minimum and maximum), as shown in the Deductible and Copayment Maximums chart in the Appendix. Your deductible applies to all medically related services, including diagnostic services such as blood tests, X-rays, psychological testing, and mental health and substance use disorder treatment, among other services, except for pharmacy-related costs. After you’ve met your deductible, the plan pays a portion and you pay a portion (your copayment) up to the specified copayment maximum for all medically related services. EPO: Under the EPO medical option, deductibles are flat dollar amounts, listed in the chart 2017 Key Provisions: PPO & EPO in the Appendix. Your

deductible applies to hospital inpatient and outpatient and emergency room services only. (You pay copays for most other services.)

Copayments Under the Medical Plan, you are responsible for a copayment — a percentage of the allowable charge — for certain services. There are differences between the copayment requirements for the PPO and the EPO. PPO: You are responsible for paying a defined percentage of the cost for certain services — a copayment — until you reach a defined maximum. For network care, your copayment is 20 percent of the allowable charges; for out-of-network care, it is 40 percent. Your copayment maximum is the annual maximum out-of-pocket costs you pay (not including office visit copays and deductibles), after which the plan pays 100 percent of the allowable costs. It is based on effective salary. Unlike deductibles, only one copayment maximum applies per family. (See the 2017 PPO Deductible and Copayment Maximums chart in the Appendix.) In almost all cases, the copayment maximum is the most you will pay in a plan year, not counting office visit copays and deductibles, and it is significantly less than the Affordable Care Act (ACA) limit on annual out-of-pocket costs. It is possible, however, for a PPO member’s or family’s costs to reach the ACA limit on annual out-of-pocket costs, which includes all healthcare-related out-ofpocket expenses, including office visit copays, deductibles, and prescription

drug expenses. In this unlikely event, the plan will pay 100 percent of the allowable costs, even if the copayment maximum has not been reached. Different deductibles and copayment maximums apply for network and outof-network care: Network providers cost you less, out-of-network providers cost you more. If you live in a network area and choose to use an out-ofnetwork provider, you are responsible for paying the difference between the physician’s charge and the plan allowance. That difference does not apply to your copayment maximum. Balance billing is the practice of billing you the difference between what the out-of-network provider charges for a service and what the plan covers. Balance billing applies under the Medical Plan only if the provider is an out-of-network provider.

Effective salary — any compensation received by a plan member from an employer during a plan year (January 1 through December 31), including sums paid for housing or the value of a manse. Effective salary is used to determine medical dues paid by employers for those in Pastor’s Participation. Effective salary also determines all PPO members’ medical deductibles and copayment maximums. For more information, see the Board’s e-learning module Effective Salary: Why It’s So Important To Get It Right or the publication Understanding Effective Salary, both available on pensions.org. You also can call the Board at 800-7737752 (800-PRESPLAN) to request a copy of Understanding Effective Salary.

Use the 2017 PPO Deductibles and Copayment Maximums chart in the Appendix to determine the deductibles and copayment maximums for your salary range. EPO: You pay 20 percent of the costs — your copayment — for hospital inpatient and outpatient services and emergency room services only. You are responsible for these copayments until you reach the copayment maximum (see the chart 2017 Key Provisions: PPO & EPO in the Appendix). The EPO copayment maximum is the same as the ACA limit: All your healthcare-related out-of-pocket expenses for covered services, including copays, deductibles, and prescription drug copays, count toward the EPO copayment maximum. Page 23

Routine Vision Exam I f yo u s e e a V S P- p a r t i c i p at i n g optometrist or ophthalmologist for a routine annual eye exam, you pay only a copay, with no deductible.

20% Member

80% Plan

If you have a routine annual eye exam with an out-of-network provider — an eye doctor who does not accept payment from VSP — you pay for the service up front, get a detailed receipt, and submit your claim manually to VSP. You will be reimbursed up to a certain dollar amount after your copay is deducted. (See the Vision Costs chart in the Appendix.)

Hospital and Emergency Room Visits When you visit hospitals and emergency rooms that participate in the BlueCard network, after you meet your annual deductible, the plan pays 80 percent of the plan allowance for your eligible expenses up to a certain amount, after which it pays 100 percent. (You pay 20 percent of the eligible expenses up to the point that the plan pays 100 percent.)

Plan Allowance Differences The Medical Plan’s reimbursement of charges by physicians and other providers is based on the plan-allowed charge in the area for each particular procedure or ser vice. This plan allowance represents the total amount payable under the plan (including your copayments) to the provider for a given procedure or service.

Page 24

The plan allowance for a given procedure or service also differs depending on whether you visit a network, out-of-network, or nonnetwork provider, as follows: Network When you use a network provider, the allowance is the Blue Cross Blue Shield network contracted rate for the procedure or service. Out of Network (PPO) When you use an out-of-network provider under the PPO option only, the allowance is the Blue Cross Blue Shield participating provider rate in that area for the procedure or service. If the provider is not a network provider, you may also be billed by the provider the amount of its charge in excess of the plan allowance. This is referred to as balance billing. Non-Network (Medical/Surgical Only) For non-network area providers, the plan covers up to 120 percent of the Blue Cross Blue Shield participating provider rate in that area.

HOW TO GET REIMBURSED To get reimbursed from the plan, you may or may not need to file claims yourself depending on your choice of provider. To be eligible for reimbursement, all claims must be submitted within 12 months of the date of service.

MEDICAL AND HOSPITAL SERVICES Network Providers When you use a network provider, you do not need to file a claim for reimbursement. The provider’s office does this for you, using identifying information from your medical ID card. The plan then pays its portion automatically, and you pay only your out-of-pocket costs.

Out-of-Network Providers (PPO Only) Many out-of-network providers will bill Highmark first and then bill you for the balance. Some out-of-network providers, however, require you to pay out of pocket and then file a claim for reimbursement. To obtain claim forms, visit highmarkbcbs.com or call Highmark at 888-835-2959. Complete a separate form for each family member for whom you are seeking reimbursement. All claims filed should include your medical ID number (on the front of your medical ID card). After completing the claim form, attach your receipt, which must itemize the procedure code, diagnosis code, and provider’s tax ID number to avoid processing delays. Send your completed claim form and receipt to Highmark Blue Cross Blue Shield 120 Fifth Ave. Fifth Avenue Place, Suite 2035 Pittsburgh, PA 15222 Retail health clinics, such as those found in large pharmacy chains, typically charge for services based on the negotiated Blue Cross Blue Shield PPO rate but may not file claims for you. You may pay out of pocket for their services and then submit the claims yourself directly to Highmark at the address listed on the claim form. (Retail health clinics typically do, however, handle claims processing for flu shots, so it’s unlikely you’ll need to pay out of pocket for these.)

CLAIMS SUMMARIES AND EXPLANATION OF BENEFITS STATEMENTS Please review your medical claims summaries or Explanation of Benefits (EOB) statements to make sure that you actually received the services being billed. These summaries and statements are available online, or you can receive printed EOBs.

Online Claims Summaries Through Highmark, you can view your claims summaries online, helping you to understand and track your claims more easily than with paper claims. To access your claims information online, go to highmarkbcbs.com and enter your user ID and password (or access the site through Benefits Connect to simplify logging in), then select Claims. In addition to viewing a summary of your claims and payments, you can expand each claim to see additional details. You can review the information by date or by covered individual, and can learn your total cost, cost breakdown, whether a claim was approved or denied, and more. In the detailed view of a claim, you can click on the EOB link to download an image of the related Explanation of Benefits (which presents the information in the familiar print format).

Explanation of Benefits If you wish to receive paper EOBs by mail and currently do not, contact Highmark by phone to make the request or, at highmarkbcbs.com, select Account Settings, then Contact Information, and indicate your preference.

Reviewing Your Claims When you review your claims, check for two things: First, make sure you received the services for which you — and the plan — are being billed. Second, be aware that, under the plan, while you are an inpatient under the care of a network physician at a network hospital, all ancillary services provided — anesthesia, diagnostic pathology, and diagnostic

Page 25

radiology, where you had no choice of provider — are covered at the more favorable, network level (80 percent), regardless of the provider’s network status. Check your online claim summary or EOB to make sure any ancillary services you receive at a network hospital are processed at the network benefit level. If you receive out-of-network benefits for these claims, please contact Highmark to request an adjustment.

Questions? If you have questions about your claims, call Highmark at 888-835-2959. After speaking with the appropriate service provider, if you need further assistance or still have concerns, please contact the Board of Pensions.

MAKE THE MOST OF YOUR MEDICAL COVERAGE Healthcare costs are high and continue to rise. It’s important to minimize your own costs and the plan’s expenses. Follow these tips to be a better healthcare consumer: Use your preventive care benefits. • Preventive care helps detect health conditions early, when they are less costly to treat, so have an annual checkup with your primary care physician or gynecologist and get scheduled screenings, tests, and immunizations at no cost to you. See the preventive schedule on pensions.org. • Complete Call to Health to improve your health and well-being and earn reduced medical deductibles. Save money on prescription drugs. • Use generic drugs whenever possible: They cost significantly less than their brand-name equivalents. • Make sure the brand-name drug you were prescribed is listed on the plan’s formulary (list of covered drugs) before you fill your prescription. If it’s not, ask your doctor for an appropriate alternative. • Use mail-order for maintenance medications. Get advance approval when required. • Request pre-certification from Highmark for the specific tests and procedures listed on the back of your medical ID card — and non-urgent healthcare facility admissions — at the time you schedule them. If you do not pre-certify as required, you are responsible for all costs. Consider emergency alternatives. • Seek emergency room care only for an emergency. The emergency room should not be used on an ongoing basis as a substitute for primary care or when visiting an urgent care center is a safe and reasonable option. • Also consider the telemedicine benefit.

Page 26

6.DRUG YOUR PRESCRIPTION BENEFITS OVERVIEW Administered by OptumRx, the Prescription Drug Program provides you with coverage for medications prescribed by your doctor to keep you healthy, treat an ongoing condition, or restore your health following an illness. For this program, your share of the cost of medically necessary drugs — your copayment — will vary with the • medication you take; • medical option you are covered under (PPO or EPO); and • pharmacy you use to fill your prescription. This section explains your benefit and, to help slow the rapid rise in prescription drug costs for you and the plan, suggests ways you can limit your costs while ensuring you receive safe and effective treatment. Your copayments for prescription drugs are summarized in the Prescription Drug Program Member Cost chart, in the Appendix and on pensions.org. There are no deductibles for this program.

DECIDING ON THE RIGHT PRESCRIPTION FOR YOU O f te n , yo u c a n c h o o s e a m o n g alternatives before your medication is prescribed, and your choice determines your out-of-pocket costs. Two similar drugs with very different prices may be equally effective. Talk with your doctor about your options.

Brand vs. Generic Drugs The brand name of a drug, protected by a limited-time patent, is the product name under which it is advertised and sold. Once the patent has expired, a generic equivalent may be manufactured and sold under its chemical name. Chemically equivalent generics are required to have the same active ingredients as their brandname counterparts and are subject to the same U.S. Food and Drug Administration (FDA) standards for quality, safety, purity, and effectiveness. Before your doctor writes a prescription for a brand-name drug, ask if a generic is available and right for you. By using a generic, you’ll pay less — sometimes a lot less — for essentially the same drug, and by using home delivery you save even more: • When you use your OptumRx ID card at a participating retail pharmacy, you pay a flat copay amount for a 30- or 90-day fill of any generic drug. • When you fill a prescription for a generic drug through OptumRx mail order, you typically pay less for a 90-day supply than at a retail pharmacy. These flat copayment amounts apply to all covered generic drugs, except prescribed contraceptives, which are 100 percent covered (no copayment) under both the PPO and EPO options. (For copayment amounts, see the Prescription Drug Program Member Cost chart.)

PPO or EPO? Prescription drug coverage under the PPO and EPO differ in the following ways: • The PPO covers non-formulary drugs at 50 percent; the EPO does not cover non-formulary drugs. • For 2017, the PPO has an annual family copayment maximum of $3,000 for prescription drugs; the EPO has no plan maximum for prescription drugs (other than the annual ACA limits of $7,150/ member and $14,300/family). • The PPO covers infer tility treatment; the EPO does not. • The copays differ. See 2017 Key Provisions: PPO& EPO chart in the Appendix. Unless otherwise specified, the benefits described in this chapter are available under both the PPO and EPO.

Page 27

Avoid Ancillary Charges

Under the PPO option, if you choose to fill a prescription for a brand-name medication when a chemically equivalent generic exists, you will be responsible for an ancillary charge, plus the applicable copayment. The ancillary charge is the cost difference between the price of the brand-name drug and the chemically equivalent generic drug.

Things To Consider about Generic Drugs • Generic drugs are regulated by the FDA, just like their brandname counterparts. They are proven to be safe and effective. • Nearly 8 in 10 prescriptions dispensed in the United States are for generic drugs. • Generics cost about 80% less than brand-name drugs, mostly because manufacturers of generic drugs do not have the expense of research, development, and advertising related to a new drug. • Trademark laws do not allow generic drugs to look exactly like their brand-name counterparts, but these differences don’t affect their effectiveness.

Listing of Covered Drugs Each time you visit the doctor ’s office, share with your physician the plan’s formulary, a list of preferred medications reviewed and approved by a group of doctors and pharmacists based on clinical effectiveness and cost, and covered by the Prescription Drug Program. Both generic and brand-name drugs are included on the formulary. Medications, mostly brand name, that are not on the formulary generally are considered non-formulary drugs (unless they are specifically excluded from coverage; see Excluded Drugs). The formulary is updated for additions and deletions twice a year and is subject to change without notice. To review the formulary, see the Appendix or go to pensions.org, select Available Resources, then Booklets and Publications, and look under Prescription Drug Program. Or, call the Board of Pensions at 800-773-7752 (800-PRESPLAN) to request a copy.

Costs for Formulary and Non-Formulary Drugs Generics are not always available or may not be the best choice for your condition. If you need to take a brandname drug, ask your physician if he or she can prescribe one that’s listed on the formulary. PPO: If you fill a prescription for a brand-name drug that is … • on the formulary, you pay a percentage of the cost (up to a maximum), except for formulary contraceptives, which are 100 percent covered — no copayment required;

Page 28

• not on the formulary, you pay a larger percentage of the cost (up to a maximum), and that amount does not count toward your annual copayment maximum. Both formulary and non-formulary brand-name drugs also have a minimum amount you must pay. If the actual cost of your prescription is for less than the minimum, you pay the actual cost. EPO: If you fill a prescription for a brand-name drug that is … • on the formulary, you pay a percentage of the cost (up to a maximum), except for formulary contraceptives, which are 100 percent covered — no copayment required; Formulary brand-name drugs also have a minimum amount you must pay. If the actual cost of your prescription is for less than the minimum, you pay the actual cost. • not on the formulary, you pay 100 percent of the cost. Refer to the Prescription Drug Program Member Cost chart in the Appendix; it lists the copayment percentages as well as the minimums and maximums for formulary brandname drugs.

Annual family copayment maximum PPO: For the PPO option, there is an annual family copayment maximum to limit your out-of-pocket costs for the Prescription Drug Program. This means you will not pay more than the copayment maximum each year for

all covered generic and formulary drug prescriptions for you and your covered family members. Once you and/or your spouse and children reach the family copayment maximum, the plan pays 100 percent of your remaining eligible generic and formulary drug prescription costs for the rest of the calendar year. Refer to the Prescription Drug Program Member Cost chart in the Appendix. EPO: There is no copayment maximum for prescription drugs specifically (i.e., the plan sets no limit on your outof-pocket prescription drug costs). The ACA limit governs, and it counts all your healthcare-related out-ofpocket expenses, including copays, deductibles, and prescription drug copays.

HOW TO GET PRESCRIPTIONS FILLED You can access your prescription drug benefits in one of two ways: Fill your prescription at your local participating pharmacy, using your OptumRx ID card; or through mail order, using OptumRx home delivery for the greatest possible savings.

At Your Local Participating Pharmacy Use your local participating pharmacy to fill short-term prescriptions — and, if you choose, to fill your longterm prescriptions as well. Use your OptumRx ID card with a pharmacy that participates in the broad OptumRx network to pay at reduced rates.

If you fill a prescription at an out-ofnetwork pharmacy, you must pay the entire cost for the medication and then submit a claim form to OptumRx for reimbursement. Your reimbursement will be based on the contracted rate for out-of-network prescriptions minus the applicable copayment (see the Appendix). Claim forms are available at optumrx.com/mycatamaranrx, or call OptumRx at 855-207-5868.

Through Mail Order

Visit optumrx.com/mycatamaranrx to view your prescription costs, order refills, and more. To find a pharmacy that participates in the OptumRx network,use the Pharmacy Locator at optumrx.com/ mycatamaranrx or call OptumRx at 855-207-5868. Prescription drugs administered during a hospital stay are considered medical expenses. Prescription drugs purchased at a hospital pharmacy for use at home are considered prescription drug expenses.

The Board has negotiated discounts with OptumRx on maintenance medications filled through mail order. To save money, use OptumRx home delivery service to fill prescriptions for your maintenance medications — those you take on a regular basis (for example, medications to treat high blood pressure, high cholesterol, or thyroid conditions). If you choose to fill prescriptions for maintenance medications at your local pharmacy, typically you — and the plan — will pay more. To order a 90-day supply of your medication through OptumRx mailorder service, do any of the following: • Have your doctor e-prescribe the prescription to OptumRx. • Ask your doctor to fax the prescription to OptumRx. • Complete a prescription order form, available at optumrx .com/ mycatamaranrx, and mail the form, plus the written prescription completed by your doctor, to the address provided on the form. Shipping is free. You can also set up Auto Refill and Auto Renewal of your prescriptions at optumrx.com/ mycatamaranrx. Page 29

SPECIAL PROGRAMS TO LIMIT COSTS Some drugs your doctor may prescribe are subject to step therapy, prior authorization, or specialty medication programs — additional ways the Prescription Drug Program seeks to slow rising costs while providing you with safe and effective medications.

Step Therapy In step therapy, specific high-cost Step 2 drugs are covered by the plan only after you try clinically appropriate, more cost-effective Step 1 drugs — usually generics. If the Step 1 drugs do not provide the desired therapeutic benefit, you will be authorized to take a formulary (Step 2), and it will be covered at the brand-name drug rate. If you do not try a Step 1 drug before filling a prescription and instead attempt to fill a brand-name prescription at a network pharmacy, the prescription will be rejected. If you do not try a Step 1 drug before filling a prescription and instead attempt to fill a brand-name prescription at an out-of-network pharmacy, you will be responsible for 100 percent of the cost. Some conditions treated by medications that may be subject to the step therapy follow: • asthma • attention deficit disorder • depression • diabetes • high blood pressure • high blood cholesterol • pain and inflammation • skin inflammation • stomach acid reduction Call OptumRx if you would like more information about a medication you are prescribed.

Page 30

Prior Authorization Prior authorization is required when more clinical information is needed about a patient’s particular medical condition before OptumRx can confirm medical necessity. Generally, prior authorization is required for prescription medications or doses that are very costly, can be prescribed for non-FDA-approved uses, or have a significant potential for negative side effects. Your doctor or nurse must contact OptumRx to provide that information before the prescription can be filled. You must obtain prior authorization from Highmark to fill a prescription for medical injectable drugs. Some examples of medications that require prior authorization are Epogen, Procrit, Aranesp, Regranex, Forteo, Remicade, Topamax, Embrel, Humari, infertility medications, and growth hormones.

Quantity Limits Certain drugs have quantity limits to encourage appropriate drug usage, enhance drug therapy, and reduce costs. The quantity limit is the maximum quantity that can be dispensed over a given period of time.

Speciality Medications Specialty medications, typically used to treat complex conditions such as cancer, hepatitis, and multiple sclerosis, are limited to a 30-day supply due to the high cost, special storage needs, limited shelf life, and frequent dosage changes. You must purchase specialty drugs through OptumRx’s specialty pharmacy, BriovaRx, to receive coverage under your prescription drug benefits; specialty medications are not available through OptumRx’s home delivery service or your local retail pharmacy. Specialty medications are subject to the same copayment minimums and maximums as other prescriptions. Contact OptumRx for more information.

DRUGS NOT COVERED The Prescription Drug Program does not cover medications that • are not approved by the FDA; • have over-the-counter equivalents; • are on the plan’s exclusion list because less expensive, clinically proven alternatives are available (see Excluded Drugs); • are appetite suppressants; • are approved or prescribed for cosmetic purposes only; or • are lost, stolen, spilled, or otherwise damaged. If you want to take a prescription that is not covered under the Prescription Drug Program, you may, but you’ll pay the full (unreduced) cost of the drug and that payment will not count toward your out-of-pocket maximum, if any.

Excluded Drugs Large pharmacy benefits managers such as OptumRx negotiate with pharmaceutical companies to buy certain medications in volume, at a discount, in exchange for excluding similar medications made by other drug companies. The Board of Pensions and OptumRx are attempting to slow the

spiraling rise in drug costs by excluding from coverage certain medications when less expensive, clinically proven alternatives are available on the formulary. To see which drugs are excluded, go to pensions.org and search for Drug Exclusion List. If you fill a prescription for a drug that is excluded from coverage, you’ll pay the full (unreduced) cost of the drug, and that payment will not count toward your out-of-pocket maximum, if any.

QUESTIONS? For more information, go to pensions.org or optumrx.com/mycatamaranrx. To find out whether a specific drug is covered, call • OptumRx, 855-207-5868 ; or • BriovaRx (for specialty medications), 855-427-4682. You also can call the Board of Pensions at 800-773-7752 (800-PRESPLAN) and speak with a service representative.

Page 31

7. OTHER WELLNESS BENEFITS Having a sense of wholeness, or well-being, is essential to effective ministry, which is why the Medical Plan offers wellness benefits. Many of the programs offered provide tools, treatments, and services that can make a difference in your overall health and well-being.

EMPLOYEE ASSISTANCE PROGRAM Your healthcare benefits include an Employee Assistance Program (EAP), provided through Cigna Behavioral Health (Cigna) 24 hours a day, seven days a week, at 866-640-2772. Your EAP is a professional, confidential resource that can help you and members of your household find answers to a variety of personal concerns. (Household members do not need to be enrolled in the Medical Plan to use the EAP.) Through it, you can receive consultations, support, and personalized assistance as well as referrals to licensed counselors and professional resources in your community. EAP services include the following: • Counseling – Up to six free private counseling sessions per issue with a licensed provider are available to you and members of your household. The EAP also provides information, community resources, and referrals by telephone. Assistance required beyond your EAP benefit is coordinated with the medical benefit under the Medical Plan. Page 32

• Financial Resources – Certified Financial Planners, certified tax preparers, enrolled agents, CPAs, and professionals from the banking and insurance industries provide telephone coaching and advice about budgeting, credit, investing, tax preparation, and more. • Legal Assistance – A free, 30-minute telephone consultation, per issue, with an attorney on legal matters, or a 60-minute telephone consultation with a fraud resolution specialist on identity theft issues is available. • Child Care – Resources and referrals to screened childcare providers, before- and after-school programs, camps, adoption organizations, and information on parenting and prenatal care are available. • Senior Care – You have access to resources and referrals to screened home health agencies, assisted living facilities, social and recreational programs, and long distance caregiving. • Pet Care – Resources and referrals for pet sitting, obedience training, veterinarians, and more are available. To learn more: • Call Cigna at any time at 866-640-2772, or use the live chat feature on its website. • Use Benefits Connect to access your EAP. • Visit cignabehavioral.com. On the Cigna website home page, in the upper left-hand menu, select Login to access your benefits. Scroll down

to the Employer ID field on the left, enter pcusa, then click Go. On the following screen, you can access the EAP services from the left-hand menu by clicking on Look Up Your Benefits, then EAP. You also have access to educational materials on this site.

HEALTH AND WHOLENESS: CALL TO HEALTH

Call to Health is a well-being initiative that runs October 1, 2016, through November 10, 2017, for employees and their spouses covered under the PPO or EPO option. Employees earn reduced deductibles by completing certain challenges presented on calltohealth.org. To answer the call, you complete required challenges, including taking the Well-Being Assessment and other challenges you select to earn points. Employees who accumulate at least 1,000 points see their individual and family deductibles reduced for the next plan year. And spouses who earn 1,000 points and employees who earn 2,000 points each receive a $100 Amazon gift card. Call to Health points may be earned through participation in Ignite Your Life, a coaching program to help employees and their spouses change their health habits, to lose weight, reduce stress, or quit smoking or using other tobacco products (see Tobacco-Free Living), among others reasons. Visit calltohealth.org often to learn about required challenges, participate in new optional challenges, and complete Call to Health.

Your Well-Being Assessment Ta k i n g t h e c o n f i d e n t i a l a n d s e c u r e Well-Being Assessment on calltohealth.org is a required challenge for Call to Health each year (as is having an annual well visit if you’re over 50). When you complete your assessment, you’ll get personalized health results, including recommendations for your top three things to improve and your top three strengths from a holistic health perspective. After you’ve completed your WellBeing Assessment, you can select activities that will help you improve or explore other activities to make your strengths even stronger.

To take the Well-Being Assessment, go to calltohealth.org and click on Take Your Assessment.

TOBACCO-FREE LIVING If you are an active member or covered spouse who uses tobacco, Ignite Your Life coaching offers a program, Breathe Easy, to help you change your habits and become tobacco-free. Offered by tobacco treatment specialists, this six-week coaching program is available online or by phone. To access Ignite Your Life coaching, go to calltohealth.org and click on Ignite Your Life or call 866-592-3624. For you and your eligible family members, certain prescription generic or formulary smoking cessation medications are 100 percent covered with a prescription from your physician. Simply show your prescription ID card when you pick up your prescription; no copay is required. If you currently use tobacco, participating in the Call to Health Tobacco-Free Living program through Ignite Your Life counts toward Call to Health.

YOUR PERSONAL HEALTH RECORD You can activate and view a Personal Health Record (PHR) on highmarkbcbs.com using a smartphone, tablet, or other computer. A PHR is an online record of your health history, which you can use to store, track, and selectively share your health information. Once you activate your PHR, it will automatically fill with content gathered from claims data provided by Highmark and OptumRx. You also can edit or add information to your record. Use your PHR to keep track of the following: • conditions • medications • doctor and hospital visits • immunizations • tests and procedures • allergies • other health-related information Page 33

To activate your PHR, watch Highmark’s e-learning module Personal Health Record Review at brainshark.com/hmk/PBOP_PHR. This module explains how to launch your PHR, selectively share your PHR with others, add or edit information, and download or print your record.

The PHR has graphing and reporting features to help you track your progress in key indicators of health and wellbeing, such as blood pressure, weight, cholesterol, blood sugar, mood, and exercise, among others. Your PHR is secure and confidential, as both Highmark and the Board of Pensions comply with all federal and state privacy laws. You control who views your PHR; to protect your privacy, the Board of Pensions and your employer cannot access it. Sharing your PHR with your doctors or other healthcare providers can help you and your doctors make more informed decisions about your healthcare. It can result in safer, higher-quality care.

24-HOUR NURSE LINE You can get valuable health information and guidance from a certified registered nurse practitioner through the 24-Hour Nurse Line. Provided at no cost to you, this service is available through Highmark to you and your eligible family members whenever you need it, including weekends and holidays. Call the 24-Hour Nurse Line at 888835-2959 if you • wonder whether you need to get medical care; • need information about a medication, test, or medical procedure; • want reliable information about a health condition; or • are not sure what questions you should ask your doctor.

Page 34

The number for the 24-Hour Nurse Line is on the back of your Highmark ID card, so you’ll have easy access whenever you have questions a nurse can help you with.

CASE MANAGEMENT Your medical benefits include a co n f i d e n t i a l Ca s e M a n a g e m e n t Program, provided by Highmark. This program helps you when you • have frequent or prolonged hospital admissions; • require ongoing healthcare services in your home; or • need ongoing care in outpatient settings. Case Management helps members get the best available treatment when underlying health conditions are complex or challenging to address. The program can assist you by • helping you understand the care resources available to you; • coordinating and helping arrange medical services for you; and • providing education and support for you and your family. A nurse case manager will work with you and your physician to facilitate approval for medically necessary services under the provisions of the Medical Plan. Your nurse case manager will also help evaluate treatment needs and options under the direction of your attending physician.

8.SPECIAL COVERAGE FOR CIRCUMSTANCES CHILDREN RESIDING AWAY FROM HOME

Your covered child who lives in a different location than you may be in a network or non-network area, depending on that location. When your child seeks services, all plan provisions and requirements continue to apply. An example would be a child attending college in another city. You can obtain a local provider list for your child at highmarkbcbs.com or by calling Highmark at 888-835-2959.

TRAVEL WITHIN THE UNITED STATES

For expenses related to non-emergency care while traveling outside your area, reimbursement depends on whether the services were provided in a network or non-network area and, if in a network area, whether network services were used. (For information on emergency care, see Emergency and Urgent Care in the Overview section.) For infor mation about net wor k providers while you are traveling within the United States, use the number(s) on your medical ID card to contact Blue Cross Blue Shield for medical/surgical providers. All plan provisions and requirements continue to apply.

Page 35

For inpatient hospital admissions when traveling abroad, members should contact BCBS Global, tollfree, at 800-810-BLUE (2583) or, collect, at 804-673-1177.

INTERNATIONAL TRAVEL The Medical Plan provides coverage for medically necessary services for active plan members and eligible dependents traveling outside the United States.

BCBS Global As a Highmark enrollee, you and your covered family members may use BCBS Global for medical attention during an international trip including • inpatient hospital care (precertification required); • outpatient hospital care and physician services; and • locating recommended hospitals and physicians. Remember to carry your Highmark ID card wherever you go. If you need medical assistance, call BCBS Global (formerly BlueCard Worldwide), collect, at 804-673-1177 from outside the United States. You may have to pay for any medical expenses when you receive treatment (cash, travelers’ checks, and credit cards usually are accepted). If you are treated as an inpatient at a hospital that belongs to the BCBS Global network, however, you may not have to pay in advance. If you pay for treatment, when you return, send your bills with a claim form to Highmark Blue Cross Blue Shield for reimbursement under the Medical Plan: Highmark Blue Cross Blue Shield 120 Fifth Ave. Fifth Avenue Place, Suite 2035 Pittsburgh, PA 15222

Page 36

International SOS To expand members’ access to medical assistance outside of the United States, the Board of Pensions also contracts with International SOS to provide assistance to plan members. International SOS has many clinics and 24-hour assistance centers throughout the world. Although International SOS refers travelers to local community services when possible, in worst-case scenarios, depending on the availability of local medical options and the severity of the medical condition, International SOS can assist a traveler with a medical evacuation to the nearest appropriate provider. International SOS is prepared 24 hours a day to help a member with a referral or an evacuation using its own air ambulance fleet or a scheduled assisted flight on a commercial airline, depending on the situation. Members planning to travel outside the United States should visit pensions.org or call the Board of Pensions to obtain a Medical Assistance during I n t e r n a t i o n a l Tr a v e l B e n e f i t s O ve r v i e w, w h i c h c o n t a i n s a membership identification card and emergency contact numbers for International SOS services. If you have questions before you leave, please call the Board of Pensions or International SOS for pre-travel information. The services of International SOS are available to active members and their families who participate in the Medical Plan or, if retired, in the Medicare Supplement coverage offered through the plan.

AFTER TERMINATION OF ELIGIBILITY

The healthcare coverage options available upon termination depend on the coverage the member had as an active member.

Overview Pastor’s Participation Installed pastors and other teaching elders in Pastor’s Participation who are temporarily unemployed and actively seeking church service, on an approved leave of absence, or under discipline may first participate in transitional participation coverage. Subsequently, if you do not return to church employment, you will be eligible for medical continuation coverage. If you enroll in medical continuation first, you will not be eligible later for transitional par ticipation coverage. (See Transitional Participation Coverage.)

Menu Options Other teaching elders and other employees in menu options whose active coverage under the Medical Plan is ending may enroll in healthcare coverage for themselves and their eligible family members under • medical continuation (on a self-pay basis and for a limited time); or

To be eligible to continue your healthcare coverage under medical continuation, you or an eligible family member must return a completed application form to the Board of Pensions within 60 days of the event that caused the termination of coverage. (Call Member Services to obtain an application form.) Surviving and former covered spouses, children losing their eligibility status, and members who retire before they are Medicare-eligible also may be eligible to enroll in medical continuation c o ve r a g e. Ty p i c a l l y, m e d i c a l continuation coverage for terminated members lasts up to 18 months. Children who lose their eligibility at age 26 (or later, if disabled) may elect medical continuation coverage for up to 36 months. Terminating members are not required to elect this medical continuation coverage; another healthcare plan’s benefits may better fit their needs and be more affordable. As long as members continue to receive coverage under a qualified plan, they will satisfy the continuous coverage requirement fo r e n r o l l i n g i n t h e M e d i c a r e Supplement Plan at age 65 (although maintaining such coverage satisfies just one of several eligibility criteria for the Medicare Supplement Plan).

• another qualified plan, including any plan on the federal Health Insurance Marketplace or a state health insurance marketplace (on a self-pay basis).

Page 37

Employment Termination

Transitional Participation Coverage

When employment ends, those members in Pastor’s Participation are eligible for 30 days of medical coverage at no cost to them. The 30 days begins on the first day after employment ends.

If you are a member in Pastor’s Participation who is seeking other church employment or are engaged in full-time church-related studies, you can continue full or partial coverage, on a self-pay basis, through transitional participation coverage. Coverage on this basis is available for 24 months for teaching elders and graduated seminary student members whose presbyteries verify their status.

The medical coverage (if any) of employees in menu options will terminate at the end of the month in which they terminate employment. Employers will be required to remit dues through the end of the month and therefore may collect applicable contributions from these employees for their coverage.

Death of Member If an active member enrolled for pension, death and disability, and medical coverage under Pastor’s Participation or menu options dies, the surviving eligible family will receive 12 months of coverage at no charge to them or their employer.

Members who reach their maximum eligibility for continuing benefits through transitional participation coverage are eligible to continue healthcare benefits under medical continuation for an additional 18 months. More information is in Continuing Coverage at Termination of Eligible Service, available on pensions.org or by calling the Board of Pensions at 800-773-7752 (800-PRESPLAN).

Employer Withdrawal

To continue coverage after this 12-month period, eligible family members must enroll in medical continuation coverage on a self-pay basis; they may enroll in this coverage for up to 36 additional months.

If coverage ends because an employer wholly withdraws or withdraws an entire employment class from the Benefits Plan, there are no extended coverage periods and affected members are not eligible for medical continuation coverage.

Divorce or Dissolution

If you are on medical continuation and your former employer ceases to offer menu options, your medical continuation coverage will end.

If, as an active member, you are divorced or your marriage is dissolved, your former covered spouse may continue coverage in the same medical option (PPO or EPO) by electing medical continuation coverage and making the monthly payments. If your former spouse wants to continue medical coverage through the Board of Pensions, he or she must elect this coverage before active coverage ends (the date of divorce). The Board must receive a copy of the divorce decree or proof of dissolution.

Page 38

9. CLAIMS AND APPEALS The plan’s rules for claims payment and procedures for appeals are covered in this section.

CLAIMS FILING DEADLINE All claims must be submitted within 12 months of the date of service to be eligible for reimbursement.

CLAIMS PAYMENT WITH DUAL COVERAGE When a member or dependent also has coverage from another source, the Medical Plan (with the exception of the Prescription Drug Program) and the other coverage are coordinated as follows.

Maintenance of Benefits The plan provides for this order of payment: • The employer plan of the patient generally pays first. • The plan of the parent with the first birthday in the calendar year pays children’s claims first (the Birthday Rule). • When paying second, this plan pays up to the benefit level it would pay if there were no other coverage. Maintenance of Benefits does not apply to the prescription drug benefit.

Member Couple Coverage When a member couple is enrolled, each has full healthcare coverage under the PPO medical option, both as an employed member and as a covered spouse. This dual coverage benefits the member couple by lowering the copayment obligation. Details are provided in Your Benefits as a Member Couple, available on pensions.org or by calling the Board of Pensions and requesting a copy.

The Birthday Rule When both parents have coverage by different plans, the Birthday Rule determines which plan pays your children’s claims first. The parent having the earlier birthday in the calendar year is responsible, regardless of which parent is older; if the birthdays are the same day, the employer-provided health insurance plan that has covered a parent longer pays first.

What Is a Member Couple? When both individuals in a marriage are employed by PC(USA) employers and each is enrolled in the PPO medical option of the Benefits Plan of the Presbyterian Church (U.S.A.), they are termed a member couple.

Page 39

Child and Divorce, Dissolution, or Separation

Coordination of Benefits with Medicare and the Medical Plan

For a covered child whose parents are not living together, are separated, or are divorced, or where a marriage has been dissolved, benefits are paid in this order:

Active Employees over Age 65

1. The plan of the parent responsible under a court decree that established financial responsibility for the healthcare expenses of the child pays first. 2. The plan of the parent meeting the Birthday Rule pays the child’s claims first if both parents are responsible under a court decree (see The Birthday Rule box). 3. If there is no court decree, this order applies: a. the plan of the parent with custody b. the plan of the stepparent married to the parent with custody c. the plan of the parent not having custody d. the plan of the stepparent married to the parent who does not have custody When these rules do not establish an order of benefit determination, the benefits of the plan that has covered the person for the longer time are primary.

Medicare When an active member reaches age 65, he or she is eligible for Medicare coverage, including Part A hospitalization coverage. You are not eligible to enroll in the Medicare Supplement Plan because it is a retireeonly plan. You will continue to be eligible as an active member of the Medical Plan as long as you continue to work. Medicare-eligible members enrolled in the active Medical Plan should enroll only in Part A of traditional Medicare coverage. Enrollment in Parts B, C, and D of Medicare, for which the Medicare beneficiary must pay premiums, should be deferred until after your active Medical Plan coverage ends. When your active Medical Plan coverage terminates, you will need to enroll in those additional Medicare programs promptly. If you fail to do so, you will incur higher premiums for the delayed enrollment.

Page 40

Unless you are working for a small employer with fewer than 20 employees, the Medical Plan will be primary to your Medicare coverage. If you are employed by a small employer, when enrolling for Medicare as you reach age 65, you should advise Medicare and the Board that you are still working and that your employer has fewer than 20 employees. Your employer must then apply for a small employer exception to the Medicare Secondary Payer rule by completing the Small Employer Exception Submittal Certification form, available on pensions.org or by calling the Board of Pensions. This form should be filed with Medicare before you reach age 65 to establish Medicare as the primary payer of your claims and the Medical Plan as secondary. This will not impact your coverage but may save the Medical Plan significant costs if you are hospitalized. If your employer grows and has more than 20 employees, it must be reported to Medicare. If you terminate active Medical Plan coverage, you must promptly enroll in Parts B, C, or D to avoid delayed enrollment penalities. Disabled Employees For disabled members covered by Medicare, Medicare is the primary payer provided the employment relationship with the member has terminated. With Medicare coverage, Maintenance of Benefits applies.

APPEALS PROCESS The Medical Plan’s service providers are responsible for processing claims according to the terms of the plan. When presented with your claim, a service provider determines whether it is payable under the Medical Plan. If it is, the claim will be paid according to plan provisions. If it is not, you’ll be advised of the reason(s) for the claim’s denial in your Explanation of Benefits, available online or in print. If your claim for a benefit under the Medical Plan is reduced or denied, you have the right to appeal that decision to the service provider who made it, whether Highmark Blue Cross Blue Shield or OptumRx. The procedures for filing an appeal and for its review are explained here.

1. You appeal a denied claim You should direct your appeal for a medical, prescription drug, or mental health/substance use disorder claim to the service provider indicated on the denial. There are two requirements: • You must make your appeal request, in writing, within 180 days of the date of the written claim denial. • The request for an appeal must explain your reasons for appealing the decision and include any additional information that supports the appeal.

2. Service provider reconsiders your claim When presented with your appeal, the service provider reviews your reasons, documents, and related information and reconsiders whether the claim is payable under the Medical Plan.

Urgent Care Your appeal of an adverse decision for an urgent care claim* will be decided no later than 72 hours after its receipt. If the service provider needs additional information to decide if benefits are payable, you’ll be notified within 24 hours and be given at least 48 hours to provide that information. You’ll be notified of the service provider’s decision within 48 hours of its receiving the additional information.

For Any Other Medical Service Denial or Reduction Your appeal will be reviewed no later than 30 days after it is received, although the service provider may have a 15-day extension, if necessary.

3. You request an external review If you are not satisfied with the results of your initial appeal decision, you may request a final review by an independent review organization (IRO). You must do so within four months of the date the initial appeal was decided, and file your appeal with the service provider that advised you of the initial review decision. IROs are state-approved and -accredited organizations that are independent of the Board of Pensions and the plan’s service providers. The service provider will select an IRO from at least three IROs, randomly or by rotation, to review your appeal.

4. The IRO reviews your claim The IRO will make its decision and notify you in writing within 45 days after the service provider receives your request for external review. Once you have exhausted the plan’s appeals process, you have the right to challenge the decision in a court of law.

Time Frames The time frame within which the Medical Plan’s service providers must decide your appeal depends on the type of claim.

*An urgent care claim is one that must be expedited because, in the professional judgment of your physician, the normal process may seriously jeopardize your life, health, or ability to regain maximum function, or could subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Page 41

10. ADMINISTRATIVE AND MISCELLANEOUS PROVISIONS CONFIDENTIALITY AND PRIVACY PRACTICES Ensuring the privacy of member information is a responsibility the Board of Pensions takes very seriously. It is important that employers and their employees cooperate with the Board’s policies concerning confidentiality. The privacy of health plan records for you, your spouse, and your children, if any, is also protected by special security and privacy regulations as mandated by HIPAA (the Health Insurance Portability and Accountability Act of 1996). The Board of Pensions Health Insurance Portability and Accountability Act (HIPAA) Privacy Notice describes the Medical Plan’s privacy practices and your rights to access your records. The notice is available on pensions.org or by calling the Board at 800-773-7752 (800-PRESPLAN). To access it on pensions.org, select Available Resources, then Member Benefits Notices, and then Health Insurance Portability and Accountability Act (HIPAA) Privacy Notice. Under HIPAA, Board employees and the Medical Plan’s representatives (such as Highmark) may not release your Medical Plan protected health information (other than enrollment information) to your employer or spouse unless you authorize this by completing a power of attorney or an authorization form and filing it with the Page 42

plan. The Board will require your written authorization before sharing your protected health information for any reason other than payment, treatment, or healthcare operations with anyone other than you or your personal representative (that is, your guardian or named representative in a power of attorney). You may be asked to fill out and return authorization forms and to provide verification of information (see the Appendix). These and other actions are taken to safeguard your privacy and that of your family. For an authorization form or more information, please visit pensions.org or call the Board.

PLAN’S RIGHT TO RECOUPMENT, SUBROGATION & REIMBURSEMENT FOR MEDICAL COSTS RECOVERED FROM THIRD PARTIES The plan does not cover medical costs that are recoverable from a third party, including a personal injury, medical malpractice, or motor vehicle claim. However, because those recoveries often take time to resolve, the plan, in its sole discretion, may advance payment for the member’s medical claims subject to the plan’s requirement that the member repay the plan, in full, for those claims from the

proceeds of the third-party recovery. The plan’s rights are a lien and first priority claim against the member until the plan is reimbursed. If you incur medical costs as a result of an accident or a negligent act for which you will recover your medical costs from insurance, a damage award or settlement, other medical coverage, or otherwise, you have the obligation to notify the Board. The Board will work with your legal counsel to assist in the recovery of your medical expenses. You should contact the Board to coordinate reimbursement to the plan when the case is settled.

FRAUD AND/OR MISREPRESENTATION If you present false or misleading information about yourself or your family member with respect to any aspect of the plan, including but not limited to eligibility or claims, the Board will take appropriate action, including the forfeiture of your benefits or loss of coverage for you or your family member. If coverage is terminated retroactively, you are responsible for repaying all benefit payments made under the plan for amounts incurred after your termination date.

LIMITATION OF LIABILITY

CONCLUSION Many things contribute to good health and a sense of well-being: getting plenty of exercise, eating healthy foods, spending time with family and friends, volunteering to help others, and worshiping God. It’s important to try to maintain good health in every way you can. For its part, the Board of Pensions offers the benefits and programs described in this guide to help you succeed in your quest for better health and wellbeing. But, ultimately, it’s up to you to help yourself to better health. We hope you’ll participate in the Call to Health and make a commitment to lead a healthier lifestyle, starting today. And remember, if you or a covered family member is sick, the Medical Plan provides comprehensive coverage to hasten your return to health. If you become critically ill, it supports your care and eases the financial burden that often accompanies prolonged illness.

The Board reserves the right to terminate or suspend the benefit coverage of any member for whom dues payments are delinquent, that is, not paid by the first day of the next month.

Amendments to the Plan and Reservation of Right To Terminate Benefits The Board of Pensions, in its sole discretion, has the right to amend the Medical Plan and report any such amendment to the next succeeding General Assembly of the Presbyterian Church (U.S.A.). Although the Board of Pensions expects and intends to continue the Medical Plan indefinitely, it reserves the right to modify, terminate, or suspend this plan and its provisions, including, but not limited to, benefits and contributions for coverage, at any time by action of the Board of Directors of the Board of Pensions. The Board is required to report amendments to the Medical Plan to the General Assembly.

Regardless of where you are on the health and wellness spectrum, we encourage you to use your healthcare benefits to your greatest advantage. It’s in every plan member’s interest to do so. If you have questions about your coverage, please contact the Board of Pensions or the appropriate service provider (see the Appendix).

The Board of Pensions will not be legally responsible for any failure of your church or employer to enroll you or your family members for coverage or to pay the dues for coverage. Page 43

CONTACT INFORMATION M E M B E R

S E R V I C E S

T YPE

PR OV IDER

PHONE

WEBS I T E

Any

The Board of Pensions of the Presbyterian Church (U.S.A.)

800-773-7752 (800-PRESPLAN) TDD: 877-522-7948 Outside the U.S.: 215-587-7200

pensions.org

8:30 a.m. – 5 p.m. ET, Monday through Friday Fax: 215-587-6215

K E Y

S E R V I C E

P R O V I D E R S

T YPE

PR OV IDER

PHONE

WEBS I T E

PPO and EPO physician and hospital information

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8 a.m. – 5 p.m. ET, Monday through Friday

highmarkbcbs.com

Employee Assistance Program (EAP)

Cigna Behavioral Health

866-640-2772 Available 24 hours

cignabehavioral.com (Employer ID: pcusa)

Prescription drugs, retail and mail order

OptumRx

855-207-5868 Available 24 hours

optumrx.com/mycatamaranrx

Vision exam

VSP

800-877-7195 8 a.m. – 11 p.m. ET, Monday through Friday 10 a.m. – 11 p.m. ET, Saturday 10 a.m. – 10 p.m. ET, Sunday

vsp.com or vsp.com/choice (to find a VSP participating provider)

E M E R G E N C Y T YPE

PR OV IDER

P H ON E

24-hour nurse line

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 Available 24 hours

Behavioral health/substance abuse

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8 a.m. – 5 p.m. ET, Monday through Friday

Inpatient emergency hospital admission* for medical/surgical

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8:30 a.m. – 7 p.m. ET, Monday through Friday; 8 a.m. – 4:30 p.m. ET, Saturday and Sunday

Inpatient emergency hospital admission* for behavioral health/substance abuse

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8:30 a.m. – 7 p.m. ET, Monday through Friday; 8 a.m. – 4:30 p.m. ET, Saturday and Sunday

Emergency hospital and medical services when traveling outside the U.S. * Call within 48 hours.

Page 44

BlueCard Worldwide – (or) – International SOS

WEBS I T E

804-673-1177

(Call collect from outside the U.S.)

– – 215-942-8226 (Call collect from outside the U.S.)

–––– pensions.org

(Download benefits overview/ ID card)

P R E - C E R T I F I C A T I O N T YPE

PR OV IDER

PHONE

Medical/surgical inpatient hospital admission and behavioral health/substance use disorder facility-based admission

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8:30 a.m. – 7 p.m. ET Monday through Friday; 8:30 a.m. – 4:30 p.m. ET Saturday and Sunday

Outpatient imaging or nuclear stress test, excluding X-rays and ultrasounds

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8:30 a.m. – 7 p.m. ET Monday through Friday; 8:30 a.m. – 4:30 p.m. ET Saturday and Sunday

Bariatric surgery

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8:30 a.m. – 7 p.m. ET Monday through Friday; 8:30 a.m. – 4:30 p.m. ET Saturday and Sunday

C L A I M S

WEBS I T E

I N F O R M A T I O N

T YPE

PR OV IDER

PHONE

WEBS I T E

Medical, surgical, and behavioral

Highmark Blue Cross Blue Shield PPO/EPO

888-835-2959 8 a.m. – 5 p.m. ET Monday through Friday

highmarkbcbs.com

T YPE

PR OV IDER

PHONE

24-hour nurse line

Highmark Blue Cross Blue Shield PPO/EPO 888-835-2959 Available 24 hours

Telemedicine

Teladoc

Personal Health Record

Highmark Blue Cross Blue Shield PPO/EPO

Tobacco-free living

Ignite Your Life

O T H E R WEBS I T E

800-835-2362 Available 24 hours highmarkbcbs.com 866-592-3624 9 a.m. – 9 p.m. ET Monday through Friday

calltohealth.org

Page 45

APPENDIX COPAYS, DEDUCTIBLES, AND COPAYMENT MAXIMUMS 2017 K E Y P R OV I S I O N S: P P O & E P O Benefit

PPO Minimum effective salary

EPO Maximum effective salary

In-network deductible

$660/member; $1,320/ family*

$1,305/member; $2,610/ family*

$2,000/member; $4,000/family

In-network Call to Health deductible

$440/member; $880/family*

$870/member; $1,740/ family*

$1,500/member; $3,000/family

After-deductible coverage (copayment)

Member pays 20%

Medical copayment maximum

$2,200/family*

Preventive care

Covered 100%

Covered 100%

Telemedicine

$10 copay

$10 copay

Primary care/behavioral health office visit

$25 copay

$40 copay

Specialist office visit

$45 copay

$60 copay

Urgent care center visit

$45 copay

$60 copay

Basic diagnostic services (imaging, X-rays, lab/pathology, etc.)

After deductible, member pays 20%

$65 copay

Advanced imaging (MRI, CAT, PET scan, etc.)

After deductible, member pays 20%

$200 copay

Physical, speech & occupational therapy

After deductible, member pays 20%

$40 copay

Spinal manipulation

After deductible, member pays 20%

$40 copay

Hearing aid (device and fitting)

After deductible, member pays 20% (plan maximum: $2,500 every 3 years)

Not covered

Vision exam

$25 at VSP provider

$25 at VSP provider

Hospital inpatient & outpatient

After deductible, member pays 20%

After deductible, member pays 20%

Emergency room services

After deductible, member pays 20%

After deductible, member pays 20%

Infertility counseling, testing & treatment

After deductible, member pays 20% (plan maximum: 3 procedures)

Not covered

Member pays 20% $4,340/family*

$7,150/member; $14,300/family**

* For deductibles at all effective salary levels, see deductible chart in the 2017 PPO Deductibles and Copayment Maximums chart. ** Includes in-network deductible, office visit copays, copayments, and prescription drug copays (reflects Affordable Care Act maximums).

Page 46

2017 K E Y P R OV I S I O N S: P P O & E P O ( co nt inue d) Benefit

PPO Minimum effective salary

EPO Maximum effective salary

Medical Out of Network

No coverage

Out-of-network deductible After-deductible coverage Out-of-pocket maximum (member & family combined)

$1,100/member; $2,200/family* Member pays 40% $6,600

$2,170/member; $4,340/family*

Prescription Drugs

Retail (30 days/90 days)

Mail order (90 days)

Retail Mail order (30 days/90 days) (90 days)

Generic Formulary brand

$10/$30 30% of cost;

$25 30% of cost;

$12/$36 35% of cost;

$30 35% of cost;

30 days: $20 min. to $100 max.

$50 min. to $250 max.

90 days: $60 min. to $300 max.

30 days: $35 min. to $150 max.

$85 min. to $375 max.

50% of cost;

50% of cost;

90 days: $105 min. to $450 max. Not covered

30 days: $50 min to $150 max.

$125 min. to $375 max.

Non-formulary brand

Prescription copayment maximum Combined maximum

$13,020

90 days: $150 min. to $450 max. $3,000 (member & family combined)

Does not apply

Minimum effective salary

Maximum effective salary

$5,860/member**; $6,520/ family**

$7,150/member**; $9,950/ family**

$7,150/member***; $14,300/ family***

* For deductibles at all effective salary levels see 2017 PPO Deductibles and Copayment Maximums chart. ** Includes in-network deductible, copayment maximum, and prescription maximum. *** Includes in-network deductible, office visit copays, copayments, and prescription drug copays (reflects Affordable Care Act maximums).

2017 K E Y P R OV I S I O N S: V I S I O N ( P P O & E P O) Your Costs Type of Visit

VSP Provider

Out of Network

Routine eye exam Contact lens exam

$25 copay 15% discount on exam (fitting and evaluation)

Submit claim; reimbursement up to $45 after $25 copay No coverage

Page 47

2 0 1 7 P P O D E D U C T I B L E S A N D C O PAY M E N T M A X I M U M S

(for covered inpatient and outpatient medically necessary services; does not include prescription drug costs and office copays you are required to make)

D E D U C T I B L E 2,3,4,5 Ne t work & O ut of Non-Ne t work N e t wor k 1 .5 % 2. 5% $660 $1,100 $735 $1,220 $805 $1,340 $875 $1,460 $950 $1,580 $1,020 $1,695 $1,090 $1,815 $1,160 $1,935 $1,235 $2,055 $1,305 $2,170

SALARY RANGE1 $0 - $48,759 $48,760 - $53,514 $53,515 - $58,269 $58,270 - $63,024 $63,025 - $67,779 $67,780 - $72,534 $72,535 - $77,289 $77,290 - $82,044 $82,045 - $86,799 $86,800 or more

C O PAY M E N T M A X I M U M 6 N e t wor k & Out of N on - N e t wor k N e t wo rk 5% 15% $2,200 $6,600 $2,440 $7,320 $2,680 $8,040 $2,915 $8,745 $3,155 $9,465 $3,390 $10,170 $3,630 $10,890 $3,865 $11,595 $4,105 $12,315 $4,340 $13,020

Deductibles and copayment amounts are based on salary range, subject to a minimum and maximum salary. Completion of Call to Health in the current year reduces the member’s deductible in the following year. 3 Members with eligible family members are responsible for two deductibles, one for the member and one for all other family members combined. Deductibles do not count toward the copayment maximum. 4 The Annual Deductible for a Disabled Member and his/her eligible family is based on the greater of the Disabled Member’s Effective Salary on the date the Disability began or the current Congregational Teaching Elders’ Median. 5 The Annual Deductible for individuals enrolled for Medical Continuation coverage shall be established on the basis of the Congregational Teaching Elders’ Median. 6 After a member reaches the annual copayment maximum; the Medical Plan pays 100 percent of eligible expenses up to the plan allowance, except for office visit copays. The copayment maximum applies to the member and family combined. Note: The combined individual and family medical and prescription drug copays, deductibles and copayment maximums are capped at the Affordable Care Act annual limitations of $7,150 and $14,300. 1 2

PLAN MAXIMUM REIMBURSEMENT LIMITS MEDICAL PLAN REIMBURSEMENT LIMITS MAXIMUM BENEFIT REIMBURSEMENT $10,000

1

C AT E G O R Y Travel and lodging benefit for the covered patient and a companion for covered transplants if the surgery occurs 100 or more miles from the patient’s home

$500

Travel and lodging benefit for the covered patient and a companion for covered services at a Blue Distinction Center if the treatment occurs 100 or more miles from the patient’s home Lifetime maximum for temporomandibular joint dysfunction (TMJ) treatment

$2,500 every three years

Hearing aid (device and fitting)1

3 procedures

Lifetime maximum for medically necessary use of advanced reproductive technology1,2

100 visits

Annual maximum visits, of up to 8 hours each, for home healthcare

180 days

Annual maximum for extended-care facilities

Covered under the PPO. Includes in vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI), ovum microsurgery, and the supplies and prescription drugs related to such therapies.

2

Page 48

January 2017 PREMIUM FORMULARY DRUG LIST FO The Optum Drug List is a guide identifying generic, Opt RM preferred brand name, and non-preferred brand um UL name medicines within select therapeutic Dru categories. The Drug List may not include all drugs AR g covered by your prescription drug benefit. Generic Y medicines are available within many of the List isDR a therapeutic categories listed, in addition to UG categories not listed, and should be considered as guid eLIS the first line of prescribing. iden T

ceftriaxone sodium cefuroxime axetil cefuroxime sodium cephalexin Ceftriaxone IN Iso-osmotic Dextrose PREFERRED Cefaclor Cephalexin NON PREFERRED Ancef Avycaz Cedax Cefaclor ER Cefazolin Cefazolin Sodium Cefazolin Sodium/Dextrose Cefazolin/Dextrose Cefazolin/D5W Cefazolin/Sodium Chloride Cefditoren Pivoxil Cefepime Cefepime/Dextrose Cefotan Cefotaxime Sodium Cefotetan Cefotetan/Dextrose Cefoxitin Sodium Ceftazidime/Dextrose Ceftibuten Ceftin Ceftriaxone Sodium Ceftriaxone/Dextrose Cefuroxime Sodium Claforan Claforan/D5W Fortaz Keflex Maxipime Rocephin Spectracef Suprax Tazicef Teflaro Zerbaxa Zinacef

Ampicillin Sodium Augmentin Augmentin ES-600 Augmentin XR Bactocill IN Dextrose Bicillin C-R Bicillin L-a Moxatag Nafcillin Nafcillin Sodium Penicillin G Potassium IN Iso-osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Pfizerpen-G Timentin Unasyn Unasyn Bulk Pack Zosyn

tifyin For benefit coverage or restrictions please check g your benefit plan document(s). This listing is revised gen periodically as new drugs and new prescribing eric, information becomes available. It is recommended pref that you bring this list of medications when you or a QUINOLONES erre covered family member sees a physician or other GENERIC d healthcare provider. ciprofloxacin bran ANTI-INFECTIVES ciprofloxacin ER d ciprofloxacin HCL nam ANTIFUNGALS GENERIC ciprofloxacin I.V.-IN D5W e, fluconazole levofloxacin and fluconazole IN dextrose nonlevofloxacin IN D5W fluconazole IN NACL pref levofloxacin IN 5% dextrose erre flucytosine moxifloxacin HCL d griseofulvin microsize Ciprofloxacin HCL bran griseofulvin ultramicrosize Ofloxacin d itraconazole NON PREFERRED nam ketoconazole Avelox e nystatin Avelox Abc Pack med terbinafine HCL Cipro icine voriconazole Cipro I.V.-IN D5W s NON PREFERRED Cipro XR withi Abelcet n Ciprofloxacin Ambisome sele Factive Amphotec ct Levaquin ther Amphotericin B Moxifloxacin HCL ape Ancobon Noroxin utic Cresemba cate Diflucan TETRACYCLINES gori Fluconazole IN NACL GENERIC es. Grifulvin V demeclocycline HCL The PENICILLINS Gris-peg doxycycline Dru GENERIC Lamisil doxycycline hyclate g amoxicillin Noxafil doxycycline hyclate DR List amoxicillin/clavulanate potassium Onmel may doxycycline monohydrate amoxicillin/clavulanate potassium ER Sporanox not minocycline HCL ampicillin inclu Sporanox Pulsepak minocycline HCL ER ampicillin sodium de Vfend tetracycline hydrochloride ampicillin-sulbactam all Vfend IV Tetracycline HCL dicloxacillin sodium drug NON PREFERRED nafcillin sodium s CEPHALOSPORINS Acticlate oxacillin sodium cove GENERIC Adoxa penicillin v potassium red cefaclor Adoxa PAK 1/100 penicillin G potassium by cefadroxil Adoxa PAK 1/150 your piperacillin sodium/ tazobactam cefazolin sodium Adoxa PAK 2/100 pres sodium cefdinir cripti piperacillin sodium/tazobactam Alodox Convenience Kit cefepime on sodium Doryx cefixime piperacillin/tazobactam drug Doryx Mpc ben cefotaxime sodium Amoxicillin/Clavulanate Potassium Minocin efit. cefotetan PREFERRED Minocin Kit Gen cefoxitin sodium Amoxicillin Monodox eric cefpodoxime proxetil Ampicillin Morgidox 1X100MG med cefprozil NON PREFERRED Morgidox 1X50MG Kit icine ceftazidime Amoxicillin ER Morgidox 2X100MG s are avail Effective January 1, 2017 v.1 able All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Page 49 withi © 2017 Optum, Inc. All rights reserved. n man y of TM

Nutridox Ocudox Solodyn Targadox Vibramycin

NSAIDS

ANTI-INFLAMMATORY GENERIC celecoxib diclofenac potassium diclofenac sodium DR diclofenac sodium ER diclofenac sodium/misoprostol etodolac etodolac ER flurbiprofen ibuprofen ibuprofen lysine indomethacin indomethacin ER ketoprofen ketorolac tromethamine mefenamic acid meloxicam nabumetone naproxen naproxen sodium naproxen sodium CR naproxen sodium ER oxaprozin piroxicam sulindac tolmetin sodium Meclofenamate Sodium Naproxen Tolmetin Sodium PREFERRED Fenoprofen Calcium Ketoprofen ER Meloxicam NON PREFERRED Anaprox DS Arthrotec 50 Arthrotec 75 Caldolor Capxib Kit Cataflam Celebrex Daypro Derma Silkrx Anodynexa PAK Derma Silkrx Diclopak Dermacinrx Inflammatral PAK Dyloject EC-naprosyn Feldene Fenortho Flanax Pain Relief Kit Ibuprofen Comfort PAC Indocin Indomethacin IC 400 IC 800 Ketorocaine-l Ketorocaine-lm Ketorolac Tromethamine Meloxicam Comfort PAC Mobic Nalfon

Page 50

Naprelan Naprosyn Naproxen Comfort PAC Neoprofen Ponstel Previdolrx Analgesic PAK Sprix Tivorbex Toronova II Suik Toronova Suik Vivlodex Voltaren-XR Zipsor

AUTO-IMMUNE PREFERRED Cimzia Cimzia Starter Kit Humira Humira Pediatric Crohns Disease Starter Pack Humira Pen Humira Pen-crohns Diseasestarter Humira Pen-psoriasis Starter Remicade Simponi Simponi Aria NON PREFERRED Actemra Enbrel Enbrel Sureclick Kineret Orencia Orencia Clickject Xeljanz Xeljanz XR

CARDIOVASCULAR ACE-INHIBITORS GENERIC benazepril HCL captopril enalapril maleate enalaprilat fosinopril sodium lisinopril moexipril HCL perindopril erbumine quinapril HCL ramipril trandolapril NON PREFERRED Accupril Aceon Altace Epaned Lotensin Mavik Prinivil Qbrelis Univasc Vasotec Zestril

ANGIOTENSIN RCPTR BLOCKER GENERIC candesartan cilexetil irbesartan losartan potassium

telmisartan valsartan Eprosartan Mesylate PREFERRED Benicar NON PREFERRED Atacand Avapro Cozaar Diovan Edarbi Micardis Teveten

BETA BLOCKERS

GENERIC acebutolol HCL atenolol betaxolol HCL bisoprolol fumarate carvedilol esmolol HCL labetalol HCL metoprolol succinate ER metoprolol tartrate nadolol pindolol propranolol HCL propranolol HCL ER sotalol HCL sotalol HCL (AF) Metoprolol Tartrate PREFERRED Bystolic Propranolol HCL Timolol Maleate NON PREFERRED Betapace Betapace AF Brevibloc Coreg Coreg CR Corgard Esmolol HCL Hemangeol Hypertenevide-12.5 Inderal LA Inderal XL Innopran XL Kerlone Levatol Lopressor Sectral Sotalol Hydrochloride Sotylize Tenormin Toprol XL Trandate Zebeta

CALCIUM CHANNEL BLOCKERS GENERIC amlodipine besylate diltiazem CD diltiazem HCL diltiazem HCL CD diltiazem HCL ER felodipine ER isradipine

Effective January 1, 2017

nicardipine HCL nifedipine nifedipine ER nimodipine nisoldipine verapamil HCL verapamil HCL ER verapamil HCL SR NON PREFERRED Adalat CC Calan Calan SR Cardene IV Cardizem Cardizem CD Cardizem LA Cleviprex Diltiazem Hydrochloride/Sodium Chloride Diltiazem HCL Nisoldipine Nisoldipine ER Norvasc Nymalize Procardia Procardia XL Sular Tiazac Verelan Verelan PM

candesartan cilexetil/hydrochlorothiazide enalapril maleate/hydrochlorothiazide fosinopril sodium/hydrochlorothiazide irbesartan/hydrochlorothiazide lisinopril/hydrochlorothiazide losartan potassium/hydrochlorothiazide metoprolol/hydrochlorothiazide moexipril/hydrochlorothiazide nadolol/bendroflumethiazide quinapril/hydrochlorothiazide telmisartan/amlodipine telmisartan/hydrochlorothiazide trandolapril/verapamil HCL trandolapril/verapamil HCL ER valsartan/hydrochlorothiazide PREFERRED Azor Benicar HCT Captopril/Hydrochlorothiazide Dutoprol Methyldopa/Hydrochlorothiazide Propranolol/Hydrochlorothiazide Tekturna HCT Tribenzor NON PREFERRED Accuretic Amturnide Atacand HCT Avalide Clorpres Corzide Diovan HCT Edarbyclor Exforge Exforge HCT Hypertensolol Hyzaar Lopressor HCT Lotensin HCT Lotrel Lytensopril Kit Lytensopril-90 Kit Micardis HCT Prestalia Tarka Tekamlo Tenoretic 100 Tenoretic 50 Teveten HCT Twynsta Vaseretic Zestoretic Ziac

NITRATES & NITRITES

GENERIC isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate ER nitroglycerin nitroglycerin lingual nitroglycerin transdermal nitroglycerin ER nitroglycerin IN dextrose 5% nitroglycerin IN 5% dextrose Nitroglycerin Lingual PREFERRED Dilatrate SR Isosorbide Dinitrate ER Nitro-bid Nitro-dur NON PREFERRED Imdur Isordil Titradose Nitroglycerin Nitroglycerin IN Dextrose 5% Nitrolingual Pumpspray Nitromist Nitronal Nitrostat

ANTI-HTN COMBINATIONS

GENERIC amlodipine besylate/benazepril hydrochloride amlodipine besylate/benazepril HCL amlodipine besylate/valsartan amlodipine/valsartan/hctz atenolol/chlorthalidone benazepril HCL/hydrochlorothiazide bisoprolol fumarate/hydrochlorothiazide

Effective January 1, 2017

ANTIHYPERLIPIDEMICS STATINS

GENERIC atorvastatin calcium fluvastatin fluvastatin sodium ER lovastatin pravastatin sodium rosuvastatin calcium simvastatin NON PREFERRED Altoprev Crestor Lescol Lescol XL

FIBRATES

Lipitor Livalo Mevacor Pravachol Zocor

GENERIC fenofibrate fenofibrate micronized fenofibric acid DR gemfibrozil Fenofibrate Fenofibric Acid PREFERRED Fibricor Lipofen NON PREFERRED Antara Fenoglide Lofibra Lopid Tricor Triglide Trilipix BILE ACID SEQUESTRANTS GENERIC cholestyramine cholestyramine light colestipol HCL PREFERRED Welchol NON PREFERRED Colestid Colestid Flavored Questran Questran Light CHOLEST ABS INHBTR/COMBO PREFERRED Vytorin NON PREFERRED Zetia NIACIN/COMBINATIONS GENERIC niacin ER PREFERRED Niacor Simcor NON PREFERRED Advicor Niaspan OMEGA-3 FATTY ACIDS GENERIC omega-3-acid ethyl esters PREFERRED Vascepa NON PREFERRED Kynamro Lovaza

ACNE

DERMATOLOGICALS GENERIC adapalene adapalene P.M. benzoyl peroxide benzoyl peroxide SHORT contact clindamycin phosphate clindamycin phosphate/tretinoin clindamycin/benzoyl peroxide

Page 51

erythromycin erythromycin/benzoyl peroxide metronidazole sodium sulfacetamide sodium sulfacetamide/sulfur sodium sulfacetamide/sulfur cleanser sodium sulfacetamide/sulfur cleansing cloths sodium sulfacetamide/sulfur green sodium sulfacetamide/sulfur w/sunscreen sodium sulfacetamide/sulfur wash sulfacetamide sodium sulfacetamide sodium/sulfur sulfacetamide sodium/sulfur cleanser tretinoin tretinoin microsphere tretinoin microsphere P.M. Doxycycline PREFERRED Clindagel Mirvaso Retinoic Acid Retinoic Acid-all Trans Soolantra Tretinoin Tretinoin (all-trans Retinoic Acid) NON PREFERRED Absorica Aczone Adapalene Akne-mycin Atralin Avar Avar LS Avar LS Cleanser Avar-e LS Azelex Benzac Ac Wash Benzefoam Benzefoam Ultra Benzefoamultra Benziq Benziq LS Clarifoam EF Cleocin-t Clindacin Etz Clindacin PAC Clindap-t Clinoin Dermapak Plus Differin Epiduo Epiduo Forte Erygel Evoclin Fabior Finacea Inova Inova 4/1 Acne Control Therapy Inova 8/2 Acne Control Therapy Klaron Metrocream Metrogel Metrolotion Neuac Kit Noritate Nuox Onexton Oracea Plexion

Page 52

Plexion Cleanser Plexion Cleansing Cloths Prascion Ra With Sunscreens Retin-a Retin-a Micro Retin-a Micro P.M. Riax Rosadan Kit Rosula Sodium Sulfacetamide/Sulfur Sodium Sulfacetamide/Sulfur Cleanser IN Urea Sodium Sulfacetamide/Sulfur IN Urea Sulfoam Sumadan Kit Sumadan Wash Sumadan XLT Sumaxin Sumaxin CP Kit Sumaxin Ts Sumaxin Wash Tretin-x Triseon Vanoxide-HC Zacare 4% Kit Zacare 8% Kit

TOPICAL ANTI-INFLAMMATORY

GENERIC alclometasone dipropionate augmented betamethasone dipropionate betamethasone dipropionate betamethasone valerate calcipotriene/betamethasone dipropionate clobetasol propionate clobetasol propionate emollient desonide desoximetasone fluocinolone acetonide fluocinonide fluocinonide-e flurandrenolide fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone acetate/aloe hydrocortisone butyrate hydrocortisone butyrate (lipid) hydrocortisone butyrate (lipophilic) hydrocortisone valerate hydrocortisone IN absorbase mometasone furoate prednicarbate triamcinolone acetonide Amcinonide Desoximetasone Diflorasone Diacetate PREFERRED Pramosone NON PREFERRED Aclovate Advanced Allergy Collection Kit Ala Scalp Capex Clobex Clocortolone Pivalate Clocortolone Pivalate P.M. Clodan Kit

Cloderm Cloderm P.M. Cordran Cordran Tape Cutivate Derma-smoothe/FS Body Derma-smoothe/FS Scalp Dermasorb HC Dermasorb Ta Dermatop Dermazone Desonate Desowen Diprolene Diprolene AF Elocon Enstilar Epifoam First-hydrocortisone Halog Kenalog Locoid Locoid Lipocream Luxiq Micort-HC Noxipak Nucort Nuzon Olux Olux-e Pandel Pediaderm HC Pediaderm Ta Rrb PAK Scalacort DK Sernivo Silazone Pharmapak Silazone-II Synalar Synalar Cream Kit Synalar Ointment Kit Synalar Ts Taclonex Temovate Temovate E Texacort Topicort Triamsil Combipak Trianex Triderma Forte Ultravate Ultravate X Validerm Vanos Verdeso Westcort Xilapak

ENDOCRINE CONTRACEPTIVE AGENTS

GENERIC desogestrel/ethinyl estradiol drospirenone/ethinyl estradiol levonorgestrel levonorgestrel and ethinyl estradiol levonorgestrel/ethinyl estradiol norethindrone norethindrone & ethinyl estradiol ferrous fumarate

Effective January 1, 2017

norethindrone acetate/ethinyl estradiol norethindrone acetate/ethinyl estradiol/ferrous fumarate norgestimate/ethinyl estradiol Levonorgestrel PREFERRED Natazia Necon 1/50-28 Necon 10/11-28 Norinyl 1+50 Nuvaring Zovia 1/50e NON PREFERRED Beyaz Brevicon-28 Cyclessa Depo-provera Desogen Ella Estrostep FE Falessa Femcon FE Generess FE Loestrin FE 1.5/30 Loestrin FE 1/20 Loestrin 1.5/30-21 Loestrin 1/20-21 Loseasonique LO Loestrin FE Minastrin 24 FE Mircette Modicon Nor-QD Norinyl 1+35 Ortho Micronor Ortho Tri-cyclen Ortho Tri-cyclen LO Ortho-cept Ortho-cyclen Ortho-novum 1/35 Ortho-novum 7/7/7 Ovcon-35 Quartette Safyral Seasonique Taytulla Tri-norinyl 28 Yasmin 28 Yaz

ESTROGENS/COMBINATIONS

GENERIC estradiol estradiol valerate estradiol/norethindrone acetate norethindrone acetate/ethinyl estradiol Estropipate PREFERRED Climara Pro Duavee Menest Premphase Prempro NON PREFERRED Activella Alora Angeliq Biest/Progesterone

Effective January 1, 2017

Climara Combipatch Delestrogen Depo-estradiol Divigel Elestrin Enjuvia Estrace Estradiol Estring Estrogel Evamist Femhrt Low Dose Femring Menostar Minivelle Prefest Premarin Vagifem Vivelle-dot

TESTOSTERONE AGENTS

GENERIC danazol methyltestosterone testosterone cypionate testosterone enanthate PREFERRED Androderm Androgel Androgel P.M. Androxy NON PREFERRED Android Aveed Depo-testosterone First-testosterone First-testosterone Mc Compounding Kit Natesto Striant Testone Cik Testopel Testosterone Testred

INSULIN

PREFERRED Humalog Humalog Kwikpen Humalog Mix 50/50 Humalog Mix 50/50 Kwikpen Humalog Mix 75/25 Humalog Mix 75/25 Kwikpen Humulin N Humulin N Kwikpen Humulin R Humulin R U-500 (concentrated) Humulin R U-500 Kwikpen Humulin 70/30 Humulin 70/30 Kwikpen Lantus Lantus Solostar Toujeo Solostar NON PREFERRED Afrezza

NON-INSULIN HYPOGLYCEMICS BIGUANIDES GENERIC metformin HCL

metformin HCL ER NON PREFERRED Fortamet Glucophage Glucophage XR Glumetza Riomet BIGUAN/SULFONYLUREA COMB. GENERIC glipizide/metformin HCL glyburide/metformin HCL NON PREFERRED Glucovance BIGUAN/THIAZOLIDEINEDIONE GENERIC pioglitazone HCL pioglitazone HCL/metformin HCL NON PREFERRED Actoplus Met Actoplus Met XR Actos Avandamet Avandia DPP-4 INHIBITORS GENERIC Alogliptin PREFERRED Januvia Tradjenta BIGUANIDE/DPP-4 COMB. GENERIC Alogliptin/Metformin HCL PREFERRED Janumet Janumet XR Jentadueto Jentadueto XR SULFONYLUREAS GENERIC glimepiride glipizide glipizide ER glyburide glyburide micronized tolazamide Glyburide Tolazamide PREFERRED Chlorpropamide Diabeta Tolbutamide NON PREFERRED Amaryl Glucotrol Glucotrol XL Glynase SULFONYLUREA/TZD COMB. GENERIC pioglitazone HCL-glimepiride NON PREFERRED Avandaryl Duetact INCRETINS PREFERRED Bydureon Bydureon Pen Byetta Trulicity Victoza

Page 53

AMYLIN ANALOGS NON PREFERRED Symlinpen 120 Symlinpen 60 DIABETIC OTHER PREFERRED Glucagen Hypokit Glucagon Emergency Kit Invokamet Invokamet XR Invokana Jardiance Proglycem Synjardy

GASTROINTESTINAL PROTON PUMP INHIBITORS

GENERIC esomeprazole magnesium esomeprazole sodium lansoprazole omeprazole pantoprazole sodium rabeprazole sodium Esomeprazole Sodium PREFERRED Dexilant NON PREFERRED Aciphex Aciphex Sprinkle Esomeprazole Strontium First-lansoprazole First-omeprazole Nexium Nexium I.v. Omeprazole + Syrspend SF Alka Prevacid Prevacid Solutab Prilosec Protonix

ULCER DRUGS

GENERIC cimetidine cimetidine HCL famotidine misoprostol nizatidine ranitidine HCL sucralfate Famotidine Nizatidine NON PREFERRED Carafate Cytotec Deprizine Fusepaq Deprizine Rapidpaq Famotidine Premixed Pepcid Zantac

GROWTH HORMONE PREFERRED Norditropin Cartridge Norditropin Flexpro Norditropin Nordiflex Pen Nutropin AQ Nuspin 10 Nutropin AQ Nuspin 20

Page 54

Nutropin AQ Nuspin 5 Nutropin AQ Pen Saizen Saizen Click.easy Serostim NON PREFERRED Zorbtive

ANTIVIRALS

HEPATITIS C

GENERIC ribavirin PREFERRED Epclusa Harvoni Ribatab Sovaldi Zepatier NON PREFERRED Copegus Moderiba Moderiba 1200 Dose Pack Moderiba 800 Dose Pack Rebetol Ribasphere Ribasphere Ribapak Technivie Viekira PAK Viekira XR

INTERFERONS

PREFERRED Pegasys Pegasys Proclick NON PREFERRED Peg-intron Peg-intron Redipen Peg-intron Redipen PAK 4 Pegintron

PROTEASE INHIBITORS

NON PREFERRED Olysio Victrelis

MULTIPLE SCLEROSIS GENERIC glatopa PREFERRED Ampyra Avonex Avonex Pen Betaseron Copaxone Tecfidera Tecfidera Starter Pack NON PREFERRED Aubagio Gilenya Lemtrada Tysabri Zinbryta

NEUROLOGICALS ALZHEIMER'S DISEASE

GENERIC donepezil HCL galantamine hydrobromide

memantine hydrochloride memantine HCL memantine HCL titration PAK rivastigmine tartrate rivastigmine transdermal system Galantamine Hydrobromide PREFERRED Namenda XR Namenda XR Titration Pack Namzaric NON PREFERRED Aricept Aricept Odt Exelon Namenda Namenda Titration PAK Razadyne Razadyne ER

ANTICONVULSANTS

GENERIC carbamazepine carbamazepine ER clonazepam clonazepam odt divalproex sodium divalproex sodium DR divalproex sodium ER ethosuximide felbamate fosphenytoin sodium gabapentin lamotrigine lamotrigine odt lamotrigine titration lamotrigine ER levetiracetam levetiracetam ER oxcarbazepine phenytoin phenytoin sodium phenytoin sodium extended primidone tiagabine hydrochloride topiramate valproate sodium valproic acid zonisamide Diazepam PREFERRED Diastat Acudial Diastat Pediatric Lyrica NON PREFERRED Aptiom Banzel Briviact Carbatrol Celontin Cerebyx Depacon Depakene Depakote Depakote ER Depakote Sprinkles Dilantin Dilantin Infatabs Dilantin-125 Fanatrex Fusepaq

Effective January 1, 2017

Felbatol Fycompa Gabitril Keppra Keppra XR Klonopin Lamictal Lamictal Chewable Dispersible Lamictal Odt Lamictal Starter/Not Taking Carbamazepine Lamictal Starter/Taking Carbamazepine/Not Taking Valproate Lamictal Starter/Taking Valproate Lamictal XR Levetiracetam Mysoline Neurontin Onfi Oxtellar XR Peganone Phenytek Potiga Qudexy XR Sabril Spritam Stavzor Tegretol Tegretol-XR Therapentin-60 Therapentin-90 Topamax Topamax Sprinkle Topiramate ER Trileptal Trokendi XR Vimpat Zarontin Zonegran

MIGRAINE/HEADACHE

GENERIC almotriptan almotriptan malate dihydroergotamine mesylate frovatriptan succinate naratriptan HCL rizatriptan benzoate rizatriptan benzoate odt sumatriptan sumatriptan succinate sumatriptan succinate refill zolmitriptan zolmitriptan odt Dihydroergotamine Mesylate Sumatriptan Succinate NON PREFERRED Alsuma Amerge Axert Cafergot D.h.e. 45 Ergomar Frova Imitrex Imitrex Statdose Refill Imitrex Statdose System Maxalt Maxalt-MLT Migergot

Effective January 1, 2017

Migral Migranal Migranow Onzetra Xsail Relpax Sumavel Dosepro Treximet Zecuity Zembrace Symtouch Zomig Zomig Nasal Spray Zomig ZMT

OPHTHALMICS ANTI-ALLERGIC AGENTS GENERIC azelastine HCL cromolyn sodium epinastine HCL olopatadine HCL PREFERRED Pataday Pazeo NON PREFERRED Alocril Alomide Bepreve Elestat Emadine Lastacaft Optivar Patanol

ANTI-GLAUCOMA AGENTS

GENERIC apraclonidine betaxolol HCL brimonidine tartrate carteolol HCL dorzolamide HCL dorzolamide HCL/timolol maleate latanoprost levobunolol HCL timolol maleate timolol maleate ophthalmic gel forming Bimatoprost Metipranolol Travoprost PREFERRED Alphagan P Azopt Betoptic-s Combigan Lumigan Timoptic Ocudose Travatan Z NON PREFERRED Betagan Betimol Cosopt Cosopt PF Iopidine Istalol Timoptic Timoptic-xe Trusopt Xalatan

ANTI-INFECTIVES

GENERIC ciprofloxacin HCL erythromycin gatifloxacin gentamicin sulfate levofloxacin ofloxacin tobramycin sulfate PREFERRED Bacitracin Moxeza Vigamox NON PREFERRED Azasite Besivance Ciloxan Garamycin Mitosol Ocuflox Tobrex Zymaxid

ANTI-INFLAMMATORY AGENTS GENERIC bromfenac cromolyn sodium diclofenac sodium flurbiprofen sodium ketorolac tromethamine NON PREFERRED Acular Acular LS Acuvail Bromfenac Bromsite Ilevro Nevanac Ocufen Prolensa

CORTICOSTEROIDS/RELATED

GENERIC dexamethasone sodium phosphate fluorometholone neomycin/polymyxin/bacitracin/hydroco rtisone neomycin/polymyxin/dexamethasone prednisolone acetate sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone PREFERRED Dexamethasone Sodium Phosphate FML FML Forte Pred Mild Prednisolone Sodium Phosphate NON PREFERRED Alrex Blephamide Blephamide S.o.p. Durezol Flarex FML Liquifilm Lotemax Maxidex Maxitrol Neomycin/Polymyxin/Hydrocortisone Omnipred

Page 55

Pred Forte Pred-G Pred-G S.o.p. Prednisolone/Moxifloxacin Prednisolone/Moxifloxacin/Bromfenac Tobradex Tobradex ST Vexol Zylet

MIOTICS

GENERIC pilocarpine HCL PREFERRED Phospholine Iodide NON PREFERRED Isopto Carpine

MISCELLANEOUS

NON PREFERRED Lacrisert Restasis

OSTEOPOROSIS BISPHOSPHONATES GENERIC alendronate sodium ibandronate sodium pamidronate disodium risedronate sodium risedronate sodium DR zoledronic acid PREFERRED Alendronate Sodium NON PREFERRED Actonel Atelvia Binosto Boniva Etidronate Disodium Fosamax Fosamax Plus D Pamidronate Disodium Reclast Zoledronic Acid Zometa

SERM

GENERIC raloxifene hydrochloride NON PREFERRED Evista Osphena

PSYCHOTHERAPEUTICS ANTIPSYCHOTICS/ANTIMANIC GENERIC aripiprazole aripiprazole odt chlorpromazine HCL clozapine clozapine odt fluphenazine decanoate fluphenazine HCL haloperidol haloperidol decanoate haloperidol lactate lithium carbonate lithium carbonate ER

Page 56

loxapine loxapine succinate olanzapine olanzapine odt paliperidone ER perphenazine prochlorperazine prochlorperazine edisylate prochlorperazine maleate quetiapine fumarate risperidone risperidone odt thioridazine HCL thiothixene trifluoperazine HCL ziprasidone HCL Clozapine Odt PREFERRED Abilify Discmelt Fluphenazine HCL Saphris Seroquel XR NON PREFERRED Abilify Abilify Maintena Adasuve Aristada Chlorpromazine HCL Clozaril Equetro Fanapt Fanapt Titration Pack Fazaclo Geodon Haldol Haldol Decanoate 100 Haldol Decanoate 50 Invega Invega Sustenna Invega Trinza Latuda Lithium Lithium Carbonate Lithobid Molindone Hydrochloride Nuplazid Rexulti Risperdal Risperdal Consta Risperdal M-TAB Seroquel Versacloz Vraylar Zyprexa Zyprexa Relprevv Zyprexa Zydis

PSYCHOTHERAPEUTICS, MISC.

GENERIC amphetamine/dextroamphetamine armodafinil clonidine HCL ER dexmethylphenidate HCL dexmethylphenidate HCL ER dextroamphetamine sulfate dextroamphetamine sulfate ER guanfacine ER methamphetamine HCL methylphenidate hydrochloride

methylphenidate HCL methylphenidate HCL CD methylphenidate HCL ER methylphenidate HCL SR modafinil Armodafinil Methylphenidate HCL ER PREFERRED Strattera Vyvanse NON PREFERRED Adderall Adderall XR Adzenys XR-odt Aptensio XR Concerta Daytrana Desoxyn Dexedrine Dyanavel XR Evekeo Focalin Focalin XR Intuniv Kapvay Metadate CD Methylin Nuvigil Procentra Provigil Quillichew ER Quillivant XR Ritalin Ritalin LA Zenzedi

SNRI ANTIDEPRESSANTS

GENERIC duloxetine HCL venlafaxine HCL venlafaxine HCL ER Venlafaxine HCL ER PREFERRED Pristiq NON PREFERRED Cymbalta Desvenlafaxine ER Duloxetine HCL Effexor XR Fetzima Fetzima Titration Pack Irenka Khedezla

SSRI ANTIDEPRESSANTS

GENERIC citalopram hydrobromide escitalopram oxalate fluoxetine DR fluoxetine HCL fluvoxamine maleate fluvoxamine maleate ER paroxetine HCL paroxetine HCL ER sertraline HCL PREFERRED Fluoxetine HCL Paxil

Effective January 1, 2017

NON PREFERRED Celexa Lexapro Luvox CR Paxil CR Pexeva Prozac Prozac Weekly Zoloft

RESPIRATORY ANAPHYLAXIS TX AGENTS PREFERRED Epipen 2-PAK Epipen-JR 2-PAK NON PREFERRED Adrenalin Adyphren II Adyphren Kit Epinephrine Episnap Epy II Kit Epy Kit

ANTICHOLINERGICS

GENERIC ipratropium bromide PREFERRED Incruse Ellipta Spiriva Handihaler Spiriva Respimat NON PREFERRED Atrovent HFA

ANTICHLNRGC/BETA AGONIST

GENERIC ipratropium bromide/albuterol sulfate PREFERRED Anoro Ellipta Combivent Respimat

BETA AGONISTS

GENERIC albuterol albuterol sulfate albuterol sulfate ER albuterol TAB 4MG levalbuterol levalbuterol HCL terbutaline sulfate PREFERRED Foradil Aerolizer Metaproterenol Sulfate Proair HFA Proair Respiclick Serevent Diskus Ventolin HFA NON PREFERRED Arcapta Neohaler Brovana Isuprel Perforomist Striverdi Respimat Vospire ER Xopenex Xopenex Concentrate

LEUKOTRIENE RCPTR ANTGNST

Effective January 1, 2017 v.1

GENERIC montelukast sodium zafirlukast NON PREFERRED Accolate Singulair

PULMONARY CORTICOSTEROIDS GENERIC budesonide PREFERRED Arnuity Ellipta Flovent Diskus Flovent HFA Pulmicort Flexhaler NON PREFERRED Aerospan Pulmicort

NASAL ANTIHISTAMINES

GENERIC azelastine HCL olopatadine HCL NON PREFERRED Astepro Patanase

NASAL CORTICOSTEROIDS

GENERIC budesonide flunisolide fluticasone propionate mometasone furoate triamcinolone acetonide NON PREFERRED Beconase AQ Flonase Nasonex Omnaris Qnasl Qnasl Childrens Rhinocort Aqua Veramyst Zetonna

STEROID/BETA AGONIST PREFERRED Advair Diskus Advair HFA Breo Ellipta Symbicort

NON PREFERRED Avodart Cardura XL Flomax Jalyn Proscar Uroxatral

ERECTILE DYSFUNCTION PREFERRED Cialis Viagra

URINARY ANTISPASMODICS

GENERIC bethanechol chloride darifenacin hydrobromide ER flavoxate HCL oxybutynin chloride oxybutynin chloride ER tolterodine tartrate tolterodine tartrate ER trospium chloride trospium chloride ER PREFERRED Vesicare NON PREFERRED Detrol Detrol LA Ditropan XL Enablex Gelnique Oxytrol Toviaz Urecholine

Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Optum. The presence of a medication on this formulary list does not guarantee coverage. To determine the most up-to-date formulary status of your medication, please visit your member website or call member services at the number listed on your ID card.

MISCELLANEOUS

PREFERRED Dymista NON PREFERRED Dermacinrx Azenase PAK

UROLOGICALS BENIGN PRSTATC HYPRPLSIA

GENERIC alfuzosin HCL ER dutasteride dutasteride/tamsulosin hydrochloride dutasteride/tamsulosin HCL finasteride tamsulosin HCL PREFERRED Rapaflo

All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. © 2017 Optum, Inc. All rights reserved. TM

Page 57

2017 Preventive Schedule PLAN YOUR CARE: KNOW WHAT YOU NEED AND WHEN TO GET IT

QUESTIONS?

Preventive or routine care helps us stay well or finds problems early, when they are easier to treat. The preventive guidelines on this schedule depend on your age, gender, health and family history. As a part of your health plan, you may be eligible to receive some of these preventive benefits with little to no cost sharing when using in-network providers. Make sure you know what is covered by your health plan and any requirements before you receive any of these services. Some services and their frequency may depend on your doctor’s advice. That’s why it’s important to talk with your doctor about the services that are right for you.

Adults: Ages 19+

Male

Call Member Service Ask your doctor Log in to your account

Female

General Health Care Physical Exam* (This exam is not the workor school-related physical)

• Ages 19 to 49: Every 1 to 2 years • Ages 50 and older: Once a year

Pelvic, Breast Exam

Once a year

Screenings/Procedures Abdominal Aortic Aneurysm Screening

Ages 65 to 75 who have ever smoked: One-time screening

Breast Cancer Genetic (BRCA) Screening (Requires prior authorization)

Those meeting specific high-risk criteria: One-time genetic assessment for breast and ovarian cancer risk

Cholesterol (Lipid) Screening

• Ages 20 and older: Once every 5 years • High-risk: More often

Colon Cancer Screening and Certain Colonoscopy Preps With Prescription

• Ages 50 and older: Once a year • High-risk: Earlier or more frequently

Diabetes Screening

High-risk: Ages 40 and older, once every 3 years

Complete Blood Count (CBC)

Annually

Hepatitis B Screening

High-risk

Hepatitis C Screening

High-risk

Lung Cancer Screening (Requires use of authorized facility)

Ages 55 to 80 with 30-pack per year history: Once a year for current smokers, or once a year if currently smoking or quit within past 15 years

Mammogram

Ages 40 and older: Once a year including 3-D (If you have/had cancer or your mammogram is positive, annual MRIs follow your diagnostic benefits)

Osteoporosis (Bone Mineral Density) Screening

Ages 60 and older: Once every 2 years

Pap Test

• Ages 21 to 65: Every 3 years, or annually, per doctor’s advice • Ages 30 to 65: Every 5 years if combined Pap and HPV are negative • Ages 65 and older: Per doctor’s advice

Prostate Cancer Screening

Discussion of risks/benefits of prostate cancer screening. Testing may include annual Prostate Specific Antigen (PSA) and/or digital rectal exam.

Sexually Transmitted Disease (STD) Screenings (Chlamydia, Gonorrhea, HIV and Syphilis)

Sexually active males and females

Urinalysis

Annually

*Physical Exam could include health history; physical; height, weight and blood pressure measures; body mass index (BMI) assessment; counseling for obesity, fall prevention, skin cancer and safety; depression screening; alcohol and drug abuse, and tobacco use assessment; and age-appropriate guidance. PREV/SCH/NG-W-1

Page 58

Adults: Ages 19+ Immunizations Chicken Pox (Varicella)

Adults with no history of chicken pox: One 2-dose series

Diphtheria, Tetanus (Td/Tdap)

• One-time Tdap • Td booster every 10 years

Flu (Influenza)

Every year (Must get at your PCP’s office or designated pharmacy vaccination provider; call Member Service to verify that your vaccination provider is in the Highmark network)

Hepatitis A

At-risk or per doctor’s advice: One 2-dose series

Hepatitis B

At-risk or per doctor’s advice: One 3-dose series

Haemophilus Influenzae Type B (Hib)

For adults with certain medical conditions to prevent meningitis, pneumonia and other serious infections; this vaccine does not provide protection against the flu and does not replace the annual flu vaccine

Human Papillomavirus (HPV)

Ages 9 to 26: One 3-dose series

Measles, Mumps, Rubella (MMR)

One or two doses

Meningitis*

At-risk or per doctor’s advice

Pneumonia

High-risk or ages 65 and older: One or two doses, per lifetime

Shingles (Zoster)

Ages 60 and older: One dose

Preventive Drug Measures That Require a Doctor’s Prescription Aspirin

Ages 50 to 59 to reduce the risk of stroke and heart attack

Folic Acid

Women planning or capable of pregnancy: Daily supplement containing .4 to .8 mg of folic acid

Raloxifene Tamoxifen

At-risk for breast cancer, without a cancer diagnosis, ages 35 and older

Tobacco Cessation (Counseling and medication)

Adults who use tobacco products

Vitamin D Supplements

Ages 65 and older who are at risk for falls

Preventive Care for Pregnant Women Screenings and Procedures

• Gestational diabetes screening • Hemoglobin (anemia) • Hepatitis B screening and immunization, if needed • HIV screening • Syphilis screening • Smoking cessation counseling • One depression screening for pregnant women and one for postpartum women

• Rh typing at first visit • Rh antibody testing for Rh-negative women • Tdap with every pregnancy • Urine culture and sensitivity at first visit

Prevention of Obesity, Heart Disease and Diabetes Adults With BMI 25 to 29.9 (Overweight) and 30 to 39.9 (Obese) Are Eligible For:

* Meningococcal B vaccine per doctor’s advice.

• Additional annual preventive office visits specifically for obesity and blood pressure measurement • Additional nutritional counseling visits specifically for obesity

• Recommended lab tests: – ALT – AST – Hemoglobin A1c or fasting glucose – Cholesterol screening

Page 59

2017 Preventive Schedule PLAN YOUR CHILD’S CARE: KNOW WHAT YOUR CHILD NEEDS AND WHEN TO GET IT

QUESTIONS?

Preventive or routine care helps your child stay well or finds problems early, when they are easier to treat. Most of these services may not have cost sharing if you use the plan’s in-network providers. Make sure you know what is covered by your health plan and any requirements before you schedule any services for your child. It’s important to talk with your child’s doctor. The frequency of services, and schedule of screenings and immunizations depends on what the doctor thinks is right for your child.

Call Member Service Ask your doctor Log in to your account

Children: Birth to 30 Months1 General Health Care

Birth

1M

2M

4M

6M

9M

12M

15M

18M

24M

30M

Wellness Exam* (This exam is not the preschool- or day care-related physical) Hearing Screening

Screenings Autism Screening Critical Congenital Heart Disease (CCHD) Screening With Pulse Oximetry Developmental Screening Hematocrit or Hemoglobin Screening Lead Screening Newborn Blood Screening

Immunizations Chicken Pox

Dose 1

Diphtheria, Tetanus, Pertussis (DTaP)

Dose 1

Dose 2

Dose 3

Flu (Influenza)**

Ages 6 months to 30 months: 1 or 2 doses annually

Hepatitis A Hepatitis B Haemophilus Influenzae Type B (Hib)

Dose 4

Dose 1 Dose 1

Dose 2 Dose 1

Dose 2

Dose 3 Dose 2

Dose 3

Measles, Mumps, Rubella (MMR)

Dose 4 Dose 1

Pneumonia

Dose 1

Dose 2

Polio (IPV)

Dose 1

Dose 2

Rotavirus

Dose 1

Dose 2

Dose 3

Dose 4

Ages 6 months to 18 months: Dose 3 Dose 3

* Wellness Exam could include height and weight measures, behavioral and developmental assessment, and age-appropriate guidance. Additional: Instrument vision screening to assess risk for ages 1 and 2 years. ** Must get at your PCP’s office or designated pharmacy vaccination provider. Call Member Service to verify that your vaccination provider is in the Highmark network.

Page 60

Children: 3 Years to 18 Years1 General Health Care

3Y

4Y

5Y

6Y

7Y

8Y

9Y

10Y

Wellness Exam* (This exam is not the preschool- or day care-related physical)

11Y

12Y

15Y

18Y

Once a year from ages 11 to 18

Ambulatory Blood Pressure Monitoring** Depression Screening

Once a year from ages 11 to 18

Hearing Screening Visual Screening***

Screenings Hematocrit or Hemoglobin Screening Lead Screening

Annually for females during adolescence and when indicated When indicated (Please also refer to your state-specific recommendations)

Immunizations Chicken Pox

Dose 2

Diphtheria, Tetanus, Pertussis (DTaP)

Dose 5

Flu (Influenza)****

1 dose of Tdap if 5 doses were not received previously

Provides long-term protection against cervical and other cancers. Ages 9 to 26: 3 doses. From dose 1, dose 2 at 2 months, dose 3 at 6 months. Dose 2 (at least 1 month apart from dose 1)

Meningitis***** Pneumonia Polio (IPV)

1 dose every 10 yrs.

Ages 3 to 18: 1 or 2 doses annually

Human Papillomavirus (HPV)

Measles, Mumps, Rubella (MMR)

If not previously vaccinated: Dose 1 and 2 (4 weeks apart)

Dose 1

Age 16: Onetime booster

Per doctor’s advice Dose 4

Care for Patients With Risk Factors BRCA Mutation Screening (Requires prior authorization)

Per doctor’s advice

Cholesterol Screening

Screening will be done based on the child’s family history and risk factors

Fluoride Varnish (Must use primary care doctor)

Ages 5 and younger

Hepatitis B Screening

Per doctor’s advice

Hepatitis C Screening

High-risk

Sexually Transmitted Disease (STD) Screenings (Chlamydia, Gonorrhea, HIV and Syphilis)

For all sexually active individuals

Tuberculin Test

Per doctor’s advice

* Wellness Exam could include height and weight measures, behavioral and developmental assessment, and age-appropriate guidance. ** To confirm new diagnosis of high blood pressure before starting treatment. *** Covered when performed in doctor’s office by having the child read letters of various sizes on a Snellen chart. Includes instrument vision screening for ages 3, 4 and 5 years. A comprehensive vision exam is performed by an ophthalmologist or optometrist and requires a vision benefit. **** Must get at your PCP’s office or designated pharmacy vaccination provider. Call Member Service to verify that your vaccination provider is in the Highmark network. ***** Meningococcal B vaccine per doctor’s advice.

Page 61

Children: 6 Months to 18 Years1 Preventive Drug Measures That Require a Doctor’s Prescription Iron

Routine supplementation for asymptomatic children age 6 to 12 months who are at increased risk for iron deficiency anemia

Oral Fluoride

For preschool children older than 6 months whose primary water source is deficient in fluoride

Prevention of Obesity and Heart Disease Children With a BMI in the 85th to • Additional annual preventive office visits specifically for obesity 94th Percentile (Overweight) and • Additional nutritional counseling visits specifically for obesity the 95th to 98th Percentile (Obese) • Recommended lab tests: Are Eligible For: – Alanine aminotransferase (ALT) – Aspartate aminotransferase (AST) – Hemoglobin A1c or fasting glucose (FBS) – Cholesterol screening

Women’s Health Preventive Schedule

(For plans renewed on or after Aug. 1, 2012, or for group plans that have chosen to cover these benefits)

Services Well-Woman Visits (Including preconception and first prenatal visit)

Up to 4 visits each year for age and developmentally appropriate preventive services

Contraception (Birth Control) Methods and Discussion*

All women planning or capable of pregnancy

Screenings/Procedures Diabetes Screening

• All women between 24 and 28 weeks pregnant • High-risk: At the first prenatal visit

HIV Screening and Discussion

All sexually active women: Once a year

Human Papillomavirus (HPV) Screening Testing

Beginning at age 30: Every 3 years

Domestic and Intimate Partner Once a year Violence Screening and Discussion Breast-feeding (Lactation) Support and Counseling, and Costs for Equipment

During pregnancy and/or after delivery (postpartum)

Sexually Transmitted Infections (STI) Discussion

All sexually active women: Once a year

* FDA-approved contraceptive methods may include sterilization and procedures as prescribed. One form of contraception in each of the 18 FDA-approved methods is covered without cost sharing. If the doctor recommends a clinical service or FDA-approved item based on medical necessity, there will be no cost sharing.

Information About the Affordable Care Act (ACA) This schedule is a reference tool for planning your family’s preventive care, and lists items and services required under the Affordable Care Act (ACA), as amended. It is reviewed and updated periodically based on the advice of the U.S. Preventive Services Task Force, laws and regulations, and updates to clinical guidelines established by national medical organizations. Accordingly, the content of this schedule is subject to change. Your specific needs for preventive services may vary according to your personal risk factors. Your doctor is always your best resource for determining if you’re at increased risk for a condition. Some services may require prior authorization. If you have questions about this schedule, prior authorizations or your benefit coverage, please call the Member Service number on the back of your member ID card.

Page 62

1

Information About Children’s Health Insurance Program (CHIP) Because the Children’s Health Insurance Program (CHIP) is a government-sponsored program and not subject to ACA, certain preventive benefits may not apply to CHIP members and/or may be subject to copayments. The ACA authorizes coverage for certain additional preventive care services. These services do not apply to “grand-fathered” plans. These plans were established before March 23, 2010, and have not changed their benefit structure. If your health coverage is a grandfathered plan, you would have received notice of this in your benefit materials.

Discrimination is Against the Law The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Plan: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: – Qualified sign language interpreters – Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: – Qualified interpreters – Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth. org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

U65_BCBS_G_M_2Col_8pt_blk_NL

10/16

CS208618

Page 63

PRIVACY FORMS The following privacy forms are available on pensions.org or by request from the Board of Pensions.

HIPAA FORMS

Page 64

FORM

AC T I O N S

Authorization to Release Medical Plan Information, HPA-001

Allows the Board of Pensions to release the protected health information to other specified persons, including a covered spouse; an organization, including a presbytery representative; or an internal Board department

Authorization for Use or Disclosure of Protected Health Information, HPA-002

Allows another health plan, a physician, practice, hospital, or healthcare provider or organization to release protected health information to the Board for purposes other than treatment, payment, or healthcare operations (for which no authorization is required)

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plan – Request for Access to PHI, HPA-003

Allows a covered individual or personal representative access to his or her protected health information maintained by the Medical Plan

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plan – Request to Amend PHI, HPA-004

Allows a covered individual or personal representative to request an amendment to his or her protected health information maintained by or for the Medical Plan

Benefits Plan of the Presbyterian Church (U.S.A.) Medical Plan – Request for Accounting of Disclosures, HPA-005

Allows a covered individual or personal representative to request an accounting of disclosures of protected health information

Member or Dependent Authorization to Use and Disclose Personal Employment and Financial Information, HPA-006

Authorizes the Board to disclose personal/employment/finance information

Personal Representative Request, ENR-903

Allows the Board to provide information to the personal representative of a covered person

Designation of Personal Representative, ENR-904

Provides limited powers of attorney to the personal representative of a covered person; authorizes the Board to provide information to that individual

Page 65

MED-119 5/17

© 2017 The Board of Pensions of the Presbyterian Church (U.S.A.)

2000 Market Street | Philadelphia, PA 19103-3298 Tel: 800-773-7752 (800-PRESPLAN) | Fax: 215-587-6215 | pensions.org