Important Questions Answers Why this Matters:

Transcription

1 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? For in-network providers $1,200 Individual/$2,400 Family For out-of-network providers $2,000 Individual/$4,000 Family Doesn t apply to in-network preventive care, mental health and substance abuse, or prescription drugs. Deductibles accumulate separately in-network and out-of-network. No. Yes. For in-network providers $3,000 Individual/$6,000 Family For out-of-network providers $5,000 Individual/N/A Family Doesn t include prescription drugs. Limits accumulate separately for in-network and outof-network charges. Payroll contributions, balance-billed charges, prescription drug costs, and health care this plan doesn t cover. No. Yes. For a list of in-network providers, see or call ; for mental health and substance abuse, see or call ; for prescription drugs call No. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. 1 of 8

2 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Out-of-network Limitations & Exceptions Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance none Specialist visit 20% coinsurance 40% coinsurance none Other practitioner office visit 20% coinsurance 40% coinsurance none Preventive care/ screening/immunization No charge 40% coinsurance none Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance none Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance none 2 of 8

3 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available on Norfolk Southern s Employee Resource Center (ERC) or by calling CVS/Caremark at Services You May Need Generic drugs, 0-30 day supply Preferred brand drugs, 0-30 day supply Non-preferred brand drugs, 0-30 day supply In-network 10% of allowed drug cost, not less than $4 and not more than $10, but Specialty Drugs have $150 maximum cost. No charge for prescription formulary generic women s contraceptives. 20% of allowed drug cost, not less than $10 and not more than $25, but Specialty Drugs have $150 maximum cost 40% of allowed drug cost, not less than $25 Out-of-network Same as In-network by reimbursement, except that usual generic charge will apply for women s contraceptives. Same as In-network by reimbursement Same as In-network by reimbursement Limitations & Exceptions Your plan uses a preferred drug list (formulary) which identifies the status of covered drugs. You may find out how a drug is categorized by calling Caremark at Clinically appropriate generic drugs will be dispensed unless prohibited by your prescribing physician. Some drugs may require prior authorization, while other drugs are subject to step therapy and quantity limits. If prior authorization is not obtained from CVS/Caremark, the drug may not be covered. Purchases at a retail pharmacy are limited to no more than a 60 days supply of the same drug in a 12-month period except for long-term maintenance drugs purchased at a CVS Pharmacy and certain other drugs. Mail order drugs are limited to a 90- day day supply. Drug costs do not count toward the annual deductible described above. Tobacco Cessation Drugs, 0-30 day supply No cost with prescription. Same as In-network by reimbursement Specialty Drugs have a maximum cost of $300 for a day supply. Prescription drugs purchased by Canadian residents or members traveling outside of the United States are covered at 80% of the purchase cost. 3 of 8

4 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs More information about this coverage is available from ValueOptions at Services You May Need In-network Out-of-network Limitations & Exceptions Facility fee (e.g., ambulatory surgery 20% coinsurance 40% coinsurance none center) Physician/surgeon fees 20% coinsurance 40% coinsurance none Emergency room 20% coinsurance 20% coinsurance none services Emergency medical transportation 20% coinsurance 20% coinsurance Urgent care 20% coinsurance 40% coinsurance none Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Physician/surgeon fee 20% coinsurance 20% coinsurance Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services The first six outpatient visits are at no cost and subsequent visits at 20% coinsurance. 20% coinsurance 40% coinsurance The first six outpatient visits are at no cost and subsequent visits at 20% coinsurance Non-participating ambulance providers are payable at billed charges. Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. 40% coinsurance Costs do not count toward the annual deductible. Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. 40% coinsurance Costs do not count toward the annual deductible. 4 of 8

5 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services In-network Out-of-network 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance Home health care 20% coinsurance 40% coinsurance Rehabilitation services 20% coinsurance 40% coinsurance Habilitation services 20% coinsurance 40% coinsurance Limitations & Exceptions Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Pre-authorization required for stays exceeding 48 hours after vaginal delivery or 96 hours after cesarean delivery. No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Precertification is required or $500 penalty will apply. $500 penalty doesn t count toward deductible. Covered to correct a condition resulting from illness, injury or surgically treated congenital defect. Limited to coverage for speech and occupational therapy for children under age 7 with an autistic diagnosis. Skilled nursing care 20% coinsurance 40% coinsurance Pre-authorization is required. Durable medical equipment 20% coinsurance 20% coinsurance Pre-authorization required if cost for rental exceeds $1,000 per year. All purchases must be pre-authorized regardless of cost. Hospice service 20% coinsurance 40% coinsurance none Eye exam 20% coinsurance 40% coinsurance Only covered to the extent necessary for the repair or alleviation of damage caused solely by bodily injury Glasses Not covered Not covered Excluded service Dental check-up Not covered Not covered Excluded service 5 of 8

6 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Hearing Aids Private-duty nursing (Except if approved by Case Manager) Dental care (Child or Adult) Infertility treatment Routine foot care Glasses Long-term care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Most coverage provided outside the United States. See Chiropractic care Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: Routine eye care (Adult) If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross BlueShield, Clinical and Operational Appeals: P.O. Box , Atlanta, GA The Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Language Access Services: Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: CDHP About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $8,840 Plan pays $5,790 Patient pays $2,650 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $1100 Radiology $200 Vaccines, other preventive $40 Total $8,840 Patient pays: Deductibles $1200 Copays $0 Coinsurance $1,450 Limits or exclusions $0 Total $2,650 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $3,400 Plan pays $1,770 Patient pays $1,630 Sample care costs: Prescriptions $900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $3,400 Patient pays: Deductibles $1,200 Copays $0 Coinsurance $430 Limits or exclusions $0 Total $1,630 Under this plan option, the Company will contribute to a health reimbursement account (HRA) that may help you pay for deductibles, out-of-pocket expenses, prescription drug co-payments, or other unreimbursed medical expenses. The Company will make the following HRA contributions under this plan option: $600/year for employee-only coverage; $900/year for employee+1 coverage; or $1,200/year for family coverage. 7 of 8

8 Norfolk Southern/Conrail: Preferred Account Coverage Period: 1/1/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: CDHP Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8

9 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? For in-network providers $1,200 Individual/$2,400 Family For out-of-network providers $2,000 Individual/$4,000 Family Doesn t apply to in-network preventive care, mental health and substance abuse,or prescription drugs. Deductibles accumulate separately in-network and out-of-network. No. Yes. For in-network providers $4,000 Individual/$8,000 Family For out-of-network providers $6,000 Individual/N/A Family Doesn t include prescription drugs. Limits accumulate separately for in-network and outof-network charges. Payroll contributions, balance-billed charges, prescription drug costs, and health care this plan doesn t cover. No. Yes. For a list of in-network providers, see or call ; for mental health and substance abuse, see or call ; for prescription drugs call No. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. 1 of 8

10 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Out-of-network Limitations & Exceptions Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance none Specialist visit 20% coinsurance 40% coinsurance none Other practitioner office visit 20% coinsurance 40% coinsurance none Preventive care/ screening/immunization No charge 40% coinsurance none Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance none Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance none 2 of 8

11 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available on Norfolk Southern s Employee Resource Center (ERC) or by calling CVS/Caremark at Services You May Need Generic drugs, 0-30 day supply Preferred brand drugs, 0-30 day supply Non-preferred brand drugs, 0-30 day supply In-network 10% of allowed drug cost, not less than $4 and not more than $10, but Specialty Drugs have $150 maximum cost. No charge for prescription formulary generic women s contraceptives. 20% of allowed drug cost, not less than $10 and not more than $25, but Specialty Drugs have $150 maximum cost 40% of allowed drug cost, not less than $25 Out-of-network Same as In-network by reimbursement, except that usual generic charge will apply for women s contraceptives. Same as In-network by reimbursement Same as In-network by reimbursement Limitations & Exceptions Your plan uses a preferred drug list (formulary) which identifies the status of covered drugs. You may find out how a drug is categorized by calling Caremark at Clinically appropriate generic drugs will be dispensed unless prohibited by your prescribing physician. Some drugs may require prior authorization, while other drugs are subject to step therapy and quantity limits. If prior authorization is not obtained from CVS/Caremark, the drug may not be covered. Purchases at a retail pharmacy are limited to no more than a 60 days supply of the same drug in a 12-month period except for long-term maintenance drugs purchased at a CVS Pharmacy and certain other drugs. Mail order drugs are limited to a 90- day day supply. Drug costs do not count toward the annual deductible described above. Tobacco Cessation Drugs, 0-30 day supply No cost with prescription. Same as In-network by reimbursement Specialty Drugs have a maximum cost of $300 for a day supply. Prescription drugs purchased by Canadian residents or members traveling outside of the United States are covered at 80% of the purchase cost. 3 of 8

12 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs More information about this coverage is available from ValueOptions at Services You May Need In-network Out-of-network Limitations & Exceptions Facility fee (e.g., ambulatory surgery 20% coinsurance 40% coinsurance none center) Physician/surgeon fees 20% coinsurance 40% coinsurance none Emergency room 20% coinsurance 20% coinsurance none services Emergency medical transportation 20% coinsurance 20% coinsurance Urgent care 20% coinsurance 40% coinsurance none Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Physician/surgeon fee 20% coinsurance 20% coinsurance Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services The first six outpatient visits are at no cost and subsequent visits at 20% coinsurance. 20% coinsurance 40% coinsurance The first six outpatient visits are at no cost and subsequent visits at 20% coinsurance Non-participating ambulance providers are payable at billed charges. Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. 40% coinsurance Costs do not count toward the annual deductible. Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. 40% coinsurance Costs do not count toward the annual deductible. 4 of 8

13 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services In-network Out-of-network 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance Home health care 20% coinsurance 40% coinsurance Rehabilitation services 20% coinsurance 40% coinsurance Habilitation services 20% coinsurance 40% coinsurance Limitations & Exceptions Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Pre-authorization required for stays exceeding 48 hours after vaginal delivery or 96 hours after cesarean delivery. No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Precertification is required or $500 penalty will apply. $500 penalty doesn t count toward deductible. Covered to correct a condition resulting from illness, injury or surgically treated congenital defect. Limited to coverage for speech and occupational therapy for children under age 7 with an autistic diagnosis. Skilled nursing care 20% coinsurance 40% coinsurance Pre-authorization is required. Durable medical equipment 20% coinsurance 20% coinsurance Pre-authorization required if cost for rental exceeds $1,000 per year. All purchases must be pre-authorized regardless of cost. Hospice service 20% coinsurance 40% coinsurance none Eye exam 20% coinsurance 40% coinsurance Only covered to the extent necessary for the repair or alleviation of damage caused solely by bodily injury Glasses Not covered Not covered Excluded service Dental check-up Not covered Not covered Excluded service 5 of 8

14 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Hearing Aids Private-duty nursing (Except if approved by Case Manager) Dental care (Child or Adult) Infertility treatment Routine foot care Glasses Long-term care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Most coverage provided outside the United States. See Chiropractic care Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: Routine eye care (Adult) If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross BlueShield, Clinical and Operational Appeals: P.O. Box , Atlanta, GA The Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Language Access Services: Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

15 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: CDHP About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $8,840 Plan pays $5,790 Patient pays $2,650 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $1100 Radiology $200 Vaccines, other preventive $40 Total $8,840 Patient pays: Deductibles $1200 Copays $0 Coinsurance $1,450 Limits or exclusions $0 Total $2,650 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $3,400 Plan pays $1,770 Patient pays $1,630 Sample care costs: Prescriptions $900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $3,400 Patient pays: Deductibles $1,200 Copays $0 Coinsurance $430 Limits or exclusions $0 Total $1,630 7 of 8

16 Norfolk Southern/Conrail: Standard Coverage Period: 1/1/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: CDHP Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8

17 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? For in-network providers $200 Individual / $600 Family For out-of-network providers $350 Individual / $0 Family Doesn t apply to in-network preventive care, mental health and substance abuse, or prescription drugs. Deductibles accumulate separately in-network and out-of-network. Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? No. Yes. For in-network providers $2,500 Individual / $5,000 Family For out-of-network providers $5,000 Individual / N/A Family Doesn t include prescription drugs. Limits accumulate separately for in-network and outof-network charges. Payroll contributions, balance-billed charges, prescription drug costs, and health care this plan doesn t cover. No. Yes. For a list of in-network providers, see or call ; for mental health and substance abuse, see or call ; for prescription drugs call No. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the outof-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. 1 of 8

18 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Out-ofnetwork Limitations & Exceptions Primary care visit to treat an injury or illness $15 copay 40% coinsurance none Specialist visit $40 copay 40% coinsurance none Other practitioner office visit Preventive care/ screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Acupuncture 20% coinsurance, Chiropractor $40 copay No charge Acupuncture and Chiropractic Care - 40% coinsurance Not covered none Routine services are not covered for out-of-network providers with the exception of children up to age 7 only. Travel immunizations are not covered. 20% coinsurance 40% coinsurance none 20% coinsurance 40% coinsurance none 2 of 8

19 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available on Norfolk Southern s Employee Resource Center (ERC) or by calling CVS/Caremark at Services You May Need Generic drugs, 0-30 day supply Preferred brand drugs, 0-30 day supply Non-preferred brand drugs, 0-30 day supply Tobacco Cessation Drugs, 0-30 day supply In-network 10% of allowed drug cost, not less than $4 and not more than $10, but Specialty Drugs have $150 maximum cost. No charge for prescription formulary generic women s contraceptives. 20% of allowed drug cost, not less than $10 and not more than $25, but Specialty Drugs have $150 maximum cost 40% of allowed drug cost, not less than $25 No cost with prescription. Out-ofnetwork Same as Innetwork by reimbursement, except that usual generic charge will apply for women s contraceptives. Same as Innetwork by reimbursement Same as Innetwork by reimbursement Same as Innetwork by reimbursement Limitations & Exceptions Your plan uses a preferred drug list (formulary) which identifies the status of covered drugs. You may find out how a drug is categorized by calling Caremark at Clinically appropriate generic drugs will be dispensed unless prohibited by your prescribing physician. Some drugs may require prior authorization, while other drugs are subject to step therapy and quantity limits. If prior authorization is not obtained from CVS/Caremark, the drug may not be covered. Purchases at a retail pharmacy are limited to no more than a 60 days supply of the same drug in a 12-month period except for long-term maintenance drugs purchased at a CVS Pharmacy and certain other drugs. Mail order drugs are limited to a 90-day day supply. Drug costs do not count toward the annual deductible described above. Specialty Drugs have a maximum cost of $300 for a day supply. Prescription drugs purchased by Canadian residents or members traveling outside of the United States are covered at 80% of the purchase cost. 3 of 8

20 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Services You May Need In-network Out-ofnetwork Limitations & Exceptions Facility fee (e.g., ambulatory surgery center) $100 copay 40% coinsurance none Physician/surgeon fees $40 copay 40% coinsurance none Emergency room services $40 copay ER Same as Innetwork provider physician, $100 copay ER facility Out-of-Network 40% coinsurance if lay person would not have treated it as emergency Emergency medical transportation 20% coinsurance 20% coinsurance Urgent care $40 copay 40% coinsurance none $100/day copay per Facility fee (e.g., hospital confiment, $1,000 room) maximum 40% coinsurance Physician/surgeon fee No charge 40% coinsurance First six outpatient Mental/Behavioral health visits at no cost and outpatient services subsequent visits at 20% coinsurance. Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services No charge First six outpatient visits at no cost and subsequent visits at 20% coinsurance No charge Non-participating ambulance providers are payable at billed charges. Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. 40% coinsurance Costs do not count toward the annual deductible. 40% coinsurance Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. 40% coinsurance Costs do not count toward the annual deductible. 40% coinsurance Out-of-network non-emergency admission that is not precertified is not covered. If emergency, precertification must be completed within 48 hours of admission. Costs do not count toward the annual deductible. 4 of 8

21 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Prenatal and postnatal care Delivery and all inpatient services In-network Out-ofnetwork $40 copay 40% coinsurance $100/day copay per confinement, $1,000 maximum 40% coinsurance Home health care 20% coinsurance 40% coinsurance Rehabilitation services $40 copay for outpatient; $100/day copay for inpatient confinement $1,000 maximum, $100 copay for cardiac rehabilitation 40% coinsurance Habilitation services $40 copay 40% coinsurance Skilled nursing care Durable medical equipment $100/day copay per confinement $1,000 maximum 20% coinsurance 40% coinsurance Limitations & Exceptions No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Pre-authorization required for stays exceeding 48 hours after vaginal delivery or 96 hours after cesarean delivery. No coverage for participant s child s pregnancy or resulting childbirth, abortion or miscarriage. Precertification is required or $500 penalty will apply. $500 penalty doesn t count toward deductible. Preauthorization required for inpatient. Covered to correct a condition resulting from illness, injury or surgically treated congenital defect. Limited to coverage for speech and occupational therapy for children under age 7 with an autistic diagnosis. 40% coinsurance Pre-authorization is required. Pre-authorization required if cost for rental exceeds $1,000 per year. All purchases must be pre-authorized regardless of cost. Hospice service 20% coinsurance 40% coinsurance none Eye exam 20% coinsurance 40% coinsurance Only covered to the extent necessary for the repair or alleviation of damage caused solely by bodily injury Glasses Not covered Not covered Excluded service Dental check-up Not covered Not covered Excluded service 5 of 8

22 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 1/1/ /31/2013 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Hearing Aids Private-duty nursing (Except if approved by Case Manager) Dental care (Child or Adult) Infertility treatment Routine foot care Glasses Long-term care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Chiropractic care Non-emergency care when traveling outside the U.S. Bariatric surgery Most coverage provided outside the United States. See Your Rights to Continue Coverage: Routine eye care (Adult) If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross BlueShield, Clinical and Operational Appeals: P.O. Box , Atlanta, GA The Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Language Access Services: Para obtener asistencia en Español, llame al To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

23 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $8,840 Plan pays $7,920 Patient pays $520 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $1100 Radiology $200 Vaccines, other preventive $40 Total $8,840 Patient pays: Deductibles $200 Copays $100 Coinsurance $220 Limits or exclusions $0 Total $520 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $3,400 Plan pays $2,670 Patient pays $730 Sample care costs: Prescriptions $900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $3,400 Patient pays: Deductibles $200 Copays $150 Coinsurance $380 Limits or exclusions $0 Total $730 Questions: Call or visit us at at www. anthem.com or call to request a copy. 7 of 8

24 Norfolk Southern/Conrail: Copay & Preferred Copay Coverage Period: 01/01/ /31/2013 Coverage Examples Coverage for: All Coverage Levels Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call or visit us at at www. anthem.com or call to request a copy. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8