OGHS Blue Cross Blue Shield

OGHS Blue Cross Blue Shield

WELCOME TO BLUE CROSS AND BLUE SHIELD OF LOUISIANA

For employees of

Opelousas General Health System

January 2021

MyHealthToolkitLA.com

BE HEALTHY. BE HAPPY. Make the most of your health plan’s benefits!

We want to welcome you as a member — and give you a quick overview of how your health benefits work. Your benefits plan gives you access to top-quality care from the largest provider network in the nation. We want you to understand and use those benefits. And we aim to make that easy so you can have a happier, healthier life.

Topics in this guide include:

♦ Using your member ID card

♦ Getting health info by texts

♦ Discounts on health products and services

♦ Finding doctors and cost details on our website

♦ Tips on the benefits available with your health plan

♦ And more!

For your health, Blue Cross and Blue Shield of Louisiana

Symbols in this guide:

Log in to your My Health Toolkit® account.

Call the number on the back of your membership ID card to speak to a customer service advocate .

TRY THIS SHORTCUT

Get easy access to your benefits information by downloading the My Health Toolkit® mobile app today! It’s free at: www.MyHealthToolkitLA.com . Register quickly through the app, using your member ID number. Or just log in, if you’re already a My Health Toolkit user.

View how other members rated a doctor

View financial accounts

Get health tips

Order a new ID card

View claims status

Find a doctor

Your GetStarted page also will link you to all of the helpful resources included with your health benefits plan.

Rather get My Health Toolkit from a desktop/laptop computer? Go to www.MyHealthToolkitLA.com and then: ♦ Click the Register Now button on the right side of the page. ♦ Enter your Member ID (from your ID card). ♦ Follow the instructions to Create Your Profile .

Now you have anywhere, anytime access to your benefits information, including claims, discounts and how you prefer to be contacted.

HELPFUL TERMS Words commonly used in health care

Health care lingo can be confusing. Here are some terms you might need to know.

Claim: A request for payment that you or your health care provider submits to your health insurance company after you receive services. Coinsurance: Your share of the costs for a covered health care service, calculated as a percentage. You pay coinsurance plus any deductibles you owe. For example, say your health plan’s allowed amount for an office visit is $100 and you’ve met your deductible. Your coinsurance payment of 20 percent would be $20. Your health plan pays the rest of the allowed amount. Copayment: The fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary, depending on the provider and the type of health care service. Deductible: The amount you pay for services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you’ve paid $1,000 toward your covered health care expenses. After that, your health plan will pay for all covered services in that benefit year. Network: The facilities, providers and suppliers your health plan contracts with to provide health care services. You will typically pay less for services received in network versus out of network. Out of pocket: Your costs for medical care expenses that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services, plus costs for services that aren’t covered. Subscriber: The person who enrolls in a health plan. There is only one subscriber per health plan. The subscriber can add eligible dependents to a family health plan. Preauthorization/prior authorization: A decision verifying that a service, prescription drug or type of treatment is medically necessary. Certain services and medications require preauthorization before you receive them, except in an emergency.

Premium: The amount you pay for your health plan, usually biweekly or monthly. Primary care physician (PCP): The main doctor and primary contact for your health care services. Specialist: A doctor or health care professional who focuses on a specific area of medicine. For example, orthopedic surgeons, dermatologists and cardiologists are specialists. Telehealth: Allows a patient to connect with a health care provider with virtual visits through an electronic device such as a smartphone or computer. Licensed telehealth providers offer non-emergency consultations for a variety of conditions and can prescribe medication, when appropriate.

WE’VE GOT YOU COVERED WITH YOUR MEMBERSHIP CARD

Your Blue Cross membership card contains important information that helps providers apply your benefits correctly. Keep it with you at all times — or download a digital ID card to keep on your smartphone. A health care provider usually will ask to see your insurance card at the beginning of your visit.

Covered family members also can use the subscriber’s card — or forward them their own digital copy of it.

Visit our main website for additional information and to log in to your My Health Toolkit account.

Your member ID contains a set of letters and numbers that are unique to you.

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Convenient option: Your digital ID

It’s all about convenience! Your digital ID card has the same information as the card you receive in the mail, but you can: ♦ View the digital ID on a smartphone, tablet or computer. ♦ Email the card to a spouse, child, doctor’s office or pharmacy. ♦ Print the card from a smartphone, tablet or computer and use the printout just like a plastic card.

Accessing your digital ID ♦

Log in to My Health Toolkit . ♦ From a mobile device, select Insurance Card . ♦ From a computer, select Insurance Card and then View Your Card .

SIGN UP FOR MEMBER MESSAGING

Occasional communications from your heath plan help you stay on top of your health, save money and make the most of your benefits.

Everyone’s busy. But don’t let that prevent you from getting the reminders and updates you need. Personalized member messages — by text, mail or email — provide info like wellness reminders, news on benefit changes and updates on prior authorization requests.

It looks like you might be overdue for your annual physical with a primary care doctor. Schedule a physical if you haven’t had one in over a year.

And you tell us how you prefer to be contacted! Check out the easy opt-in tips, below.

Don’t have a primary care doctor? Find one now.

Health tips

Log in to My Health Toolkit, and under My Profile, select My Contact Preferences. Update your contact information and tell us the best way to reach you. You also can opt in to receive text messages by calling 844-206-0624.

WHERE SHOULD YOU GO WHEN YOU NEED CARE?

Your primary care physician should be your first call for routine medical care. But what if your doctor’s office is closed? Or it may be an emergency?

Here are tips to help you choose the right type of care for various situations:

Doctor’s Office

Urgent Care Center

Emergency Room

Your primary care physician, or regular doctor, is the best option for routine medical care like: ♦ Annual checkups, physicals ♦ Health screenings, immunizations ♦ Prescription refills And unexpected health issues, if they can wait a day, like: ♦ Sprained muscles ♦ Minor cuts and bruises ♦ Cold and flu symptoms, including fever, coughing, sore throat and mild nausea ♦ Sinus or respiratory infections ♦ Urinary tract infections ♦ Seasonal allergies ♦ Pinkeye ♦ Migraines ♦ Rashes, insect bites, sunburn, other skin irritations

If you can’t wait for an appointment with your regular doctor, an urgent care center may be your best option for unexpected health issues like: ♦ Minor fractures and sprains, especially if an X-ray is required ♦ Minor cuts and animal bites, especially if stitches may be required ♦ Cold and flu symptoms, including fever, coughing, sore throat and mild nausea ♦ Sinus or respiratory infections ♦ Urinary tract infections ♦ Seasonal allergies ♦ Pinkeye ♦ Migraines ♦ Rashes, insect bites, sunburn and other skin irritations

Go to the ER or call 911 for potentially life-threatening conditions like:

♦ Heavy, uncontrolled bleeding ♦ Signs of a heart attack, like chest pain that lasts more than two minutes ♦ Signs of stroke, such as numbness, sudden loss of speech or vision ♦ Loss of consciousness or sudden dizziness ♦ Major injuries such as broken bones or head trauma ♦ Coughing up or vomiting blood ♦ Severe allergic reactions

TOTAL CARE Better care, outcomes and costs

Total Care is a national Blue Cross Blue Shield program that recognizes doctors and hospitals that are committed to improving health care for patients.

What’s different about Total Care doctors? Doctors and hospitals with Total Care designation have access to enhanced technology and information that can improve the way they care for patients. A Total Care team might include a primary care doctor, pharmacist, care coordinator and a dietitian. Who should use a Total Care doctor? Anyone can choose a doctor with Total Care designation. The team-based approach is especially helpful for people with chronic health conditions like high blood pressure, heart failure or diabetes. How does Total Care benefit you? ♦ Care is personalized and consistent. You will see a member of your care team who knows you and your medical history. ♦ Results of your medical procedures are shared with members of your team so they have a complete picture of your health. ♦ Total Care’s improved screenings, medication management and other programs help provide better outcomes and lower costs for patients.

To find Total Care doctors and hospitals:

♦

Log in to My Health Toolkit and select the

Resources tab ♦ Click Find a Doctor or Hospital ♦ Enter your location and the specialty type, then click Search ♦ On the left side, click Total Care

Or call the number on the back of your membership card to talk to a customer service advocate.

Smart health care consumers check their EOBs! EXPLANATION OF BENEFITS

Doctors’ bills can be complicated — and then you get an email saying there’s an Explanation of Benefits to look at. But don’t skip your EOB or just stash it away. It’s pretty simple, and an important way to stay on top of your health care spending.

What is an EOB? Whenever you use your health insurance, we send you an Explanation of Benefits. It shows you: ♦ How much the doctor charged. ♦ How much your health plan paid. ♦ The amount applied toward your deductible. ♦ How much you may still owe. Why look at your EOB? When you eat out, you at least glance at the bill before paying, right? Double-checking your medical expenses is even more important. You can: ♦ Compare your doctor and hospital bills with the EOB to make sure you’re being billed — and paying — the correct amount. ♦ Share your EOB with your provider if you notice any differences. Check your EOBs easily in My Health Toolkit® We make it simple, through your health plan’s website or our My Health Toolkit app. ♦ Log in to My Health Toolkit and select the Benefits tab. ♦ Click Claims Status , then “View Your Summary Explanation of Benefits.” ♦ To see a particular claim, check the Claims Status List or search by date or claim number. ♦ On the My Health Toolkit mobile app, just click on the Claims tab and select a specific claim to view your EOB.

MAKE SURE YOU’RE COVERED Why coordination of benefits is important

Do you have other health insurance? Coordination of benefits — COB, for short — affects your benefits when you or a family member also is covered under another health insurance plan. COB makes sure the right plan processes your claims first. It prevents overpayments and duplication of services. And that helps keep costs down for everyone.

♦

Examples of other insurance: These may include coverage under a spouse’s insurance plan, Medicaid or Medicare. What you need to do: Be sure we have up-to-date information about your other insurance. That way we can process your claims correctly and promptly. ♦ If you receive an Other Health Insurance Questionnaire in the mail, fill it out and return it right away. Even if you do not have coverage with another health plan, we need to know that, too.

You also can give us this information by logging in to My Health Toolkit . Select the Benefits tab, then Other Health Coverage . ♦ Or call the number on the back of your membership card and provide the information to a customer service advocate. We appreciate your help with this.

♦ You also may be able to get coverage if you have a new dependent because of marriage, birth, adoption or placement for adoption. Again, you must request enrollment within 30 days of the event. Please note that you may have been required to provide a written statement when you declined enrollment with us. If you did not provide this written statement, this health plan is not required to grant special enrollment rights to you or your dependents. For more information, contact your employer’s benefit department.

Getting benefits after you have declined coverage Special enrollment rights may apply to you, your spouse or other dependents even after you have declined coverage. ♦ For example, you might have declined coverage because other health insurance or another group health plan was in effect. Later, you may want to seek coverage with this plan if you or your dependents became ineligible for the other coverage or the employer stopped contributing to the other coverage. You must request our coverage within 30 days after this other coverage ends OR after the employer contribution stops.

MEMBER PERKS Discounts for you — just for being Blue!

In addition to superior health coverage, your membership provides access to exclusive discounts on a variety of products and services. The member discounts program includes items that generally are not covered by health insurance.

Go to our website and select the Member Discounts tab. You’ll find details on discounts for:

Fitness ♦ Gym memberships ♦ Wearable fitness devices ♦ Activewear ♦ Magazine subscriptions ♦ 5K and obstacle course registration ♦ Home fitness equipment ♦ Vitamins and nutritional supplements

Personal care ♦ Allergy relief ♦ Acupuncture ♦ Chiropractic services ♦ Massage therapy

Healthy eating ♦ Weight loss programs ♦ Cookbooks and recipes ♦ Online cooking classes

♦ Hair restoration ♦ Teeth whitening

Hearing and vision ♦ Hearing aids ♦ Eyewear

Lifestyle ♦ Travel clubs ♦ Vacation packages ♦ Pet care

YOU’VE GOT A HEALTH COACH IN YOUR CORNER

Ready to get on track with your health but not sure where to start? You don’t have to figure it out on your own. Your health plan includes one-on-one coaching from a health care professional for free.

What is a health coach? Our team of nationally accredited health coaches includes registered nurses, health educators, respiratory therapists, certified diabetes educators, licensed behavioral health specialists and other health and well-being professionals. Wherever you are in your journey, we can connect you to the right coach. He or she will work with you to make positive, meaningful changes at your own pace.

Behavioral and chronic disease coaching ♦ Attention deficit hyperactivity disorder (ADHD), adults ♦ Asthma (adults and children) ♦ Bipolar disorder ♦ Heart disease ♦ Heart failure ♦ Chronic obstructive pulmonary disease (COPD) ♦ Depression ♦ Diabetes (adults and children) ♦ High blood pressure ♦ High cholesterol ♦ Metabolic health (metabolic syndrome and prediabetes) ♦ Migraine ♦ Recovery support for substance use disorder Connect with an app The My Health Planner SM app is free for eligible members! It helps you keep track of what you need to do between doctor visits, and stay in touch with your care team.

Ready to become a healthier you?

To learn more and download resources, log in to My Health Toolkit , select the Wellness tab, then click Health Coaching . To enroll, call the health coaching team at 855-838-5897 .

GETTING HEALTHIER JUST GOT EASIER

Simple changes in your daily routine can make a big difference in your health and well-being. To help, your health plan partners with Rally®, a website and mobile app that helps you set smart goals for yourself and stay on target. Rally is a product of Rally Health Inc., an independent company that offers a digital health platform on behalf of your health plan. You’ll get personalized recommendations to get you moving more, eating better, feeling great — and you’ll have fun doing it.

Start with a quick Health Survey. From that, you’ll get your Rally Age, a measure of your overall health. Then Rally will recommend Goals and Missions for you — simple activities designed to improve your diet, fitness and mood. Other missions address important areas such as financial well-being and stress reduction. Start easy, and level up when you’re ready.

Plus, there are lots of ways to earn Rally Coins, which you can use for a chance to win awesome rewards. You also can trade in your coins for significant discounts on fitness- related items. Rack up coins for participating in Missions, pushing yourself in a Challenge — even just for logging in every day. Also check out ways to use coins for auctions of products and gift cards, or to make charitable donations.

Use Rally on the web or download the app for the convenience of Rally on the go. The Rally Health app is available in the App Store (iOS) or on Google Play (Android).

1. Log in to your My Health Toolkit® account 2. Select Wellness , then Rally Get started today!

Link up with AccrueHealth through your My Health Toolkit. You can view your account balance, submit claims, store receipts and much more An HSA is a special savings account that allows you to set aside pretax or after-tax funds for future medical and retirement expenses. You can invest these funds in your choice of stocks or mutual funds or manage the HSA like a traditional savings account. A qualified bank, financial institution or t ustee can administer your HSA. Y u can use your HSA funds to pay your first medical expenses, including office visits, prescriptions and other health care costs. The amount you spend from the HSA for covered medical expenses counts toward your health plan deductible. Once you meet the deductible, the health plan coverage kicks in, and you are only responsible for coinsurance payments. Health Savings Account (HSA) MEDICAL SPENDING ACCOUNTS employer deposits a set amount of money into a tax-free account, which you can use to pay for medical expenses. In addition to the HRA, your employer offers a traditional health plan to cover other medical bills. For a complete list of eligible and ineligible HRA expenses, consult your Human Resources department. Or visit the Internal Revenue Service website at www.irs.gov and view Publication 502. Flexible Spending Account (FSA) FSAs are designed to help you save money by paying for qualified medical or dependent care expenses on a tax-free basis. An FSA lets you set aside pretax funds from each paycheck. Those funds must be used to pay for qualified expenses incurred during the benefits period. For a complete list of eligible and ineligible FSA expenses, consult your Human Resources department. Or visit the Internal Revenue Service website at www.irs.gov and view Publication 502. Dependent Care FSA This type of flexible spending account allows you to use the pretax funds in your account to cover nonmedical costs for a dependent who is under age 13, mentally or physically disabled, or elderly. Examples of these costs include day care, after-school care and summer camps. Your Human Resources department can provide details. Limited Purpose FSA Limited Purpose FSAs are designed to help you save money by paying for qualified dental and vision care expenses on a tax-free basis. Limited Purpose FSAs allow you to set aside pretax funds from each paycheck. Those funds must be used to pay for qualified expenses incurred during the benefits period. Consult your Human Resources department for a list of qualified expenses specific to your company’s Limited Purpose FSA.

YOUR HEALTH CARE FSA Flexible solutions to enhance your health, save you money

Regular checkups, generic medications, comparing costs … they’re all good ways to make the most of your health care dollars. Here’s another good way: using a medical flexible spending account (FSA).

Setting up an FSA is easy through AccrueHealth, our administrator for these accounts. It lets you set aside money for health-related expenses your insurance plan does not cover — like an extra pair of eyeglasses, LASIK surgery and copayments for medical or dental services. And you save money by designating pretax earnings for your FSA. Here are the basics: ♦ You set up your payroll deduction for an FSA during open enrollment. Note: These accounts are not for members who choose a consumer-driven health plan (CDHP). ♦ You can designate a maximum of $2,750 of your pretax earnings for your FSA. The full amount will be available to you at the beginning of your benefit year and you will see pretax payroll deductions each pay period.

How does an FSA save you money? There are no payroll or federal income taxes on the money you shift into your FSA. You’ve lowered your total taxable income — and you can use the money you save

to enhance your health. Online & mobile access

Link up with AccrueHealth through My Health Toolkit (web or mobile) or through the AccrueHealth mobile app. You can view your FSA balance, submit claims, store receipts and much more.

More about FSAs

FSA-eligible expenses include: Medical, vision and dental copayments and deductibles Vision, hearing and physical exams Prescription drugs Orthodontics Acupuncture treatments Experimental medical therapies

Ineligible expenses include: Nonprescription drugs, except for insulin Vitamins and dietary supplements Health spa visits Fitness center dues Cosmetic surgery Hair removal, hair transplants Teeth whitening Medicines from other countries

Ambulance services Alcoholism treatment LASIK surgery Wheelchairs

FSA tips

♦ You may change the payroll election amount only if you experience a major life change, such as: ♦ Marriage, divorce or separation ♦ Death of a spouse or dependent child ♦ Change in spouse’s employment status ♦ Birth, adoption or legal guardianship of a child

♦ For more on federal requirements and what can be covered by FSA funds, see Publication 502 at www.IRS.gov . ♦ For more on your employer’s FSA program, contact your Human Resources department. Important: There’s a “use it or lose it” IRS rule for FSAs. If you don’t submit qualifying expenses to use up your balance by the end of the plan year, you lose the funds that are left.

ADULT WELLNESS GUIDELINES Adult health – for ages 18 and over

Preventive care is very important for adults. By making healthier choices, you can improve your overall health and well-being. Some of these positive choices include:

♦ Eat a healthy diet ♦ Get regular exercise ♦ Don’t use tobacco products

♦ Limit alcohol use ♦ Strive for a healthy weight ♦ Take medications as prescribed by your doctor

Adult recommendations

Screenings

Physical Exam

Every year, or as directed by your doctor.

Body Mass Index (BMI) Blood Pressure (BP) Colon Cancer Screening

Every year.

At least every two years.

Beginning at age 50 — colonoscopy every 10 years, flexible sigmoidoscopy every five years, fecal occult blood test every year. Screening should begin at age 45. If you have high blood pressure, high cholesterol, are over- weight or have a close family history of diabetes, you should consider being screened earlier. Immunizations 19-21 years 22-26 years 27-49 years 50-64 years 65 and older

Diabetes Screening

Influenza (Flu)*

Once each year

Tetanus, Diphtheria, Pertussis (Tdap)* Herpes Zoster (Shingles) - RZV*

One dose with a booster every 10 years

Two doses RZV for those 60 and older

or Herpes Zoster (Shingles) - ZVL*

OR one dose ZVL for those 50 and older

Varicella (Chickenpox)*

Two doses

Pneumococcal (Pneumonia)* Measles, Mumps & Rubella (MMR)* Human Papillomavirus (HPV) – Female* Human Papillomavirus (HPV) – Male*

Two doses

One or two doses if no evidence of immunity

One or two doses if no evidence of immunity

Two or three doses depending on age at series initiation

Hepatitis A** Hepatitis B** Meningitis**

Two or three doses for at-risk adults. Discuss with your doctor if this vaccine is right for you. Three doses for at-risk adults. Discuss with your doctor if this vaccine is right for you. One to three doses depending on indication. This vaccine is only recommended for specific groups of adults. Discuss the risks and benefits with your doctor. One to three doses depending on health risks. This vaccine is only recommended for specific groups of adults. Discuss the risks and benefits with your doctor.

Hib*

*Recommended for most adults. **Recommended for adults with certain health risks.

CHILDREN’S HEALTH

Put your children on the path to wellness by scheduling regular office visits with a doctor. The doctor will watch your baby’s growth and progress, and should talk with you about eating and sleeping habits, safety and behavior issues.

According to the Bright Futures recommendations from the American Academy of Pediatrics, the doctor should: ♦ Check your child’s body mass index percentile regularly beginning at age 6. ♦ Conduct a yearly wellness exam beginning at age 3. ♦ Test vision at least once between the ages of 3 and 5.

Routine Children’s Immunization Schedule

1.5-3 yrs.

4-6 yrs.

Vaccine

Birth 1 mo. 2 mo. 4 mo. 6 mo. 12 mo. 15 mo. 18 mo.

Hepatitis B (HepB)

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l l l *

Rotavirus (RV)

Diphtheria, Tetanus and Pertussis (DTaP) Haemophilus Influenzae Type B (Hib) Pneumococcal Conjugate (PCV) Inactivated Polio Vaccine (IPV)

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l Recommended yearly starting at age 6 months with 2 doses given the first year.

Influenza (Flu)

Measles, Mumps and Rubella (MMR)

l †

l

Varicella (Chickenpox)

l

l

l First dose: 12 – 23 months. l Second dose: 6 – 18 months later.

Hepatitis A (HepA)

l One dose n Range of recommended dates * Number of doses needed varies depending on vaccine used. Ask your doctor. † 12 months is minimum age for routine vaccination: two-dose series at 12 to 15 months and 4 to 6 years. Second dose may be given as early as four weeks after the first dose. Sources: U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, U.S. Preventive Services Task Force Some of these recommendations may not be covered by your health plan. Please refer to your summary of benefits to verify which services are covered.

WOMEN’S HEALTH

You play the role of a superwoman very well. But that doesn’t mean you’re invincible.

Ladies, your supernatural ability to keep everything and everyone in order is truly impressive. But Before you can save the world, you must first take care of yourself. Make sure everything is healthy underneath that cape by scheduling regular health screenings. These recommendations are in addition to the standard wellness guidelines for adults. remember that your powers have a limit.

Women’s Recommendations Mammogram Every year for women beginning at age 40. Cholesterol Ages 30 – 35 should be tested if at high risk. Women 45 and older should be tested.

Pap Test

Women ages 21 – 65: Pap test every 3 years. Another option for ages 30 – 65: Pap test and HPV test every 5 years. Women who have had a hysterectomy or are over age 65 may not need a Pap test. * Beginning at age 65, or at age 60 if risk factors are present. * At ages 50 – 79, talk with your doctor about the benefits and risks of aspirin use.

Osteoporosis Screening

Aspirin Use

Pelvic Exam Every year for ages 21 and over.

* R ecommendations may vary. Discuss screening options with your doctor, especially if you are at increased risk. Sources: American Cancer Society, U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, U.S. Preventive Services Task Force

MEN’S HEALTH Even the toughest machines depend on regular maintenance.

Preventive care is important to men’s health. If you’re going to keep firing on all cylinders, you need to make time for tuneups. So, let’s man up and schedule that appointment! In addition to the standard wellness guidelines for adults, men should discuss these recommendations with their doctor.

Men’s Recommendations

Cholesterol

Ages 20 – 35 should be tested if at high risk. Men age 35 and over should be tested. Once between ages 65 and 75 if you have ever smoked. At ages 50 – 79, talk with your doctor about the benefits and risks of aspirin use.

Abdominal Aortic Aneurysm

Aspirin Use

Sources: American Cancer Society, U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, U.S. Preventive Services Task Force

ARE YOU TAKING ADVANTAGE OF BEING BLUE ® ?

Your benefits plan is about more than health insurance. It also entitles you to some special perks and discounts, just for being Blue. In fact, if you only think of your health plan when you’re sick, you are not taking full advantage of your benefits. Check it out! Log in to your health plan’s website, click on Plan Perks or Member Discounts, and learn more about the advantages of being Blue.

Additional perks come with your health plan — at no additional cost. These resources can help you improve your health and overall well-being throughout the year.

Opelousas General Health System MEDICAL and RX BENEFITS Blue Cross Blue Shield of Louisiana & MedImpact

Comprehensive and preventive healthcare coverage is important in protecting you and your family from the financial risks of unexpected illness and injury. A little prevention usually goes a long way—especially in healthcare. Routine exams and regular preventive care provide an inexpensive review of your health. Small problems can potentially develop into large expenses. By identifying the problems early, often they can be treated at little cost. In case of an illness or injury, you and your family are covered with an excellent medical plan through Opelousas General Health System. OGHS offers two medical plan options using the OGHS & BCBS of LA PPO Network. PLAN 1 TRADITIONAL PLAN (PPO)

Tier 1 - OGHS OGHS and OGHS Pharmacy $500 Single $1,500 Family $3,000 Single $8,000 Family

Tier 2 - PPO When Services Are NOT Available at OGHS

Tier 3 - PPO When Services ARE Available at OGHS

Tier 4 Non PPO Provider

Unlimited Lifetime Benefit Maximum

$1,500 Single $4,500 Family $5,000 Single $15,000 Family

$5,000 Single $10,000 Family $6,650 Single $16,625 Family

$6,000 Single $12,000 Family

Annual Calendar Year Deductible

Annual Out-of-Pocket Maximum (includes deductible)

Unlimited

Coinsurance

80%-100%

80%

50%

40%

DOCTOR’S OFFICE Primary Care & Specialist Visit

80% after Deductible 80% after Deductible 50% after Deductible 40% after Deductible

100%; Deductible Waived 100%; Deductible Waived

100%; Deductible Waived

100%; Deductible Waived

Wellness Care

Not Covered

Diagnostic Tests & Imaging (x-ray, blood work, CT/PT scans, MRI)

80% after Deductible 50% after Deductible 50% after Deductible

Urgent Care

80% after Deductible 80% after Deductible 50% after Deductible 40% after Deductible

HOSPITAL SERVICES Emergency Room—Accident Emergency Room—All Other

$150 Copay

$150 Copay

$150 Copay

$150 Copay

80% after Deductible 80% after Deductible 80% after Deductible 80% after Deductible

$2,000 Copay per Stay, then Deductible/50%

$3,000 Copay per Stay, then Deductible/50%

Inpatient Services: Facility Fee

90%; Deductible Waived $500 Copay per Stay, then Deductible/80%

80% after Deductible 80% after Deductible 50% after Deductible 50% after Deductible 100%; Deductible Waived 80% after Deductible 50% after Deductible 50% after Deductible 80% after Deductible 80% after Deductible 50% after Deductible 50% after Deductible

Inpatient Services: Physician Fee Outpatient Surgery: Facility Fee Outpatient Surgery: Physician Fee Mental Health/Substance Abuse Inpatient Services Mental Health/Substance Abuse Outpatient Services

$2,000 Copay per Stay, then Deductible/50%

$3,000 Copay per Stay, then Deductible / 50%

90%; Deductible Waived $500 Copay per Stay, then Deductible / 80%

80% after Deductible 80% after Deductible 50% after Deductible 50% after Deductible

PRESCRIPTION DRUGS (30 DAY SUPPLY)

TIER 2 OOP MAX APPLIES TO RX BENEFITS

Calendar Year Rx Deductible (per person)

$150 (Tier 1)

$200

Generic Drugs

75% of theactual cost of the drug; Deductible Waived

Brand Name Drugs, No Generic Available Brand Name Drugs, Generic Available

75% of the actual cost of the drug after Rx Deductible

75% of the cost of the generic drug after Rx Deductible (Member Pays Differential)

Specialty Drugs Deductible then 70% of the cost of the drug * Certain Specialty Medications must be dispensed by Ochsner Specialty Pharmacy who can be reached at (855) 312-4193 ; limited to a 30-day supply and may require Prior Authorization. Specialty medications are subject to a copay of 30% of the actual cost of the drug. * Requirement of 90-day supply for Non-Specialty Maintenance Drugs dispensed at the OGHS Pharmacy. * All in-network tiers cross apply; out-of-network tier does not.

Opelousas General Health System

MEDICAL and RX BENEFITS

PLAN 2

HIGH DEDUCTIBLE PLAN (HSA QUALIFIED)

Tier 4 Non PPO Provider

Tier 1 - OGHS OGHS and OGHS Pharmacy $2,500 Single $5,000 Family $2,500 Single $5,000 Family

Tier 2 - PPO When Services Are NOT Available at OGHS

Tier 3 - PPO When Services ARE Available at OGHS

Unlimited Lifetime Benefit Maximum

$3,500 Single $7,000 Family $4,000 Single $8,000 Family

$5,000 Single $10,000 Family $6,650 Single $13,300 Family

$6,000 Single $12,000 Family

Annual Calendar Year Deductible

Annual Out-of-Pocket Maximum (includes deductible)

Unlimited

Coinsurance

100%

100%

50%

50%

DOCTOR’S OFFICE Primary Care & Specialist Visit

100% after Deductible 100% after Deductible

50% after Deductible 100%; Deductible Waived

50% after Deductible

100%; Deductible Waived

100%; Deductible Waived

Wellness Care

Not Covered

Diagnostic Tests & Imaging (x-ray, blood work, CT/PT scans, MRI)

100% after Deductible 100% after Deductible

50% after Deductible

50% after Deductible

Urgent Care

100% after deductible 100% after Deductible

50% after deductible

50% after deductible

HOSPITAL SERVICES Emergency Room—Accident Emergency Room—All Other

100% after Deductible 100% after Deductible 100% after Deductible 100% after Deductible

50% after deductible 50% after deductible

50% after deductible 50% after deductible $3,000 Copay per Stay, then Deductible / 50% 50% after deductible 50% after deductible 50% after deductible $3,000 Copay per Stay, then Deductible / 50% 50% after deductible

Inpatient Services: Facility Fee

100% after Deductible 100% after Deductible $2,000 Copay per Stay, then Deductible, / 50%

100% after Deductible 100% after Deductible 100% after Deductible 100% after Deductible 100% after Deductible 100% after Deductible

50% after deductible 50% after deductible 50% after deductible

Inpatient Services: Physician Fee Outpatient Surgery: Facility Fee Outpatient Surgery: Physician Fee Mental Health/Substance Abuse Inpatient Services Mental Health/Substance Abuse Outpatient Services

100% after Deductible 100% after Deductible $2,000 Copay per Stay, then Deductible, / 50%

100% after Deductible 100% after Deductible

50% after deductible

PRESCRIPTION DRUGS (30 DAY SUPPLY)

TIER 2 DEDUCTIBLE & OOP MAX APPLIES TO RX BENEFITS

Calendar Year Rx Deductible (per person)

Integrated with Medical Deductible (Tier 2)

Generic Drugs

Deductible then 100% of the actual cost of the drug

Brand Name Drugs, No Generic Available Brand Name Drugs, Generic Available

Deductible then 100% of the actual cost of the drug

Deductible then 100% of the actual cost of the drug (Member Pays Differential)

Specialty Drugs * Certain Specialty Medications must be dispensed by Ochsner Specialty Pharmacy who can be reached at (855) 312-4193 ; limited to a 30-day supply and may require Prior Authorization. Specialty medications are subject to a coinsurance of 30% of the actual cost of the drug. * Requirement of 90-day supply for Non-Specialty Maintenance Drugs dispensed at the OGHS Pharmacy. * All in-network tiers cross apply; out-of-network tier does not. Deductible then 70% of the actual cost of the drug

Opelousas General Health System

DENTAL BENEFITS

Administered by Blue Cross Blue Shield of La (Coverage available to FT & PT EEs) Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the Opelousas General Health System’s dental benefit plan. Please refer to the plan document for complete details.

DENTAL SERVICES

IN NETWORK Discounted Fee Schedule

OUT OF NETWORK

UCR 85th%

Benefits Paid On

$50 Single; $150 Family

Annual Deductible

$1,000

Annual Benefit Maximum Class 1: Preventive Services  Oral Exams  Bitewing X-rays  Full Mouth / Panoramic X-rays Max Age 17: Class 2: Basic Services  Non-Routine Visits  Fillings  Endodontics  Periodontics/Periodontal Maintenance  Surgical Extractions Class 3: Major Services  Bridges and Dentures  Crowns, Inlays, Onlays  Repairs of Dentrures, Crowns, Inlays & Onlays  Fluoride Treatments  Sealants (per tooth)  Space Maintainers Class 4: Orthodontia  Calendar Year Max—$1,000

Finding In-Network Dental Providers You pay less for services when you use a provider in the BCBS of LA Network. To find

100%; no deductible

100%; no deductible

network providers near you, visit www.myhealthtoolkitla.com.

80% after Deductible

80% after Deductible

50% after Deductible

50% after Deductible

50%

50%

 Covered to age 19  $3,000 Lifetime Max

We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. Non-Discrimination Statement and Foreign Language Access We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. If you or someone you’re assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice. Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below. If you or someone you’re assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice. Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below. If you think we have not provided these services or have discriminated in any way, you can file a grievance online at [email protected] or by calling our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800- 537-7697 (TDD). If you think we have not provided these services or have discriminated in any way, you can file a grievance online at [email protected] or by calling our Compliance area at 800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 800-368-1019 or 800-537-7697 (TDD) . NON - DISCRIMINATION STATEMENT AND FOREIGN LANGUAGE ACCESS

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-396- 0183 . (Spanish)

如果您，或是您正在協助的對象，有關於本健康計畫方面的問題，您有權利免費以您的母語得到幫助和訊 息。洽詢一位翻譯員，請撥電話 [ 在此插入數字 1-844-396-0188 。 (Chinese)

Nếu quý vị, hoặc là người mà quý vị đang giúp đỡ, có những câu hỏi quan tâm về chương trình sức khỏe này, quý vị sẽ được giúp đở với các thông tin bằng ngôn ngữ của quý vị miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-389-4838 (Vietnamese)

이 건보험에 관하여 궁금한 사항 혹은 질문이 있으시면 1-844-396-0187 로 연락주십시오. 귀하의 비용 부담없이 한국어로 도와드립니다. PC 명조 (Korean)

Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa planong pangkalusugang ito , may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-844-389-4839 . (Tagalog)

Если у Вас или лица, которому вы помогаете, имеются вопросы по поводу Вашего плана медицинского обслуживания, то Вы имеете право на бесплатное получение помощи и информации на русском языке. Для разговора с переводчиком позвоните по телефону 1-844-389-4840 . (Russian)

إن ﻛﺎن ﻟدﯾك أو ﻟدى ﺷﺧص ﺗﺳﺎﻋده أﺳﺋﻠﺔ ﺑﺧﺻوص ﺧطﺔ اﻟﺻﺣﺔ ھذه ، ﻓﻠدﯾك اﻟﺣق ﻓﻲ اﻟﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة واﻟﻣﻌﻠوﻣﺎت اﻟﺿرورﯾﺔ ﺑﻠﻐﺗك ﻣن دون اﯾﺔ ﺗﻛﻠﻔﺔ . ﻟﻠﺗﺣدث ﻣﻊ ﻣﺗرﺟم اﺗﺻل ب (Arabic) 1-844-396-0189

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Si ou menm oswa yon moun w ap ede gen kesyon konsènan plan sante sa a, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232 . (French/Haitian Creole)

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de ce plan m édical , vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-396-0190 . (French)

Jeśli Ty lub osoba, której pomagasz, macie pytania odnośnie planu ubezpieczenia zdrowotnego, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-396-0186 . (Polish)

Se você, ou alguém a quem você está ajudando, tem perguntas sobre este plano de saúde, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-396-0182 . (Portuguese)

Se tu o qualcuno che stai aiutando avete domande su questo piano sanitario, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-844-396-0184 . (Italian)

あなた、またはあなたがお世話をされている方が、この健康保険 についてご質問がございましたら、ご 希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳 とお話される場合、 1-844-396-0185 までお電話ください。 (Japanese)

Falls Sie oder jemand, dem Sie helfen, Fragen zu diesem Krankenversicherungsplan haben bzw. hat, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-396-0191 an. (German)

اﮔﺮ ﺷﻤﺎ ﯾﺎ ﻓﺮدی ﮐﮫ ﺑﮫ او ﮐﻤﮏ ﻣﯽ ﮐﻨﯿﺪ ﺳﺆاﻻﺗﯽ در ﺑﺎره ی اﯾﻦ ﺑﺮﻧﺎﻣﮫ ی ﺑﮭﺪاﺷﺘﯽ داﺷﺘﮫ ﺑﺎﺷﯿﺪ، ﺣﻖ اﯾﻦ را دارﯾﺪ ﮐﮫ ﮐﻤﮏ و اﻃﻼﻋﺎت ﺑﮫ زﺑﺎن ﺧﻮد را ﺑﮫ ﻃﻮر راﯾﮕﺎن ﺑﺎ ﺷﻤﺎره ً درﯾﺎﻓﺖ ﮐﻨﯿﺪ. ﺑﺮای ﺻﺤﺒﺖ ﮐﺮدن ﺑﺎ ﻣﺘﺮﺟﻢ، ﻟﻄﻔﺎ ی 1-844-398-6233 ﺗﻤﺎس ﺣﺎﺻﻞ ﻧﻤﺎﯾﯿﺪ. (Persian-Farsi)

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NOTES

We’re glad to have you as a member of Blue Cross and Blue Shield of Louisiana. What did you think of this open enrollment guide? Please take a moment to give us feedback at: www.MyHealthToolkitLA.com/feedback .

Blue Cross and Blue Shield of Louisiana provides administrative claims payment services only

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.

LA-9999-5-2019