2021 QVXUDQFH%HQH4WV*XLGH - South Carolina

1 2021 insurance benefits GuideInsurance benefits Guide2 Table of contentsTell us what you think ..9 Disclaimer ..10 State Health Plan s grandfathered status ..10 Notice of non-discrimination ..10 Language assistance ..11 General information ..12 What s new for 2021? ..13 Eligibility for insurance benefits ..13 Active employees ..13 benefits in which eligible employees may enroll ..14An eligible retiree ..14An eligible spouse ..15An eligible child ..15A survivor ..16 Initial enrollment ..16 Employees ..16 Retirees ..17 Information you need at enrollment ..18 Documents you need at enrollment ..18 Completing your initial enrollment through your benefits administrator.

2 19 After your initial enrollment ..19 insurance cards ..19 benefits Identification Number ..19 Enrolling as a transferring employee ..20 Annual open enrollment ..20 Changing plans or coverage during an open enrollment period ..20 MyBenefits ..21 PEBA s online insurance benefits enrollment system ..21 Special eligibility situations ..21 Marriage ..22 Divorce ..22 Adding children ..23 Dropping a spouse or children ..24 Gaining other coverage ..25 Gain of Medicare coverage ..25 Loss of other coverage ..25 Coverage under Medicaid or the Children s Health insurance Program (CHIP) ..26 Leaves of absence ..27 Premiums while on unpaid leave.

3 27 Life insurance while on unpaid leave ..27 Supplemental Long Term Disability insurance while on paid or unpaid leave ..28 Family and Medical Leave Act (FMLA) leave . 28 Military leave ..28 Workers compensation ..28 When coverage ends ..28 Continuation of coverage (COBRA) ..29 Eligibility ..28 When continued coverage will not be offered ..29 How to continue coverage under COBRA ..29 Example COBRA scenario ..29 How continued coverage under COBRA may end ..30 When benefits provided under COBRA run out .. 30 Extending continued coverage ..30 Other coverage options ..30 Death of a subscriber or covered spouse insurance benefits Guide3or child.

4 31 Survivors ..31 Appeals of eligibility determinations ..32 What if I disagree with a decision about eligibility? ..32 Health insurance ..34 Your State Health Plan choices ..35 Standard Plan ..35 Savings Plan ..35 Medicare Supplemental Plan ..35 Comparing the plans ..35 Comparison of health plans ..36 Your online State Health Plan tools ..38 How the State Health Plan pays for covered benefits ..40 Allowed amount ..40 Paying health care expenses with the Standard Plan ..40 Annual deductible ..40 Copayments ..41 Coinsurance ..42 Coinsurance maximum ..42 Paying health care expenses with the Savings Plan ..42 Annual deductible.

5 42 Copayments ..43 Coinsurance ..43 Coinsurance maximum ..43 Paying health care expenses if you re eligible for Medicare ..44 Coordination of benefits ..44 End stage renal disease ..45 Using State Health Plan provider networks ..45 Finding a medical or behavioral health network provider ..45 Finding a network provider out of state or overseas ..46 Prescription drug provider network ..47 Vision care provider network ..47 Out-of-network benefits ..47 Balance billing ..48 Out-of-network differential ..48 Standard Plan ..48 Savings Plan ..48 Getting preauthorization for your medical care 49 Health care preauthorization.

6 49 Lab work preauthorization ..49 Penalties for not calling ..49 How to preauthorize your treatment ..49 Behavioral health service preauthorization . 51 Advanced radiology preauthorization: National Imaging Associates ..52 Managing your health ..52 Adult well visits .. 52 How to get the most out of your benefits ..53 PEBA Perks ..54 Naturally Slim ..58 Health coaching ..58 Medical case management programs ..60 Natural BlueSM and member discounts ..61 Additional State Health Plan benefits ..62 Advanced practice registered nurse ..62 Alternative treatment plan ..62 Ambulance service ..62 Autism spectrum disorder benefits .

7 63 insurance benefits Guide4 Behavioral health benefits ..63 Behavioral health case management ..63 Bone, stem cell and solid organ transplants ..63 Chiropractic care ..64 Contraceptives ..64 Dental care ..64 Diabetic supplies ..65 Doctor visits ..65 Durable medical equipment ..65 Home health care ..65 Hospice care ..65 Infertility ..65 Inpatient hospital services ..66 Outpatient facility services ..66 Patient-centered medical homes ..67 Pregnancy and pediatric care ..67 Prescription drugs ..68 Reconstructive surgery after a medically necessary mastectomy ..68 Rehabilitation care ..68 Second opinions ..69 Skilled nursing facility.

8 69 Speech therapy ..69 Surgery ..70 Other covered benefits ..70 Exclusions services not covered ..70 Additional limits in the Standard Plan ..73 Additional limits and exclusions in the Savings Plan ..73 How to file a State Health Plan claim ..73 Services in South Carolina ..73 Services outside of South Carolina ..73 Appeals ..74 Claims and preauthorization appeals to third-party claims processors ..74 Appeals to PEBA: preauthorizations and services that have been provided ..74 GEA TRICARE Supplement Plan ..75 Eligibility ..75 Eligible dependent children ..76 How to enroll ..76 Plan features ..77 Filing claims ..77 Medicare eligibility and the TRICARE Supplement Plan.

9 77 Loss of TRICARE eligibility ..77 More information ..77 Prescription benefits ..79 Using your prescription benefits ..80 Member resources ..80 State Health Plan Prescription Drug Program ..80 Standard Plan ..80 Savings Plan ..81 Express Scripts Medicare ..81 Pharmacy network ..81 How to find participating pharmacies ..81 Retail pharmacies ..81 Smart90 Network and Preferred90 Network ..81 Mail order through Express Scripts Pharmacy ..81 Prescription copayments and formulary ..82 Tier 1: generic ..83 Tier 2: preferred brand ..83 insurance benefits Guide5 Tier 3: non-preferred brand ..83 Non-covered formulary drugs.

10 83 Express Scripts Patient Assurance Program ..83 Pay-the-difference policy ..83 Specialty pharmacy programs ..84 Coverage reviews ..84 Prior authorization ..84 Drug quantity management ..85 Step therapy ..85 Compound prescriptions ..85 Coordination of benefits ..85 Medicare coverage for self-administered medications during an outpatient hospital observation stay ..85 Exclusions ..86 Value-based prescription benefits at no cost to you ..86 Filing a prescription drug claim ..86 Appeals ..87 Appeals to PEBA ..87 Dental insurance ..88 Online resources ..89 Classes of treatment ..89 Dental Plus ..89 Dental Plus network.