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1 2022 Insurance Benefits GuideInsurance Benefits Guide2 Table of contentsDisclaimer ..10 State Health plan s grandfathered status ..10 Notice of non-discrimination ..10 Language assistance ..11 General information ..12 What s new for 2022? ..13 Eligibility for insurance benefits ..13 Active employees ..13 Benefits in which eligible employees may enroll ..14An eligible retiree ..15An eligible spouse ..15An eligible child ..15A survivor ..16 Initial enrollment ..17 Employees ..17 Retirees ..17 Submitting your enrollment ..18 Information you need at enrollment ..18 Documents you need at enrollment ..18 Completing your initial enrollment ..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.

2 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 ..26 Coverage under Medicaid or the Children s Health Insurance Program (CHIP) ..27 Leaves of absence ..27 Premiums while on unpaid leave ..27 Life insurance while on unpaid leave ..28 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 ..29 When continued coverage will not be offered ..29 How to continue coverage under COBRA ..29 Example COBRA scenario ..30 How continued coverage under COBRA may end ..30 When benefits provided under COBRA run out.

3 30 Extending continued coverage ..30 Other coverage options ..30 Death of a subscriber or covered spouse or child 31 Survivors ..31 Insurance Benefits Guide3 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 ..42 Copayments ..43 Coinsurance ..43 Coinsurance maximum ..43 Paying health care expenses if you re eligible for Medicare.

4 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 Out-of-network benefits ..47 Balance billing ..48 Out-of-network differential ..48 Standard plan ..48 Savings plan ..49 Getting prior authorization for your medical care ..49 Health care prior authorization ..49 Lab work prior authorization ..49 Penalties for not calling ..49 How to prior authorize your treatment ..50 Behavioral health service prior authorization ..51 Advanced radiology prior authorization: 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 Wondr Health (formerly Naturally Slim) ..58 Health coaching.

5 58 Medical case management programs ..60 Blue365 and member discounts ..62 Additional State Health plan benefits ..62 Advanced practice registered nurse ..63 Alternative treatment plan ..63 Ambulance service ..63 Autism spectrum disorder benefits ..63 Behavioral health benefits ..63 Behavioral health case management ..63 Insurance Benefits Guide4 Bone, stem cell and solid organ transplants ..64 Chiropractic care ..64 Contraceptives ..65 Dental care ..65 Diabetic supplies ..65 Doctor visits ..65 Durable medical equipment ..65 Home health care ..66 Hospice care ..66 Infertility ..66 Inpatient hospital services ..66 Outpatient facility services ..67 Patient-centered medical homes ..67 Pregnancy and pediatric care ..68 Prescription drugs ..68 Reconstructive surgery after a medically necessary mastectomy ..68 Rehabilitation care ..69 Second opinions ..69 Skilled nursing facility.

6 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 ..74 Appeals ..74 Claims and prior authorization appeals to third-party claims processors ..74 Appeals to PEBA: prior authorizations and services that have been provided ..75 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 ..77 Loss of TRICARE eligibility ..77 More information ..78 Prescription benefits ..79 Using your prescription benefits ..80 Member resources ..80 State Health plan Prescription Drug Program ..80 Standard plan .

7 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 Tier 3: non-preferred brand ..83 Non-covered formulary drugs ..83 Insurance Benefits Guide5 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.

8 86 Appeals ..87 Appeals to PEBA ..87 Dental insurance ..88 Online resources ..89 Classes of treatment ..89 Dental Plus ..89 Dental Plus network ..89 Basic Dental ..90 Special provisions of Basic Dental ..90 Comparing Dental Plus and Basic Dental ..91 plan comparison examples ..92 Scenario 1: Routine checkup ..92 Scenario 2: Two surface amalgam fillings ..92 Exclusions dental services not covered ..93 General benefits not offered ..93 Benefits covered by another plan ..93 Specific procedures not covered ..93 Limited benefits ..94 Prosthodontic and orthodontic benefits ..95 Coordination of benefits ..95 How to file a dental claim ..96 What if I need help? ..97 Appeals ..97 Vision care ..98 Online vision benefits information ..99 State Vision plan ..99 Eye exams ..99 Frequency of benefits ..99 Vision benefits at a glance ..100 Eyeglasses ..100 Eyeglasses (cont .) ..101 Progressive lens and anti-reflective coating.

9 101 Contact lenses ..102 Diabetic vision benefits at a glance ..103 Using the EyeMed provider network ..103To find a network provider ..103 How to order contact lenses online ..103 Out-of-network benefits ..103 Exclusions and limitations ..104 Contact EyeMed ..104 Appeals ..105 State Vision plan examples ..106 Example one ..106 Example two ..106 Example three ..106 Insurance Benefits Guide6 Life insurance ..107 Eligibility ..108 Actively at Work requirement ..108 Applications ..108 Basic Life insurance ..109 Optional Life insurance ..109 Initial enrollment - active employees ..109 Late entry ..110 Premiums ..110 Changing your coverage amount ..110 Dependent Life insurance ..111 Eligible dependents ..111 Excluded dependents ..112 Dependent Life-Spouse coverage ..112 Dependent Life-Child coverage ..112 Enrollment ..112 Premiums ..114 Beneficiaries ..114 Changing your beneficiaries.

10 114 Assignment ..114 Accidental Death and Dismemberment ..115 Schedule of accidental losses and benefits ..115 What is not covered? ..115 Accidental Death and Dismemberment benefits ..116 MetLife AdvantagesSM ..118 Will Preparation ..118 Estate Resolution Services ..118 WillsCenter .com ..118 Funeral Planning Assistance ..118 Grief Counseling ..118 Live Settlement Account ..118 Transition Solutions ..119 Delivering the Promise ..119 Claims ..119 Your accelerated benefit ..119 How to file a claim ..119 Suicide provision ..119 How Accidental Death and Dismemberment claims are paid ..119 Examinations and autopsies ..120 When your coverage ends .. 120 Termination of coverage ..120 Termination of Dependent Life insurance coverage ..120 Extension of benefits ..120 Leave of absence ..120 When you lose eligibility for active benefits due to disability ..121 Continuing or converting your life insurance.