Autism Spectrum DisorderBenefit information

Premera Blue Cross (Premera) administers the Autism Spectrum Disorder (ASD) benefit for all eligible members. This unique benefit provides coverage for behavioral interventions based on the principles of Applied Behavioral Analysis (ABA).

To help you understand this benefit and how to use it, were providing you with a description of the benefits eligibility and coverage. We also include information on how to access providers and services, and receive reimbursement for treatment costs.

Make sure to bring this information to appointments so they are aware of your coverage.

Information to help you access this benefit

Were here to help! If you have any questions about this benefit, claims or the process, call Premera Customer Service at 877.995.2696 or email AmazonABA@premera.com.

Understanding your benefits and coverage. In addition to the benefit information included here, review your Summary Plan Description (SPD) to better understand your benefit coverage and eligibility requirements.

Review the guide for ABA therapy access. This guide will help you navigate ABA therapy, from finding providers to getting reimbursed.

Review frequently asked questions (FAQ). The FAQ addresses common questions about the ASD benefit and how your medical plan covers these services.

Review the necessary forms.

ABA Therapy Provider Verification Form the program provider must complete and submit this form to Premera to verify they are certified to perform ABA services.

ABA Therapy Services Billing Summary you and the program provider must sign this form. You, or the program provider, need to submit this form for eligible claim reimbursement.

026695 (05-2016)

The information provided in this guide is not a guarantee for payment or coverage; refer to your benefit booklet for benefit and coverage information. The included forms are also available on premera.com/amazon.

Procedures

Premera has designated specific codes that are to be used for direct treatment, program development, treatment planning and supervision.

Covered codes for ABA services will include:

H0031 Mental health assessment

To be used for initial evaluation/assessment and done by a licensed provider or Board Certified Behavioral Analyst (BCBA).

Allowed amount per hour:MD/DO $201.57PhD $181.41Masters level $151.18

H0032 Mental health service plan development

To be used for program development, treatment planning and supervision. To be done by the licensed provider or BCBA (Program Manager).

Allowed amount per hour:MD/DO $157.89PhD $142.10Masters level $118.42OT/PT/ST $118.42

H2014 Skills training and development, per 15 minutes

To be used for direct services by a therapy assistant with the identified patient and/or family.

Allowed amount per 15 minutes unit $11.25

H2019 Therapeutic behavioral services, per 15 minutes

To be used for direct services by a licensed provider or BCBA with the identified patient and/or family.

Allowed amount per 15 minutes unit:MD/DO $39.47 PhD $35.53 Masters level $29.61 OT/ST/PT $29.61

The ASD benefit will consist of the following components: Applied Behavioral Analysis (ABA); occupational, speech, and physical therapies; and behavioral health treatment.

Diagnosis

Coverage will be provided for the above-noted services for eligible members whose primary diagnosis is one of the following:

Autistic Disorder (ICD-10 code F84.0)

Other Childhood Disintegrative Disorder (ICD-10 code F84.3)

Aspergers Disorder (ICD-10 code F84.5)

Retts Disorder (ICD-10 code F84.2)

Other Pervasive Developmental Disorder (ICD-10 code F84.8)

Pervasive Development Disorder Not Otherwise Specified (ICD-10 code F84.9)

Applied Behavioral Analysis benefit

This benefit will provide coverage for behavioral interventions through ABA and will be available to eligible members covered by one of the medical plans administered by Premera.

It will cover up to the following components of ABA:

Initial assessment

Direct clinical treatment

Program development

Treatment planning

Supervision of the providers of direct service

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Autism Spectrum Disorder benefit description

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Covered providers

The following types of providers are eligible for coverage for ABA services:

Licensed providers Medical doctors (MD), doctors of osteopathic medicine (DO), nurse practitioners (NP, ANP, ARNP, etc.), masters-level mental health clinicians, occupational, physical and speech therapists when providing ABA services and practicing within their scope of practice.

Board Certified Behavioral Analysts Board Certified Behavioral Analysts (BCBAs) are certified by the Behavior Analyst Certification Board. These providers have masters or doctoral degrees. Some are also licensed in a masters or doctoral level mental health field; however, most are not licensed providers. For ABA, either a licensed provider or a BCBA can function as a Program Manager. The Program Manager conducts behavioral assessments, including functional analyses, and provides behavior analytic interpretations of the results. The Program Manager designs and periodically reviews behavior analytic interventions (program development and treatment planning). For ABA programs which utilize unlicensed therapy assistants, the Program Manager also supervises the therapy assistants.

Therapy assistants These are providers who are not licensed or certified. They are trained by a licensed provider or a BCBA and then deliver direct treatment to individuals and their families. Although some ABA programs utilize licensed providers or BCBAs for direct treatment services, many ABA programs use therapy assistants. Therapy assistants receive direction and supervision from a licensed provider or a BCBA (Program Manager). The Program Manager is responsible for signing off on the time billed for therapy assistant services.

Limitations and exclusions

The following are not covered under this benefit:

Accompanying children or family members to health care appointments that are not part of the direct provision of ABA services

Services provided in a home school, or public/private school environment that are part of a childs schooling as distinct from specific ABA treatment services (e.g., acting as the teachers aide or helping a child with homework)

Time spent doing housework or chores

Travel time

Transporting parents or family members

Babysitting

Respite for parents/family members

Training of therapy assistants and family members (as distinct from supervision)

Services for a child who has not been diagnosed as having one of the autism spectrum disorders

Parent training or classes, except for one-on-one or one-on-two direct training of the parents of one identified patient

Equestrian therapy

Call 855.435.4333 or visit guidanceresources.com. Use Company ID AmazonEAP when registering online for the first time.

Medical Advice Line

Get help right away with the Medical Advice Line at 877.995.2696. This confidential service is available to you and your covered family members 24/7.

Talk to a registered nurse who can help you decide what to do. They may suggest you go to your primary care doctor, a local urgent care center or the emergency room. Alternatively, they may be able to give you tips for home treatment.

If appropriate, the nurse can connect you with a doctor that can diagnose, treat and send a prescription to your pharmacy of choice via phone consult (office visit fees will apply).

Rethink Benefits

Rethink Benefits is a program that helps families with children who have autism and/or other developmental disabilities build the skills they need to reach their fullest potential. Families can access a variety of resources and support at no cost, including:

Three hours of live clinical support

An innovative online library of over 1,500 video-based lessons based on proven applied behavior analysis (ABA) teaching techniques

Research-based assessments, which help guide parents and service providers in building unique treatment plans individualized for the particular needs of their child

Rethinks Training Center, which helps train parents and service providers in ABA teaching techniques and strategies for implementing lessons

Data collection tools to help monitor your childs progress and guide instruction

These comprehensive resources have been developed by a team of experienced, caring clinicians and are continually updated to offer you the latest treatment techniques and research. To access Rethink Benefits, register online at amazon.rethinkbenefits.com or call 877.988.8871.

Additional services

Professional treatment Occupational, speech and physical therapies will be covered under this benefit when billed with a diagnosis of an autism spectrum disorder, and will not be subject to visit limits. Any services rendered by these providers for the treatment of illness or injury not related to autism will apply to the standard rehabilitation benefit.

Occupational therapy (OT) is a medically prescribed treatment concerned with improving or restoring functions that have been impaired by illness, injury or disability through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.

Speech therapy (ST) is the treatment of communication impairment and swallowing disorders.

Physical therapy (PT) is a medically prescribed treatment concerned with improving or restoring physical function following disease, injury or loss of body part.

Behavioral health treatment Mental health and chemical dependency treatment, including psychotherapy and other psychiatric/psychological treatment services, will also be covered under this benefit when billed with a diagnosis of an autism spectrum disorder (subject to plan provisions and limitations). These services will not have visit limitations.

Resources

Employee Assistance Program (EAP)

The EAP provides free, confidential support, resources and referrals for every aspect of your work and personal life and is available 24/7 for you and family members living with you.

Call the EAP for resources and referrals for counseling services related to marital issues, depression, anxiety or stress. Additionally, the EAP can assist with legal and financial questions, finding child or elder care, moving and other personal needs. Up to three counseling sessions are available for each issue.

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Rethink, an independent provider of Autism curriculum and support, does not provide Blue Cross Blue Shield products or services. Rethink is solely responsible for its products and services.

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Guide for ABA therapy access

1 Understanding benefits and coverage First, arm yourself with knowledge. Review your plans benefit booklet and this guide for a detailed benefit description and a list of guidelines and plan exclusions.

If you have questions about what is covered and who is eligible, you can contact Premera Customer Service at 877.995.2696 for assistance.

2 Finding an ABA provider ABA therapy may be rendered by either a licensed professional (MD, PhD) or a Board Certified Behavioral Analystboth providers can act as a Program Manager.

Visit the Premera website at premera.com/amazon to search for licensed providers near you.

The Behavioral Analyst Certification Board (BACB) website also has provider resources available at bacb.com.

Please note that the provider must complete the ABA Therapy Program Provider Verification Form and submit this to Premera before services are rendered.

3 Finding a therapy assistant In many cases, your provider or Program Manager will not perform direct ABA treatment. If they do not, usually a therapy assistant will perform the direct treatment. Therapy assistants are not licensed or certified, however they are trained by a licensed provider or a Program Manager.

The Behavioral Analyst Certification Board (BACB) website also has therapy assistant resources available at bacb.com.

4 Receiving treatment The ASD benefit will cover ABA; occupational speech and physical therapies; and behavioral health treatment based upon your plans cost shares. Its a good idea to keep track of services rendered, as you and your provider will need to complete the ABA Therapy Services Billing Summary.

5 Getting reimbursed After receiving care, eligible services will be reimbursed based upon your plans cost shares. You or your provider will need to complete and submit the ABA Therapy Services Billing Summary and send it to Premera for processing. The form can be found online at premera.com/amazon. Claim processing can take up to 30 days to complete.

Receipts or proof of payment are required for member-submitted claims (to ensure member paid amounts are consistent with charged amounts).

Send the Billing Summary to:

Premera Blue Cross PO Box 91059 Seattle, WA 98111-9159

OR

Fax to: 888.617.0495

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Frequently asked questions

1. Which plans provide coverage for the ASD Benefit?

All medical plans administered by Premera offer the ASD benefit:

Shared Deductible Plan Standard Plan Health Savings Plan In-Network Only Plan

2. What are my cost shares for ABA therapy?

If you receive ABA therapy from BCBA Program Managers and therapy assistants, these providers are not contracted with Premera; they will be paid as in-network providers. If charges billed by your provider exceed the allowed amount, you may be billed the difference by the provider.

If you are enrolled in the Shared Deductible Plan, Standard Plan, or the Health Savings Plan, ABA treatment will apply first to the deductible and then Premera will pay 90% until youve reached your out-of-pocket maximum for the plan year. Then services will be covered in full up to the allowed amount.

See below to find out which deductible applies to you:

Shared Deductible Plan $1,000 Individual $2,000 Employee + Child(ren) $3,000 Employee + Family

Standard Plan $300 Individual $900 Family

Health Savings Plan $1,500 Individual

$3,000 Employee + Child(ren) $4,500 Employee + Family

If you are enrolled in the In-Network Only Plan, treatment costs will apply toward your deductible and then Premera will pay 100% up to the allowed amount.

In-Network Only Plan $100 Individual $300 Family

3. Are there any visit or hour limitations for treatment?

No. There are no visit limits for ABA therapy; occupational, speech and physical therapies; or behavioral health therapies that are rendered for treatment of ASD. Occupational, speech and physical therapies billed with a diagnosis other than ASD will apply to the Outpatient Rehabilitation benefit on your plan and subject to the 60 visit per plan year limit.

4. Are any procedures specifically NOT covered for ABA therapy?

Yes. A list of limitations and exclusions is included on page 3.

5. Is mental health counseling covered?

Yes. Mental health counseling is covered and subject to your plan cost shares. Please refer to the applicable Summary Plan Description for additional information about mental health.

6. Who is eligible for ASD benefits?

All enrolled members with an ASD diagnosis are eligible for ASD benefits. Dependents are eligible for coverage until the age of 26. Coverage may continue beyond the age of 26 for a dependent child who cant support himself or herself because of a developmental or physical disability when certain criteria are met. This eligibility is reviewed on a case-by-case basis. Please refer to the applicable Summary Plan Description for additional information about dependent eligibility.

7. What if I have services rendered for another neurodevelopmental disorder?

Your plan does cover other neurodevelopmental disorders as well, however there may be different cost shares or coverage limitations based on your medical plan selection. Refer to the applicable Summary Plan Description for additional details. The neurodevelopmental benefit, in general, and except when used to treat a mental health condition, is combined with the overall outpatient rehabilitation visit maximum of 60 visits combined for cognitive, physical, occupational, and speech therapy per plan year. Neurodevelopmental services for members under age 7 are not subject to this limit.

8. What provider types are considered covered providers under this plan?

To find an in-network provider, search the Find a Doctor tool at premera.com/amazon. You can search by provider name, specialty or location to find many provider typesfrom pediatricians to speech therapists to behavioral health providers.

For the ABA therapy benefit only, you may choose to access care from these providers or through a Board Certified Behavior Analyst (BCBA). For more information on BCBA providers, or to search for one near you, refer to the Behavior Analyst Certification Board website at bacb.com. When choosing a BCBA provider, its always a good idea to verify credentials and ensure that the provider is a good fit for your child.

9. Will my Program Manager or I receive confirmation from Premera regarding provider verification?

Yes. Premera will contact you by mail or phone to confirm that your provider has been verified. Once the ABA Provider Verification Form has been received by Premera, we will respond within 30 days.

This document represents a summary of Amazons Autism Spectrum Disorder Benefit. It is not intended to provide a complete description. For full information on your benefits, including any limitations that may apply, please see the official Summary Plan Description (SPD). You can access your SPD by logging in to the Benefits Enrollment tool. From outside the network, you can login through amazon.ehr.com. Although every effort has been made to ensure information in this document is accurate, the provisions of the official SPD will govern in case of any discrepancy. Benefits offered through the Amazon Corporate LLC Group Health & Welfare Plan are subject to review by Amazon and may be modified or terminated at any time for any reason.

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026698 (06-2016) Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

Amazon and Subsidiaries

ABA Therapy Program Provider Verification FormPlease fax or mail completed form and required attachments to:

888.617.0495Premera Blue Cross PO BOX 91059 Seattle, WA 98111-9159

For questions, call Premera Customer Service at 877.995.2696.

Section 1: General Information A. Subscriber ID #: B. Provider Name (Program Manager):

Last First M.I.

C. Social Security Number:OR

Tax Identification Number: Either SSN or TIN may be provided; however, billing statements must use the SSN or TIN provided.

D. Date of Birth (mm/dd/yyyy): E. National Provider Identifier Number (if available):

F. Service Location (no PO Box):

G. Billing Address:

H. Telephone Number: I. Email Address:

Section 2: Required Qualifications

Please check one:

I certify that I am a Behavioral Analyst credentialed by the Behavioral Analyst Certification Board (BCBA)

Attach a copy of your certificate.Renewals required as available.Attach a copy of your W-9.

Other Licensed Provider (make a selection)

Medical Doctors (MD)

Doctors of Osteopathic Medicine (DO)

Nurse Practitioners (NP, ANP, ARNP, etc.)

PhD

Masters-Level Health Clinicians

Occupational, Physical and Speech Therapists

(when providing ABA services and practicing within their scope of license)

PsyD (Doctor of Psychology)

Section 3: Security Data

In the past seven years, have you been released from prison or convicted of any crime? Include convictions for which you pleaded guilty or nolo contendre(no contest), paid a fine, received a suspended sentence and/or were incarcerated. Do not include minor motor vehicle violations and convictions thathave been annulled, expunged, sealed, or pardoned by a court. Yes No At any time in your life, have you ever been convicted of any criminal felony involving dishonesty or breach of trust or been convicted of an offense underSection 320603 of the Violent Crime Control and Law Enforcement Act of 1994, 18 U.S.C. Section 1033 (federal insurance crime law)? Yes No If YES, please explain the circumstances of the conviction(s), including date, nature, town/city and state of each offense, disposition, and any other relevant information you may want to bring to our attention. Attach additional pages if necessary.

Section 4: Signature

I certify that all information I have provided in this application, including any attachments, is accurate and complete to the best of my knowledge. I understand that any false statement or misrepresentation of the information I have provided on my certification request or attachments will be grounds forrejection of my certification request or termination of my certification.

Applicant Signature: Date (mm/dd/yyyy):

026699 (06-2016) Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

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Amazon and Subsidiaries

ABA Therapy Services Billing SummarySection 1: General Information

A. Member ID #: B. Patients Name:Last First M.I.

E. Patients Address (no PO Box): City State Zip Code F. Phone

G.Program Manager: H.Tax ID:

I. Indicate Highest Clinical-Related Degree: MD/DO PhD Masters level OT/PT/STJ. Therapy Assistant(s):

Please note: Services provided by volunteers, child care providers,family members or paid by other funding sources are not eligible for reimbursement.

Section 2: Signature

This form is not valid unless signed and dated. Signature of parent of the insured is verification that the claim is an accurate reflection of servicedates and payments.

Parent Signature: Date (mm/dd/yyyy):

Section 3: Service Breakdown by Program A. Statement Date (mm/dd/yyyy) : B. Billing Period:

C.Amount paid to therapy assistant(s):

D.Program specifics: Provider Name

Description of Services(i.e., services of Autism ProgramManager, H0031, H0032 and/or

H2019, services of a TherapyAssistant, H2014)

Date

(mm/dd/yyyy)

Duration

Rates

Start time

End time

Per hour

Total

E. Payment for the attached bills should be made to (check one): Member Provider

Section 4: Program Manager Signature

This form is not valid unless signed and dated. Signature by the Program Manager verifies that the hours billed accurately reflect the plan for care.

Program Manager Signature: Date (mm/dd/yyyy):

026699 (06-2016) Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

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Amazon and Subsidiaries

ABA Therapy Services Billing SummaryMember Procedures for Filing a Claim

Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defraudingthe insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer maydeny insurance benefits if false information materially related to a claim was provided by the applicant.

California Residents: For your protection, California law requires notice of the following: Any person whoknowingly and with intent to defraud or deceive any insurance company files a statement of claimcontaining any materially false, incomplete, or misleading information is guilty of a crime and may besubject to fines, confinement in a state prison, and substantial civil penalties.

Please Note:1. Complete form in full, sections one through four.2. This form is not valid unless signed by the submitting member and the program manager.3. Send the completed claim form and bills to:

Premera Blue CrossPO Box 91059Seattle, WA 98111-9159

OR

Fax to: 888.617.0495

For questions, call Premera Customer Service at 877.995.2696.

037338 (07-2016)

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Romn (Romanian): Prezenta notificare conine informaii importante. Aceast notificare poate conine informaii importante privind cererea sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue Cross. Pot exista date cheie n aceast notificare. Este posibil s fie nevoie s acionai pn la anumite termene limit pentru a v menine acoperirea asigurrii de sntate sau asistena privitoare la costuri. Avei dreptul de a obine gratuit aceste informaii i ajutor n limba dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357). P (Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY: 800-842-5357). Faasamoa (Samoan): Atonu ua iai i lenei faasilasilaga ni faamatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei faasilasilaga o se fesoasoani e faamatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Faamolemole, ia e iloilo faalelei i aso faapitoa oloo iai i lenei faasilasilaga taua. Masalo o lea iai ni feau e tatau ona e faia ao lei aulia le aso ua taua i lenei faasilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo oloo e iai i ai. Oloo iai iate oe le aia tatau e maua atu i lenei faasilasilaga ma lenei famatalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Espaol (Spanish): Este Aviso contiene informacin importante. Es posible que este aviso contenga informacin importante acerca de su solicitud o cobertura a travs de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura mdica o ayuda con los costos. Usted tiene derecho a recibir esta informacin y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357). (Thai): Premera Blue Cross 800-722-1471 (TTY: 800-842-5357) (Ukrainian): . Premera Blue Cross. , . , , . . 800-722-1471 (TTY: 800-842-5357). Ting Vit (Vietnamese): Thng bo ny cung cp thng tin quan trng. Thng bo ny c thng tin quan trng v n xin tham gia hoc hp ng bo him ca qu v qua chng trnh Premera Blue Cross. Xin xem ngy quan trng trong thng bo ny. Qu v c th phi thc hin theo thng bo ng trong thi hn duy tr bo him sc khe hoc c tr gip thm v chi ph. Qu v c quyn c bit thng tin ny v c tr gip bng ngn ng ca mnh min ph. Xin gi s 800-722-1471 (TTY: 800-842-5357).