1 of 15

Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015

"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
(his is on'$ a s#mmar$) If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-855-271-4549.
*mpor&an& +#es&ions Answers ,h$ &his Ma&&ers:
What is the
overall
deductible?
For in-network
providers
-1.000 individual /
-2.500 family
Doesnt apply to in-
network preventive care
and routine eye eam.
!ou must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. "heck your policy or
plan document to see when the deductible starts over #usually, but
not always, $anuary %st&. 'ee the chart starting on page ( for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for
seci!c services?
!es. "25# deductible
for Durable )edical
*+uipment per member
per calendar year.
!ou must pay all of the costs for these services up to the speci,c
deductible amount before this plan begins to pay for these services.
$s there an out%
of%oc&et limit
on m' e(enses?
!es. For in-network
providers
-/.!50 individual /
-12.000 family
-he out-of-oc&et limit is the most you could pay during a coverage
period #usually one year& for your share of the cost of covered
services. -his limit helps you plan for health care epenses.
What is not
included in the
out%of%oc&et
limit?
.alance-.illed charges,
/ealth "are this plan
doesnt cover,
0remiums, and 1ut-of-
network pharmacy
claims.
*ven though you pay these epenses, they dont count toward the
out-of-oc&et limit.
$s there an
overall annual
limit on what the
lan a's?
2o.
-he chart starting on page ( describes any limits on what the plan
will pay for specifc covered services, such as o3ice visits.
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
2 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
+oes this lan
use a networ& of
roviders?
!es. For a list of
referred roviders,
see www.anthem.com
or call %-566-78%-969:
If you use an in-network doctor or other health care rovider, this
plan will pay some or all of the costs of covered services. .e aware,
your in-network doctor or hospital may use an out-of-network
rovider for some services. 0lans use the term in-network,
referred, or participating for roviders in their networ&. 'ee the
chart starting on page ( for how this plan pays di3erent kinds of
roviders.
+o $ need a
referral to see a
secialist?
2o.
!ou can see the secialist you choose without permission from this
plan.
Are there
services this lan
doesn,t cover?
!es.
'ome of the services this plan doesnt cover are listed on page 6. 'ee
your policy or plan document for additional information about
e(cluded services.
-oa'ments are ,ed dollar amounts #for eample, ;%6& you pay for covered health care, usually when you
receive the service.
-oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed
amount for the service. For eample, if the plans allowed amount for an overnight hospital stay is
;%,<<<, your coinsurance payment of 7<= would be ;7<<. -his may change if you havent met your
deductible.
-he amount the plan pays for covered services is based on the allowed amount. If an out-of-network
rovider charges more than the allowed amount, you may have to pay the di3erence. For eample, if an
out-of-network hospital charges ;%,6<< for an overnight stay and the allowed amount is ;%,<<<, you may
have to pay the ;6<< di3erence. #-his is called balance billin..&
-his plan may encourage you to use in-networ& roviders by charging you lower deductibles,
coa'ments and coinsurance amounts.
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
! of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'ou visit a
health care
rovider,s
o/ice or clinic
0rimary care visit to treat an
in>ury or illness
;(<
copay/visit
2ot "overed ????????????none????????????
'pecialist visit
;6<
copay/visit
2ot "overed ????????????none????????????
1ther practitioner o3ice visit
"hiropractor
;6<
copay/visit
@cupuncturist
2ot covered
"hiropractor
2ot "overed
@cupuncturist
2ot covered
????????????none????????????
0reventive
care/screening/immuniAation
2o "ost
'hare
2ot "overed ????????????none????????????
$f 'ou have a
test
Diagnostic test #-ray, blood
work&
<=
coinsurance
2ot "overed ????????????none????????????
Imaging #"-/0*- scans, )BIs&
<=
coinsurance
2ot "overed ????????????none????????????
$f 'ou need
dru.s to treat
'our illness or
condition
)ore
information
about
rescrition
dru. covera.e
is available at
www.medco.com
4eneric drugs #Betail/(< dayC )ail/:<
day&
;%6 Betail/;(<
)ail
2ot "overed
If pre-auth re+uired D not obtained,
drug may not be covered. "ertain
0reventive meds no copay. If a generic
e+uivalent is available D brand is
prescribed/member will pay brand
name cost di3erence. 0lan uses
preferred drug list to identify
coverage.
0referred brand drugs #Betail/(< dayC
)ail/:< day&
;(6 Betail/;58.6
)ail
2ot "overed
2on-preferred brand #Betail/(<dayC
)ail/:<day&
;8< Betail/;%86
)ail
2ot "overed
'pecialty drugs
@ll 'pecialty
meds process
through
@ccredo at
the mail order
costs.
2ot "overed
-he mail order cost will be
based on the medication tier
#generic, preferred, non-
preferred&. 'pecialty meds can
not be ,lled at retail
pharmacies.
Facility fee #e.g., ambulatory
surgery center&
<=
coinsurance
2ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
8 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'ou have
outatient
sur.er'
0hysician/surgeon fees
<=
coinsurance
2ot "overed ????????????none????????????
$f 'ou need
immediate
medical
attention
*mergency room services
;76< copay
/visitE
professional
and other
services
sub>ect to
deductible
;76<
copay/visitE
professional
and other
services
sub>ect to
deductible
;76< "opay waived if
admitted. )ember may be
balance billed for out of
network services.
*mergency medical
transportation
<=
coinsurance
<=
coinsurance
)ember may be balance
billed for out of network
services.
Frgent care
;6<
copay/visit
2ot "overed ????????????none????????????
$f 'ou have a
hosital sta'
Facility fee #e.g., hospital room&
<=
coinsurance
<=
coinsurance
0hysical )edicine and
Behabilitation limited to %<<
days per member per
calendar year.
0hysician/surgeon fee
<=
coinsurance
<=
coinsurance
????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
5 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'ou have
mental health0
behavioral
health0 or
substance
abuse needs
)ental/.ehavioral health
outpatient services
)ental/.ehavi
oral /ealth
13ice Gisit
;(<
copay/visit
)ental/.ehavi
oral /ealth
Facility
Gisit
<=
coinsurance
)ental/.ehavi
oral/ealth
13ice
Gisit
2ot
"overed
)ental/.ehavi
oral /ealth
Facility
Gisit
2ot
"overed
????????????none????????????
)ental/.ehavioral health
inpatient services
<=
coinsurance
2ot "overed ????????????none????????????
'ubstance use disorder
outpatient services
'ubstance
@buse 13ice
Gisit
;(<
copay/visit
'ubstance
@buse
Facility Gisit
<=
coinsurance
'ubstance
@buse 13ice
Gisit
2ot
"overed
'ubstance
@buse Facility
Gisit
2ot
"overed
????????????none????????????
'ubstance use disorder inpatient
services
<=
coinsurance
2ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
/ of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'ou are
re.nant
0renatal and postnatal care
<=
coinsurance
2ot "overed ????????????none????????????
Delivery and all inpatient services
<=
coinsurance
2ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
0 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'ou need
hel recoverin.
or have other
secial health
needs
/ome health care
<=
coinsurance
2ot "overed ????????????none????????????
Behabilitation services
;6<
copay/visit for
outpatient
services.
Inpatient
services
sub>ect to
deductible.
2ot "overed
Himited to I< visits per
member per calendar year
for physical therapy,
occupational therapy, and
speech therapy combined.
/abilitation services
;6<
copay/visit for
outpatient
services.
Inpatient
services
sub>ect to
deductible.
2ot "overed
@ll rehabilitation and
habilitation visits count
toward your rehabilitation
visit limit.
'killed nursing care
<=
coinsurance
2ot "overed
Himited to %<< days per
calendar year.
Durable medical e+uipment
;76<
deductible
then 7<=
coinsurance
2ot "overed
'upplies are sub>ect to ;76<
deductible per member per
year. -)$ @ppliances are not
covered.
/ospice service
<=
coinsurance
2ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
9 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
Medi1a' Even&
"ervi1es 2o# Ma$ 3eed
2o#r Cos& *f
2o# 4se an
*nne&wor5
Provider
2o#r Cos& *f
2o# 4se an
O#&ofne&wor5
Provider
Limi&a&ions 6 E71ep&ions
$f 'our child
needs dental or
e'e care
*ye eam 2o cost share 2ot "overed
1ne eam each calendar
year for members ages %5
years and younger. 1ne
eam every two calendar
years for members %: years
and older.
4lasses 2ot "overed 2ot "overed ?????????????none????????????
Dental check-up 2ot "overed 2ot "overed ?????????????none????????????
E71'#ded "ervi1es 6 O&her Covered "ervi1es:
"ervi1es 2o#r P'an :oes 3O( Cover 12his isn,t a comlete list. -hec& 'our olic' or lan document for other
e(cluded services.3
J @cupuncture
J "osmetic surgery
J Dental care #@dult&
J /earing aids
J Infertility treatment
J Hong-term care
J Boutine foot care
J Keight loss programs
O&her Covered "ervi1es 12his isn,t a comlete list. -hec& 'our olic' or lan document for other covered
services and 'our costs for these services.3
J .ariatric surgery #Himitations )ay
@pply&
J "hiropractic care #Himitations
@pply&
J )ost coverage provided outside the
Fnited 'tates. 'ee
www..".'.com/bluecardworldwide
J 0rivate-duty nursing #covered
under /ome /ealth "are&
J Boutine eye care #@dult ?
Himitations )ay @pply&
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
; of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
2o#r Righ&s &o Con&in#e Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provide
protections that allow you to keep health coverage. @ny such rights may be limited in duration and will re+uire you
to pay a remium, which may be signi,cantly higher than the premium you pay while covered under the plan.
1ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at %-5<<-765-6(%5. !ou may also contact
your state insurance department, the F.'. Department of Habor, *mployee .ene,ts 'ecurity @dministration at %-5II-
999-(787 or www.dol.gov/ebsa, or the F.'. Department of /ealth and /uman 'ervices at %-588-7I8-7(7( I%6I6 or
www.cciio.cms.gov.
2o#r <rievan1e and Appea's Righ&s:
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
10 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
If you have a complaint or are dissatis,ed with a denial of coverage for claims under your plan, you may be able to
aeal or ,le a .rievance. For +uestions about your rights, this notice, or assistance, you can contactC
@nthem .lue "ross .lue 'hield
"linical @ppealsC 0.1. .o %<66I5 @tlanta, 4@ (<(95
1perational @ppealsC 0.1. .o %<66I5 @tlanta, 4@ (<(95
For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back of
prescription member ID card or visit www.epress-scripts.com.
For *BI'@ information contactC
Department of Habors *mployee .ene,ts 'ecurity @dministration
%-5II-999-*.'@ #(787&
www.dol.gov/ebsa/healthreform
@dditionally, a consumer assistance program can help you ,le your appeal. "ontactC
2ew /ampshire Department of Insurance
7% 'outh Fruit 'treet, 'uite %9
"oncord, 2/ <((<%
#5<<& 567-(9%I
www.nh.gov/insurance
consumerservicesLins.nh.gov
:oes &his Coverage Provide Minim#m Essen&ia' Coverage=
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
11 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
-he @3ordable "are @ct re+uires most people to have health care coverage that +uali,es as Mminimum essential
coverage.N This plan or policy does provide minimum essential coverage.
:oes &his Coverage Mee& &he Minim#m >a'#e "&andard=
-he @3ordable "are @ct establishes a minimum value standard of bene,ts of a health plan. -he minimum value
standard is I<= #actuarial value&. This health coverage does meet the minimum value standard for the
benefts it provides.
Lang#age A11ess "ervi1es:
??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next
page.???????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
?aving a @a@$
#normal delivery&
Managing &$pe 2 dia@e&es
#routine maintenance of
a well-controlled condition&
12 of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
Coverage E7amp'es
Coverage for: Individual/Family | P'an ($pe: EPO
A@o#& &hese Coverage
E7amp'es:
-hese eamples show how this plan
might cover medical care in given
situations. Fse these eamples to
see, in general, how much ,nancial
protection a sample patient might
get if they are covered under
di3erent plans.
Amo#n& owed &o providers: $7,54
P'an pa$s $!,"7
Pa&ien& pa$s $#,#7
"amp'e 1are 1os&s:
/ospital charges #mother&
;7,8<
<
Boutine obstetric care
;7,%<
<
/ospital charges #baby& ;:<<
@nesthesia ;:<<
Haboratory tests ;6<<
0rescriptions ;7<<
Badiology ;7<<
Gaccines, other preventive ;9<
2otal
"7054
#
Pa&ien& pa$s:
Deductibles
;%,<<
<
"opays ;7<
"oinsurance ;<
Himits or eclusions ;%6<
2otal
"1017
#
Amo#n& owed &o providers: $5,4
P'an pa$s $$!
Pa&ien& pa$s $4,44
"amp'e 1are 1os&s:
0rescriptions
;7,:<
<
)edical *+uipment and
'upplies
;%,(<
<
13ice Gisits and 0rocedures ;8<<
*ducation ;(<<
Haboratory tests ;%<<
Gaccines, other preventive ;%<<
2otal
"504#
#
Pa&ien& pa$s:
Deductibles
;%,76
<
"opays ;8%<
"oinsurance ;7<<
Himits or eclusions ;5<
2otal
"2024
#
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.

(his is
no& a 1os&
es&ima&or)
Dont use these
eamples to estimate
your actual costs under
this plan. -he actual
care you receive will be
di3erent from these
eamples, and the cost
of that care will also be
di3erent.
'ee the net page for
important information
about these eamples.
1! of 15
Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015 12/!1/2015
Coverage E7amp'es
Coverage for: Individual/Family | P'an ($pe: EPO
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
+#es&ions and answers a@o#& &he Coverage E7amp'es:
,ha& are some of &he
ass#mp&ions @ehind &he
Coverage E7amp'es=
"osts dont include remiums.
'ample care costs are based on
national averages supplied by
the F.'. Department of /ealth
and /uman 'ervices, and
arent speci,c to a particular
geographic area or health plan.
-he patients condition was not
an ecluded or preeisting
condition.
@ll services and treatments
started and ended in the same
coverage period.
-here are no other medical
epenses for any member
covered under this plan.
1ut-of-pocket epenses are
based only on treating the
condition in the eample.
-he patient received all care
from in-network roviders. If
the patient had received care
from out-of-network roviders,
costs would have been higher.
,ha& does a Coverage E7amp'e
show=
For each treatment situation, the
"overage *ample helps you see
how deductibles, coa'ments,
and coinsurance can add up. It
also helps you see what epenses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
:oes &he Coverage E7amp'e
predi1& m$ own 1are needs=
4o. -reatments shown are >ust
eamples. -he care you would
receive for this condition could
be di3erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
:oes &he Coverage E7amp'e
predi1& m$ f#&#re e7penses=
4o. "overage *amples are not
cost estimators. !ou cant use
the eamples to estimate costs
for an actual condition. -hey are
for comparative purposes only.
!our own costs will be di3erent
depending on the care you
receive, the prices your
roviders charge, and the
reimbursement your health plan
allows.
Can * #se Coverage E7amp'es
&o 1ompare p'ans=
5es. Khen you look at the
'ummary of .ene,ts and
"overage for other plans, youll
,nd the same "overage
*amples. Khen you compare
plans, check the M0atient 0aysN
bo in each eample. -he
smaller that number, the more
coverage the plan provides.
Are &here o&her 1os&s * sho#'d
1onsider when 1omparing
p'ans=
5es. @n important cost is the
remium you pay. 4enerally,
the lower your remium, the
more youll pay in out-of-pocket
costs, such as coa'ments,
deductibles, and coinsurance.
!ou should also consider
contributions to accounts such
as health savings accounts
#/'@s&, Oeible spending
arrangements #F'@s& or health
reimbursement accounts #/B@s&
that help you pay out-of-pocket
epenses.