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Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO
This is only a summary. 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. Important Questions Answers For in-network providers $1,000 individual / $2,500 family Doesnt apply to innetwork preventive care and routine eye exam. Yes. $250 deductible for Durable Medical Equipment per member per calendar year. Yes. For in-network providers $6,350 individual / $12,700 family Premiums, balancebilled charges, penalties for non compliance, pharmacy claims and health care this plan doesnt cover. No. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services? Is there an out ofpocket limit on my expenses? What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays?
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
Even though you pay these expenses, they dont count toward the out-of-pocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 1 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, Yes. For a list of Does this plan your in-network doctor or hospital may use an out-of-network preferred providers, use a network of provider for some services. Plans use the term in-network, see www.anthem.com providers? preferred, or participating for providers in their network. See the or call 1-855-271-4549 chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesnt cover? No. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 5. See your policy or plan document for additional information about excluded services.
Yes.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you
receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Your Cost If You Use an In-network Provider $30 copay/visit Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Not Covered none
Services You May Need Primary care visit to treat an injury or illness
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 2 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered none none none none none
If pre-auth required & not obtained, drug may not be covered. Certain Preventive meds no copay. If a generic equivalent is available & brand is prescribed/member will pay brand name cost difference. Plan uses preferred drug list to identify coverage.
Specialty drugs
All Specialty meds process through Not Covered Accredo at the mail order costs. No Charge No Charge Not Covered Not Covered
The mail order cost will be based on the medication tier (generic, preferred, non-preferred). Specialty meds can not be filled at retail pharmacies.
none none
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 3 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider $250 copay/visit; professional Copay waived if admitted. and other Member may be balance billed services for out of network services. subject to deductible Member may be balance billed No Charge for out of network services. Not Covered Not Covered Not Covered none Failure to precertify may result in a penalty of $500. none
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 4 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider
Not Covered
none
Not Covered
Not Covered
none
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 5 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Rehabilitation services
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Not Covered none Inpatient rehabilitation limited to 60 days per calendar year. Outpatient services limited to 60 visits per member per Not Covered calendar year for physical therapy, occupational therapy, and speech therapy combined. Limits are combined in and out-of- network.
If you need help recovering or have other Habilitation services special health needs
Not Covered
All rehabilitation and habilitation visits count toward your rehabilitation visit limit.
Not Covered
Limited to 100 days per calendar year. Failure to precertify may result in a penalty of $500. Supplies are subject to $250 deductible per member per year. TMJ Appliances are not covered. none
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 6 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Eye exam If your child needs dental or eye care Glasses Dental check-up
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider One exam each calendar year for members ages 18 years Not Covered and younger. One exam every two calendar years for members 19 years and older. Not Covered none Not Covered none
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery (Limitations may apply) Chiropractic care Coverage provided outside the United States. See www.BCBS.com/bluecardworldwide Routine eye care (Adult - Limitations Questions: Call 1-855-271-4549 or visit us at www.anthem.com 7 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy. Private-duty nursing (covered under Home Health Care)
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 8 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross Blue Shield Clinical Appeals: P.O. Box 105568 Atlanta, GA 30348 Operational Appeals: P.O. Box 105568 Atlanta, GA 30348 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.express-scripts.com. For ERISA information contact: Department of Labors Employee Benefits Security Administration 1-866-444-EBSA (3272) www.dol.gov/ebsa/healthreform Additionally, a consumer assistance program can help you file your appeal. Contact: New Hampshire Department of Insurance 21 South Fruit Street, Suite 14 Concord, NH 03301 (800) 852-3416 www.nh.gov/insurance consumerservices@ins.nh.gov
Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 10 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO
Having a baby
(normal delivery)
This is not a cost Amount owed to providers: $7,540 estimator. Plan pays $6,390
Patient pays $1,150 Dont use these examples to estimate Sample care costs: your actual costs under Hospital (mother) this plan.charges The actual care you receive will be Routine obstetric care different from these examples, and the cost Hospital charges (baby) of that care will also be Anesthesia different. Laboratory tests Prescriptions See the next page for Radiology important information Vaccines, other preventive about these examples. Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 11 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 12 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
premium you pay. Generally, the lower your premium, the more youll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should also consider contributions to accounts such as
health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement