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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: PPO
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/$3,000 family For out-of-network providers $5,000 individual/$10,000 family Doesnt apply to innetwork preventive care, routine eye exams or outpatient labs/x-rays or ultrasounds. Yes. $250 deductible for Durable Medical Equipment per member per calendar year. Yes. For in-network providers $3,000 individual/$9,000 family For out-of-network providers $10,000 individual/ $20,000 family 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 3 for how much you pay for covered services after you meet the deductible.
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.
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 1 of 15 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.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Out-of-Network deductible, premiums, What is not balance-billed charges, included in the Even though you pay these expenses, they dont count toward the penalties for non outofpocket out-of-pocket limit. compliance, pharmacy limit? claims and health care this plan doesnt cover. Is there an overall annual limit on what the plan pays? No.
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO
The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits. 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, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 7. See your policy or plan document for additional information about excluded services.
Do I need a referral to see a specialist? Are there services this plan doesnt cover?
No.
Yes.
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 2 of 15 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: PPO 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. Common Medical Event Your Cost If You Use an In-network Provider $30 copay/visit $50 copay/visit $50 copay/visit No Charge Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance 50% none coinsurance Chiropractic care is limited to 50% 12 visits per member per coinsurance calendar year. 50% none coinsurance 50% Deductible waived for office coinsurance and outpatient services. 50% none coinsurance
Services You May Need Primary care visit to treat an injury or illness
Diagnostic test (x-ray, blood work) No Charge Imaging (CT/PET scans, MRIs) 20% coinsurance
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 3 of 15 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.
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider $10 Retail/$20 Generic drugs (Retail/30 day: Mail/90 If you need Not Covered day) Mail drugs to treat $35 Retail/$87.5 Preferred brand drugs (Retail/30 day: your illness or Not Covered Mail/90 day) Mail condition Non-preferred brand (Retail/30day: $60 Retail/$150 Not Covered Mail/90day) Mail More information All Specialty about meds process prescription through Specialty drugs Not Covered drug coverage Accredo at the is available at mail order www.medco.com costs. Facility fee (e.g., ambulatory 20% 50% If you have surgery center) coinsurance coinsurance outpatient 20% 50% surgery Physician/surgeon fees coinsurance coinsurance $250 $250 copay/visit; copay/visit; professional professional Emergency room services and other and other If you need services 20% services 20% immediate coinsurance coinsurance medical attention Emergency medical 20% 20% transportation coinsurance coinsurance $50 copay/ $50 copay/ Urgent care visit visit 20% 50% Facility fee (e.g., hospital room) coinsurance coinsurance If you have a hospital stay 20% 50% Physician/surgeon fee coinsurance coinsurance
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider
Maintenance Meds are required to be filled mail order after 3 fills at retail (penalty applies). 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.
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
Copay waived if admitted. Member may be balance billed for out of network services. Member may be balance billed for out of network services. Member may be balance billed for out of network services. 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 15 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: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider
50% coinsurance
none
50% coinsurance
50% coinsurance
none
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 5 of 15 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: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance Inpatient rehabilitation limited to 100 days per calendar year. Outpatient services limited to 60 visits per member per 50% calendar year for physical coinsurance therapy, occupational therapy, and speech therapy combined. Limits are combined in and out-of- network. All rehabilitation and habilitation visits count toward your rehabilitation visit limit. 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. Member may be balance billed for out of network services. none
If you need help recovering Habilitation services or have other special health needs Skilled nursing care
50% coinsurance
50% coinsurance
Hospice service
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 6 of 15 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
No Charge
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider One exam per calendar year for members 18 years and 50% younger. coinsurance One exam every 2 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 Coverage provided outside the Private-duty nursing (covered Apply) United States. See under Home Health Care) www.BCBS.com/bluecardworldwide Chiropractic care (Limitations Apply) Routine eye care (Adult Limitations May Apply) Questions: Call 1-855-271-4549 or visit us at www.anthem.com 7 of 15 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: PPO
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 8 of 15 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: PPO 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 Coverage for: Individual/Family | Plan Type: PPO
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 15 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: PPO
Having a baby
(normal delivery)
This is not a cost Amount owed to providers: $7,540 estimator. Plan pays $5,260
Patient pays $2,280 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 $1,00 0 $20 $1,11 0 $150 $2,28 0
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 11 of 15 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: PPO
Amount owed to providers: $5,400 Plan pays $3,360 Patient pays $2,040 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1,25 0 $510 $200 $80 $2,04 0 $2,90 0 $1,30 0 $700 $300 $100 $100 $5,40 0
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 12 of 15 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: PPO
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 13 of 15 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