Professional Documents
Culture Documents
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
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 1-800-852-6592. Important Questions Answers For in-network providers $500 individual / $1,250 family For out-of-network providers $5,000 individual / $10,000 family Doesnt apply to in-network preventive care, routine eye exams or outpatient labs/x-rays or ultrasounds. Yes. For durable medical equipment there is a $250 deductible. For in-network providers Is there an outof pocket limit on my expenses? $1,000 individual / $2,500 family For out-of-network providers $10,000 individual / $20,000 family Premiums, penalties for non-compliance, balancebilled charges, pharmacy claims, and health care this plan doesnt cover. 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. 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.
Even though you pay these expenses, they dont count toward the out-of-pocket limit.
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 1 of 13 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 1-800-852-6592 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 Is there an overall The chart starting on page 3 describes any limits on what the annual limit on what No. plan will pay for specific covered services, such as office the plan pays? 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 6. 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.
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.
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 2 of 13 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 1-800-852-6592 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% none coinsurance 50% none coinsurance Chiropractic limited to 12 50% visits per member per coinsurance calendar year. 50% none coinsurance 50% none coinsurance 50% none coinsurance Not Covered Not Covered Not Covered
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.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medco.com If you have outpatient surgery
Specialty drugs
All Specialty meds process through Accredo at the mail order costs. 10% coinsurance 10% coinsurance
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 1-800-852-6592 or visit us at www.anthem.com 3 of 13 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 1-800-852-6592 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 $100 copay / visit; $100 copay is waived if professional admitted for inpatient stay. and other Members may be balance services billed for out of network 10% coinsuranc services. e Members may be balance 10% billed for out of network coinsurance services $50 copay/visit; professional and other services 10% coinsurance 50% coinsurance 50% coinsurance Members may be balance billed for out of network services Precertification is required for Inpatient hospital admission or $500 penalty is applied. none
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 4 of 13 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 1-800-852-6592 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% none coinsurance Precertification is required for 50% Inpatient hospital admission coinsurance or $500 penalty is applied. 50% none coinsurance Precertification is required for 50% Inpatient hospital admission coinsurance or $500 penalty is applied. 50% none coinsurance 50% none coinsurance
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 5 of 13 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 1-800-852-6592 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 physical medicine rehabilitation is limited to 100 days per member per calendar year. Limited to 60 50% visits combined physical coinsurance therapy, speech therapy and occupational therapy. All therapy limits are combined in and out of network. 50% coinsurance All rehabilitation and habilitation visits count toward your rehabilitation visit limit. Limited to 100 inpatient days per member per calendar year. Precertification is required or $500 penalty is applied. $250 deductible combined in and out of network. Members may be balance billed for out of network services. Precertification is required for Inpatient hospital admission or $500 penalty is applied.
If you need help recovering Habilitation services or have other special health needs Skilled nursing care
Hospice service
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 6 of 13 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 1-800-852-6592 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 Limited to one exam per year 50% for 18 and younger. Limited coinsurance to one exam every 2 years for 19 and older Not Covered none Not Covered none
Non-emergency care when traveling Routine foot care outside the U.S. Weight loss programs
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 Chiropractic care Infertility treatment (Limits Apply) Coverage provided outside the Hearing Aids (Limitations apply) United States. Routine eye care (Adult See www.BCBS.com/bluecardworldwi Limitations apply) de
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 7 of 13 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 1-800-852-6592 to request a copy.
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 8 of 13 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 1-800-852-6592 to request a copy.
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 9 of 13 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 1-800-852-6592 to request a copy.
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 10 of 13 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 1-800-852-6592 to request a copy.
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 See the next page for Prescriptions important Radiology information about these examples. Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total
Questions: Call 1-800-852-6592 or visit us at www.anthem.com 11 of 13 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 1-800-852-6592 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 accounts (HRAs) that help you pay out-of-pocket expenses.