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Anthem Blue Cross of California

Anthem Gold PPO 1000/20%/4000
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 12/01/2015 – 11/30/2016
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/ca/sbc or by calling (855) 383-7248.
Important Questions

What is the overall
deductible?

Are there other
deductibles for specific
services?

Is there an
out–of–pocket limit on
my expenses?
What is not included in
the out–of–pocket
limit?
Is there an overall
annual limit on what
the plan pays?
Does this plan use a

Answers
$1,000 person / $3,000 family
for In-Network Providers. Does
not apply to Prescription Drugs,
Preventive Care, Primary Care
visit, and Specialist visit. $2,000
person / $4,000 family for Outof-Network Providers.
Yes; $250 person / $500 family
for In-Network and NonNetwork Providers combined
Tier 2, Tier 3 and Tier 4
Prescription Drugs. There are
no other specific deductibles.
Yes; $4,000 person / $8,000
family for In-Network
Providers. $8,000 person /
$16,000 family for Out-ofNetwork Providers.
Premiums, Balance-Billed
charges, and Health Care this
plan doesn't cover.
No.
Yes, Prudent Buyer PPO.

Why this Matters:
You must pay all 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.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
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

Questions: Call (855) 383-7248 or visit us at www.anthem.com/ca
CA/S/F/Anthem Gold PPO 1000/20%/4000/1K33/NA/01-15
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call (855) 383-7248 to request a copy.
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com/ca or call (855) 383-7248. Plans use the term in-network. see www. See the chart starting on page 3 for how this plan pays different kinds of providers. See your policy or plan document for additional information about excluded services. No. preferred. your in-network doctor or hospital may use an out-of-network provider for some services. Some of the services this plan doesn’t cover are listed on page 7. of the costs of covered services.Important Questions network of providers? Do I need a referral to see a specialist? Are there services this plan doesn’t cover? Answers Why this Matters: For a list of In-Network providers. Be aware. or participating for providers in their network. you do not need a referral to see a specialist. Dental and Vision benefits may access a different network of providers. 2 of 11 . You can see the specialist you choose without permission from this plan.anthem. Yes.

3 of 11 . For example. Covers up to a 30 day supply (retail pharmacy). copayments and coinsurance amounts Common Medical Event If you visit a health care provider’s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit Your Cost if You Use an Non-Network Provider Limitations & Exceptions $20 copay per visit 50% coinsurance --------none-------- $40 copay per visit 50% coinsurance Other practitioner office visit Chiropractor $20 copay per visit Acupuncture $20 copay per visit Chiropractor 50% coinsurance Acupuncture 50% coinsurance --------none-------Chiropractor Coverage for In-Network Providers and Non-Network Providers combined is limited to 20 visits per benefit period. If an out-of-network provider charges more than the allowed amount. For example. calculated as a percent of the allowed amount for the service. This may change if you haven’t met your deductible. blood work) Lab – Office 20% coinsurance X-Ray – Office 20% coinsurance Lab – Office 50% coinsurance X-Ray – Office 50% coinsurance Lab – Office --------none-------X-Ray – Office --------none-------- Imaging (CT/PET scans.· Copayments are fixed dollar amounts (for example. if the plan’s allowed amount for an overnight hospital stay is $1.000.) · This plan may encourage you to use In-Network providers by charging you lower deductibles.000.50 copay per prescription (home 50% coinsurance (retail only home delivery not covered) If you have a test If you need drugs to treat your illness or condition Your Cost if You Use an In-Network Provider Tier1 .500 for an overnight stay and the allowed amount is $1.Typically Generic Coverage for Non-Network Providers is limited to $800 maximum benefit per procedure. if an out-of-network hospital charges $1. you may have to pay the difference. · Coinsurance is your share of the costs of a covered service. No coverage for non-formulary drugs. you may have to pay the $500 difference. · The amount the plan pays for covered services is based on the allowed amount. usually when you receive the service. Acupuncture --------none-------- Preventive care/screening/immunization No charge 50% coinsurance --------none-------- Diagnostic test (x-ray. (This is called balance billing. Coverage for NonNetwork Providers is limited to $25 maximum benefit per visit. Covers up to a 90 day supply (home delivery program). your coinsurance payment of 20% would be $200. $15) you pay for covered health care. MRIs) 20% coinsurance 50% coinsurance $15 copay per prescription (retail only) and $37.

hospital room) Physician/surgeon fee If you have mental Mental/Behavioral health outpatient health. Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. --------none-------Mental/Behavioral Health Office Visit 20% coinsurance 50% coinsurance 20% coinsurance Mental/Behavioral Health Office Visit 50% coinsurance Mental/Behavioral Health Office Visit 4 of 11 .Typically Non-Preferred / Specialty Drugs $70 copay per prescription (retail only) and $175 copay per prescription (home delivery only) 50% coinsurance (retail only home delivery not covered) Tier4 .g.. If you select a brand name drug when a generic drug is available. If you select a brand name drug when a generic drug is available. additional cost sharing amounts may apply.Typically Preferred / Brand 50% coinsurance (retail only home delivery not covered) Tier3 .. Covered as In-Network 50% coinsurance --------none---------------none-------Coverage for Non-Network Providers is limited to $650 maximum benefit per day. Covers up to a 30 day supply (home delivery program).Common Medical Event More information about prescription drug coverage is available at http://www. No coverage for non-formulary drugs. ambulatory surgery center) Physician/surgeon fees If you need immediate medical attention If you have a hospital stay Your Cost if You Use an Non-Network Provider $35 copay per prescription (retail only) and $87. Covers up to a 30 day supply (retail pharmacy). additional cost sharing amounts may apply.Typically Specialty Drugs 25% coinsurance up to $250 (retail and home delivery) 50% coinsurance (retail only home delivery not covered) 20% coinsurance 50% coinsurance 20% coinsurance $200 copay per visit and then 20% coinsurance 20% coinsurance $40 copay per visit 50% coinsurance Facility fee (e. behavioral services Limitations & Exceptions Covers up to a 30 day supply (retail pharmacy). --------none-------- Covered as In-Network Copay waived if admitted.anthe m.g. No coverage for non-formulary drugs.50 copay per prescription (home delivery only) Anthem National Drug List 4 Tier If you have outpatient surgery Your Cost if You Use an In-Network Provider delivery only) Emergency room services Emergency medical transportation Urgent care Facility fee (e.com/pharmacyin formation/ Services You May Need Tier2 . additional cost sharing amounts may apply. Covers up to a 30 day supply (retail pharmacy). Coverage for Non-Network Providers is limited to $380 maximum benefit per admission. If you select a brand name drug when a generic drug is available. Covers up to a 90 day supply (home delivery program).

or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Your Cost if You Use an In-Network Provider Your Cost if You Use an Non-Network Provider $20 copay per visit Mental/Behavioral Health Facility Visit Facility Charges 20% coinsurance 50% coinsurance Mental/Behavioral Health Facility Visit Facility Charges 50% coinsurance Mental/Behavioral health inpatient services 20% coinsurance 50% coinsurance Substance use disorder outpatient services Substance Use Office Visit $20 copay per visit Substance Use Facility Visit . Coverage for In-Network Providers and Non-Network Providers combined is limited to 100 visits per benefit period.Facility Charges 20% coinsurance Substance Use Office Visit 50% coinsurance Substance Use Facility Visit . --------none---------------none-------Coverage for In-Network Providers and Non-Network Providers combined is limited to 100 days per 5 of 11 . Other cost shares may apply depending on services provided. Coverage for Non-Network Providers is limited to $650 maximum benefit per day. Substance Use Office Visit --------none-------Substance Use Facility Visit .Facility Charges Coverage for Non-Network Providers is limited to $380 maximum benefit per admission.Facility Charges Coverage for Non-Network Providers is limited to $380 maximum benefit per admission. --------none-------Coverage for Non-Network Providers is limited to $650 maximum benefit per day.Common Medical Event Services You May Need health. Applies to inpatient facility. Coverage for Non-Network Providers is limited to $650 maximum benefit per day.Facility Charges 50% coinsurance Substance use disorder inpatient services 20% coinsurance 50% coinsurance Prenatal and postnatal care 20% coinsurance 50% coinsurance Delivery and all inpatient services 20% coinsurance 50% coinsurance Home health care $20 copay per visit 50% coinsurance Rehabilitation services Habilitation services $20 copay per visit $20 copay per visit 50% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance Skilled nursing care Limitations & Exceptions --------none-------Mental/Behavioral Health Facility Visit . Coverage for NonNetwork Providers is limited to $75 maximum benefit per visit.

Coverage for In-Network Providers and Non-Network Providers combined is limited to 1 unit per benefit period. Coverage for NonNetwork Providers is limited to $150 maximum benefit per day.Common Medical Event Services You May Need Durable medical equipment Hospice service If your child needs dental or eye care Your Cost if You Use an In-Network Provider Your Cost if You Use an Non-Network Provider 20% coinsurance 0% coinsurance 50% coinsurance 50% coinsurance Eye exam No charge No charge Glasses No charge No charge Dental check-up No charge No charge Limitations & Exceptions benefit period. --------none-------- 6 of 11 . --------none---------------none-------Coverage for In-Network Providers and Non-Network Providers combined is limited to 1 exam per benefit period.

Private-duty nursing Coverage is limited to 100 visits per benefit period. See www.com/bluecardworldwide.bcbs.) · · · · · Acupuncture Bariatric surgery Chiropractic care Coverage is limited to 20 visits per benefit period.Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services. Check your policy or plan document for other excluded services.) · · · · · Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment Long-term care · · · · Non-Formulary drugs Routine eye care (Adult) Routine foot care Weight loss programs Other Covered Services (This isn’t a complete list. 7 of 11 . Most coverage provided outside the United States.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan. or assistance. Federal and State laws may provide protections that allow you to keep health coverage.gov/ebsa. Box 4310 Woodland Hills.healthhelp. then. Any such rights may be limited in duration and will require you to pay a premium.S. For more information on your rights to continue coverage.dol. Department of Labor.O.gov/ebsa/healthreform Department of Managed Health Care California Help Center 980 9th Street Suite 500 Sacramento. or the U. Department of Health and Human Services at 1-877-267-2323 x61565 or www. you can contact: ATTN: Grievances and Appeals P. CA 95814 (888) 466-2219 http://www. CA 95814-2725 (888) HMO-2219 California Department of Managed Health Care Help Center 980 9th Street.gov helpline@dmhc.cms. the U.gov 8 of 11 .Your Rights to Continue Coverage: If you lose coverage under the plan. Other limitations on your rights to continue coverage may also apply. Suite 500 Sacramento.gov.cciio. contact the plan at (855) 383-7248. Employee Benefits Security Administration at 1-866-444-3272 or www.ca. you may be able to appeal or file a grievance.ca. this notice. Employee Benefits Security Administration (866) 444-EBSA (3272) www. CA 91365-4310 Department of Labor.dol. depending upon the circumstances. You may also contact your state insurance department.S. For questions about your rights. which may be significantly higher than the premium you pay while covered under the plan.

Hai’dąą iini’taago eíya. xin liên lạc với đại diện thương mãi của quý vị hoặc quản trị viên nhóm. le suplicamos que se ponga en contacto con su agente de ventas o con el administrador de su grupo. Nếu quý vị chưa phải là một hội viên và cần được giúp đỡ bằng Tiếng Việt.Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.–––––––––––––––––––––– 9 of 11 . Eí doo biigha daago ni ba’nija’go ho’aałagíí bich’į hodiilní.Nếu quý vị đã ghi danh. 아직 가입하지 않았거나 한국어로 된 도움말이 필요한 경우 영업 관리자나 그룹 관리자에게 문의하시기 바랍니다. Language Access Services: 如果您是非會員並需要中文協助,請聯絡您的銷售代表或小組管理員。如果您已參保,則請使用您 ID 卡上的號碼聯絡客戶服務人員。 Doo bee a’tah ni’liigoo eí dooda’í. le rogamos que llame al número de servicio de atención al cliente que aparece en su tarjeta de identificación. Kung naka-enroll ka na. t’áá shoodí ba na’ałníhí ya sidáhí bich’į naabídííłkiid. 이미 가입한 경우 ID 카드에 있는 번호를 사용하여 고객 서비스에 문의하시기 바랍니다. xin liên lạc với dịch vụ khách hàng qua việc dùng số điện thoại ghi trên thẻ ID của quý vị. Kung hindi ka pa miyembro at kailangan ng tulong sa wikang Tagalog. mangyaring makipag-ugnayan sa serbisyo para sa customer gamit ang numero sa iyong ID card. see the next page. mangyaring makipag-ugnayan sa iyong sales representative o administrator ng iyong pangkat. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. Si ya está inscrito. The minimum value standard is 60% (actuarial value). ––––––––––––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation. This health coverage does meet the minimum value standard for the benefits it provides. shikáa adoołwoł íínízinigo t’áá diné k’éjíígo. Si no es miembro todavía y necesita ayuda en idioma español.” This plan or policy does provide minimum essential coverage. t’áá shoodí diné ya atáh halne’ígíí ní béésh bee hane’í wólta’ bi’ki si’niilígíí bi’kéhgo bich’į hodiilní.

300 $700 $300 $100 $100 $5.About These Coverage Examples: These examples show how this plan might cover medical care in given situations. in general. The actual care you receive will be different from these examples.500 $0 $0 $2. Use these examples to see. Managing type 2 diabetes Having a baby (routine maintenance of a well-controlled condition) (normal delivery) n Amount owed to providers: $7.200 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2. Don’t use these examples to estimate your actual costs under this plan.400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $700 $1. how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator.000 $80 $1.900 $1.200 n Patient pays $2. and the cost of that care will also be different.200 $0 $2.540 $1.700 $2. See the next page for important information about these examples.540 n Plan pays $5.400 n Plan pays $3.200 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines. other preventive Total $2. other preventive Total Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines.280 n Amount owed to providers: $5.280 10 of 11 .100 $900 $900 $500 $200 $200 $40 $7.260 n Patient pays $2.

When you look at the Summary of Does the Coverage Example predict my own care needs? û No. üYes. the lower your premium. Questions: Call (855) 383-7248 or visit us at www. The care you would receive for this condition could be different based on your doctor’s advice.S. the more coverage the plan provides. Generally.anthem. Your own costs will be different depending on the care you receive. costs would have been higher. What does a Coverage Example show? Can I use Coverage Examples to compare plans? For each treatment situation. · The patient received all care from innetwork providers. co payments.gov or call (855) 383-7248 to request a copy. You can view the Glossary at www. The smaller that number. Are there other costs I should consider when comparing plans? üYes. and coinsurance. Does the Coverage Example predict my future expenses? ûNo. see the Glossary. and coinsurance can add up. you’ll find the same Coverage Examples. deductibles. You should also consider contributions to accounts such as health savings accounts (HSAs). If the patient had received care from out-of-network providers. check the “Patient Pays” box in each example.cciio. and the reimbursement your health plan allows. When you compare plans. the Coverage Example helps you see how deductibles. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Coverage Examples are not cost estimators. and many other factors. Treatments shown are just examples. · Out-of-pocket expenses are based only on treating the condition in the example. Benefits and Coverage for other plans. the more you’ll pay in out-ofpocket costs. An important cost is the premium you pay. · All services and treatments started and ended in the same coverage period. · The patient’s condition was not an excluded or preexisting condition.com/ca CA/S/F/Anthem Gold PPO 1000/20%/4000/1K33/NA/01-15 If you aren’t clear about any of the underlined terms used in this form.Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? · Costs don’t include premiums. You can’t use the examples to estimate costs for an actual condition. flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Department of Health and Human Services. 11 of 11 . how serious your condition is. · Sample care costs are based on national averages supplied by the U.cms. your age. such as copayments. and aren’t specific to a particular geographic area or health plan. They are for comparative purposes only. the prices your providers charge. · There are no other medical expenses for any member covered under this plan.