Filing at a Glance

Company: Rocky Mountain Hospital And Medical Service, Inc., D.B.A. Anthem Blue Cross And Blue
Shield
Product Name: CO PPO SG Off-Exchange 2015
State: Colorado
TOI: H16G Group Health - Major Medical
Sub-TOI: H16G.003A Small Group Only - PPO
Filing Type: Form
Date Submitted: 06/06/2014
SERFF Tr Num: ANTP-129563088
SERFF Status: Pending State Action
State Tr Num: 288387
State Status: Open
Co Tr Num: CO PPO OFF EXCHANGE 2015
Implementation
Date Requested:
01/01/2015
Author(s): Sandi Lay, Gemma Cruz, Michael Coe, Jennifer Gunther
Reviewer(s): Tara Smith (primary), Susan Buth, Staci Lewis, Jimmy Potts, Robert Potts, Earl Brown
Disposition Date:
Disposition Status:
Implementation Date:
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
General Information

Company and Contact
Project Name: Status of Filing in Domicile:
Project Number: Date Approved in Domicile:
Requested Filing Mode: File & Use Domicile Status Comments:
Explanation for Combination/Other: Market Type: Group
Submission Type: New Submission Group Market Size: Small
Group Market Type: Employer Overall Rate Impact:
Filing Status Changed: 07/30/2014
State Status Changed: 06/09/2014 Deemer Date:
Created By: Sandi Lay Submitted By: Sandi Lay
Corresponding Filing Tracking Number:
PPACA: Non-Grandfathered Immed Mkt Reforms
PPACA Notes: null
Include Exchange Intentions:
No
Filing Description:
We are filing PPO plans for off-exchange purposes.
The documents found in the Form Schedule tab include the template Evidence of Coverage (EOC); within the EOC we include
a Schedule of Benefits. For 2014 we filed form numbers for each benefit package and assigned a form number that was
needed for the C4HCO submission. We realize in hindsight that the form numbers we assigned were only needed for the
purpose of transfer to C4HCO. For 2015 since we are going to a template and have reassigned a form number, however the
form is the same as last year with the changes needed based on approved benefit modifications, updates due to state and
federal laws and our own updates as we have found areas of clarification.
We are including a statement of variability since we are filing a template. At the end of that Statement of Variability you will find
a table of the 2014 Form Number and the 2015 Form Number. In that same table you will find the 2014 Plan Name and the
2015 Plan Name. We have previously advised the DOI that we are making changes to the plan name.
We previously filed and received approval of benefit modifications for these plans. That approval is under SERFF Tracking
number ANTP-129440334.
We thank you for your time in reviewing this filing and we look forward to your approval.
Filing Contact Information
Sandra Lay, Contracts Compliance Advisor sandra.lay@wellpoint.com
700 Broadway
Denver, CO 80273
303-831-2126 [Phone]
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Filing Fees
State Specific
Filing Company Information
Rocky Mountain Hospital And
Medical Service, Inc., D.B.A.
Anthem Blue Cross And Blue
Shield
700 Broadway
Denver, CO 80273
(303) 831-2126 ext. [Phone]
CoCode: 11011
Group Code: 671
Group Name:
FEIN Number: 84-0747736
State of Domicile: Colorado
Company Type: Life & Health
State ID Number: 87269
Fee Required?
No
Retaliatory?
No
Fee Explanation:
Please enter state-specific code(s) found in Colorado's Filing Requirements Bulletins, or on the General Instructions page.
Please list all applicable state-specific codes. If no codes are applicable, please enter N/A.: 701, 649, 645
All rate and loss cost filing types MUST be submitted with completed Rate Data Fields in accordance with Sections 10-4-401
and 10-16-107 C.R.S. This requirement does not apply to form filing types. Rate and loss cost filings not including this data
will be rejected. If this is a rate or loss cost filing, have these fields been completed?: N/A
Have you completed the Forms Schedule Tab? ALL Life, Accident, and Health Rate and Form filing types require the Form
Schedule Tab to be completed. In addition, all Form, Annual Form Certification, and Refund Calculation filing types require the
Form Schedule Tab to be completed. The actual form must be attached to Form filing types only when filing: Medicare
Supplement, Long-Term Care Partnership, Stop Loss, P&C Summary Disclosure Forms, and Workers Compensation. It is not
necessary to submit the actual form for other lines of insurance. Thank you.: N/A
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
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Objection Letter
Objection Letter Status Pending Industry Response
Objection Letter Date 07/30/2014
Submitted Date 07/30/2014
Respond By Date 07/31/2014
Dear Sandra Lay,
Introduction:
This filing has been received, but before further action can be taken, please address the following:
Objection 1
Comments: I have no objections related to the forms in this filing. Please upload clean copies.
Conclusion:
Please submit the revised forms ASAP. Thanks for your assistance in completing this filing. Jimmy
Sincerely,
Jimmy Potts
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Objection Letter
Objection Letter Status Pending Industry Response
Objection Letter Date 07/30/2014
Submitted Date 07/30/2014
Respond By Date 07/31/2014
Dear Sandra Lay,
Introduction:
This filing has been received, but before further action can be taken, please address the following:
Objection 1
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Pursuant to our discussion, please provide a redline copy of the EOC with noted changes.
Conclusion:
Sincerely,
Jimmy Potts
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Objection Letter
Objection Letter Status Pending Industry Response
Objection Letter Date 07/25/2014
Submitted Date 07/25/2014
Respond By Date 07/29/2014
Dear Sandra Lay,
Introduction:
This filing has been received, but before further action can be taken, please address the following:
Objection 1
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Exclusion 8
10-3-1104(1)(f)(XIII) prohibits any unfair discrimination between individuals of the same class . . . in the amount of premium, policy
fees, or rates charged for any policy of sickness and accident insurance, in the benefits payable under such policy, in the terms or
conditions of the policy, or in any other manner.
Colorado Bulletin B-4.49 provides clarification to this law. The Divisions position is a carrier, based on sexual orientation, may not:
deny, exclude, or otherwise limit coverage for medically necessary services, as determined by an individuals medical provider, if the
item or service would be provided based on current standards of care to another individual without regard to their sexual orientation.
Conclusion:
Please revise the forms accordingly and resubmit by the noted due date. A REDLINED COPY NOTING ALL CHANGES MADE
TO THE SUBMITTED FORMS MUST BE INCLUDED WITH THE RESUBMISSION. THE REDLINED VERSION SHOULD BE
INCLUDED IN THE SUPPORTING DOCUMENTATION TAB. The forms review has not yet been completed and additional
objections may be noted in subsequent review and transmitted at that time.
Colorado Insurance Regulation 1-1-8 requires that every person shall provide a complete response in writing to any inquiry from the
Division of Insurance. This reply must be submitted by July 29, 2014, which is within 4 calendar days from the date of this
correspondence. If additional time is required to provide a complete response, including any documentation which is requested, a
request for an extension of time must be submitted by July 28, 2014.
The request for an extension of time must state the reason for such request and the number of additional days required to provide a
complete response. Requests for additional time will be granted for good cause shown and for a reasonable period at the discretion
of the Division. Requests for an extension of time must be submitted through SERFF.
Failure to provide a full or complete response, or to request an extension for a specified period, may result in the imposition of a $500
fine under Colorado Insurance Regulation 1-1-8 and applicable surcharge pursuant to 24-34-108(2), C.R.S. This surcharge will be
used to fund the development, implementation and maintenance of a consumer outreach and education program. Pursuant to
Section 6 of Colorado Insurance Regulation 1-1-8, and after notice and hearing, additional sanctions may be sought under 10-1-
215, C.R.S., and other fining and penalty provisions of Title 10.
Sincerely,
Staci Lewis
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Objection Letter
Objection Letter Status Pending Industry Response
Objection Letter Date 07/16/2014
Submitted Date 07/16/2014
Respond By Date 07/25/2014
Dear Sandra Lay,
Introduction:
This filing has been received, but before further action can be taken, please address the following:
Objection 1
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Summary of Benefits
The below objections may not apply to all SOBs. Please make any applicable changes to all affected SOBs.
Adult Dental Exclusions
Orthodontics - 10-16-104(1)(c)(II)(A) prohibits age limitations for medically necessary treatment of cleft lip, cleft palate. Any
limitations on orthodontia treatment must clearly state that it does not apply to treatment for such conditions.
Skilled Nursing Facility/Habilitation Services/Rehabilitation Services
Regulation 4-2-42 sets for the requirement of providing 100 days of inpatient confinement. Regulation 4-2-42 provides for up to 2
months of inpatient rehabilitation. These limits are separate and distinct for each level of service and cannot be combined into an
aggregated benefit. Please address the levels of service as separate benefits.
Partial Hospitalization Program/Intensive Outpatient Services
These services are subject to mental health parity. Are the cost-sharing arrangement comparable to how similar services, not related
to mental health/substance abuse being covered?
Therapy Services
Benefit Maximums - Outpatient therapy services has an aggregate benefit limit of 40 per therapy (speech, occupational and physical)
per person. A minimum limit of 20 visits per therapy must apply separately to rehabilitation and to habilitation. Per Regulation 4-2-42
these are separate EHBs.
Chiropractic Care Chiropractic Services is limited but the limitation does not apply to osteopaths. Based on CRS 10-16-107.7 and
Colorado Bulletin B-4.60 these service limitations should be consistent with services by other providers.
Pediatric Vision 45 CFR 147.126 prohibits the imposition of annual or lifetime dollar limits on EHBs. Out-of-network benefit for
pediatric vision examination cannot be limited by a dollar amount.
Prescription Drug Deductible - Pursuant to Public Law 111-148, Section 1302(c)(3) the "Out-of-Pocket Maximum" includes the
deductible, coinsurance and copayments. The policy form must clearly indicate that the prescription drug deductible applies to the
OOPM.
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Special Enrollment Notice - 10-16-102(17) defines dependent to include a partner in a civil union. Please include in this provision.
Objection 2
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Contact Us
This page should include the company name, address and phone number in addition to the website listed.
Objection 3
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Eligibility
Dependents - 10-16-102(17) defines an overage dependent as an unmarried child of any age who is medically certified as disabled
and dependent upon the parent. The bullet point that begins For unmarried dependents is too restrictive. Please revise to comply
with Colorado law.
Enrolling Dependent Children (newborn and adopted) - 45 CFR 155.420(d) sets forth special enrollment time frame requirements as
being 60 days for a QHP. 45 CFR 155.420(b)(ii)(2)(i) includes newborns and children placed for adoption within this requirement of
allowing 60 days to add such newly acquired dependents.
Objection 4
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Benefits/Coverage
Ambulance Services - 45 CFR 147.138(b) and 10-16-704(5.5) require that out-of-network emergency services be provided on the
same basis as in-network emergency services. This provision must clearly indicate that ambulance/air ambulance services are
provided without need of preauthorization and are not subject to company selection of the provider.
Clinical Trials - Minimum conditions for coverage in the first paragraph are stipulated in CRS 10-16-104 (20). Please revise policy
language to be no more restricted than the statute. Item 1 may not be more restrictive than permitted.
Benefits are limited to the following trials: The clinical trial or study must be approved under the September 19, 2000, Medicare
national coverage decision regarding clinical trials, as amended. [C.R.S. 10-16-104 (20)(II)]
Please disclose that prior to participation in a clinical trial or study, the covered person must sign a statement of consent indicating in
part that the coverage provided by an individual or group health benefit plan will be consistent with the coverage provided in the
covered person's health benefit plan, and whether out-of-network rates will apply.
Under Your plan is not required to provide benefits for the following services, please delete iii A service that is clearly inconsistent
with widely accepted and established standards of care for a particular diagnosis, as this is not a permitted exclusion as detailed in
CRS 10-16-104 (b)(20).
Home Health Care
Regulation 4-2-8 sets forth the coverage requirements for home health care. The requirement that you must essentially be confined
to the home is too restrictive.
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Preventive
Smoking Cessation - Regulation 4-2-42 provides that tobacco use screening and tobacco cessation benefits include intervention by
the primary care physician, not just prescription drug benefits.
Early Intervention Services - 10-16-104(1.3) sets forth the benefit for early intervention services. Bulletin B-4.51 sets forth the
requirement that there be 45 sessions, which is the actuarial equivalent of $6,361 which was the previously required dollar limit for
such services. Please explain how sessions calculated in 15 minute intervals achieves the actuarially equivalent of 45 sessions and
the prior dollar limit.
Objection 5
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Exclusions/Limitations
34. Orthodontic Care - 10-16-104(1)(c)(II)(A) prohibits age limitations for medically necessary treatment of cleft lip, cleft palate. Any
limitations on orthodontia treatment must clearly state that it does not apply to treatment for such conditions.
Prescription Drug
8. Drugs that do not need a prescription Certain OTC drugs are required to be covered as an EHB, i.e., aspirin therapy. Also the
booklet explicitly covers OTC drugs for smoking cessation, as a required EHB. This exclusion is overly broad and should be revised.
20. Onychomycosis Drugs- why are these excluded as it is a medical condition that is being treated.
Objection 6
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Appeals and Complaints
Regulation 4-2-21 Section 5.B sets forth the requirements for the description of the external review procedures. Please review and
revise your provision to include all required information set forth in paragraphs 2 and 3 of that section.
Binding Arbitration
10-3-1116 provides for a cause of action regarding claims benefits. Please modify the arbitration provision to accommodate the
rights under Colorado law.
Legal Actions
10-3-1116 provides for a cause of action regarding claims benefits. Please modify the legal actions provision to accommodate the
rights under Colorado law.
Objection 7
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Missing from Booklet If contained in the Booklet, please advise the pertinent provision.
10-16-104(5.5) sets forth the requirement for coverage for biologically based mental illnesses. Please include the benefit and a
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
definition of this illness.
10-16-104(17) requires coverage for a cervical cancer vaccine. Please add this benefit.
Regulation 4-2-8 requires that the definition of complication of pregnancy be included in each policy. Please include the definition
and the associated benefit.
10-16-104(1)(c)(III)(A) requires coverage for inherited enzymatic disorders caused by singe gene defects. We note that foods are
covered, however, the booklet must set forth the specific benefit.
Conclusion:
Please revise the forms accordingly and resubmit by the noted due date. A REDLINED COPY NOTING ALL CHANGES MADE
TO THE SUBMITTED FORMS MUST BE INCLUDED WITH THE RESUBMISSION. THE REDLINED VERSION SHOULD BE
INCLUDED IN THE SUPPORTING DOCUMENTATION TAB. The forms review has not yet been completed and additional
objections may be noted in subsequent review and transmitted at that time.
Colorado Insurance Regulation 1-1-8 requires that every person shall provide a complete response in writing to any inquiry from the
Division of Insurance. This reply must be submitted by July 25, 2014, which is within 9 calendar days from the date of this
correspondence. If additional time is required to provide a complete response, including any documentation which is requested, a
request for an extension of time must be submitted by July 24, 2014.
The request for an extension of time must state the reason for such request and the number of additional days required to provide a
complete response. Requests for additional time will be granted for good cause shown and for a reasonable period at the discretion
of the Division. Requests for an extension of time must be submitted through SERFF.
Failure to provide a full or complete response, or to request an extension for a specified period, may result in the imposition of a $500
fine under Colorado Insurance Regulation 1-1-8 and applicable surcharge pursuant to 24-34-108(2), C.R.S. This surcharge will be
used to fund the development, implementation and maintenance of a consumer outreach and education program. Pursuant to
Section 6 of Colorado Insurance Regulation 1-1-8, and after notice and hearing, additional sanctions may be sought under 10-1-
215, C.R.S., and other fining and penalty provisions of Title 10.
Sincerely,
Jimmy Potts
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
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Response Letter
Response Letter Status Submitted to State
Response Letter Date 07/27/2014
Submitted Date 07/27/2014
Dear Tara Smith,
Introduction:
Below is our comment to Objection 1.
Response 1
Comments:
Exclusion 8 is an exclusion for complications of non-covered services.
We dont believe it has any application to the transgender services / gender identity discrimination issues of the statute or bulletin. As
you know, we removed the exclusions regarding gender reassignment surgery and added transgender surgery into the covered
benefits. In short, for the fully-insured plan at issue, medically necessary gender reassignment surgery is a covered benefit and thus
any complication of an authorized surgery would not fall within this exclusion.
Related Objection 1
Applies To:
- Evidence of Coverage for PPO Off Exchange Plans with bracket variables , COSGPPO (Form)
Comments: Exclusion 8
10-3-1104(1)(f)(XIII) prohibits any unfair discrimination between individuals of the same class . . . in the amount of premium, policy
fees, or rates charged for any policy of sickness and accident insurance, in the benefits payable under such policy, in the terms or
conditions of the policy, or in any other manner.
Colorado Bulletin B-4.49 provides clarification to this law. The Divisions position is a carrier, based on sexual orientation, may not:
deny, exclude, or otherwise limit coverage for medically necessary services, as determined by an individuals medical provider, if the
item or service would be provided based on current standards of care to another individual without regard to their sexual orientation.
Changed Items:
No Supporting Documents changed.
No Form Schedule items changed.
No Rate/Rule Schedule items changed.
Conclusion:
Sincerely,
Michael Coe
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
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P
M
Note To Reviewer
Created By:
Michael Coe on 07/31/2014 05:59 PM
Last Edited By:
Michael Coe
Submitted On:
07/31/2014 05:59 PM
Subject:
HMO CO Response
Comments:
Yes, both HMO final masters were recently uploaded.
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
Note To Filer
Created By:
Jimmy Potts on 07/31/2014 02:14 PM
Last Edited By:
Jimmy Potts
Submitted On:
07/31/2014 02:14 PM
Subject:
HMO CO
Comments:
Mike, how soon will you be putting clean documents up on HMO Colorado?
SERFF Tracking #: ANTP-129563088 State Tracking #: 288387 Company Tracking #: CO PPO OFF EXCHANGE 2015
State: Colorado Filing Company: Rocky Mountain Hospital And Medical Service,
Inc., D.B.A. Anthem Blue Cross And Blue Shield
TOI/Sub-TOI: H16G Group Health - Major Medical/H16G.003A Small Group Only - PPO
Product Name: CO PPO SG Off-Exchange 2015
Project Name/Number: /
PDF Pipeline for SERFF Tracking Number ANTP-129563088 Generated 08/04/2014 06:06 PM
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[Repository ID/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HIOS ID]_20150101]


Certificate
(Referred to as Booklet in the following pages)

Anthem
[Anthem Silver Blue Priority PPO 2500/20%/6000 Plus]
[Anthem Gold PPO 1000/20%/3500]
[Anthem Gold PPO 2000/40%/4000]
[Anthem Silver PPO 2000/50%/6350]
[Anthem Gold PPO 750/20%/4500]
[Anthem Gold PPO 1500/20%/4000]
[Anthem Gold PPO 500/20%/4500]
[Anthem Silver PPO 2000/30%/4500 Plus w/Dental]
[Anthem Silver PPO 2000/30%/4500 Plus]
[Anthem Silver PPO 3000/30%/4000 Plus]
[Anthem Bronze PPO 5850/30%/6600 Plus]
[Anthem Gold PPO 500/20%/3000 Plus w/Dental]
[Anthem Gold PPO 500/20%/3000 Plus]
[Anthem Silver PPO 1500/30%/4250 Plus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem Silver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 Plus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 Plus w/HSA]
[Anthem Silver PPO 2500/20%/4500 w/HSA]
[Anthem Gold PPO 2000/20%/5000 Plus w/HRA]
[Anthem Gold PPO 4000/20%/5000 Plus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 Plus]

January 1, 2015

[Repository ID/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HIOS ID]_20150101]






Si necesita ayuda en espaol para entender este documento, puede solicitarla sin costo adicional,
llamando al nmero de servicio al cliente.

If you need Spanish-language assistance to understand this document, you may request it at no
additional cost by calling Customer Service at the number on the back of your Identification Card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products are
underwritten by HMO Colorado, Inc. Life and disability products underwritten by Anthem Life Insurance Company. Independent
licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association
1
Section 1. Schedule of Benefits (Who Pays What)

In this section you will find an outline of the benefits included in your Plan and a summary of any Deductibles,
Coinsurance, and Copayments that you must pay. Also listed are any Benefit Period Maximums or limits that apply.
Please read the "Benefits/Coverage (What is Covered)"section for more details on the Plans Covered Services. Read
the Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for details on Excluded Services.

All Covered Services are subject to the conditions, Exclusions, limitations, and terms of this Booklet including any
endorsements, amendments, or riders.

To get the highest benefits at the lowest out-of-pocket cost, you must get Covered Services from an In-Network
Provider. Benefits for Covered Services are based on the Maximum Allowed Amount, which is the most the Plan will
allow for a Covered Service. When you use an Out-of-Network Provider you may have to pay the difference between the
Out-of-Network Providers billed charge and the Maximum Allowed Amount in addition to any Coinsurance, Copayments,
Deductibles, and non-covered charges. This amount can be substantial. Please read the Claims Procedure (How to File
a Claim) section for more details.

Deductibles, Coinsurance, and Benefit Period Maximums are calculated based upon the Maximum Allowed Amount, not
the Providers billed charges.

Essential Health Benefits provided within this Booklet are not subject to lifetime or annual dollar maximums.
Certain non-essential health benefits, however, are subject to either a lifetime and/or dollar maximum.

Essential Health Benefits are defined by federal law and refer to benefits in at least the following categories:

Ambulatory patient services,
Emergency services,
Hospitalization,
Maternity and newborn care,
Mental health and substance use disorder services, including behavioral health treatment,
Prescription drugs,
Rehabilitative and Habilitative Services and devices,
Laboratory services,
Preventive and wellness services, and
Chronic disease management and pediatric services, including oral and vision care.

Such benefits shall be consistent with those set forth under the Patient Protection and Affordable Care Act of
2010 and any regulations issued pursuant thereto.

Benefit Period [Calendar][Plan] Year

Dependent Age Limit To the end of the month in which the child attains age 26.

Please see the Eligibility section for further details.

Deductible In-Network Out-of-Network
Per Member [$500 to 5,900] [$1,250 to 14,750]
Per Family
{Aggregate: [(All other Members combined)]
[$1,500 to 11,800] [$2,500 to 29,500]
The In-Network and Out-of-Network Deductibles are separate and cannot be combined.

{Option for Non-Embedded plans of HSA/HRA: [If you, the Subscriber, are the only person covered by this Plan,
only the per Member amounts applies to you. If you also cover Dependents (other family members) under this Plan,
only the per Family amount applies.)]


2
Deductible In-Network Out-of-Network
When the Deductible applies, you must pay it before benefits begin. See the sections below to find out when the
Deductible applies.

{Deductible First for HRA plans: [Note: To meet the In-Network Deductible, your Plan will work as follows:

Step 1 - Upfront In-Network Deductible Members must pay a certain part of the In-Network Deductible
listed above, $[1,000 to 2,000] per Member / $[2,000 to 4,000] per Family, before using their HRA account.
HRA funds cannot be used for this part of the Deductible (known as the upfront Deductible). Amounts paid
toward the upfront Deductible will apply toward the annual In-Network Deductible.

Step 2 - Health Reimbursement Account After meeting the upfront Deductible, Members can use money in
their HRA to help meet the rest of the annual In-Network Deductible.

Step 3 - Traditional Health Coverage - Once the Annual In-Network Deductible has been met, coverage
under this Plan begins.]

Copayments and Coinsurance are separate from and do not apply to the Deductible.

{Deductible First for HRA plans: [HRA funds cannot be used for services listed under Dental Services for Members
age 19 and Older or for services listed under Vision Services for Members age 19 and Older.]


Coinsurance In-Network Out-of-Network
Plan Pays [50 to 100%] [50 to 90]%
Member Pays [0 to 50%] [10 to 50]%
Reminder: Your Coinsurance will be based on the Maximum Allowed Amount. If you use an Out-of-Network Provider,
you may have to pay Coinsurance plus the difference between the Out-of-Network Providers billed charge and the
Maximum Allowed Amount.

Note: The Coinsurance listed above may not apply to all benefits, and some benefits may have a different Coinsurance.
Please see the rest of this Schedule for details.


Out-of-Pocket Limit In-Network Out-of-Network
Per Member $[3,000 to 6,600]

$[6,000 to 19,800]
Per Family
{Aggregate: [(All other Members combined)]
$[6,000 to 13,200] $[18,000 to 39,600]
{Option for Non-Embedded plans of HSA/HRA: [If you, the Subscriber, are the only person covered by this Plan,
only the per Member amount applies to you. If you also cover Dependents (other family members) under this Plan,
only the per Family amount applies.)]

The Out-of-Pocket Limit includes all Deductibles, [[and] Coinsurance], [and Copayments] you pay during a Benefit
Period unless otherwise indicated below. It does not include charges over the Maximum Allowed Amount or amounts
you pay for non-Covered Services.

The Out-of-Pocket Limit does not include amounts you pay for the following benefits:

{Option for embedded adult dental benefit: [Services listed under Dental Services for Members Age 19 and
Older
{Option for embedded adult vision benefit: [Services listed under Vision Services for Members Age 19 and
3
Out-of-Pocket Limit In-Network Out-of-Network
Older]
Out-of-Network Human Organ and Tissue Transplant services.

Once the Out-of- Pocket Limit is satisfied, you will not have to pay additional Deductibles, [[or] Coinsurance], or
Copayments] for the rest of the Benefit Period, except for the services listed above.

The In-Network and Out-of-Network Out-of-Pocket Limits are separate and do not apply toward each other.

Important Notice about Your Cost Shares

In certain cases, if we pay a Provider amounts that are your responsibility, such as Deductibles, Copayments or
Coinsurance, we may collect such amounts directly from you. You agree that we have the right to collect such amounts
from you.

The tables below outline the Plans Covered Services and the cost share(s) you must pay. In many spots you will see the
statement, Benefits are based on the setting in which Covered Services are received. In these cases you should
determine where you will receive the service (i.e., in a doctors office, at an outpatient hospital facility, etc.) and look up
that location to find out which cost share will apply. For example, you might get physical therapy in a doctors office, an
outpatient hospital facility, or during an inpatient hospital stay. For services in the office, look up Office Visits. For
services in the outpatient department of a hospital, look up Outpatient Facility Services. For services during an inpatient
stay, look up Inpatient Services.

Benefits In-Network Out-of-Network
Acupuncture/Nerve Pathway Therapy See Therapy Services.

Allergy Services Benefits are based on the setting in which
Covered Services are received.

Ambulance Services (Air and Water) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an In-Network Provider.

Important Note: Air ambulance services for non-Emergency Hospital to Hospital transfers must be approved through
precertification. Please see How to Access Your Services and Obtain Approval of Benefits for details.


Ambulance Services (Ground) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an In-Network Provider.

Important Note: All scheduled ground ambulance services for non-Emergency transfers, except transfers from one
acute Facility to another, must be approved through precertification. Please see How to Access Your Services and
Obtain Approval of Benefits for details.

Autism Services


Applied Behavioral Analysis Services Benefit Maximum
Benefits are based on the setting in which
Covered Services are received.

The following annual Benefit Period maximums
are effective for Applied Behavior Analysis
services for In- and Out-of-Network services
4
Benefits In-Network Out-of-Network
combined:
From birth to age eight (up to Members ninth
birthday): 550 sessions of 25 minutes for
each session, however we may exceed this
limit if required by state law
Age nine to age eighteen (up to Members
nineteenth birthday): 185 sessions of 25
minutes for each session, however we may
exceed this limit if required by state law
The limits for physical, occupational, and speech therapy will not apply to children between age 3 and 6 with Autism
Spectrum Disorders, if part of a Members Autism Treatment Plan, and determined Medically Necessary by Us.

When you get physical, occupational or speech therapy which also is considered by Us as Applied Behavioral Analysis
for the treatment of autism, the Applied Behavioral Analysis visit limit will apply instead of the Therapy Services limits
listed below.

Behavioral Health Services See Mental Health, Alcohol and Substance
Abuse Services.

Cardiac Rehabilitation See Therapy Services.

Chemotherapy See Therapy Services.

Clinical Trials Benefits are based on the setting in which
Covered Services are received.

Dental Services For Members Through Age 18

Note: To get the In-Network benefit, you must use a participating dental Provider. If you need help finding a
participating dental Provider, please call us at the number on the back of your ID card.
{Embedded Pediatric/Adult Dental plan: [Each Member must pay a Deductible of $50 per Benefit Period for the
dental services below. This Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan.]
Diagnostic and Preventive Services {Embedded Pediatric
Dental: [Deductible
waived, subject to]
10% Coinsurance
30% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Basic Restorative Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Endodontic Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible}
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Periodontal Services Not Covered Not Covered
Oral Surgery Services 50% Coinsurance
{Embedded Pediatric
50% Coinsurance
{Embedded
5
Benefits In-Network Out-of-Network
Dental: [after
Deductible]
Pediatric Dental:
[after Deductible]
Major Restorative Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Prosthodontic Services Not Covered Not Covered
Dentally Necessary Orthodontic Care 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]

{Embedded Adult Dental:
[Dental Services For Members Age 19 and Older

Note: To get the In-Network benefit, you must use a participating dental Provider. If you need help finding a
participating dental Provider, please call us at the number on the back of your ID card.
Each Member must pay a Deductible of $50 per Benefit Period for the dental services below. This Deductible is
separate and does not apply toward any other Deductible for Covered Services in this Plan.
Diagnostic and Preventive Services No Copayment,
Deductible, or
Coinsurance
50% Coinsurance
Basic Restorative Services 20% Coinsurance 60% Coinsurance
Endodontic Services 50% Coinsurance 75% Coinsurance
Periodontal Services 50% Coinsurance 75% Coinsurance
Oral Surgery Services 50% Coinsurance 75% Coinsurance
Major Restorative Services 50% Coinsurance 75% Coinsurance
Prosthodontic Services 50% Coinsurance 75% Coinsurance
Orthodontic Care Not covered Not covered
Dental Services for Members Age 19 and Older Benefit Maximum $1,000 per Benefit Period
In- and Out-of-Network combined
Orthodontic Care for members age 19 and older may be covered for certain medically necessary conditions. See the
section Dental Services (All Members / All Ages) for more information.]

Dental Services (All Members / All Ages) Benefits are based on the setting in which
Covered Services are received.

Diabetes Equipment, Education, and Supplies Benefits are based on the setting in which
Covered Services are received.
Screenings for gestational diabetes are covered
under Preventive Care.

6
Benefits In-Network Out-of-Network
Diagnostic Services

Benefits are based on the setting in which
Covered Services are received.

Dialysis See Therapy Services.

Durable Medical Equipment (DME) and Medical Devices,
Orthotics, Prosthetics, Medical and Surgical Supplies (Received
from a Supplier)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible

The cost-shares listed above only apply when you get the equipment or supplies from a third-party supplier. If you
receive the equipment or supplies as part of an office or outpatient visit, or during a Hospital stay, benefits will be based
on the setting in which the covered equipment or supplies are received.
Hearing Aid Benefit Maximum for Members under 18 years of age One hearing aid every 5 years
In- and Out-of-Network combined

Emergency Room Services
Emergency Room
Emergency Room Facility Charge

[$[200 to 250] Copayment] [per visit] [plus] [[0 to
50]% Coinsurance] [after Deductible]
[Copayment waived if admitted]
Emergency Room Doctor Charge [0 to 50]% Coinsurance after Deductible
Other Facility Charges (including diagnostic x-ray and lab
services, medical supplies)
[0 to 50]% Coinsurance after Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans) [0 to 50]% Coinsurance after Deductible
For Emergency services from an Out-of-Network Provider you do not need to pay any more than you would have paid
for services from an In-Network Provider.

Home Care
Home Care Visits [$[20 to 60] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Home Dialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Infusion Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Specialty Prescription Drugs [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Home Care Services / Supplies [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Care Benefit Maximum 28 hours of visits per week
7
Benefits In-Network Out-of-Network
In- and Out-of-Network combined
The limit does not apply to Home Infusion
Therapy or Home Dialysis.

Home Infusion Therapy See Home Care.

Hospice Care
Home Care
Respite Hospital Stays

[No Copayment or
Coinsurance after
Deductible] [After
Deductible no
Coinsurance]
[10 to 50]%
Coinsurance after
Deductible

Human Organ and Tissue Transplant (Bone Marrow / Stem Cell)
Services
Please see the separate summary later in this
section.

Infertility Services See Maternity and Reproductive Health
Services.

Inpatient Services
Facility Room & Board Charge:
Hospital / Acute Care Facility

[$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Inpatient Rehabilitation Services Benefit Maximum 2 months per Benefit Period In- and Out-of-
Network combined
Skilled Nursing Facility [$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility / Habilitation Services / Outpatient Day
Rehabilitation Program Benefit Maximum
100 days per Benefit Period In- and Out-of-
Network combined
Other Facility Services / Supplies (including diagnostic lab/x-ray,
medical supplies, therapies, anesthesia)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Addition if Copayment cost share: [Hospital Transfers: If you are transferred between Facilities, only one
Copayment will apply. You will not have to pay separate Copayments per Facility.

Hospital Readmissions: If you are readmitted to the Hospital within 72 hours of your discharge for the same medical
diagnosis, you will not have to pay an additional Copayment upon readmission.]
Doctor Services for:
General Medical Care / Evaluation and Management (E&M) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Surgery [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
8
Benefits In-Network Out-of-Network
Deductible

Manipulation Therapy See Therapy Services.

Maternity and Reproductive Health Services
Maternity Visits (Global fee for the ObGyns prenatal, postnatal,
and delivery services)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Inpatient Services (Delivery) See Inpatient Services.
Newborn / Maternity Stays: If the newborn needs services other than routine nursery care or stays in the Hospital
after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission.
Infertility

Benefits are based on the setting in which
Covered Services are received.
Infertility Benefit Maximum Unlimited

Massage Therapy See Therapy Services.

Mental Health, Biologically Based Mental Illness, Alcohol and
Substance Abuse Services

Inpatient Facility Services

[$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Residential Treatment Center Services [$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] after
Deductible]
[50-90]%
Coinsurance after
Deductible
Inpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Outpatient Facility Services

[$250 Copayment per
visit] [plus][[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Outpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Partial Hospitalization Program / Intensive Outpatient Services [$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Office Visits [$[15 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Mental Health, Biologically Based Mental Illness, Alcohol and Substance Abuse Services will be covered as required by
9
Benefits In-Network Out-of-Network
state and federal law. Please see Mental Health Parity and Addiction Equity Act in the Additional Federal Notices
section for details.

Occupational Therapy See Therapy Services.

Office Visits


Primary Care Physician / Provider (PCP) [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]
Retail Health Clinic Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Online Care Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Counseling Incudes
Family Planning and
Nutritional Counseling
(Other than Eating
Disorders)
[$[10 to 60] Copayment
per visit] [[for the first 3
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Nutritional Counseling for
Eating Disorders
[$[10 to 60] Copayment
per visit] [[for the first [3]
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Allergy Testing [$[10 to 60] Copayment
per visit] [[0 to
50]%Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / Injections (other than allergy serum) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
10
Benefits In-Network Out-of-Network
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests (non-preventive; including hearing and EKG) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy Services:
- Acupuncture/Nerve Pathway Therapy, Manipulation
Therapy & Massage Therapy
[$[20 to 30] Copayment
per visit] [for the first 3
visits, then [0 to 50]%
Coinsurance] [after
Deductible]
Not Covered
- Physical, Speech, & Occupational Therapy [$[20 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Dialysis / Hemodialysis

[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Radiation / Chemotherapy / Non-Preventive Infusion &
Injection
[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Cardiac Rehabilitation & Pulmonary Therapy [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
See Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
11
Benefits In-Network Out-of-Network

{Plans with copay for first 3 visits: [Important Note on Office Visit Copayments: Several services listed above
have a Copayment for the first three visits. This Copayment applies to any combination of services for the first three
visits during the Benefit Period. Starting with the fourth visit, you pay Deductible and Coinsurance, instead of a
Copayment. The three Copayments will not apply to Preventive Care, Maternity Services, or Urgent Care visits. You
will not have to pay any Deductible or Coinsurance when you pay the Copayment.]

Orthotics See Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Outpatient Facility Services
Facility Surgery Charge

[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges (including diagnostic x-ray and
lab services, medical supplies)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Doctor Surgery Charges [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Doctor Charges (including Anesthesiologist, Pathologist,
Radiologist, Surgical Assistant)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Facility Charges (for procedure rooms or other ancillary
services)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests: Hearing, EKG, etc. (Non-Preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
12
Benefits In-Network Out-of-Network
Advanced Diagnostic Imaging (including MRIs, CAT scans) [$250 Copayment [per
service] [per visit] [plus]
[[0 to 50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy:
- Manipulation Therapy

[0 to 50]% Coinsurance
after Deductible
Not Covered
- Physical, Speech, & Occupational Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Radiation / Chemotherapy / Non-Preventive Infusion &
Injection
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Dialysis / Hemodialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Cardiac Rehabilitation & Pulmonary Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
See Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in an Outpatient Facility [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Site-of-Service:
[Outpatient Freestanding Facility
Facility Surgery Charge / Ambulatory Surgery Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges/ Ambulatory Surgical Center
(including diagnostic x-ray and lab services, medical supplies)
[0 to 50]% Coinsurance [10 to 50]%
Coinsurance after
Deductible
Doctor Charges in Ambulatory Surgical Center / Freestanding
Radiology Center (including Anesthesiologist, Pathologist,
Radiologist, Surgery, Surgical Assistant)
No Copayment,
Deductible, or
Coinsurance

[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray / Freestanding Radiology Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans)/
Freestanding Radiology Center
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible]]

Physical Therapy See Therapy Services.

Preventive Care


No Copayment,
Deductible, or
Coinsurance
[10 to 50]%
Coinsurance after
Deductible
Preventive care from an Out-of-Network Provider is not subject to the Maximum Allowed Amount.
13
Benefits In-Network Out-of-Network

Prosthetics See Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Pulmonary Therapy See Therapy Services.

Radiation Therapy See Therapy Services.

Rehabilitation Services Benefits are based on the setting in which
Covered Services are received.

Respiratory Therapy See Therapy Services.

Skilled Nursing Facility See Inpatient Services.

Speech Therapy See Therapy Services.

Surgery Benefits are based on the setting in which
Covered Services are received.

Telemedicine
Primary Care Physician / Provider (PCP) $[20 to 60] Copayment
per visit [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) $[20 to 100] Copayment
per visit] [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]

Temporomandibular and Craniomandibular Joint Treatment Benefits are based on the setting in which
Covered Services are received.

14
Benefits In-Network Out-of-Network
Therapy Services Benefits are based on the setting in which
Covered Services are received.
Benefit Maximum(s): Benefit Maximum(s) are for In- and Out-of-
Network visits combined, and for office and
outpatient visits combined.
Physical & Occupational Therapy 20 visits each per Benefit Period for
rehabilitative services
20 visits each per Benefit Period for habilitative
services
Speech Therapy 20 visits per Benefit Period for rehabilitative
services
20 visits per Benefit Period for habilitative
services
For cleft palate or cleft lip conditions, Medically
necessary speech therapy is not limited, but
those visits lower the number of speech therapy
visits available to treat other problems.
Acupuncture/Nerve Pathway Therapy, Manipulation Therapy &
Massage Therapy
20 visits per Benefit
Period
Limit does not apply to
osteopathic therapy
Not covered
Cardiac Rehabilitation Unlimited
Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice
benefit.

Transgender Services Benefits are based on the setting in which
Covered Services are received.

Transplant Services See Human Organ and Tissue Transplant
(Bone Marrow / Stem Cell) Services.

Urgent Care Services (Office Visits)
Urgent Care Office Visit Charge [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Testing [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / Injections (other than allergy serum) [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
15
Benefits In-Network Out-of-Network
Other Charges (e.g., diagnostic x-ray and lab services, medical
supplies)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans)

[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75]
Copayment per visit]
[then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]%
Coinsurance after
Deductible
[10 to 50]%
Coinsurance after
Deductible
If you get urgent care at a Hospital or other outpatient Facility, please refer to Outpatient Facility Services for details
on what you will pay.

{Pediatric exam only: [Vision Services For Members Through Age 18

Note: To get the In-Network benefit, you must use an In-Network vision Provider. If you need help finding an In-
Network vision Provider, please call us at the number on the back of your ID card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
Deductible]

{Pediatric vision:
[Vision Services For Members Through Age 18

Note: To get the In-Network benefit, you must use an In-Network vision Provider. If you need help finding an In-
Network vision Provider, please call us at the number on the back of your ID card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
Deductible
Standard Plastic Lenses
Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Progressive $20 Copayment Covered up to $40
Note: In-Network, lenses include factory scratch coating and UV coating at no additional cost. Polycarbonate and
photocromic lenses are also covered at no extra cost In Network
Frames $0 Copayment, Covered
up to $130
Covered up to $45
Limited to one set of frames from the Anthem formulary every other Benefit Period.
Contact Lenses
Limited to one set of contact lenses from the Anthem formulary every other Benefit Period. Available only if the
eyeglass lenses benefit is not used.
16
Benefits In-Network Out-of-Network
Elective Contact Lenses (Conventional or Disposable) $0 Copayment, Covered
up to $80
Covered up to $60
Non-Elective Contact Lenses No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

{Adult vision:
[Vision Services For Members Age 19 and Older
Note: To get the In-Network benefit, you must use an In-Network vision Provider. If y Provider, please call us at the
number on the back of your ID card. ou need help finding an In-Network vision
Routine Eye Exam

Limited to one exam per Benefit Period
$20 Copayment Covered up to $30
Standard Plastic Lenses

Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Photochromic $20 Copayment (in
addition to lens
Copayment)
Not covered
Note: In-Network, lenses include factory scratch coating at no additional cost.
Frames

Limited to one set of frames every other Benefit Period.
Covered up to $130 Covered up to $45
Contact Lenses

Limited to one set of contact lenses every other Benefit Period. Available only if the eyeglass lenses benefit is not
used.
Elective Contact Lenses (Conventional or Disposable) Covered up to $80 Covered up to $60
Non-Elective Contact Lenses


No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

Vision Services (All Members / All Ages)
(For medical and surgical treatment of injuries and/or diseases of
the eye)

Certain vision screenings required by Federal law are covered
under the "Preventive Care" benefit.
Benefits are based on the setting in which
Covered Services are received.


17
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services


Please call our Transplant Department as soon you think you may need a transplant to talk about your benefit
options. You must do this before you have an evaluation and/or work-up for a transplant. To get the most
benefits under your Plan, you must get certain human organ and tissue transplant services from a Network
Transplant Provider. Even if a Hospital is an In-Network Provider for other services, it may not be an In-Network
Transplant Provider for certain transplant services. Please call us to find out which Hospitals are In-Network Transplant
Providers. (When calling Customer Service, ask for the Transplant Case Manager for further details.)

The requirements described below do not apply to the following:

Cornea and kidney transplants, which are covered as any other surgery; and
Any Covered Services related to a Covered Transplant Procedure, that you get before or after the Transplant
Benefit Period. Please note that the initial evaluation, any added tests to determine your eligibility as a candidate
for a transplant by your Provider, and the harvest and storage of bone marrow/stem cells is included in the Covered
Transplant Procedure benefit regardless of the date of service.

Benefits for Covered Services that are not part of the Human Organ and Tissue Transplant benefit will be based on the
setting in which Covered Services are received. Please see the Benefits/Coverage (What is Covered) section for
additional details.

Transplant Benefit Period In-Network Transplant
Provider

Out-of-Network Transplant
Provider
Starts one day before a
Covered Transplant
Procedure and lasts for the
applicable case rate / global
time period. The number of
days will vary depending on
the type of transplant
received and the In-Network
Transplant Provider
agreement. Call the Case
Manager for specific In-
Network Transplant
Provider information for
services received at or
coordinated by an In-
Network Transplant
Provider Facility.
Starts one day before a
Covered Transplant
Procedure and continues to
the date of discharge at an
Out-of- Network Transplant
Provider Facility.

Covered Transplant Procedure during the
Transplant Benefit Period
In-Network Transplant
Provider Facility

Out-of-Network Transplant
Provider Facility

Precertification required


During the Transplant
Benefit Period, [$500
Copayment per admission]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible].

Before and after the
Transplant Benefit Period,
Covered Services will be
covered as Inpatient
Services, Outpatient
Services, Home Visits, or
Office Visits depending
where the service is
During the Transplant Benefit
Period, [10 to 50]%
Coinsurance after Deductible.

During the Transplant Benefit
Period, Covered Transplant
Procedure charges at an Out-
of-Network Transplant
Provider Facility will NOT
apply to your Out-of-Pocket
Limit.

If the Provider is also an In-
Network Provider for this Plan
(for services other than
18
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services

performed. Covered Transplant
Procedures), then you will not
have to pay for Covered
Transplant Procedure charges
over the Maximum Allowed
Amount.

If the Provider is an Out-of-
Network Provider for this
Plan, you will have to pay for
Covered Transplant
Procedure charges over the
Maximum Allowed Amount.

Prior to and after the
Transplant Benefit Period,
Covered Services will be
covered as Inpatient Services,
Outpatient Services, Home
Visits, or Office Visits
depending where the service
is performed.

Covered Transplant Procedure during the
Transplant Benefit Period
In-Network Transplant
Provider Professional and
Ancillary (non-Hospital)
Providers

Out-of-Network Transplant
Provider Professional and
Ancillary (non-Hospital)
Providers
[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Transportation and Lodging

[0 to 50]% Coinsurance
after Deductible
[10 to 50]% Coinsurance after
Deductible

Transportation and Lodging Limit

Covered, as approved by us, up to $10,000 per transplant.
In- and Out-of-Network combined

Unrelated donor searches from an authorized,
licensed registry for bone marrow/stem cell
transplants for a Covered Transplant Procedure

[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Donor Search Limit Covered, as approved by us, up to $30,000 per transplant.
In- and Out-of-Network combined

Live Donor Health Services [0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

19
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services

Donor Health Service Limit Donor benefits are limited to benefits not available to the
donor from any other source. Medically Necessary charges
for getting an organ from a live donor are covered up to our
Maximum Allowed Amount, including complications from the
donor procedure for up to six weeks from the date of
procurement.

Prescription Drug Retail Pharmacy and Home
Delivery (Mail Order) Benefits
In-Network Out-of-Network
Each Prescription Drug will be subject to a cost share (e.g., Copayment/Coinsurance) as described below. If your
Prescription Order includes more than one Prescription Drug, a separate cost share will apply to each covered Drug.
You will be required to pay the lesser of your scheduled cost share or the Maximum Allowed Amount.
{Prescription deductible:
[Prescription Drug Deductible
Does not apply to Tier 1
Per Member $[250 to 500] In- and Out-of-Network combined
Per Family $[500 to 1,000] In- and Out-of-Network combined
Note: The Prescription Drug Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan. You must pay the Deductible before you pay any Copayments / Coinsurance listed below. The
Prescription Drug Deductible is included in the Out-of-Pocket Limit.]
Day Supply Limitations Prescription Drugs will be subject to various day supply and quantity limits. Certain
Prescription Drugs may have a lower day-supply limit than the amount shown below due to other Plan requirements
such as prior authorization, quantity limits, and/or age limits and utilization guidelines.
Retail Pharmacy (In-Network and Out-of-Network) 30 days
Home Delivery (Mail Order) Pharmacy 90 days
Specialty Pharmacy (In-Network and Out-of-
Network)
30 days*
*See additional information in the Specialty Drug
Copayments / Coinsurance section below.
Retail Pharmacy Copayments / Coinsurance:

Tier 1 Prescription Drugs

[$15 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 2 Prescription Drugs [$35 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance][ after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 3 Prescription Drugs

[$70 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
[10 to 50]% Coinsurance
[after Deductible]
20
Prescription Drug Retail Pharmacy and Home
Delivery (Mail Order) Benefits
In-Network Out-of-Network
Home Delivery Pharmacy Copayments /
Coinsurance:


Tier 1 Prescription Drugs

[$38 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered

Tier 2 Prescription Drugs [$88 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 3 Prescription Drugs [$175 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
Not covered
Specialty Drug Copayments / Coinsurance:
Please note that certain Specialty Drugs are only available from a Specialty Pharmacy and you will not be able to get
them at a Retail Pharmacy or through the Home Delivery (Mail Order) Pharmacy. Please see Specialty Pharmacy in
the section Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy for further details. When
you get Specialty Drugs from a Specialty Pharmacy, you will have to pay the same Copayments/Coinsurance you pay
for a 30-day supply at a Retail Pharmacy.

{Preferred Generic / Brand Penalty:
[Note: Prescription Drugs will always be dispensed as ordered by your Doctor. You may ask for, or your Doctor may
order, the Brand Name Drug. However, if a Generic Drug is available, you will have to pay the difference in the cost
between the Generic and Brand Name Drug, as well as your Tier 1 Copayment. By law, Generic and Brand Name
Drugs must meet the same standards for safety, strength, and effectiveness. Using generics generally saves money,
yet gives the same quality. We reserve the right, in our sole discretion, to remove certain higher cost Generic Drugs
from this policy.]
{Regular PPO:
[Note: No Copayment, Deductible, or Coinsurance applies to certain diabetic and asthmatic supplies when you get
them from an In-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical Equipment
if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable Prescription
Drug Copayment / Coinsurance.]
{HSA plans:
[Note: Certain diabetic and asthmatic supplies are covered subject to applicable Prescription Drug Copayments when
you get them from an In-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical
Equipment if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable
Prescription Drug Copayment / Coinsurance.]


21
Federal Patient Protection and Affordable Care Act Notices
Choice of Primary Care Physician / Provider
We generally allow the designation of a Primary Care Physician / Provider (PCP). You have the right to designate any
PCP who participates in our network and who is available to accept you or your family members. For information on how
to select a PCP, and for a list of PCPs, contact the telephone number on the back of your Identification Card or refer to
our website, www.anthem.com. For children, you may designate a pediatrician as the PCP.
Access to Obstetrical and Gynecological (ObGyn) Care
You do not need referral or authorization from us or from any other person (including a PCP) in order to obtain access to
obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or
gynecology. The health care professional, however, may be required to comply with certain procedures, including
obtaining prior authorization for certain services or following a pre-approved treatment plan. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of your
Identification Card or refer to our website, www.anthem.com.
22
Additional Federal Notices
Statement of Rights under the Newborns and Mothers Health Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the
mothers or newborns attending Provider, after consulting with the mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that
a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
Statement of Rights under the Womens Cancer Rights Act of 1998
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Womens Health and
Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in
a manner determined in consultation with the attending Physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other medical and surgical
benefits provided under this Plan. (See the Schedule of Benefits (Who Pays What) for details.) If you would like more
information on WHCRA benefits, call us at the number on the back of your Identification Card.
Coverage for a Child Due to a Qualified Medical Support Order (QMCSO)
If you or your spouse are required, due to a QMCSO, to provide coverage for your child(ren), you may ask the Group to
provide you, without charge, a written statement outlining the procedures for getting coverage for such child(ren).
Mental Health Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate treatment limitations
(day or visit limits) on mental health and substance abuse benefits with day or visit limits on medical and surgical benefits.
In general, group health plans offering mental health and substance abuse benefits cannot set day/visit limits on mental
health or substance abuse benefits that are lower than any such day or visit limits for medical and surgical benefits. A plan
that does not impose day or visit limits on medical and surgical benefits may not impose such day or visit limits on mental
health and substance abuse benefits offered under the plan. Also, the plan may not impose Deductibles, Copayment,
Coinsurance, and out of pocket expenses on mental health and substance abuse benefits that are more restrictive than
Deductibles, Copayment, Coinsurance and out of pocket expenses applicable to other medical and surgical benefits.
Medical Necessity criteria are available upon request.
Special Enrollment Notice
If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance
coverage, you may in the future be able to enroll yourself or your Dependents in this Plan if you or your Dependents lose
eligibility for that other coverage (or if the employer stops contributing towards your or your Dependents other coverage).
However, you must request enrollment within 31 days after your or your Dependents other coverage ends (or after the
employer stops contributing toward the other coverage.
In addition, if you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and Your Dependents. However, you must request enrollment within 31 days after the marriage,
birth, adoption, or placement for adoption.
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
23
The Subscribers or Dependents Medicaid or Childrens Health Insurance Program (CHIP) coverage is terminated as
a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program).
The Subscriber or Dependent must request Special Enrollment within 60 days of the loss of Medicaid/CHIP or of the
eligibility determination.
To request special enrollment or obtain more information, call us at the Customer Service telephone number on your
Identification Card, or contact the Group.
Statement of ERISA Rights
Please note: This section applies to employer sponsored plans other than Church employer groups and government
groups. If you have questions about whether this Plan is governed by ERISA, please contact the Plan Administrator (the
Group).
The Employee Retirement Income Security Act of 1974 (ERISA) entitles you, as a Member of the Group under this
Contract, to:
Examine, without charge, at the Plan Administrators office and at other specified locations such as worksites and
union halls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed by this plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions;
Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for these copies; and
Receive a summary of the plans annual financial report. The Plan Administrator is required by law to furnish each
participant with a copy of this summary financial report.
In addition to creating rights for you and other employees, ERISA imposes duties on the people responsible for the
operation of your employee benefit plan. The people who operate your plan are called plan fiduciaries. They must handle
your plan prudently and in the best interest of you and other plan participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you
from obtaining a welfare benefit or exercising your right under ERISA. If your claim for welfare benefits is denied, in whole
or in part, you must receive a written explanation of the reason for the denial. You have the right to have your claims
reviewed and reconsidered.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the
Plan Administrator and do not receive them within 30 days, you may file suit in a federal court. In such case, the court
may require the Plan Administrator to provide you the materials and pay you up to $110 a day until you receive the
materials, unless the materials are not sent because of reasons beyond the control of the Plan Administrator. If your
claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. If plan fiduciaries
misuse the plans money or if you are discriminated against for asserting your rights, you may seek assistance from the
U.S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal
fees. It may order you to pay these expenses, for example, if it finds your claim is frivolous. If you have any questions
about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your
rights under ERISA, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee
Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
24
Notices Required by State Law
Cancer Screenings
At Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado, Inc., we believe cancer screenings
provide important preventive care that supports our mission: to improve the lives of the people we serve and the health of
our communities. We cover cancer screenings as described below.
Pap Tests
All Plans provide coverage under the preventive care benefits for a routine annual Pap test and the related office visit.
Payment for the routine Pap test is based on the Plans provisions for preventive care service. Payment for the related
office visit is based on the Plans preventive care provisions.
Mammogram Screenings
All Plans provide coverage under the preventive care benefits for routine screening or diagnostic mammogram regardless
of age. Payment for the mammogram screening benefit is based on the Plans provisions for preventive care.
Prostate Cancer Screenings
All Plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for
the prostate cancer screening is based on the Plans provisions for preventive care.
Colorectal Cancer Screenings
Several types of colorectal cancer screening methods exist. All Plans provide coverage for routine colorectal cancer
screenings, such as fecal occult blood tests, barium enema, sigmoidoscopies and colonoscopies. Depending on the type
of colorectal cancer screening received, payment for the benefit is based on where the services are rendered and if
rendered as a screening or medical procedure. Colorectal cancer screenings are covered under preventive care as long
as the services provided are for a preventive screening. Payment for preventive colorectal cancer screenings based on
the Plans provisions for preventive care.
The information above is only a summary of the benefits described. The rest of this Booklet includes important additional
information about limitations, exclusions and covered benefits. The Schedule of Benefits (Who Pays What) section
includes additional information about Copayments, Deductibles and Coinsurance. If you have any questions, please call
Customer Service at the number on the back of your Identification Card.
{No adult dental:
[No-Adult Dental Services

This policy does not provide any dental benefits to individuals age nineteen (19) or older, except as specifically provided
in the benefit booklet. This policy is being offered so the purchaser will have pediatric dental coverage as required by the
Affordable Care Act. If you want adult dental benefits, you will need to buy a plan that has adult dental benefits. Except as
stated in the benefit booklet, this plan will not pay for any adult dental care, so you will have to pay the full price of any
care you receive.]




25
Notice of
Protection Provided by
Life and Health Insurance Protection Association
This notice provides a brief summary of the Life and Health Insurance Protection Association (the Association) and the
protection it provides for policyholders. This safety net was created under Colorado law, which determines who and what
is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or health insurance
company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should
happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Colorado law, with
funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
Life Insurance
- $300,000 in death benefits
- $100,000 in cash surrender or withdrawal values
Health Insurance
- $500,000 in hospital, medical and surgical insurance benefits
- $300,000 in disability insurance benefits
- $300,000 in long-term care insurance benefits
- $100,000 in other types of health insurance benefits
Annuities
- $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000.
Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to
any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the
account value of a variable life insurance policy or a variable annuity contract. There are also various residency
requirements and other limitations under Colorado law.
To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please
visit the Associations website http://colorado.lhiga.com, email jkelldorf@aol.com or contact:
Colorado Life and Health
Insurance Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 292-5022
Colorado Division of Insurance
1560 Broadway, Suite 850
Denver, CO 80202

(303) 894-7499
Insurance companies and agents are not allowed by Colorado law to use the existence of the Association or its
coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you
should not rely on Association coverage. If there is any inconsistency between this notice and Colorado law,
then Colorado law will control.
26
Section 2. Title Page (Cover Page)

Anthem Blue Cross and Blue Shield


[Anthem Silver Blue Priority PPO 2500/20%/6000 Plus]
[Anthem Gold PPO 1000/20%/3500]
[Anthem Gold PPO 2000/40%/4000]
[Anthem Silver PPO 2000/50%/6350]
[Anthem Gold PPO 750/20%/4500]
[Anthem Gold PPO 1500/20%/4000]
[Anthem Gold PPO 500/20%/4500]
[Anthem Silver PPO 2000/30%/4500 Plus w/Dental]
[Anthem Silver PPO 2000/30%/4500 Plus]
[Anthem Silver PPO 3000/30%/4000 Plus]
[Anthem Bronze PPO 5850/30%/6600 Plus]
[Anthem Gold PPO 500/20%/3000 Plus w/Dental]
[Anthem Gold PPO 500/20%/3000 Plus]
[Anthem Silver PPO 1500/30%/4250 Plus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem Silver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 Plus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 Plus w/HSA]
[Anthem Silver PPO 2500/20%/4500 w/HSA]
[Anthem Gold PPO 2000/20%/5000 Plus w/HRA]
[Anthem Gold PPO 4000/20%/5000 Plus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 Plus]




27

Section 3. Contact Us
Welcome to Anthem!
We are pleased that you have become a Member of our health insurance Plan. We want to make sure
that our services are easy to use. Weve designed this Booklet to give a clear description of your
benefits, as well as our rules and procedures.
The Booklet explains many of the rights and duties between you and us. It also describes how to get
health care, what services are covered, and what part of the costs you will need to pay. Many parts of
this Booklet are related. Therefore, reading just one or two sections may not give you a full understanding
of your coverage. You should read the whole Booklet to know the terms of your coverage.
This Booklet replaces any Booklet issued to you in the past. The coverage described is based upon the
terms of the Group Contract issued to your Group, and the Plan that your Group chose for you. This
Booklet, and any endorsements, amendments or riders attached, form the entire legal contract under
which Covered Services are available. In addition the Group has a Group Contract and Group
Application which includes terms that apply to this coverage.
Many words used in the Booklet have special meanings (e.g., Group, Covered Services, and Medical
Necessity). These words are capitalized and are defined in the "Definitions" section. See these
definitions for the best understanding of what is being stated. Throughout this Booklet you will also see
references to we, us, our, you, and your. The words we, us, and our mean Anthem Blue
Cross and Blue Shield. The words you and your mean the Member, Subscriber and each covered
Dependent.
If you have any questions about your Plan, please be sure to call Customer Service at the number on the
back of your Identification Card. You can also contact us at:
800-234-0111
Anthem Blue Cross and Blue Shield
700 Broadway
Denver, CO 80273
Also be sure to check our website, www.anthem.com for details on how to find a Provider, get answers to
questions, and access valuable health and wellness tips. Thank you again for enrolling in the Plan!
{HSA plans:
[High-Deductible Health Plan for Use with Health Savings Accounts
This Plan is meant to be federally tax qualified and used with a qualified health savings account. Approval
by the Division of Insurance does not guarantee tax qualification and this Plan has not been submitted for
approval by the IRS. Please seek the advice of a tax advisor.]
How to Get Language Assistance
Anthem is committed to communicating with our Members about their health Plan, no matter what their
language is. Anthem employs a language line interpretation service for use by all of our Customer Service
call centers. Simply call the Customer Service phone number on the back of your Identification Card and
a representative will be able to help you. Translation of written materials about your benefits can also
be asked for by contacting Customer Service. TTY/TDD services also are available by dialing 711. A
special operator will get in touch with us to help with your needs.


28


Mike Ramseier
President and General Manager
Anthem Blue Cross and Blue Shield
29

Your Rights and Responsibilities as an Anthem Blue Cross and Blue
Shield Member
As a Member you have certain rights and responsibilities when receiving your health care. You also have
a responsibility to take an active role in your care. As your health care partner, were committed to making
sure your rights are respected while providing your health benefits. That also means giving you access to
our In-Network Providers and the information you need to make the best decisions for your health and
welfare.

You have the right to:
Speak freely and privately with your Doctors and other health Providers about all health care
options and treatment needed for your condition. This is no matter what the cost or whether its
covered under your Plan.
Work with your Doctors in making choices about your health care.
Be treated with respect and dignity.
Expect us to keep your personal health information private. This is as long as it follows state and
Federal laws and our privacy policies.
Get the information you need to help make sure you get the most from your health Plan, and share
your feedback. This includes information on:
- Our company and services.
- Our network of Doctors and other health care Providers.
- Your rights and responsibilities.
- The rules of your health care Plan.
- The way your health Plan works.
Make a complaint or file an appeal about:
- Your Plan.
- Any care you get.
- Any Covered Service or benefit ruling that your Plan makes.
Say no to any care, for any condition, sickness or disease, without it affecting any care you may get in
the future. This includes the right to have your Doctor tell you how that may affect your health now
and in the future.
Get all of the most up-to-date information from a Doctor or other health care professional Provider
about the cause of your illness, your treatment and what may result from it. If you dont understand
certain information, you can choose a person to be with you to help you understand.

You have the responsibility to:
Read and understand, to the best of your ability, all information about your health benefits or ask for
help if you need it.
Follow all Plan rules and policies.
Choose an In-Network Primary Care Physician (Doctor) / Provider, also called a PCP, if your health
care Plan requires it.
Treat all Doctors, health care Providers and staff with courtesy and respect.
Keep all scheduled appointments with your health care Providers. Call their office if you may be late
or need to cancel.
Understand your health problems as well as you can and work with your Doctors or other health care
Providers to make a treatment plan that you all agree on.
Tell your Doctors or other health care Providers if you dont understand any type of care youre
getting or what they want you to do as part of your care plan.

30
Follow the care plan that you have agreed on with your Doctors or health care Providers.
Give us, your Doctors and other health care professionals the information needed to help you get the
best possible care and all the benefits you are entitled to. This may include information about other
health and insurance benefits you have in addition to your coverage with us.
Let our customer service department know if you have any changes to your name, address or family
members covered under your Plan.

We are committed to providing quality benefits and customer service to our Members. Benefits and
coverage for services provided under the benefit program are governed by the Booklet and not by this
Member Rights and Responsibilities statement.
We value your feedback regarding the benefits and service provided under Our policies and your overall
thoughts and concerns regarding Our operations. If you have any concerns regarding how your benefits
were applied or any concerns about services you requested which were not covered under this Booklet,
you are free to file a complaint or appeal as explained in this Booklet. If you have any concerns regarding
a participating Provider or facility, you can file a grievance as explained in this Booklet. And if you have
any concerns or suggestions on how we can improve Our overall operations and service, We encourage
you to contact customer service.
If you need more information or would like to contact us, please go to anthem.com and select Customer
Support > Contact Us. Or call the Member Services number on your ID card.




31

Section 4. Table of Contents
Section 1. Schedule of Benefits (Who Pays What) .................................................................................. 1
Section 2. Title Page (Cover Page) .......................................................................................................... 26
Section 3. Contact Us ............................................................................................................................... 27
Welcome to Anthem! ............................................................................................................................... 27
[High-Deductible Health Plan for Use with Health Savings Accounts ..................................................... 27
How to Get Language Assistance ........................................................................................................... 27
Your Rights and Responsibilities as an Anthem Blue Cross and Blue Shield Member .......................... 29
Section 4. Table of Contents .................................................................................................................... 31
Section 5. Eligibility .................................................................................................................................. 36
Who is Eligible for Coverage ................................................................................................................... 36
The Subscriber ..................................................................................................................................... 36
Dependents .......................................................................................................................................... 36
Types of Coverage ............................................................................................................................... 37
When You Can Enroll .............................................................................................................................. 37
Initial Enrollment .................................................................................................................................. 37
Open Enrollment .................................................................................................................................. 38
Special Enrollment Periods .................................................................................................................. 38
Special Rules if Your Group Health Plan is Offered Through an Exchange ....................................... 38
Medicaid and Childrens Health Insurance Program Special Enrollment ............................................ 39
Late Enrollees ...................................................................................................................................... 39
Members Covered Under the Groups Prior Plan ................................................................................ 39
Enrolling Dependent Children ................................................................................................................. 39
Newborn Children ................................................................................................................................ 39
Adopted Children ................................................................................................................................. 39
Adding a Child due to Award of Legal Custody or Guardianship ........................................................ 40
Qualified Medical Child Support Order ................................................................................................ 40
Updating Coverage and/or Removing Dependents ................................................................................ 40
Nondiscrimination .................................................................................................................................... 40
Statements and Forms ............................................................................................................................ 40
Section 6. How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) ................................................................................................................................................. 41
Introduction .............................................................................................................................................. 41
In-Network Services ................................................................................................................................ 41
Out-of-Network Services ......................................................................................................................... 42
How to Find a Provider in the Network .................................................................................................... 42
[Designated Participating Provider Program ........................................................................................... 42
Continuity of Care .................................................................................................................................... 43
Crediting Prior Plan Coverage ................................................................................................................. 43
The BlueCard Program ............................................................................................................................ 43
Identification Card .................................................................................................................................... 44
Obtain Approval of Benefits ..................................................................................................................... 45
Types of Requests ................................................................................................................................... 45
Request Categories ................................................................................................................................. 46
Decision and Notice Requirements ......................................................................................................... 47
Health Plan Individual Case Management .............................................................................................. 48
Section 7. Benefits/Coverage (What is Covered) ................................................................................... 49
Acupuncture/Nerve Pathway ................................................................................................................... 49
Allergy Services ....................................................................................................................................... 49
Ambulance Services ................................................................................................................................ 49

32
Autism Services ....................................................................................................................................... 50
Behavioral Health Services ..................................................................................................................... 51
Cardiac Rehabilitation ............................................................................................................................. 51
Chemotherapy ......................................................................................................................................... 51

Clinical Trials ........................................................................................................................................... 51
Dental Services ....................................................................................................................................... 52
Your Dental Benefits ............................................................................................................................ 52
Pretreatment Estimate ......................................................................................................................... 53
[Pediatric Dental for Members through Age 18 ................................................................................... 53
[Dental Services ...................................................................................................................................... 56
Dental Services for Members through Age 18 ..................................................................................... 56
Diagnostic and Preventive Services .................................................................................................... 56
Basic Restorative Services .................................................................................................................. 56
Major Restorative Services .................................................................................................................. 57
Oral Surgery ......................................................................................................................................... 57
Orthodontic Care .................................................................................................................................. 57
Dental Services for Members Age 19 and Older ................................................................................. 58
Diagnostic and Preventive Services .................................................................................................... 58
Basic Restorative Services .................................................................................................................. 59
Endodontic Services ............................................................................................................................ 59
Periodontal Services ............................................................................................................................ 59
Oral Surgery Services .......................................................................................................................... 60
Major Restorative Services .................................................................................................................. 61
Prosthodontic Services ........................................................................................................................ 61
Dental Services (All Members / All Ages) ................................................................................................ 63
Preparing the Mouth for Medical Treatments ...................................................................................... 63
Accident-Related Dental Services ....................................................................................................... 63
Cleft Palate and Cleft Lip Conditions ................................................................................................... 63
Dental Anesthesia for Children ............................................................................................................ 63
Diabetes Equipment, Education, and Supplies ....................................................................................... 63
Diagnostic Services ................................................................................................................................. 64
Diagnostic Laboratory and Pathology Services ................................................................................... 64
Diagnostic Imaging Services and Electronic Diagnostic Tests ............................................................ 64
Advanced Imaging Services ................................................................................................................ 64
Dialysis .................................................................................................................................................... 64
Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies ................................................................................................................................................... 64
Durable Medical Equipment and Medical Devices .............................................................................. 64
Hearing Aid Services ........................................................................................................................... 65
Orthotics ............................................................................................................................................... 65
Prosthetics ........................................................................................................................................... 65
Medical and Surgical Supplies ............................................................................................................. 66
Blood and Blood Products ................................................................................................................... 66
Emergency Care Services ....................................................................................................................... 66
Emergency Services ............................................................................................................................ 66
Home Care Services ............................................................................................................................... 67
Home Infusion Therapy ........................................................................................................................... 67
Hospice Care ........................................................................................................................................... 67
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services ........................................... 68
Prior Approval and Precertification ...................................................................................................... 69
Infertility Services .................................................................................................................................... 70
Inpatient Services .................................................................................................................................... 70
Inpatient Hospital Care ........................................................................................................................ 70
Inpatient Professional Services ........................................................................................................... 71
Maternity and Reproductive Health Services .......................................................................................... 71

33
Maternity Services ............................................................................................................................... 71
Contraceptive Benefits ......................................................................................................................... 72
Sterilization Services ............................................................................................................................ 72
Abortion Services ................................................................................................................................. 72
Infertility Services ................................................................................................................................. 72
Mental Health, Alcohol and Substance Abuse Services ......................................................................... 72
Occupational Therapy ............................................................................................................................. 73
Office Visits and Doctor Services ............................................................................................................ 74
Orthotics .................................................................................................................................................. 74
Outpatient Facility Services ..................................................................................................................... 74
Physical Therapy ..................................................................................................................................... 75
Preventive Care ....................................................................................................................................... 75
Prosthetics ............................................................................................................................................... 76
Pulmonary Therapy ................................................................................................................................. 76
Radiation Therapy ................................................................................................................................... 76
Rehabilitation Services ............................................................................................................................ 76
Habilitative Services ............................................................................................................................. 76
Respiratory Therapy ................................................................................................................................ 76
Skilled Nursing Facility ............................................................................................................................ 76
Smoking Cessation .................................................................................................................................. 76
Speech Therapy ...................................................................................................................................... 77
Surgery .................................................................................................................................................... 77
Oral Surgery ......................................................................................................................................... 77
Reconstructive Surgery........................................................................................................................ 77
Transgender Surgery ........................................................................................................................... 78
Telemedicine ........................................................................................................................................... 78
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services ................................................. 78
Therapy Services ..................................................................................................................................... 78
Physical Medicine Therapy Services ................................................................................................... 78
Early Intervention Services .................................................................................................................. 79
Other Therapy Services ....................................................................................................................... 79
Transplant Services ................................................................................................................................. 80
Urgent Care Services .............................................................................................................................. 80
Routine Eye Exam ............................................................................................................................... 81
Eyeglass Lenses .................................................................................................................................. 81
Frames ................................................................................................................................................. 81
Contact Lenses .................................................................................................................................... 81
[Vision Services for Members Age 19 and Older .................................................................................... 82
Routine Eye Exam ............................................................................................................................... 82
Eyeglass Lenses .................................................................................................................................. 82
Frames ................................................................................................................................................. 82
Contact Lenses .................................................................................................................................... 82
Vision Services (All Members / All Ages) ................................................................................................ 82
Prescription Drugs Administered by a Medical Provider ......................................................................... 83
Important Details About Prescription Drug Coverage .......................................................................... 83
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy ..................................... 84
Prescription Drug Benefits ................................................................................................................... 84
Section 8. Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) .................. 88
Whats Not Covered Under Your Prescription Drug Retail or Home Delivery (Mail Order) Pharmacy
Benefit ...................................................................................................................................................... 93
Pre-existing Conditions ............................................................................................................................ 95
Section 9. Member Payment Responsibility........................................................................................... 96
Your Cost-Shares .................................................................................................................................... 96
Maximum Allowed Amount ...................................................................................................................... 96
Claims Review ......................................................................................................................................... 99

34
Section 10. Claims Procedure (How to File a Claim) ........................................................................... 100
Notice of Claim & Proof of Loss ............................................................................................................ 100
Claim Forms .......................................................................................................................................... 100
Members Cooperation .......................................................................................................................... 100
Payment of Benefits .............................................................................................................................. 100
Inter-Plan Programs .............................................................................................................................. 101
Out-of-Area Services ............................................................................................................................. 101
BlueCard

Program ........................................................................................................................... 101

Non-Participating Healthcare Providers Outside Our Service Area .................................................. 102
Section 11. General Policy Provisions .................................................................................................. 103
Assignment ............................................................................................................................................ 103
Automobile Insurance Provisions .......................................................................................................... 103
Clerical Error .......................................................................................................................................... 103
Confidentiality and Release of Information............................................................................................ 104
Conformity with Law .............................................................................................................................. 104
Contract with Anthem ............................................................................................................................ 104
Entire Contract ....................................................................................................................................... 104
Form or Content of Booklet ................................................................................................................... 105
Government Programs .......................................................................................................................... 105
Medical Policy and Technology Assessment ........................................................................................ 105
Medicare ................................................................................................................................................ 105
Modifications .......................................................................................................................................... 105
Network Access Plan ............................................................................................................................. 106
Not Liable for Provider Acts or Omissions ............................................................................................. 106
Policies and Procedures ........................................................................................................................ 106
Relationship of Parties (Group-Member-Anthem) ................................................................................. 106
Relationship of Parties (Anthem and In-Network Providers) ................................................................. 106
Reservation of Discretionary Authority .................................................................................................. 107
Right of Recovery .................................................................................................................................. 107
Unauthorized Use of Identification Card ................................................................................................ 108
Value-Added Programs ......................................................................................................................... 108
Value of Covered Services .................................................................................................................... 108
Voluntary Clinical Quality Programs ...................................................................................................... 108
Voluntary Wellness Incentive Programs ................................................................................................ 108
Waiver .................................................................................................................................................... 109
Workers Compensation ........................................................................................................................ 109
Subrogation and Reimbursement .......................................................................................................... 109
Subrogation ........................................................................................................................................ 109
Reimbursement .................................................................................................................................. 109
The Members Duties ......................................................................................................................... 110
Coordination of Benefits When Members Are Insured Under More Than One Plan ............................ 110
Section 12. Termination/Nonrenewal/Continuation ............................................................................. 115
Termination ............................................................................................................................................ 115
Removal of Members ............................................................................................................................ 115
Special Rules if Your Group Health Plan is Offered Through an Exchange ......................................... 116
Continuation of Coverage Under Federal Law (COBRA) ...................................................................... 116
Qualifying events for Continuation Coverage under Federal Law (COBRA) ..................................... 116
If Your Group Offers Retirement Coverage ....................................................................................... 117
Second qualifying event ..................................................................................................................... 117
Notification Requirements .................................................................................................................. 118
Disability extension of 18-month period of continuation coverage .................................................... 118
Trade Adjustment Act Eligible Individual ........................................................................................... 118
When COBRA Coverage Ends .......................................................................................................... 119
If You Have Questions ....................................................................................................................... 119
Continuation of Coverage Under State Law .......................................................................................... 119

35
Continuation of Coverage Due To Military Service ............................................................................... 120
Maximum Period of Coverage During a Military Leave ..................................................................... 121
Reinstatement of Coverage Following a Military Leave .................................................................... 121
Family and Medical Leave Act of 1993 ................................................................................................. 121
Benefits After Termination Of Coverage ............................................................................................... 122
Section 13. Appeals and Complaints .................................................................................................... 123
Complaints ............................................................................................................................................. 123
Appeals .................................................................................................................................................. 124
Grievances ............................................................................................................................................ 126
Division of Insurance Inquiries ........................................................................................................... 126
Binding Arbitration .............................................................................................................................. 126
Legal Action ....................................................................................................................................... 126
Section 14. Information on Policy and Rate Changes ......................................................................... 128
Insurance Premiums .............................................................................................................................. 128
Section 15. Definitions ............................................................................................................................ 129

36
Section 5. Eligibility
In this section you will find information on who is eligible for coverage under this Plan and when Members
can be added to your coverage. Eligibility requirements are described in general terms below. For more
specific information, please see your Human Resources or Benefits Department.
Who is Eligible for Coverage
The Subscriber
To be eligible to enroll as a Subscriber, the individual must:
Be an employee of the Group, and;
Be entitled to participate in the benefit Plan arranged by the Group, and;
Have satisfied any probationary or waiting period established by the Group and perform the duties of
your principal occupation for the Group.
Dependents
To be eligible to enroll as a Dependent, you must be listed on the enrollment form completed by the
Subscriber, meet all Dependent eligibility criteria established by the Group, and be one of the following:
The Subscribers spouse, including the partner to a civil union as recognized by Colorado law. For
information on spousal eligibility please contact the Group.
Common-law spouse. A Common-Law Marriage Affidavit is needed to enroll a common-law spouse.
You can get the affidavit from your employer or you can call us. All references to spouse in this
Booklet include a common-law spouse.
A common law spouse is an eligible Dependent who has a valid common-law marriage in Colorado.
This is the same as any other marriage and can only end by death or divorce.
Designated beneficiary. Your Group may have decided to offer benefits under this plan to designated
beneficiaries. Check with your Group to learn more. If they are recognized by the Group, all
references to spouse in this Booklet include a designated beneficiary. A Recorded Designated
Beneficiary Agreement will need to be provided. A designated beneficiary is not eligible for COBRA
under this Booklet.
A designated beneficiary is an agreement entered into by two people for the purpose of making each
a beneficiary of the other and which has been recorded with the county clerk and recorder in the
county in which one of the person lives. The agreement is based on the Colorado Designated
Beneficiary Act.
Same-sex domestic partner. Domestic Partner, or Domestic Partnership means a person of the same
sex who has signed the Domestic Partner Affidavit certifying that he or she is the Subscribers sole
Domestic Partner; he or she is mentally competent; he or she is not related to the Subscriber by
blood closer than permitted by state law for marriage; he or she is not married to anyone else; and he
or she is financially interdependent with the Subscriber.
For purposes of this Plan, a Domestic Partner or partner to a recognized civil union shall be treated
the same as a spouse, and that partners child, adopted child, or child for whom he or she has legal
guardianship shall be treated the same as any other child. The coverage of a Domestic Partner, civil
union partner, or the child of any such partner ends on the date of dissolution of the Domestic
Partnership or civil union.
While this Booklet will recognize and provide benefits for a Member who is a spouse or child in
connection with a Domestic Partner or recognized civil union relationship, not every federal or state

37
law that applies to a Member who is a spouse or child under this Plan will also apply to a Domestic
Partner or a partner under a civil union. This includes but is not limited to, COBRA and FMLA.
We reserve the right to make the ultimate decision in determining eligibility of the Domestic Partner.
The children of the Subscriber or the Subscribers spouse, including natural children, stepchildren,
newborn and legally adopted children and children who the Group has determined are covered under
a Qualified Medical Child Support Order as defined by ERISA or any applicable state law.
Children, including grandchildren, for whom the Subscriber or the Subscribers spouse is a permanent
legal guardian or as otherwise required by law.
All enrolled eligible children will continue to be covered until the age limit listed in the Schedule of
Benefits (Who Pays What). Coverage may be continued past the age limit in the following circumstances:
For unmarried children of any age who are medically certified as disabled and dependent upon the
parent. The Dependents disability must start before the end of the period they would become
ineligible for coverage. We must be informed of the Dependents eligibility for continuation of
coverage within 31 days after the Dependent would normally become ineligible. You must then give
proof as often as we require. This will not be more often than once a year after the two-year period
following the child reaching the limiting age. You must give the proof at no cost to us. You must
notify us if the Dependents marital status changes and they are no longer eligible for continued
coverage.
We may require you to give proof of continued eligibility for any enrolled child. Your failure to give this
information could result in termination of a childs coverage.
To obtain coverage for children, we may require you to give us a copy of any legal documents awarding
permanent guardianship of such child(ren) to you.

Your group may have limited or excluded the eligibility of certain Dependent types and so not all
Dependents listed in this Plan may be entitled to enroll. For more specific information, please see your
Human Resources or Benefits Department.
Types of Coverage
Your Group offers some or all of the enrollment options listed below. After reviewing the available options,
you may choose the option that best meets your needs. The options may include:
Subscriber only (also referred to as single coverage);
Subscriber and spouse; or Domestic Partner;
Subscriber and child(ren);
Subscriber and family.
When You Can Enroll
Initial Enrollment
The Group will offer an initial enrollment period to new Subscribers and their Dependents when the
Subscriber is first eligible for coverage. Coverage will be effective based on the waiting period chosen by
the Group, and will not exceed 90 days.
If you did not enroll yourself and/or your Dependents during the initial enrollment period you will only be
able to enroll during an Open Enrollment period or during a Special Enrollment period, as described
below.

38
Open Enrollment
Open Enrollment refers to a period of time, usually 60 days, during which eligible Subscribers and
Dependents can apply for or change coverage. Open Enrollment occurs only once per year. The Group
will notify you when Open Enrollment is available.
Special Enrollment Periods
If a Subscriber or Dependent does not apply for coverage when they were first eligible, they may be able
to join the Plan prior to Open Enrollment if they qualify for Special Enrollment. Except as noted otherwise
below, the Subscriber or Dependent must request Special Enrollment within 31 days of a qualifying event.
Special Enrollment is available for eligible individuals who:
Lost eligibility under a prior health plan for reasons other than non-payment of premium or due to
fraud or intentional misrepresentation of a material fact;
Lost coverage due to death of a covered employee; the termination or reduction in number of hours of
the covered employees employment (regardless of eligibility for COBRA or state continuation
coverage); involuntary termination of coverage; lost eligibility under the Colorado Medical Assistance
Act or the Childrens Basic Health Plan; or the covered employee becoming eligible for benefits under
Title XVIII of the Federal Social Security Act, as amended;
Lost coverage under a health benefit plan due to the divorce or legal separation of the covered
employee from the covered employees spouse or partner in civil union, or due to the termination of a
recognized domestic partnership;
Is now eligible for coverage due to marriage (including a civil union where recognized in the state
where the Subscriber resides), birth, adoption, placement for adoption, by entering into a Designated
Beneficiary Agreement, or pursuant to a QMCSO or other court or administrative order mandating
that the individual be covered;
Exhausted COBRA or state continuation benefits or stopped receiving group contributions toward the
cost of the prior health plan; or
Lost employer contributions towards the cost of the other coverage.

Important Notes about Special Enrollment:
Members who enroll during Special Enrollment are not considered Late Enrollees.
Individuals must request coverage within 31 days of a qualifying event (i.e., marriage, exhaustion of
COBRA, etc.).
If the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Special Rules if Your Group Health Plan is Offered Through an Exchange
If your Plan is offered through a public exchange operated by the state or federal government as part of
the Patient Protection and Affordable Care Act (Exchange), all enrollment changes must be made
through the Exchange by you or your Group. Each Exchange will have rules on how to do this. For plans
offered on the Exchange there are additional opportunities for Special Enrollment. They include:
Your enrollment or non-enrollment in another qualified health plan was unintentional, inadvertent or
erroneous and was a result of an error, misrepresentation, or inaction by an employee or
representative of the Exchange;
You adequately demonstrate to the Exchange that the health plan under which you are enrolled has
substantially violated a material provision of its contract with you;
You move and become eligible for new qualified health plans;

39
You are a Native American Indian, as defined by section 4 of the Indian Health Care Improvement
Act, and allowed to change from one qualified health plan to another as often as once per month; or
The Exchange determines, under federal law, that you meet other exceptional circumstances that
warrant a Special Enrollment.
You must give the Exchange notice within 30 days of the above events if you wish to enroll.
Medicaid and Childrens Health Insurance Program Special Enrollment
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
The Subscribers or Dependents Medicaid or Childrens Health Insurance Program (CHIP) coverage
is terminated as a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program)
The Subscriber or Dependent must request Special Enrollment within 60 days of the above events.
Late Enrollees
If the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Members Covered Under the Groups Prior Plan
Members who were previously enrolled under another plan offered by the Group that is being replaced by
this Plan are eligible for coverage on the Effective Date of this coverage.
Enrolling Dependent Children
Newborn Children
Newborn children are covered automatically from the moment of birth. Following the birth of a child, you
should submit an application / change form to the Group within 31, but no more than 60, days to add the
newborn to your Plan. During the first 31 days after birth, a newborn child will be covered for Medically
Necessary care. This includes well child care and treatment of medically diagnosed congenital defects
and birth abnormalities. This is regardless of the limitations and exclusions applicable to other conditions
or procedures of this Booklet.
Even if no additional Premium is required, you should still submit an application / change form to the
Group to add the newborn to your Plan, to make sure we have accurate records and are able to cover
your claims.
Adopted Children
A child will be considered adopted from the earlier of: (1) the moment of placement in your home; or (2)
the date of an entry of an order granting custody of the child to you. The placement begins when you
assume or retain a legal obligation to partially or totally support a child in anticipation of the child's
adoption. A placement terminates at the time such legal obligation terminates. The child will continue to
be considered adopted unless the child is removed from your home prior to issuance of a legal decree of
adoption.
Your Dependents Effective Date will be the date of the adoption or placement for adoption if you send us
the completed application / change form within 31 days of the event.

40
Adding a Child due to Award of Legal Custody or Guardianship
If you or your spouse is awarded permanent legal custody or permanent guardianship for a child, an
application must be submitted within 31 days of the date legal custody or guardianship is awarded by the
court. Coverage will be effective on the date the court granted legal custody or guardianship.
Qualified Medical Child Support Order
If you are required by a qualified medical child support order or court order, as defined by ERISA and/or
applicable state or federal law, to enroll your child in this Plan, we will permit the child to enroll at any time
without regard to any Open Enrollment limits and will provide the benefits of this Plan according to the
applicable requirements of such order. However, a child's coverage will not extend beyond any
Dependent Age Limit listed in the Schedule of Benefits (Who Pays What).
Updating Coverage and/or Removing Dependents
You are required to notify the Group of any changes that affect your eligibility or the eligibility of your
Dependents for this Plan. When any of the following occurs, contact the Group and complete the
appropriate forms:
Changes in address;
Marriage or divorce or entering into or terminating a recognized civil union or domestic partnership;
Death of an enrolled family member (a different type of coverage may be necessary);
Enrollment in another health plan or in Medicare;
Eligibility for Medicare;
Dependent child reaching the Dependent Age Limit (see Termination/Nonrenewal/Continuation);
Enrolled Dependent child either becomes totally or permanently disabled, or is no longer disabled.
Failure to notify us of individuals no longer eligible for services will not obligate us to cover such services,
even if Premium is received for those individuals. All notifications must be in writing and on approved
forms.
Nondiscrimination
No person who is eligible to enroll will be refused enrollment based on health status, health care needs,
genetic information, previous medical information, disability, sexual orientation or identity, gender or age.
Statements and Forms
All Members must complete and submit applications or other forms or statements that we may reasonably
request.
Any rights to benefits under this Plan are subject to the condition that all such information is true, correct,
and complete. Any intentional material misrepresentation by you may result in termination of coverage as
provided in the "Termination/Nonrenewal/Continuation" section. We will not use a statement made by you
to void or reduce your coverage after that coverage has been in effect for two years, unless such
statement is contained in a written instrument signed by you making such statement and a copy of that
instrument is or has been given to you or your beneficiary.


41
Section 6. How to Access Your Services and Obtain Approval
of Benefits (Applicable to managed care plans)
Introduction
Your Plan is a PPO plan. The Plan has two sets of benefits: In-Network and Out-of-Network. If you
choose an In-Network Provider, you will pay less in out-of-pocket costs, such as Copayments,
Deductibles, and Coinsurance. If you use an Out-of-Network Provider, you will have to pay more out-of-
pocket costs.
In-Network Services
When you use an In-Network Provider or get care as part of an Authorized Service, Covered Services will
be covered at the In-Network level. Regardless of Medical Necessity, benefits will be denied for care that
is not a Covered Service. We have final authority to decide the Medical Necessity of the service.
In-Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for you. Referrals are never needed to visit an In-Network Specialist, including behavioral
health Providers.
To see a Doctor, call their office:
Tell them you are an Anthem Member,
Have your Member Identification Card handy. The Doctors office may ask you for your group or
Member ID number.
Tell them the reason for your visit.
When you go to the office, be sure to bring your Member Identification Card with you.
For services from In-Network Providers:
1. You will not need to file claims. In-Network Providers will file claims for Covered Services for you.
(You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be
billed by your In-Network Provider(s) for any non-Covered Services you get or when you have not
followed the terms of this Booklet.
2. Precertification will be done by the In-Network Provider. (See this section for further details.)
We do not guarantee that an In-Network Provider is available for all services and supplies covered under
your PPO plan. For some services and supplies We may not have arrangements with In-Network
Providers. For example, some Hospital-based labs are not part of our Reference Lab Network. Please
read the Member Payment Responsibility section for additional information on Authorized Services.
After Hours Care
If you need care after normal business hours, your Doctor may have several options for you. You should
call your Doctors office for instructions if you need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. If you have an Emergency, call 911 or go to the nearest
Emergency Room.

42
Out-of-Network Services
When you do not use an In-Network Provider or get care as part of an Authorized Service, Covered
Services are covered at the Out-of-Network level, unless otherwise indicated in this Booklet.
For services from an Out-of-Network Provider:
1. In addition to any Deductible and/or Coinsurance/Copayments, the Out-of-Network Provider can
charge you the difference between their bill and the Plans Maximum Allowed Amount;
2. You may have higher cost sharing amounts (i.e., Deductibles, Coinsurance, and/or Copayments);
3. You will have to pay for services that are not Medically Necessary;
4. You will have to pay for non-Covered Services;
5. You may have to file claims; and
6. You must make sure any necessary Precertification is done. (Please see this section for more
details.)
We will not deny or restrict Covered Services just because you get treatment from an Out-of-Network
Provider; however, you may have to pay more.
We pay the benefits of this Booklet directly to Out-of-Network Providers, if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of you.
We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services.
How to Find a Provider in the Network
There are three ways you can find out if a Provider or Facility is in the network for this Plan. You can also
find out where they are located and details about their license or training.
See your Plans directory of In-Network Providers at www.anthem.com, which lists the Doctors,
Providers, and Facilities that participate in this Plans network.
Call Customer Service to ask for a list of Doctors and Providers that participate in this Plans network,
based on specialty and geographic area.
Check with your Doctor or Provider.
If you need help choosing a Doctor who is right for you, call the Customer Service number on the back of
your Member Identification Card. TTY/TDD services also are available by dialing 711. A special operator
will get in touch with us to help with your needs.
{Narrow network:
[Please note that we have several networks, and that a Provider that is In-Network for one plan may not
be In-Network for another. Be sure to check your Identification Card or call Customer Service to find out
which network this Plan uses.]

{Tiered plan:
[Designated Participating Provider Program
Certain Providers are part of our Designated Participating Provider Program, a program aimed at
improving the quality of our Members health care. Providers in this program agree to coordinate much of
your care and will prepare care plans for Members who have multiple, complex health conditions.]

43
Continuity of Care
If you are getting ongoing care for a medical condition when you first enroll in this coverage, We may be
able to help ease the transition. Examples of ongoing care are prenatal/obstetrical care, Home Care or
Hospice Care. We try to avoid disruption of a new Members care through Our transition of care policy. If
interested, you or your Provider must review the reference sheet, complete a Transition of Care Form
and submit them to Us for review. You or your Provider can get these materials by calling Our Customer
Service.
Crediting Prior Plan Coverage
If you were covered by the Groups prior carrier / plan immediately before the Group signs up with us, with
no break in coverage, then you will get credit for any accrued Deductible and, if applicable and approved
by us, Out of Pocket amounts under that other plan. This does not apply to people who were not covered
by the prior carrier or plan on the day before the Groups coverage with us began, or to people who join
the Group later.
If your Group moves from one of our plans to another, (for example, changes its coverage from HMO to
PPO), and you were covered by the other product immediately before enrolling in this product with no
break in coverage, then you may get credit for any accrued Deductible and Out of Pocket amounts, if
applicable and approved by us. Any maximums, when applicable, will be carried over and charged
against the maximums under this Plan.
If your Group offers more than one of our products, and you change from one product to another with no
break in coverage, you will get credit for any accrued Deductible and, if applicable, Out of Pocket
amounts and any maximums will be carried over and charged against maximums under this Plan.
If your Group offers coverage through other products or carriers in addition to ours, and you change
products or carriers to enroll in this product with no break in coverage, you will get credit for any accrued
Deductible, Out of Pocket, and any maximums under this Plan.
This Section Does Not Apply To You If:
Your Group moves to this Plan at the beginning of a Benefit Period.
You change from one of our individual policies to a group plan;
You change employers; or
You are a new Member of the Group who joins the Group after the Group's initial enrollment with us.
The BlueCard Program
Like all Blue Cross & Blue Shield plans throughout the country, we participate in a program called
"BlueCard." This program lets you get Covered Services at the In-Network cost-share when you are
traveling out of state and need health care, as long as you use a BlueCard Provider. All you have to do is
show your Identification Card to a participating Blue Cross & Blue Shield Provider, and they will send your
claims to us.
If you are out of state and an Emergency or urgent situation arises, you should get care right away.
In a non-Emergency situation, you can find the nearest contracted Provider by visiting the BlueCard
Doctor and Hospital Finder website (www.BCBS.com) or call the number on the back of your Identification
Card.
You can also access Doctors and Hospitals outside of the U.S. The BlueCard program is recognized in
more than 200 countries throughout the world.

44
Care Outside the United States BlueCard

Worldwide
Before you travel outside the United States, check with your Group or call Customer Service at the
number on your Identification Card to find out if your plan has BlueCard Worldwide benefits. Your
coverage outside the United States may be different and we suggest:
Before you leave home, call the Customer Service number on your Identification Card for coverage
details.
Always carry your up to date Anthem Identification Card.
In an Emergency, go straight to the nearest Hospital.
The BlueCard Worldwide Service Center is on hand 24 hours a day, seven days a week toll-free at
(800) 810-BLUE (2583) or by calling collect at (804) 673-1177. An assistance coordinator, along with
a health care professional, will arrange a Doctor visit or Hospital stay, if needed.
Call the Service Center in these non-emergency situations:
You need to find a Doctor or Hospital or need health care. An assistance coordinator, along with a
medical professional, will arrange a Doctor visit or Hospital stay, if needed.
You need Inpatient care. After calling the Service Center, you must also call us to get approval for
benefits at the phone number on your Identification Card. Note: this number is different than the
phone numbers listed above for BlueCard Worldwide.
Payment Details
Participating BlueCard Worldwide Hospitals. In most cases, when you make arrangements for a
Hospital stay through BlueCard Worldwide, you should not need to pay upfront for Inpatient care at
participating BlueCard Worldwide hospitals except for the out-of-pocket costs (non-Covered Services,
Deductible, Copayments and Coinsurance) you normally pay. The Hospital should send in your claim
for you.
Doctors and/or non-participating Hospitals. You will need to pay upfront for outpatient services,
care received from a Doctor, and Inpatient care not arranged through the BlueCard Worldwide
Service Center. Then you can fill out a BlueCard Worldwide claim form and send it with the original
bill(s) to the BlueCard Worldwide Service Center (the address is on the form).
Claim Filing
The Hospital will file your claim if the BlueCard Worldwide Service Center arranged your Hospital
stay. You will need to pay the Hospital for the out-of-pocket costs you normally pay.
You must file the claim for outpatient and Doctor care, or Inpatient care not arranged through the
BlueCard Worldwide Service Center. You will need to pay the Provider and subsequently send an
international claim form with the original bills to us.
Claim Forms
You can get international claim forms from us, the BlueCard Worldwide Service Center, or online at
www.bcbs.com/bluecardworldwide. The address for sending in claims is on the form.
Identification Card
We will give an Identification Card to each Member enrolled in the Plan. When you get care, you must
show your Identification Card. Only a Member who has paid the Premiums for this Plan has the right to
services or benefits under this Booklet. If anyone gets services or benefits to which they are not entitled to
under the terms of this Booklet, he/she must pay for the actual cost of the services.

45
Obtain Approval of Benefits
Your Plan includes the processes of Precertification, Predetermination and Post Service Clinical Claims
Review to decide when services should be covered by your Plan. Their purpose is to aid the delivery of
cost-effective health care by reviewing the use of treatments and, when proper, the setting or place of
service that they are performed. Covered Services must be Medically Necessary for benefits to be
covered. When setting or place of service is part of the review, services that can be safely given to you in
a lower cost setting will not be Medically Necessary if they are given in a higher cost setting.
Prior Authorization: In-Network Providers must obtain prior authorization in order for you to get benefits
for certain services. Prior authorization criteria will be based on many sources including medical policy,
clinical guidelines, and pharmacy and therapeutics guidelines. Anthem may decide that a service that was
first prescribed or asked for is not Medically Necessary if you have not tried other treatments which are
more cost effective.
If you have any questions about the information in this section, you may call the Customer Service phone
number on the back of your Identification Card.
Types of Requests
Precertification A required review of a service, treatment or admission for a benefit coverage
determination which must be done before the service, treatment or admission start date. For
Emergency admissions, you, your authorized representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a reasonable period of time. For labor / childbirth
admissions, Precertification is not needed unless there is a problem and/or the mother and baby are
not sent home at the same time.
Predetermination An optional, voluntary Prospective or Continued Stay Review request for a
benefit coverage determination for a service or treatment. We will check your Booklet to find out if
there is an Exclusion for the service or treatment. If there is a related clinical coverage guideline, the
benefit coverage review will include a review to decide whether the service meets the definition of
Medical Necessity under this Booklet or is Experimental / Investigational as that term is defined in this
Booklet.
Post Service Clinical Claims Review A Retrospective review for a benefit coverage determination
to decide the Medical Necessity or Experimental / Investigational nature of a service, treatment or
admission that did not need Precertification and did not have a Predetermination review performed.
Medical reviews are done for a service, treatment or admission in which we have a related clinical
coverage guideline and are typically initiated by us.
Typically, In-Network Providers know which services need Precertification and will get any Precertification
or ask for a Predetermination when needed. Your Primary Care Physician / Provider and other In-
Network Providers have been given detailed information about these procedures and are responsible for
meeting these requirements. Generally, the ordering Provider, Facility or attending Doctor will get in touch
with us to ask for a Precertification or Predetermination review (requesting Provider). We will work with
the requesting Provider for the Precertification request. However, you may choose an authorized
representative to act on your behalf for a specific request. The authorized representative can be anyone
who is 18 years of age or older.

46
Who is responsible for Precertification
Services given by an In-
Network Provider
Services given by a BlueCard/Out-of-Network/Non-
Participating Provider
Provider
Member must get Precertification.
If Member fails to get Precertification, Member may be
financially responsible for service and/or setting in
whole or in part.
For Emergency admissions, you, your authorized
representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a
reasonable period of time.

We use our clinical coverage guidelines, such as medical policy, clinical guidelines, preventative care
clinical coverage guidelines and other applicable policies and procedures to help make our Medical
Necessity decisions, including decisions about Prescription and Specialty Drug services. Medical policies
and clinical guidelines reflect the standards of practice and medical interventions identified as proper
medical practice. We reserve the right to review and update these clinical coverage guidelines from time
to time. Your Booklet and Group Contract take precedence over these guidelines.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning your
request. To ask for this information, call the Precertification phone number on the back of your
Identification Card.
Anthem may, from time to time, waive, enhance, change or end certain medical management processes
(including utilization management, case management, and disease management) if in our discretion,
such change furthers the provision of cost effective, value based and/or quality services.
We may also select certain qualifying Providers to take part in a program that exempts them from certain
procedural or medical management processes that would otherwise apply. We may also exempt your
claim from medical review if certain conditions apply.
Just because Anthem exempts a process, Provider or Claim from the standards which otherwise would
apply, it does not mean that Anthem will do so in the future, or will do so in the future for any other
Provider, claim or Member. Anthem may stop or change any such exemption with or without advance
notice.
You may find out whether a Provider is taking part in certain programs by checking your on-line Provider
Directory or contacting the Customer Service number on the back of your ID card.

We also may identify certain Providers to review for potential fraud, waste, abuse or other inappropriate
activity if the claims data suggests there may be inappropriate billing practices. If a Provider is selected
under this program, then we may use one or more clinical utilization management guidelines in the review
of claims submitted by this Provider, even if those guidelines are not used for all Providers delivering
services to this Plans Members.
Request Categories
Expedited A request for Precertification or Predetermination that, in the view of the treating
Provider or any Doctor with knowledge of your medical condition, could; without such care or
treatment, seriously threaten your life or health or your ability to regain maximum function; or subject
you to severe pain that cannot be adequately managed without such care or treatment; or if you have

47
a physical or mental disability, create an imminent and substantial limitation on your existing ability to
live independently.
Prospective A request for Precertification or Predetermination that is conducted before the service,
treatment or admission.
Continued Stay Review - A request for Precertification or Predetermination that is conducted during
the course of outpatient treatment or during an Inpatient admission.
Retrospective - A request for Precertification that is conducted after the service, treatment or
admission has happened. Post Service Clinical Claims Reviews are also retrospective.
Retrospective review does not include a review that is limited to an evaluation of reimbursement
levels, veracity of documentation, accuracy of coding or adjudication of payment.
Decision and Notice Requirements
We will review requests for benefits according to the timeframes listed below. The timeframes and
requirements listed are based on state and federal laws. Where state laws are stricter than federal laws,
we will follow state laws. If you live in and/or get services in a state other than the state where your
Contract was issued other state-specific requirements may apply. You may call the phone number on the
back of your Identification Card for more details.
Request Category Timeframe Requirement for Decision and
Notification
Prospective Expedited 72 hours from the receipt of request
Prospective Non-Expedited 15 calendar days from the receipt of the request
Continued Stay Review when hospitalized
at the time of the request
72 hours from the receipt of the request and prior to
expiration of current certification.
Continued Stay Review Expedited when
request is received more than 24 hours
before the end of the previous authorization
24 hours from the receipt of the request
Continued Stay Review Expedited when
request is received less than 24 hours
before the end of the previous authorization
or no previous authorization exists
72 hours from the receipt of the request
Continued Stay Review Non-Expedited 15 calendar days from the receipt of the request
Retrospective 30 calendar days from the receipt of the request
If more information is needed to make our decision, we will tell the requesting Provider and send written
notice to you or your authorized representative of the specific information needed to finish the review. If
we do not get the specific information we need or if the information is not complete by the timeframe
identified in the written notice, we will make a decision based upon the information we have.
We will give notice of our decision as required by state and federal law. Notice may be given by the
following methods:
Verbal: Oral notice given to the requesting Provider by phone or by electronic means if agreed to by
the Provider.
Written: Mailed letter or electronic means including email and fax given to, at a minimum, the
requesting Provider and you or your authorized representative
For benefits to be covered, Precertification will consider the following:
1. You must be eligible for benefits;

48
2. Premium must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under your Plan;
4. The service cannot be subject to an Exclusion under your Plan;
5. You must not have exceeded any applicable limits under your Plan; and
6. You did not perform an act, practice, or omission that constitutes fraud or abuse when requesting the
Precertification.
Health Plan Individual Case Management
Our health plan case management programs (Case Management) help coordinate services for Members
with health care needs due to serious, complex, and/or chronic health conditions. Our programs
coordinate benefits and educate Members who agree to take part in the Case Management program to
help meet their health-related needs.
Our Case Management programs are confidential and voluntary and are made available at no extra cost
to you. These programs are provided by, or on behalf of and at the request of, your health plan case
management staff. These Case Management programs are separate from any Covered Services you are
receiving.
If you meet program criteria and agree to take part, we will help you meet your identified health care
needs. This is reached through contact and team work with you and/or your chosen authorized
representative, treating Doctor(s), and other Providers.
In addition, we may assist in coordinating care with existing community-based programs and services to
meet your needs. This may include giving you information about external agencies and community-
based programs and services.
In certain cases of severe or chronic illness or injury, we may provide benefits for alternate care that is not
listed as a Covered Service through our Case Management program. We may also extend Covered
Services beyond the Benefit Maximums of this Plan. We will make our decision case-by-case, if in our
discretion the alternate or extended benefit is in the best interest of the Member and Anthem. A decision
to provide extended benefits or approve alternate care in one case does not obligate us to provide the
same benefits again to you or to any other Member. We reserve the right, at any time, to alter or stop
providing extended benefits or approving alternate care. In such case, we will notify you or your
authorized representative in writing.


49
Section 7. Benefits/Coverage (What is Covered)
This section describes the Covered Services available under your Plan. Covered Services are subject to
all the terms and conditions listed in this Booklet, including, but not limited to, Benefit Maximums,
Deductibles, Copayments, Coinsurance, Exclusions and Medical Necessity requirements. Please read
the Schedule of Benefits (Who Pays What)" for details on the amounts you must pay for Covered
Services and for details on any Benefit Maximums. Also be sure to read "How to Access Your Services
and Obtain Approval of Benefits (Applicable to managed care plans)" for more information on your Plans
rules. Read the Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for
important details on Excluded Services.
Your benefits are described below. Benefits are listed alphabetically to make them easy to find. Please
note that several sections may apply to your claims. For example, if you have inpatient surgery, benefits
for your Hospital stay will be described under Inpatient Hospital Care "and benefits for your Doctors
services will be described under Inpatient Professional Services. As a result, you should read all
sections that might apply to your claims.
You should also know that many of Covered Services can be received in several settings, including a
Doctors office, an Urgent Care Facility, an Outpatient Facility, or an Inpatient Facility. Benefits will often
vary depending on where you choose to get Covered Services, and this can result in a change in the
amount you need to pay. Please see the Schedule of Benefits (Who Pays What) for more details on
how benefits vary in each setting.
Acupuncture/Nerve Pathway Therapy
Please see Therapy Service later in this section.
Allergy Services
Your Plan includes benefits for Medically Necessary allergy testing and treatment, including allergy serum
and allergy shots.
Ambulance Services
Medically Necessary ambulance services are a Covered Service when one or more of the following
criteria are met:
You are transported by a state licensed vehicle that is designed, equipped, and used only to transport
the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other
certified medical professionals. This includes ground, water, fixed wing, and rotary wing air
transportation.
For ground ambulance, you are taken:
- From your home, the scene of an accident or medical Emergency to a Hospital;
- Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an In-Network Hospital
- Between a Hospital and a Skilled Nursing Facility or other approved Facility.
For air or water ambulance, you are taken:
- From the scene of an accident or medical Emergency to a Hospital;
- Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an In-Network Hospital
- Between a Hospital and an approved Facility.

50
Emergency ambulance services do not require prior authorization and are allowed regardless of whether
the Provider is an In-Network or Out-of-Network Provider. However non-Emergency ambulance services
are subject to Medical Necessity reviews by us. When using an air ambulance for non-Emergency
services, we reserve the right to select the air ambulance Provider. For non-Emergency ambulance
services if you do not use the air ambulance Provider we select, the Out-of-Network Provider may bill you
for any charges that exceed the Plans Maximum Allowed Amount.
You must be taken to the nearest Facility that can give care for your condition. In certain cases we may
approve benefits for transportation to a Facility that is not the nearest Facility.
Benefits also include Medically Necessary treatment of a sickness or injury by medical professionals from
an ambulance service, even if you are not taken to a Facility.
Ambulance services are not covered when another type of transportation can be used without
endangering your health. Ambulance services for your convenience or the convenience of your family or
Doctor are not a Covered Service.
Other non-covered ambulance services, include but are not limited to, trips to:
A Doctors office or clinic;
A morgue or funeral home.
Important Notes on Air Ambulance Benefits
Benefits are only available for air ambulance when it is not appropriate to use a ground or water
ambulance. For example, if using a ground ambulance would endanger your health and your medical
condition requires a more rapid transport to a Facility than the ground ambulance can provide, the Plan
will cover the air ambulance. Air ambulance will also be covered if you are in an area that a ground or
water ambulance cannot reach.
Air ambulance will not be covered if you are taken to a Hospital that is not an acute care Hospital (such
as a Skilled Nursing Facility), or if you are taken to a Physicians office or your home.
Hospital to Hospital Transport
If you are moving from one Hospital to another, air ambulance will only be covered if using a ground
ambulance would endanger your health and if the Hospital that first treats cannot give you the medical
services you need. Certain specialized services are not available at all Hospitals. For example, burn
care, cardiac care, trauma care, and critical care are only available at certain Hospitals. To be covered,
you must be taken to the closest Hospital that can treat you. Coverage is not available for air
ambulance transfers simply because you, your family, or your Provider prefers a specific Hospital
or Physician.
Autism Services
Covered Services are provided for the assessment, diagnosis, and treatment of Autism Spectrum
Disorders (ASD) for a covered child. The following treatments will not be considered Experimental or
Investigational and will be considered appropriate, effective, or efficient for the treatment of Autism
Spectrum Disorders where We determine such services are Medically Necessary:
Evaluation and assessment services;
Behavior training and behavior management and Applied Behavior Analysis, including but not limited
to consultations, direct care, supervision, or treatment, or any combination thereof, for Autism
Spectrum Disorders provided by Autism Services Providers;

51
Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy,
or speech therapy, or any combination of those therapies;
Prescription Drugs;
Psychiatric care;
Psychological care, including family counseling; and
Therapeutic care.
Treatment for Autism Spectrum Disorders must be prescribed or ordered by a Doctor or psychologist, and
services must be provided by a Provider covered under this Plan and approved to provide those services.
However, behavior training, behavior management, or Applied Behavior Analysis services (whether
provided directly or as part of Therapeutic Care), must be provided by an Autism Services Provider.
Coverage of Autism Spectrum Disorders in this section is in addition to coverage provided for early
intervention and Congenital Defects and Birth Abnormality. Autism services and the Autism Treatment
Plan are subject to review under the How to Access Your Services and Obtain Approval of Benefits
(Applicable to managed care plans) section.
Behavioral Health Services
See Mental Health, Alcohol and Substance Abuse Services later in this section.
Cardiac Rehabilitation
Please see Therapy Services later in this section.
Chemotherapy
Please see Therapy Services later in this section.

Clinical Trials
Benefits include coverage for services given to you as a participant in an approved clinical trial if the
services are Covered Services under this Plan. An approved clinical trial means a phase I, phase II,
phase III, or phase IV clinical trial that studies the prevention, detection, or treatment of cancer or other
life-threatening conditions. The term life-threatening condition means any disease or condition from which
death is likely unless the disease or condition is treated.
Benefits are limited to the following trials:
1. Federally funded trials approved or funded by one of the following:
a. The National Institutes of Health.
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.
e. Cooperative group or center of any of the entities described in (a) through (d) or the Department
of Defense or the Department of Veterans Affairs.

52
f. A qualified non-governmental research entity identified in the guidelines issued by the National
Institutes of Health for center support grants.
g. Any of the following in i-iii below if the study or investigation has been reviewed and approved
through a system of peer review that the Secretary determines 1) to be comparable to the system
of peer review of studies and investigations used by the National Institutes of Health, and 2)
assures unbiased review of the highest scientific standards by qualified individuals who have no
interest in the outcome of the review.
i. The Department of Veterans Affairs.
ii. The Department of Defense.
iii. The Department of Energy.
2. Studies or investigations done as part of an investigational new drug application reviewed by the
Food and Drug Administration;
3. Studies or investigations done for drug trials which are exempt from the investigational new drug
application.
Your Plan may require you to use an In-Network Provider to maximize your benefits.
When a requested service is part of an approved clinical trial, it is a Covered Service even though it might
otherwise be Investigational as defined by this Plan. All other requests for clinical trials services that are
not part of approved clinical trials will be reviewed according to our Clinical Coverage Guidelines, related
policies and procedures.
Your Plan is not required to provide benefits for the following services. We reserve our right to exclude
any of the following services:
i. The Investigational item, device, or service, itself; or
ii. Items and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
Dental Services
Your Dental Benefits
Anthem does not determine whether dental services listed in this section are medically necessary to treat
your specific condition or restore your dentition. There is a preset schedule of dental services that are
covered under this Plan. We evaluate the procedures submitted to us on your claim to determine if they
are a covered service under this Plan.

Exception: Claims for orthodontic care will be reviewed to determine if it was Dentally Necessary
Orthodontic Care. See the section Orthodontic Care for more information.
Your dentist may recommend or prescribe other dental care services that are not covered, are cosmetic in
nature, or exceed the benefit frequencies of this Plan. While these services may be necessary for your
dental condition, they may not be covered by us. There may be an alternative dental care service
available to you that is covered under your Plan. These alternative services are called optional
treatments. If an allowance for an optional treatment is available, you may apply this allowance to the
initial dental service prescribed by your dentist. You are responsible for any costs that exceed the
allowance, in addition to any coinsurance or deductible you may have.

53
The decision as to what dental care treatment is best for you is solely between you and your dentist.
Pretreatment Estimate
A pretreatment estimate is a valuable tool for you and your dentist. It provides you and the dentist with an
idea of what your out of pocket costs will be for the dental care treatment. This will allow the dentist and
you to make any necessary financial arrangements before treatment begins. It is a good idea to get a
pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or
orthodontic care
The pretreatment estimate is recommended, but not required for you to receive benefits for covered
dental care services.
A pretreatment estimate does not authorize treatment or determine its medical necessity (except for
orthodontics), and does not guarantee benefits. The estimate will be based on your current eligibility and
the Plan benefits in effect at the time the estimate is submitted to us. This is an estimate only. Our final
payment will be based on the claim that is submitted at the time of the completed dental care service(s).
Submission in other claims, changes to your eligibility or changes to the Plan may affect our final
payment.
You can ask your dentist to submit a pretreatment estimate for you, or you can send it to us yourself.
Please include the procedure codes for the services to be performed (your dentist can tell you what
procedure codes). Pretreatment estimate requests can be sent to the address on your dental ID card.
{Pediatric dental:
[Pediatric Dental for Members through Age 18

This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.

Diagnostic and Preventive Services

Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive

Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s)
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.

Dental Cleaning (Prophylaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.

Fluoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.


54
Sealants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.

Space Maintainers and Recementation of Space Maintainer - Covered only for premature loss of
primary posterior (back) teeth.

Emergency (Palliative) Treatment (for pain relief).

Basic Restorative Services

Amalgam (silver) Restoration Treatment to restore decayed or fractured permanent or primary
posterior (back) teeth. Covered once in a 24 month period per tooth surface.

Composite (white) Resin Restorations Covered once in a 24 month period for the same amalgam
restoration.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.

Major Restorative Services

Recement Crown.

Prefabricated Stainless Steel or Resin Crown - Covered once per tooth in a 24 month period.

Sedative Filling.

Pin Retention per tooth in addition to restoration.

Oral Surgery

Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

Complex Surgical Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth

Note: Surgical removal of 3rd molars are covered only if the removal is associated with symptoms of oral
pathology.

Endodontic Services

Therapeutic Pulpotomy - Covered for primary teeth only.

Root Canal Therapy - Covered for permanent teeth only .


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Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

Dentally Necessary Orthodontic Care
To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:
a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth when
you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores at a
level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem that
interferes with the biting function.

Orthodontic treatment may include the following:
Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
Interceptive Treatment - A limited (phase I) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments
Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive ongoing
payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate of
Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued. A
new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve as
the claim form to be submitted 6 months from the date of appliance placement.]


56
{Pediatric/Adult dental:
[Dental Services
Dental Services for Members through Age 18
This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.
Diagnostic and Preventive Services
Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive
Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s) 4 single x-rays per 12-month period.
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.
Dental Cleaning (Prophylaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.
Fluoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.
Sealants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.
Space Maintainers and Recementation of Space Maintainer. Covered only for premature loss of
primary posterior (back) teeth.
Emergency (Palliative) Treatment (for pain relief).
Basic Restorative Services
Amalgam (silver) Restoration Treatment to restore decayed or fractured permanent or primary teeth
posterior (back) teeth. Covered once in a 24 month period per tooth surface.
Composite (white) Resin Restorations Covered once in a 24 month period per tooth surface.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be

57
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.
Major Restorative Services
Recement Crown.
Prefabricated Stainless Steel or Resin Crown. Covered once per tooth in a 24 month period.
Sedative Filling.
Pin Retention per tooth in addition to restoration.
Oral Surgery
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

Complex Surgical Extractions

Surgical removal of impacted tooth

Note: Surgical removal of 3
rd
molars are covered only if the removal is associated with symptoms
of oral pathology.

Endodontic Services

Therapeutic Pulpotomy. Covered only for primary teeth.

Root Canal Therapy. Covered for permanent teeth only.
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

Dentally Necessary Orthodontic Care

To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:

a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth
when you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores
at a level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem
that interferes with the biting function.


58
Orthodontic treatment may include the following:

Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
Interceptive Treatment - A limited (phase I) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments

Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive
ongoing payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate
of Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued.
A new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve
as the claim form to be submitted 6 months from the date of appliance placement.]
Dental Services for Members Age 19 and Older
This Plan covers the dental services below for Members age 19 and older when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive treatment.
Diagnostic and Preventive Services
Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Radiographs (X-rays)
Bitewings - 1 series per 24-month period.
Full Mouth (Complete Series) or Panoramic - Once per 60-month period.
Periapical(s) - 4 single x-rays per 12-month period.
Occlusal - 2 series per 24-month period.

59
Dental Cleaning (Prophylaxis) Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain
from teeth. Any combination of this procedure and periodontal maintenance (See Periodontal Services
below) are covered 2 times per calendar year.
Basic Restorative Services
Emergency Treatment Emergency (palliative) treatment for the temporary relief of pain or infection.
Amalgam (silver) Restorations Treatment to restore decayed or fractured permanent or primary teeth.
Composite (white) Resin Restorations
Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anterior
(front) teeth.
Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posterior
(back) teeth.
Benefits will be limited to the same surfaces and allowances for amalgam (silver filling). You must pay
the difference in cost between the Maximum Allowed Amount for the Covered Service and the optional
treatment plus any Deductible and/or Coinsurance.
Benefits for amalgam or composite restorations will be limited to one service per tooth surface per 24-
month period.
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root
Brush Biopsy - Covered once per 36-month period for Members age 20 to 39. Covered once per 12-
month period for Members age 40 and older.
Endodontic Services
Endodontic Therapy on Primary Teeth
Pulpal Therapy
Therapeutic Pulpotomy
Endodontic Therapy on Permanent Teeth
Root Canal Therapy
Root Canal Retreatment
All of the above endodontic services are limited to once per tooth per lifetime.
Periodontal Services
Periodontal Maintenance A procedure that includes removal of bacteria from the gum pocket areas,
scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patients who
have completed periodontal treatment.

60
Benefits for any combination of this procedure and dental cleanings (see Diagnostic and Preventive
Services section) are limited to 2 times per calendar year.
Basic Non-Surgical Periodontal Care Treatment of diseases of the gingival (gums) and bone
supporting the teeth.
Periodontal scaling & root planning is covered once per 36 months if the tooth has a pocket depth of
4 millimeters or greater.
Full mouth debridement is covered once per lifetime.
Complex Surgical Periodontal Care Surgical treatment of diseases of the gingival (gums) and bone
supporting the teeth. The following services are considered complex surgical periodontal services:
Gingivectomy/gingivoplasty;
Gingival flap;
Apically positioned flap;
Osseous surgery;
Bone replacement graft;
Pedicle soft tissue graft;
Free soft tissue graft;
Subepithelial connective tissue graft;
Soft tissue allograft;
Combined connective tissue and double pedicle graft;
Distal/proximal wedge - Covered on natural teeth only
Complex surgical periodontal services are limited as follows:
Only one complex surgical periodontal service is covered per 36-month period per single tooth; or
Only one complex surgical periodontal service is covered per 36-month period for multiple teeth in the
same quadrant if the pocket depth of the tooth is 5 millimeters or greater.
Oral Surgery Services
Complex Surgical Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth
Surgical removal of residual tooth roots
Surgical removals of third molars are only covered if the removal is associated with symptoms of oral
pathology.
Other Complex Surgical Procedures Covered only when required to prepare for dentures and limited to
once in a 60-month period:
Alveoloplasty
Vestibuloplasty
Removal of exostosis-per site
Surgical reduction of osseous tuberosity
Surgical Reduction of Fibrous Tuberosity Covered once every 6 months.

61
Adjunctive General Services
Intravenous Conscious Sedation, IV Sedation, and General Anesthesia Covered only when given
with covered complex surgical services. Benefits are not available when given with non-surgical
dental care.
Major Restorative Services
Gold foil restorations The Plan will cover an amalgam (silver filling) benefit equal to the same number of
surfaces and allowances.
You must pay the difference in cost between the Maximum Allowed Amount for the Covered Services and
optional treatment plus any Deductible and/or Coinsurance that applies. Covered once per 24-month
period.
Inlays Benefit will equal an amalgam (silver) restoration for the same number of surfaces.
If an inlay is performed to restore a posterior (back) tooth with a metal, porcelain, or any composite
(white) based resin material, the patient must pay the difference in cost between the Maximum Allowed
Amount for the Covered Service and inlay, plus any Deductible and/or Coinsurance that applies.
Onlays and/or Permanent Crowns Covered once every 7 years if the tooth has extensive loss of natural
tooth structure due to decay or tooth fracture such that a restoration cannot be used to restore the tooth.
We will pay up to the Maximum Allowed Amount for a porcelain to noble metal crown. You must pay the
difference in cost between the porcelain to noble metal crown and the optional treatment, plus any
Deductible and/or Coinsurance that applies.
Implant Crowns See Prosthodontic Services.
Recement Inlay, Onlay, and Crowns Covered 6 months after initial placement.
Crown/Inlay/Onlay Repair Covered once per 12-month period per tooth when the submitted narrative
from the treating dentist supports the procedure.
Restorative cast post and core build-up, including 1 post per tooth and 1 pin per surface Covered
once every 7 years when necessary to retain an indirectly fabricated restoration due to extensive loss of
actual tooth structure due to caries or fracture.
Prosthodontic Services
Tissue Conditioning Covered once per 24-month period.
Reline and Rebase Covered once per 24-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge).
Repairs, Replacement of Broken Artificial Teeth, Replacement of Broken Clasp(s) Covered once per
6-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance;

62
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge); and
When the submitted narrative from the treating dentist supports the procedure.
Denture Adjustments Covered 2 times per 12-month period when:
The denture is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the denture.
Partial and Bridge Adjustments Covered 2 times per 24-month period when:
The partial or bridge is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the partial or bridge.
Removable Prosthetic Services (Dentures and Partials) Covered once per 7 year period:
For the replacement of extracted (removed) permanent teeth;
If 7 years have passed since the last covered removable prosthetic appliance (denture or partial) and
the existing denture or partial cannot be repaired or adjusted.
Fixed Prosthetic Services (Bridge) Covered once every 7 years:
For the replacement of extracted (removed) permanent teeth;
If no more than 3 teeth are missing in the same arch;
A natural, healthy, sound tooth is present to serve as the anterior and posterior retainer;
No other missing teeth in the same arch that have not been replaced with a removable partial
denture;
If none of the individual units of the bridge has been covered previously as a crown or cast restoration
in the last 7 years;
If 7 years have passed since the last covered removable prosthetic appliance (bridge) and the
existing bridge cannot be repaired or adjusted.
If there are multiple missing teeth, benefits may only be paid for a removable partial denture if it would be
the least costly, commonly performed course of treatment. Any optional benefits are subject to all
contract limits on the Covered Service.
Recement Fixed Prosthetic Covered once per 12 months.
Single Tooth Implant Body, Abutment and Crown Covered once per 7 year period. Coverage includes
only the single surgical placement of the implant body, implant abutment and implant/abutment supported
crown.
Some adjunctive implant services may not be covered. We recommend that you get a
pretreatment estimate to estimate the amount of payment before you begin treatment.

Orthodontic Services
Orthodontic services for members age 19 and older is not covered, except as provided under the Dental
Services (All Members / All Ages) section below.]

63
Dental Services (All Members / All Ages)
Preparing the Mouth for Medical Treatments
Your Plan includes coverage for dental services to prepare the mouth for medical services and treatments
such as radiation therapy to treat cancer and prepare for transplants. Covered Services include:
Evaluation
Dental x-rays
Extractions, including surgical extractions
Anesthesia
Accident-Related Dental Services
Benefits are also available for dental work needed to treat injuries to the jaw, sound natural teeth, mouth
or face as a result of an accident. An injury that results from chewing or biting is not considered an
Accidental Injury under this Plan, unless the chewing or biting results from a medical or mental condition.
Treatment must begin within 90 days of the injury to be a Covered Service under this Plan.
Cleft Palate and Cleft Lip Conditions
Benefits are available for inpatient care and outpatient care, including:
Orofacial surgery
Surgical care and follow-up care by plastic surgeons and oral surgeons
Orthodontics and prosthodontic treatment
Prosthetic treatment such as obturators, speech appliances, and prosthodontic
Prosthodontic and surgical reconstruction for the treatment of cleft palate and/or cleft lip
If you have a dental plan, the dental plan would be the main plan and must fully cover orthodontics and
dental care for cleft palate and cleft lip conditions.
Dental Anesthesia for Children
Benefits are available for general anesthesia from a Hospital, outpatient surgical Facility or other Facility,
and for the Hospital or Facility charges needed for dental care for a covered Dependent child who:
Has a physical, mental or medically compromising condition
Has dental needs for which local anesthesia is not effective because of acute infection, anatomic
variation or allergy
Is extremely uncooperative, unmanageable, uncommunicative or anxious and whose dental needs
are deemed sufficiently important that dental care cannot be deferred
Has sustained extensive orofacial and dental trauma.
Diabetes Equipment, Education, and Supplies
Your Plan covers diabetes training and medical nutrition therapy if you have diabetes (whether or not it is
insulin dependent), or if you have raised blood glucose levels caused by pregnancy. Other medical
conditions may also qualify. But the services need to be ordered by a Doctor and given by a Provider
who is certified, registered or with training in diabetes. Diabetes training sessions must be provided by a
Provider in an outpatient Facility or in a Doctors office.

64
Screenings for gestational diabetes are covered under Preventive Care later in this section.
Diagnostic Services
Your Plan includes benefits for tests or procedures to find or check a condition when specific symptoms
exist. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or
Hospital admission. Benefits include the following services:
Diagnostic Laboratory and Pathology Services
Diagnostic Imaging Services and Electronic Diagnostic Tests
X-rays / regular imaging services
Ultrasound
Electrocardiograms (EKG)
Electroencephalography (EEG)
Echocardiograms
Hearing and vision tests for a medical condition or injury (not for screenings or preventive care)
Tests ordered before a surgery or admission.
Advanced Imaging Services
Benefits are also available for advanced imaging services, which include but are not limited to:
CT scan
CTA scan
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Angiography (MRA)
Magnetic resonance spectroscopy (MRS)
Nuclear Cardiology
PET scans
PET/CT Fusion scans
QTC Bone Densitometry
Diagnostic CT Colonography
The list of advanced imaging services may change as medical technologies change.
Dialysis
See Therapy Services later in this section.
Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies
Durable Medical Equipment and Medical Devices
Your Plan includes benefits for durable medical equipment and medical devices when the equipment
meets the following criteria:
Is meant for repeated use and is not disposable.
Is used for a medical purpose and is of no further use when medical need ends.
Is meant for use outside a medical Facility.

65
Is only for the use of the patient.
Is made to serve a medical use.
Is ordered by a Provider.
Benefits include purchase-only equipment and devices (e.g., crutches and customized equipment),
purchase or rent-to-purchase equipment and devices (e.g., Hospital beds and wheelchairs), and
continuous rental equipment and devices (e.g., oxygen concentrator, ventilator, and negative pressure
wound therapy devices). Continuous rental equipment must be approved by us. We may limit the
amount of coverage for ongoing rental of equipment. We may not cover more in rental costs than the cost
of simply purchasing the equipment.
Benefits include repair and replacement costs as well as supplies and equipment needed for the use of
the equipment or device, for example, a battery for a powered wheelchair.
Oxygen and equipment for its administration are also Covered Services. Benefits are also available for
cochlear implants.
Hearing Aid Services
For children under 18, subject to the terms of the Booklet, your Plan covers the following hearing aids and
the services that go with them when provided by or purchased as a result of a written recommendation
from an otolaryngologist or a state-certified audiologist:
Audiological testing to measure the level of hearing loss and to choose the proper make and model of
a hearing aid. These evaluations will be provided under the prior Diagnostic Services of this
section;
Hearing aids (monaural or binaural) including ear mold(s), the hearing aid instrument, batteries, cords
and other ancillary equipment. The Plan covers auditory training when it is offered using approved
professional standards. Initial and replacement hearing aids will be supplied every 5 years, a new
hearing aid may be a covered service when alterations to your existing hearing aid cannot adequately
meet your needs or be repaired; and
Visits for fitting, counseling, adjustments and repairs after receiving the covered hearing aid.
Orthotics
Benefits are available for certain types of orthotics (braces, boots, splints). Covered Services include the
initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support,
align, prevent, or correct deformities or to improve the function of movable parts of the body, or which
limits or stops motion of a weak or diseased body part.
Prosthetics
Your Plan also includes benefits for prosthetics, which are artificial substitutes for body parts for functional
or therapeutic purposes, when they are required to adequately meet your needs.
Benefits include the purchase, fitting, adjustments, repairs and replacements. Covered Services may
include, but are not limited to:
1) Artificial limbs and accessories. For prosthetic arms and legs we cover up to the benefits amounts
provide by federal laws for Medicare or where needed to meet state insurance laws;
2) One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes);
3) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Womens
Health and Cancer Rights Act;

66
4) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to
ostomy care;
5) Restoration prosthesis (composite facial prosthesis);
Medical and Surgical Supplies
Your Plan includes coverage for medical and surgical supplies that serve only a medical purpose, are
used once, and are purchased (not rented). Covered supplies include syringes, needles, surgical
dressings, splints, diabetic supplies, and other similar items that serve only a medical purpose. Covered
Services do not include items often stocked in the home for general use like Band-Aids, thermometers,
and petroleum jelly.
Blood and Blood Products
Your Plan also includes coverage for the administration of blood products unless they are received from a
community source, such as blood donated through a blood bank.
Emergency Care Services
Emergency Services
Benefits are available in a Hospital Emergency Room for services and supplies to treat the onset of
symptoms, screen and stabilize an Emergency, which is defined below:
Emergency (Emergency Medical Condition)
Emergency or Emergency Medical Condition means health care services provided in connection with
any event that a prudent layperson having average knowledge of health services and medicine and acting
reasonably would believe threatens his or her life or limb in such a manner that a need for immediate
medical care is created to prevent death or serious impairment of health.
Emergency Care
Emergency Care means a medical exam done in the Emergency Department of a Hospital, and
includes services routinely available in the Emergency Department to evaluate an Emergency Condition.
It includes any further medical exams and treatment required to stabilize the patient.
If you are experiencing an Emergency please call 911 or visit the nearest Hospital for treatment.
Medically Necessary services will be covered whether you get care from an In-Network or Out-of-Network
Provider. Emergency Care you get from an Out-of-Network Provider will be covered as an In-Network
service, you will not need to pay more than what you would have if you had seen an In-Network Provider.
If you are admitted to the Hospital from the Emergency Room, be sure that you or your Doctor calls us as
soon as possible. We will review your care to decide if a Hospital stay is needed and how many days you
should stay. See How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) for more details. If you or your Doctor do not call us, you may have to pay for services that
are determined to be not Medically Necessary.
With respect to an Emergency, stabilize means to provide such medical treatment of the condition as may
be necessary to assure, within reasonable medical probability, that no material deterioration of the
condition is likely to result from or occur during the transfer of the Member from a facility. With respect to
a pregnant woman who is having contractions, the term stabilize also means to deliver (including the

67
placenta), if there is inadequate time to effect a safe transfer to another Hospital before delivery or
transfer may pose a threat to the health or safety of the woman or the unborn child. Treatment you get
after your condition has stabilized is not Emergency Care. If you continue to get care from an Out-of-
Network Provider, Covered Services will be covered at the Out-of-Network level unless we agree to cover
it as an Authorized Service.
Home Care Services
Benefits are available for Covered Services performed by a Home Health Care Agency or other Provider
in your home. Home care is covered only when such care is necessary as an alternative to Hospital
stay. Prior Hospital stay is not required. Home care must be prescribed by a Doctor, under a plan of care
established by the Doctor in collaboration with a Home Health Care Agency. We must preauthorize all
care and reserve the right to review treatment plans at periodic intervals.
Covered Services include but are not limited to:
Intermittent skilled nursing services by an R.N. or L.P.N.
Medical / social services
Diagnostic services
Nutritional guidance
Training of the patient and/or family/caregiver
Home health aide services. You must be receiving skilled nursing or therapy. Services must be given
by appropriately trained staff working for the Home Health Care Provider. Other organizations may
give services only when approved by us, and their duties must be assigned and supervised by a
professional nurse on the staff of the Home Health Care Provider.
Therapy Services of physical, occupational, speech and language, respiratory and inhalation (except
for Manipulation Therapy which will not be covered when given in the home)
Medical supplies
Durable medical equipment, prosthetics and orthopedic appliances
Private duty nursing in the home
Home Infusion Therapy
See Therapy Services later in this section.
Hospice Care
The services and supplies listed below are Covered Services when given by a Hospice for the palliative
care of pain and other symptoms that are part of a terminal disease. Palliative care means care that
controls pain and relieves symptoms, but is not meant to cure a terminal illness. Hospice care includes
routine home care, constant home care, inpatient Hospice and inpatient respite. Covered Services
include:
Care from an interdisciplinary team with the development and maintenance of an appropriate plan of
care.
Short-term Inpatient Hospital care when needed in periods of crisis or as respite care.
Skilled nursing services, home health aide services, and homemaker services given by or under the
supervision of a registered nurse.
Doctor services and diagnostic testing.
Social services and counseling services from a licensed social worker.
Nutritional support such as intravenous feeding and feeding tubes and nutritional counseling.
Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed
therapist.

68
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition,
including oxygen and related respiratory therapy supplies.
Prosthetics and orthopedic appliances.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Members death.
Bereavement services are available to the patient/family consisting of those individuals who are
closely linked to the patient, including the immediate family, the primary or designated care giver and
individuals with significant personal ties.
Transportation.
Your Doctor and Hospice medical director must certify that you are terminally ill and likely have less than
six months to live. Your Doctor must agree to care by the Hospice and must be consulted in the
development of the care plan. The Hospice must keep a written care plan on file and give it to us upon
request.
Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy
given as palliative care, are available to a Member in Hospice. These additional Covered Services will be
covered under other parts of this Plan. Any care you get that has to do with an unrelated illness or
medical condition will be subject to the provisions of this plan that deals with that illness.
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell)
Services
Your Plan includes coverage for Medically Necessary human organ and tissue transplants. Certain
transplants (e.g., cornea and kidney) are covered like any other surgery, under the regular inpatient and
outpatient benefits described elsewhere in this Booklet.
This section describes benefits for certain Covered Transplant Procedures that you get during the
Transplant Benefit Period. Any Covered Services related to a Covered Transplant Procedure, received
before or after the Transplant Benefit Period, are covered under the regular Inpatient and outpatient
benefits described elsewhere in this Booklet.
In this section you will see some key terms, which are defined below:
Covered Transplant Procedure
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage.
It also includes Medically Necessary myeloablative or reduced intensity preparative chemotherapy,
radiation therapy, or a combination of these therapies.
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and transfusions including necessary acquisition procedures, harvest and storage, and
including Medically Necessary preparatory myeloablative therapy.
In-Network Transplant Provider
A Provider that we have chosen as a Center of Excellence and/or a Provider selected to take part as an
In-Network Transplant Provider by a designee. The Provider has entered into a Transplant Provider
Agreement to give Covered Transplant Procedures to you and take care of certain administrative duties
for the transplant network. A Provider may be an In-Network Transplant Provider for:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.

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Out-of-Network Transplant Provider
Any Provider that has NOT been chosen as a Center of Excellence by us or has not been selected to
take part as an In-Network Transplant Provider by a designee.
Transplant Benefit Period
At an In-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts for the applicable case rate / global time period. The number of
days will vary depending on the type of transplant received and the In-Network Transplant Provider
agreement. Call the Case Manager for specific In-Network Transplant Provider details for services
received at or coordinated by an In-Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
Prior Approval and Precertification
To maximize your benefits, you should call our Transplant Department as soon as you think you
may need a transplant to talk about your benefit options. You must do this before you have an
evaluation and/or work-up for a transplant. We will help you maximize your benefits by giving you
coverage information, including details on what is covered and if any clinical coverage guidelines, medical
policies, In-Network Transplant Provider rules, or Exclusions apply. Call the Customer Service phone
number on the back of your Identification Card and ask for the transplant coordinator. Even if we give a
prior approval for the Covered Transplant Procedure, you or your Provider must call our Transplant
Department for Precertification prior to the transplant whether this is performed in an Inpatient or
Outpatient setting.
Precertification is required before we will cover benefits for a transplant. Your Doctor must certify, and we
must agree, that the transplant is Medically Necessary. Your Doctor should send a written request for
Precertification to us as soon as possible to start this process. Not getting Precertification will result in a
denial of benefits.
Please note that there are cases where your Provider asks for approval for HLA testing, donor searches
and/or a harvest and storage of stem cells prior to the final decision as to what transplant procedure will
be needed. In these cases, the HLA testing and donor search charges will be covered as routine
diagnostic tests. The harvest and storage request will be reviewed for Medical Necessity and may be
approved. However, such an approval for HLA testing, donor search and/or harvest and storage is NOT
an approval for the later transplant. A separate Medical Necessity decision will be needed for the
transplant.
Donor Benefits
Benefits for an organ donor are as follows:
When both the person donating the organ and the person getting the organ are our covered
Members, each will get benefits under their Plan.
When the person getting the organ is our covered Member, but the person donating the organ is not,
benefits under this Plan are limited to benefits not available to the donor from any other source. This
includes, but is not limited to, other insurance, grants, foundations, and government programs.
If our covered Member is donating the organ to someone who is not a covered Member, benefits are
not available under this Plan.

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Transportation and Lodging
We will cover the cost of reasonable and necessary travel costs when you get prior approval and need to
travel more than 75 miles from your permanent home to reach the Facility where the Covered Transplant
Procedure will be performed. Our help with travel costs includes transportation to and from the Facility,
and lodging for the patient and one companion. If the Member receiving care is a minor, then reasonable
and necessary costs for transportation and lodging may be allowed for two companions. You must send
itemized receipts for transportation and lodging costs in a form satisfactory to us when claims are filed.
Call us for complete information.
For lodging and ground transportation benefits, we will cover costs up to the current limits set forth in the
Internal Revenue Code.
Non-Covered Services for transportation and lodging include, but are not limited to:
Child care,
Mileage within the medical transplant Facility city,
Rental cars, buses, taxis, or shuttle service, except as specifically approved by us,
Frequent Flyer miles,
Coupons, Vouchers, or Travel tickets,
Prepayments or deposits,
Services for a condition that is not directly related, or a direct result, of the transplant,
Phone calls,
Laundry,
Postage,
Entertainment,
Travel costs for donor companion/caregiver,
Return visits for the donor for a treatment of an illness found during the evaluation,
Meals.
Infertility Services
Please see Maternity and Reproductive Health Services later in this section.
Inpatient Services
Inpatient Hospital Care
Covered Services include acute care in a Hospital setting.
Benefits for room, board, and nursing services include:
A room with two or more beds.
A private room. The most the Plan will cover for private rooms is the Hospitals average semi-private
room rate unless it is Medically Necessary that you use a private room for isolation and no isolation
facilities are available.
A room in a special care unit approved by us. The unit must have facilities, equipment, and supportive
services for intensive care or critically ill patients.
Routine nursery care for newborns during the mothers normal Hospital stay.

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Newborn care for during and after the mothers maternity Hospital stay for treatment of injury and
sickness and medically diagnosed Congenital Defects and Birth Abnormalities.
Meals, special diets.
General nursing services.
Benefits for ancillary services include:
Operating, childbirth, and treatment rooms and equipment.
Prescribed Drugs.
Anesthesia, anesthesia supplies and services given by the Hospital or other Provider.
Medical and surgical dressings and supplies, casts, and splints.
Diagnostic services.
Therapy services.
Inpatient Professional Services
Covered Services include:
Medical care visits.
Intensive medical care when your condition requires it.
Treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for
surgery. Benefits include treatment by two or more Doctors during one Hospital stay when the nature
or severity of your health problem calls for the skill of separate Doctors.
A personal bedside exam by another Doctor when asked for by your Doctor. Benefits are not
available for staff consultations required by the Hospital, consultations asked for by the patient,
routine consultations, phone consultations, or EKG transmittals by phone.
Surgery and general anesthesia.
Newborn exam. A Doctor other than the one who delivered the child must do the exam.
Professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology.
Manipulation Therapy
Please see Therapy Services later in this section.
Maternity and Reproductive Health Services
Maternity Services
Covered Services include services needed during a normal or complicated pregnancy, Complications of
Pregnancy, and for services needed for a miscarriage. Covered maternity services include:
Professional and Facility services for childbirth in a Facility or the home including the services of an
appropriately licensed nurse midwife;
Routine nursery care for the newborn during the mothers normal Hospital stay, including circumcision
of a covered male Dependent;
Prenatal and postnatal services; and
Fetal screenings, which are genetic or chromosomal tests of the fetus, as allowed by us.
If you are pregnant on your Effective Date and in the first trimester of the pregnancy, you must change to
an In-Network Provider to have Covered Services covered at the In-Network level. If you are pregnant on
your Effective Date and in your second or third trimester of pregnancy (13 weeks or later) as of the
Effective Date, benefits for obstetrical care will be available at the In-Network level even if an Out-of-
Network Provider is used if you fill out a Continuation of Care Request Form and send it to us. Covered

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Services will include the obstetrical care given by that Provider through the end of the pregnancy and the
immediate post-partum period.
Important Note About Maternity Admissions: Under federal law, we may not limit benefits for any
Hospital length of stay for childbirth for the mother or newborn to less than 48 hours after vaginal birth, or
less than 96 hours after a cesarean section (C-section). If the baby is born between 8:00 p.m. and 8:00
a.m., coverage will continue until 8:00 a.m. on the morning after the 48 or 96 hours timeframe. However,
federal law as a rule does not stop the mothers or newborns attending Provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours, or 96 hours, as applicable. In
any case, as provided by federal law, we may not require a Provider to get authorization from us before
prescribing a length of stay which is not more than 48 hours for a vaginal birth or 96 hours after a C-
section.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain
contraceptives are covered under the Preventive Care benefit. Please see that section for further
details.
Sterilization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the Preventive Care benefit.
Abortion Services
Benefits include services for therapeutic or elective abortion regardless if Medically Necessary, unless
applicable law or regulation prohibits the Group from providing such coverage (in which case, Covered
Services are provided only to the extent necessary to prevent the death of the mother or unborn baby).
Infertility Services
Important Note: Although this Plan offers limited coverage of certain infertility services, it does not cover
all forms of infertility treatment. Benefits do not include assisted reproductive technologies (ART) or the
diagnostic tests and Drugs to support it. Examples of ART include artificial insemination, in-vitro
fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT).
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy,
endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical
conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
Fertility treatments such as artificial insemination and in-vitro fertilization are not a Covered Service.
Medical Foods
Covered Services include Medically Necessary medical foods for home use for metabolic disorders which
may be taken by mouth or enterally. A Provider must have prescribed the medical foods that are
designed and manufactured for the treatment of inherited enzymatic disorders caused by single gene
defects involved in the metabolism of amino, organic, and fatty acids. Such disorders include:
Phenylketonuria, if you are 21 or younger (35 or younger for women of child-bearing age);
Maternal phenylketonuria;

73
Maple syrup urine disease;
Tyrosinemia;
Homocystinuria;
Histidinemia;
Urea cycle disorders;
Hyperlysinemia;
Glutaric acidemias;
Methylmalonic academia; and
Propionic acidemia.
Covered Services do not include enteral nutrition therapy or medical foods for Members with cystic
fibrosis or lactose- or soy- intolerance. Also all covered medical foods must be obtained through a
Pharmacy and are subject to the pharmacy payment requirements. Please see Prescription Drug Benefit
at a Retail or Home Delivery (Mail Order) Pharmacy later in this section.
Mental Health, Biologically Based Mental Illness, Alcohol and
Substance Abuse Services
Covered Services include the following:

Inpatient Services in a Hospital or any facility that we must cover per state law. Inpatient benefits
include psychotherapy, psychological testing, electroconvulsive therapy, and detoxification.

Outpatient Services including office visits and treatment in an outpatient department of a Hospital or
outpatient Facility, such as partial hospitalization programs and intensive outpatient programs.

Residential Treatment which is specialized 24-hour treatment in a licensed residential treatment
center. It offers individualized and intensive treatment and includes:

Observation and assessment by a psychiatrist weekly or more often,
Rehabilitation, therapy, and education.

You can get Covered Services under this section from the following Providers:

Psychiatrist,
Psychologist,
Neuropsychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
Licensed professional counselor (L.P.C) or
Any agency licensed by the state to give these services, when we have to cover them by law.
Occupational Therapy
Please see Therapy Services later in this section.

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Office Visits and Doctor Services
Covered Services include:
Office Visits for medical care (including second surgical opinions) to examine, diagnose, and treat an
illness or injury.
Home Visits for medical care to examine, diagnose, and treat an illness or injury. Please note that
Doctor visits in the home are different than the Home Care Services benefit described earlier in this
Booklet.
Retail Health Clinic Care for limited basic health care services to Members on a walk-in basis. These
clinics are normally found in major pharmacies or retail stores. Health care services are typically given by
Physicians Assistants or Nurse Practitioners. Services are limited to routine care and treatment of
common illnesses for adults and children.
Walk-In Doctors Office for services limited to routine care and treatment of common illnesses for adults
and children. You do not have to be an existing patient or have an appointment to use a walk-in Doctors
office.
Urgent Care as described in Urgent Care Services later in this section.
Online Care Visits when available in your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online care visits do not include reporting normal lab or
other test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Hearing Exams and tests to determine the need for hearing correction. For additional information on
hearing aid services, please see Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies earlier in this section.
Prescription Drugs Administered in the Office
Orthotics
See Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies earlier in this section.
Outpatient Facility Services
Your Plan includes Covered Services in an:
Outpatient Hospital,
Ambulatory Surgical Facility,
Mental Health / Substance Abuse Facility, or
Other Facilities approved by us.
Benefits include Facility and related (ancillary) charges, when proper, such as:
Surgical rooms and equipment,
Prescription Drugs, including Specialty Drugs,
Anesthesia and anesthesia supplies and services given by the Hospital or other Facility,

75
Medical and surgical dressings and supplies, casts, and splints,
Diagnostic services,
Therapy services.
Physical Therapy
Please see Therapy Services later in this section.
Preventive Care
Preventive care includes screenings and other services for adults and children with no current symptoms
or history of a health problem.
Members who have current symptoms or a diagnosed health problem will get benefits under the
Diagnostic Services benefit, not this benefit.
Preventive care services will meet the requirements of federal and state law. Many preventive care
services are covered with no Deductible, Copayments or Coinsurance when you use an In-Network
Provider. That means we cover 100% of the Maximum Allowed Amount. Covered Services fall under
four broad groups:
1. Services with an A or B rating from the United States Preventive Services Task Force. Examples
include screenings for:
a. Breast cancer,
b. Cervical cancer,
c. Colorectal cancer,
d. High blood pressure,
e. Type 2 Diabetes Mellitus,
f. Cholesterol,
g. Child and adult obesity.
Tobacco use screening and tobacco cessation counseling and intervention is also covered.
2. Immunizations for children, adolescents, and adults, including cervical cancer vaccinations for
females, where recommended by the Advisory Committee on Immunization Practices of the Centers
for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as listed in the guidelines
supported by the Health Resources and Services Administration; and
4. Preventive care and screening for women as listed in the guidelines supported by the Health
Resources and Services Administration, including:
a. Womens contraceptives, sterilization treatments, and counseling. This includes Generic and
single-source Brand Drugs as well as injectable contraceptives and patches. Contraceptive
devices such as diaphragms, intra uterine devices (IUDs), and implants are also covered. Multi-
source Brand Drugs will be covered under the Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy.
b. Breastfeeding support, supplies, and counseling. Benefits for breast pumps are limited to one
pump per pregnancy.
c. Gestational diabetes screening.

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You may call Customer Service at the number on your Identification Card for more details about these
services or view the federal governments web sites,https://www.healthcare.gov/what-are-my-preventive-
care-benefits, http://www.ahrq.gov, and http://www.cdc.gov/vaccines/acip/index.html.
Prosthetics
See Durable Medical Equipment and Medical Devices, Orthotics, and Medical and Surgical Supplies
earlier in this section.
Pulmonary Therapy
Please see Therapy Services later in this section.
Radiation Therapy
Please see Therapy Services later in this section.
Rehabilitation Services
Benefits include services in a Hospital, free-standing Facility, Skilled Nursing Facility, or in an outpatient
day rehabilitation program.
Covered Services involve a coordinated team approach and several types of treatment, including skilled
nursing care, physical, occupational, and speech therapy, and services of a social worker or psychologist.
To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period
of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing
toward those goals.
Habilitative Services
Benefits also include Habilitative Services that help you keep, learn or improve skills and functioning for
daily living. Examples include therapy for a child who isnt walking or talking at the expected age. These
services may include physical and occupational therapy, speech-language pathology and other services
for people with disabilities in a variety of inpatient and/or outpatient settings.
Respiratory Therapy
Please see Therapy Services later in this section.
Skilled Nursing Facility
When you require Inpatient skilled nursing and related services for convalescent and rehabilitative or
habilitative care, Covered Services are available if the Facility is licensed or certified under state law as a
Skilled Nursing Facility, or is otherwise licensed to provide the services. Custodial Care is not a Covered
Service.
Smoking Cessation
Please see Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy later in this
Booklet.

77
Speech Therapy
Please see Therapy Services later in this section.
Surgery
Your Plan covers surgical services on an Inpatient or outpatient basis, including office surgeries.
Covered Services include:
Accepted operative and cutting procedures;
Other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain
or spine;
Endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Treatment of fractures and dislocations;
Anesthesia and surgical support when Medically Necessary;
Medically Necessary pre-operative and post-operative care.
Oral Surgery
Important Note: Although this Plan covers certain oral surgeries, many oral surgeries (e.g. removal of
wisdom teeth) are not covered, except as listed in this Booklet.
Benefits are limited to certain oral surgeries including:
Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;
Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or
lower jaw and is Medically Necessary to attain functional capacity of the affected part.
Oral / surgical correction of accidental injuries as indicated in the Dental Services (All Members/All
Ages) section.
Treatment of non-dental lesions, such as removal of tumors and biopsies.
Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses
Your Plan also covers certain oral surgeries for children. Please refer to Pediatric Dental Services for
Members through Age 18 for details.
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or
developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal
appearance. Benefits include surgery performed to restore symmetry after a mastectomy. Reconstructive
services needed as a result of an earlier treatment are covered only if the first treatment would have been
a Covered Service under this Plan.
Note: This section does not apply to orthognathic surgery. See the Oral Surgery section above for that
benefit.
Mastectomy Notice
A Member who is getting benefits for a mastectomy or for follow-up care for a mastectomy and who
chooses breast reconstruction, will also get coverage for:
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to give a symmetrical appearance; and

78
Prostheses and treatment of physical problems of all stages of mastectomy, including lymphedemas.
When due to breast cancer, reconstructive and surgical coverage will be provided in a manner
determined in consultation with the attending Physician and the Member. Members will have to pay the
same Deductible, Coinsurance, and/or Copayments that normally apply to surgeries in this Plan.
Transgender Surgery
This Plan provides benefits for many of the charges for transgender surgery (also known as sex
reassignment surgery). Benefits must be approved by us for the type of transgender surgery requested
and must be authorized prior to being performed. Changes for services that are not authorized for the
transgender surgery requested will not be considered Covered Services. Some conditions apply,
and all services must be authorized by us as outlined in the "How to Access Your Services and
Obtain Approval of Benefits" section.
Telemedicine
When you can!t travel to a Provider!s office, telemedicine benefits might be available when provided by
covered Providers. Telemedicine is the real-time transfer of health data and help. Services include the
use of interactive audio, video, or other electronic media to discuss and treat your health problem.
Typically, you communicate through an interactive means that is enough to start a link to the Provider
who is working at a different location from you. These services are covered if they would be Covered
Services when given in a face-to-face meeting with the Provider.
There are limits. Telemedicine does not include the use of phones or fax machines. It also is not
covered if you can go into the office of an In-Network Provider in the area where you live. Telemedicine
benefits may also be limited to only certain areas in Colorado. Please check with Customer Services to
see if your area is eligible.
Non-covered services are:
Reporting normal lab or other test results;
Office appointment requests;
Billing, insurance coverage or payment questions;
Requests for referrals to doctors outside the online care panel;
Benefit Preauthorization; Doctor talking to another Doctor.
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services
Benefits are available to treat temporomandibular and craniomandibular disorders. The
temporomandibular joint connects the lower jaw to the temporal bone at the side of the head and the
craniomandibular joint involves the head and neck muscles.
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care,
and diagnostic services. Covered Services do not include fixed or removable appliances that involve
movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).
Therapy Services
Physical Medicine Therapy Services
Your Plan includes coverage for the therapy services described below. To be a Covered Service, the
therapy must improve your level of function within a reasonable period of time.

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For children under age 6, your Plan covers at least 20 visits, each, of physical, speech and occupational
therapy. Benefits include the treatment of Congenital Defects and Birth Abnormalities, even if it is a long
term condition. It also doesn!t matter if the reason for the therapy is to maintain (not improve) the child!s
skills.
Covered Services include:
Physical therapy The treatment by physical means to ease pain, restore health, and to avoid
disability after an illness, injury, or loss of an arm or a leg. It includes hydrotherapy, heat, physical
agents, bio-mechanical and neuro-physiological principles and devices.
Speech therapy and speech-language pathology (SLP) services Services to identify, assess,
and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or
treat communication or swallowing skills to correct a speech impairment.
Occupational therapy Treatment to restore a physically disabled persons ability to do activities of
daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a
bed, and bathing. It also includes therapy for tasks needed for the persons job. Occupational therapy
does not include recreational or vocational therapies, such as hobbies, arts and crafts.
Osteopathic / Manipulation Therapy Includes therapy to treat problems of the bones, joints, and
the back. The two therapies are similar, but Manipulation Therapy focuses on the joints of the spine
and the nervous system, while osteopathic therapy also focuses on the joints and surrounding
muscles, tendons and ligaments.
Massage therapy - Injury or illness for which massage has a therapeutic result. Coverage is provided
for up to a 60 minute session per visit. Some Covered Services include acupressure and deep tissue
massage, or other approved services.
Acupuncture/Nerve Pathway therapy Is limited to the treatment of neuromusculoskeletal pain,
through the use of needles inserted along specific nerve pathways to ease pain.
Early Intervention Services
From the Members birth until the Members third (3rd) birthday, this Plan covers Early Intervention
Services (as defined in this Booklet and by Colorado law in accordance with part C), that are authorized
through an eligible child's individualized family service plan (IFSP) and delivered by a Qualified Early
Intervention Service Provider to an eligible child, to the extent required by applicable law. The services
stated in an IFSP will be considered Medically Necessary. Coverage for early intervention services does
not include: nonemergency medical transportation; respite care; service coordination, as defined in
federal law; or assistive technology (unless covered under the applicable insurance policy as durable
medical equipment). Coverage is limited to up to 45 visits, per Benefit Period.
This visit limit does not apply to rehabilitation or therapeutic services that are necessary as the result of
an acute medical condition or post-surgical rehabilitation or services provided to a child who is not
participating in part C. The coverage for Early Intervention Services is in addition to any other coverage
provided under this Booklet for congenital defects or birth abnormalities.
Other Therapy Services
Benefits are also available for:
Cardiac Rehabilitation Medical evaluation, training, supervised exercise, and psychosocial
support to care for you after a cardiac event (heart problem). Benefits do not include home programs,
on-going conditioning, or maintenance care.
Chemotherapy Treatment of an illness by chemical or biological antineoplastic agents. See the
section Prescription Drugs Administered by a Medical Provider for more details.
Dialysis Services for acute renal failure and chronic (end-stage) renal disease, including
hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis

80
(CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Covered Services include
dialysis treatments in an outpatient dialysis Facility. Covered Services also include home dialysis and
training for you and the person who will help you with home self-dialysis.
Infusion Therapy Nursing, durable medical equipment and Drug services that are delivered and
administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN),
Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections
(intra-muscular, subcutaneous, continuous subcutaneous). See the section Prescription Drugs
Administered by a Medical Provider for more details.
Pulmonary Rehabilitation Includes outpatient short-term respiratory care to restore your health
after an illness or injury.
Radiation Therapy Treatment of an illness by x-ray, radium, or radioactive isotopes. Covered
Services include treatment (teletherapy, brachytherapy and intraoperative radiation, photon or high
energy particle sources), materials and supplies needed, and treatment planning.
Respiratory Therapy Includes the use of dry or moist gases in the lungs, nonpressurized
inhalation treatment; intermittent positive pressure breathing treatment, air or oxygen, with or without
nebulized medication, continuous positive pressure ventilation (CPAP); continuous negative pressure
ventilation (CNP); chest percussion; therapeutic use of medical gases or Drugs in the form of
aerosols, and equipment such as resuscitators, oxygen tents, and incentive spirometers; broncho-
pulmonary drainage and breathing exercises.
Transplant Services
See Human Organ and Tissue Transplant earlier in this section.
Urgent Care Services
Often an urgent rather than an Emergency health problem exists. An urgent health problem is an
unexpected illness or injury that calls for care that cannot wait until a regularly scheduled office visit.
Urgent health problems are not life threatening and do not call for the use of an Emergency Room.
Urgent health problems include earache, sore throat, and fever (not above 104 degrees).
Benefits for urgent care include:
X-ray services;
Care for broken bones;
Tests such as flu, urinalysis, pregnancy test, rapid strep;
Lab services;
Stitches for simple cuts; and
Draining an abscess.

{Pediatric vision exam only:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.]

{Pediatric vision full coverage:
[Vision Services For Members Through Age 18

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The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
Eyeglass Lenses
This Plan also covers a choice of eyeglass lenses. Benefits include polycarbonate, photochromic and
factory scratch coating when In-Network.

Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:

Single vision
Bifocal
Trifocal (FT 25-28)
Progressive
Frames
A selection of frames is covered under this Plan. Members must choose a frame from the Anthem
formulary.
Contact Lenses
The Plan offers the following benefits for contact lenses:

Elective Contact Lenses Contacts chosen for comfort or appearance;

Non-Elective Contact Lenses Only for the following medical conditions:

Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.

Special Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASIK.

This Plan only covers a choice of contact lenses or eyeglasses, but not both. If you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglasses until the next Benefit Period. If
you choose eyeglasses during a Benefit Period, no benefits will be available for contact lenses until the
next Benefit Period.]

{Adult vision:

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[Vision Services for Members Age 19 and Older
The vision benefits described in this section only apply to Members age 19 or older.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
Eyeglass Lenses
This Plan also covers a choice of eyeglass lenses. Lens benefits include factory scratch coating when In-
Network. Photochromic lenses are also available.
Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:
Single vision
Bifocal
Trifocal (FT 25-28)
Frames
A selection of frames is covered under this Plan. Members will get a benefit allowance toward the
purchase of any frame. If the frame you choose costs more than the Plans allowance, you will have to
pay the amount over the Plans allowance.
Contact Lenses
The Plan offers the following benefits for contact lenses:
Elective Contact Lenses Contacts chosen for comfort or appearance;
Non-Elective Contact Lenses Only for the following medical conditions:
Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.
Special Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASIK.
This Plan only covers a choice of contact lenses or eyeglass lenses, but not both. If you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglass lenses until the next Benefit
Period. If you choose eyeglass lenses during a Benefit Period, no benefits will be available for contact
lenses until the next Benefit Period.]
Vision Services (All Members / All Ages)
Benefits include medical and surgical treatment of injuries and illnesses of the eye. Certain vision
screenings required by Federal law are covered under the Preventive Care benefit.
Benefits do not include glasses or contact lenses except as listed in the Prosthetics benefit.

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Prescription Drugs Administered by a Medical Provider
Your Plan covers Prescription Drugs when they are administered to you as part of a doctors visit, home
care visit, or at an outpatient Facility. This includes Drugs for infusion therapy, chemotherapy, Specialty
Drugs, blood products, and office-based injectables that must be administered by a Provider. This
section applies when your Provider orders the Drug and administers it to you. Benefits for Drugs that you
can inject or get at a Pharmacy (i.e., self-administered injectable Drugs) are not covered under this
section. Benefits for those Drugs are described in the Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy section.
Note: When Prescription Drugs are covered under this benefit, they will not also be covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit. Also, if
Prescription Drugs are covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, they will not be covered under this benefit.
Important Details About Prescription Drug Coverage
Your Plan includes certain features to determine when Prescription Drugs should be covered, which are
described below. As part of these features, your prescribing Doctor may be asked to give more details
before we can decide if the Drug is Medically Necessary. We may also set quantity and/or age limits for
specific Prescription Drugs or use recommendations made as part of our Medical Policy and Technology
Assessment Committee and/or Pharmacy and Therapeutics Process.
Prior Authorization
Prior authorization may be needed for certain Prescription Drugs to make sure proper use and guidelines
for Prescription Drug coverage are followed. We will contact your Provider to get the details we need to
decide if prior authorization should be given. We will give the results of our decision to both you and your
Provider.
If prior authorization is denied you have the right to file a Grievance as outlined in the Appeals and
Complaints section of this Booklet.
For a list of Drugs that need prior authorization, please call the phone number on the back of your
Identification Card. The list will be reviewed and updated from time to time. Including a Drug or related
item on the list does not promise coverage under your Plan. Your Provider may check with us to verify
Drug coverage, to find out whether any quantity (amount) and/or age limits apply, and to find out which
brand or generic Drugs are covered under the Plan.
Step Therapy
Step therapy is a process in which you may need to use one type of Drug before we will cover another.
We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These
guidelines help you get high quality and cost effective Prescription Drugs. If a Doctor decides that a
certain Drug is needed, the prior authorization will apply.
Therapeutic Substitution
Therapeutic substitution is an optional program that tells you and your Doctors about alternatives to
certain prescribed Drugs. We may contact you and your Doctor to make you aware of these choices.
Only you and your Doctor can determine if the therapeutic substitute is right for you. We have a
therapeutic Drug substitutes list, which we review and update from time to time. For questions or issues
about therapeutic Drug substitutes, call Customer Service at the phone number on the back of your
Identification Card.

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Prescription Drug Benefit at a Retail or Home Delivery (Mail Order)
Pharmacy
Your Plan also includes benefits for Prescription Drugs you get at a Retail or Mail Order Pharmacy. We
use a Pharmacy Benefits Manager (PBM) to manage these benefits. The PBM has a network of Retail
Pharmacies, a Home Delivery (Mail Order) Pharmacy, and a Specialty Pharmacy. The PBM works to
make sure Drugs are used properly. This includes checking that Prescriptions are based on recognized
and appropriate doses and checking for Drug interactions or pregnancy concerns.
Please note: Benefits for Prescription Drugs, including Specialty Drugs, which are administered to you in
a medical setting (e.g., doctors office, home care visit, or outpatient Facility) are covered under the
Prescription Drugs Administered by a Medical Provider benefit. Please read that section for important
details.
Prescription Drug Benefits
As described in the Prescription Drugs Administered by a Medical Provider section, Prescription Drug
benefits may depend on reviews to decide when Drugs should be covered. These reviews may include
prior authorization, step therapy, use of a Prescription Drug List, Therapeutic Substitution, day / supply
limits, and other utilization reviews. Your In-Network Pharmacist will be told of any rules when you fill a
Prescription, and will be also told about any details we need to decide benefits.
Covered Prescription Drugs
To be a Covered Service, Prescription Drugs must be approved by the Food and Drug Administration
(FDA) and, under federal law, require a Prescription. Prescription Drugs must be prescribed by a
licensed Provider and you must get them from a licensed Pharmacy.
Benefits are available for the following:
Prescription Legend Drugs from either a Retail Pharmacy or the PBMs Home Delivery Pharmacy;
Specialty Drugs;
Self-administered injectable Drugs. These are Drugs that do not need administration or monitoring by
a Provider in an office or Facility. Office-based injectables and infused Drugs that need Provider
administration and/or supervision are covered under the Prescription Drugs Administered by a
Medical Provider benefit;
Self-injectable insulin and supplies and equipment used to administer insulin;
Self-administered contraceptives, including oral contraceptive Drugs, self-injectable contraceptive
Drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the
Preventive Care benefit. Please see that section for more details;
Special food products or supplements, including metabolic formulas, when prescribed by a Doctor if
we agree they are Medically Necessary,
Flu Shots (including administration). These will be covered under the Preventive Care benefit;
Prescription Drugs that help you stop smoking or reduce your dependence on tobacco products.
These Drugs will be covered under the Preventive Care benefit;
FDA-approved smoking cessation products, including over the counter nicotine replacement
products, when obtained with a Prescription for a Member age 18 or older. These products will be
covered under the Preventive Care benefit.
Certain Legend Drugs, including orally administered anticancer medication, may also be used for
treatment of cancer even though it has not been approved by the Food and Drug Administration (FDA) for
treatment of a specific type of cancer, if the following conditions are met:

85
the off-label use of the FDA approved drug is supported for the treatment of cancer by the
authoritative reference compendia identified by the Department of Health and Human Services; and
the condition being treated is covered under this Booklet.
Where You Can Get Prescription Drugs
In-Network Pharmacy
You can visit one of the local Retail Pharmacies in our network. Give the Pharmacy the prescription from
your Doctor and your Identification Card and they will file your claim for you. You will need to pay any
Copayment, Coinsurance, and/or Deductible that applies when you get the Drug. If you do not have your
Identification Card, the Pharmacy will charge you the full retail price of the Prescription and will not be
able to file the claim for you. You will need to ask the Pharmacy for a detailed receipt and send it to us
with a written request for payment.
Specialty Pharmacy
If you need a Specialty Drug, you or your Doctor should order it from the PBMs Specialty Pharmacy. We
keep a list of Specialty Drugs that may be covered based upon clinical findings from the Pharmacy and
Therapeutics (P&T) Process, and where appropriate, certain clinical economic reasons. This list will
change from time to time.
The PBMs Specialty Pharmacy has dedicated patient care coordinators to help you take charge of your
health problem and offers toll-free twenty-four hour access to nurses and pharmacists to answer your
questions about Specialty Drugs.
When you use the PBMs Specialty Pharmacy a patient care coordinator will work with you and your
Doctor to get prior authorization and to ship your Specialty Drugs to you or your Doctors office. Your
patient care coordinator will also tell you when it is time to refill your prescription.
You can get the list of covered Specialty Drugs by calling Customer Service at the phone number on the
back of your Identification Card or check our website at www.anthem.com.
Home Delivery Pharmacy
The PBM also has a Home Delivery Pharmacy which lets you get certain Drugs by mail if you take them
on a regular basis. You will need to contact the PBM to sign up when you first use the service. You can
mail written prescriptions from your Doctor or have your Doctor send the prescription to the Home
Delivery Pharmacy. Your Doctor may also call the Home Delivery Pharmacy. You will need to send in
any Copayments, Deductible, or Coinsurance amounts that apply when you ask for a prescription or refill.
Out-of-Network Pharmacy
You may also use a Pharmacy that is not in our network. You will be charged the full retail price of the
Drug and you will have to send your claim for the Drug to us. (Out-of-Network Pharmacies wont file the
claim for you.) You can get a claims form from us or the PBM. You must fill in the top section of the form
and ask the Out-of-Network Pharmacy to fill in the bottom section. If the bottom section of this form
cannot be filled out by the pharmacist, you must attach a detailed receipt to the claim form. The receipt
must show:
Name and address of the Out-of-Network Pharmacy;
Patients name;
Prescription number;
Date the prescription was filled;
Name of the Drug;

86
Cost of the Drug;
Quantity (amount) of each covered Drug or refill dispensed.
You must pay the amount shown in the Schedule of Benefits (Who Pays What). This is based on the
Maximum Allowed Amount as determined by our normal or average contracted rate with network
pharmacies on or near the date of service.
What You Pay for Prescription Drugs
Tiers
Your share of the cost for Prescription Drugs may vary based on the tier the Drug is in.
Tier 1 Drugs have the lowest Coinsurance or Copayment. This tier contains low cost and preferred
Drugs that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.
Tier 2 Drugs have a higher Coinsurance or Copayment than those in Tier 1. This tier contains
preferred Drugs that may be Generic, single source, or multi-source Brand Drugs.
Tier 3 Drugs have a higher Coinsurance or Copayment than those in Tier 2. This tier contains non-
preferred and high cost Drugs. This includes Drugs considered Generic, single source brands, and
multi-source brands.
Tier 4 Drugs have a higher Coinsurance or Copayment than those in Tier 3.
We assign drugs to tiers based on clinical findings from the Pharmacy and Therapeutics (P&T) Process.
We retain the right, at our discretion, to decide coverage for doses and administration (i.e., by mouth,
shots, topical, or inhaled). We may cover one form of administration instead of another, or put other forms
of administration in a different tier.
Prescription Drug List
We also have an Anthem Prescription Drug List, (a formulary), which is a list of FDA-approved Drugs that
have been reviewed and recommended for use based on their quality and cost effectiveness. Benefits
may not be covered for certain Drugs if they are not on the Prescription Drug List.
The Drug List is developed by us based upon clinical findings, and where proper, the cost of the Drug
relative to other Drugs in its therapeutic class or used to treat the same or similar condition. It is also
based on the availability of over the counter medicines, Generic Drugs, the use of one Drug over another
by our Members, and where proper, certain clinical economic reasons.
We retain the right, at our discretion, to decide coverage for doses and administration methods (i.e., by
mouth, shots, topical, or inhaled) and may cover one form of administration instead of another as
Medically Necessary.
Additional Features of Your Prescription Drug Pharmacy Benefit
Day Supply and Refill Limits
Certain day supply limits apply to Prescription Drugs as listed in the Schedule of Benefits (Who Pays
What). In most cases, you must use a certain amount of your prescription before it can be refilled. In
some cases we may let you get an early refill. For example, we may let you refill your prescription early if
it is decided that you need a larger dose. We will work with the Pharmacy to decide when this should
happen.

87
If you are going on vacation and you need more than the day supply allowed, you should ask your
pharmacist to call our PBM and ask for an override for one early refill. If you need more than one early
refill, please call Customer Service at the number on the back of your Identification Card.
Half-Tablet Program
The Half-Tablet Program lets you pay a reduced Copayment on selected once daily dosage Drugs on
our approved list. The program lets you get a 30-day supply (15 tablets) of the higher strength Drug
when the Doctor tells you to take a ! tablet daily. The Half-Tablet Program is strictly voluntary and you
should talk to your Doctor about the choice when it is available. To get a list of the Drugs in the program
call the number on the back of your Identification Card.
Special Programs
From time to time we may offer programs to support the use of more cost-effective or clinically effective
Prescription Drugs including Generic Drugs, Home Delivery Drugs, over the counter Drugs or preferred
products. Such programs may reduce or waive Copayments or Coinsurance for a limited time. We may
discontinue a program at any time. If you are participating in a program that We discontinue, We will
provide you at least a 30 day advance written notice of the discontinuance.

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Section 8. Limitations/Exclusions (What is Not Covered and
Pre-Existing Conditions)
In this section you will find a review of items that are not covered by your Plan. Excluded items will not be
covered even if the service, supply, or equipment is Medically Necessary. This section is only meant to be
an aid to point out certain items that may be misunderstood as Covered Services. This section is not
meant to be a complete list of all the items that are excluded by your Plan.

We will have the right to make the final decision about whether services or supplies are Medically
Necessary and if they will be covered by your Plan.
1) Acts of War, Disasters, or Nuclear Accidents In the event of a major disaster, epidemic, war, or
other event beyond our control, we will make a good faith effort to give you Covered Services. We will
not be responsible for any delay or failure to give services due to lack of available Facilities or staff.
Benefits will not be given for any illness or injury that is a result of war, service in the armed forces, a
nuclear explosion, nuclear accident, release of nuclear energy, a riot, or civil disobedience.
2) Administrative Charges
a) Charges to complete claim forms,
b) Charges to get medical records or reports,
c) Membership, administrative, or access fees charged by Doctors or other Providers. Examples
include, but are not limited to, fees for educational brochures or calling you to give you test
results.
3) Alternative / Complementary Medicine Services or supplies for alternative or complementary
medicine, regardless of the Provider rendering such services or supplies. This includes, but is not
limited to:
a. Holistic medicine,
b. Homeopathic medicine,
c. Hypnosis,
d. Aroma therapy,
e. Reiki therapy,
f. Herbal, vitamin or dietary products or therapies,
g. Naturopathy,
h. Thermography,
i. Orthomolecular therapy,
j. Contact reflex analysis,
k. Bioenergial synchronization technique (BEST),
l. Iridology-study of the iris,
m. Auditory integration therapy (AIT),
n. Colonic irrigation,
o. Magnetic innervation therapy,
p. Electromagnetic therapy,
q. Neurofeedback / Biofeedback.
4) Before Effective Date or After Termination Date Charges for care you get before your Effective
Date or after your coverage ends, except as written in this Plan.

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5) Certain Providers Services you get from Providers that are not licensed by law to provide Covered
Services as defined in this Booklet. .
6) Charges Over the Maximum Allowed Amount Charges over the Maximum Allowed Amount for
Covered Services, except as written in this Plan.
7) Charges Not Supported by Medical Records Charges for services not described in your medical
records.
8) Complications of Non-Covered Services Care for problems directly related to a service that is not
covered by this Plan. Directly related means that the care took place as a direct result of the non-
Covered Service and would not have taken place without the non-Covered Service.
9) Cosmetic Services Treatments, services, Prescription Drugs, equipment, or supplies given for
cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or
are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or
treatments to change the texture or look of your skin or to change the size, shape or look of facial or
body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).
10) Court Ordered Testing Court ordered testing or care unless the testing or care is Medically
Necessary and otherwise a Covered Service under this Booklet.
11) Crime Treatment of an injury or illness that results from a crime you committed, or tried to commit.
This Exclusion does not apply if your involvement in the crime was solely the result of a medical or
mental condition, or where you were the victim of a crime, including domestic violence.
12) Custodial Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to
Hospice services.
13) [Dental Services
a) {Pediatric dental: [Dental services for Members age 19 or older, unless listed as covered in this
Booklet]
b) Dental services not listed as covered in this Booklet.
c) New, experimental or investigational dental techniques or services may be denied until there is, to
our satisfaction, an established scientific basis for recommendation.
d) Dental services completed prior to the date the member became eligible for coverage.
e) Services of anesthesiologists.
f) Analgesia, analgesia agents, anxiolysis, nitrous oxide, medicines, or drugs for non-surgical or
dental care
g) Intravenous conscious sedation, IV sedation and general anesthesia are not covered when given
with non-surgical dental care. EXCEPTION: General anesthesia for dental services for members
under age 19 years of age when rendered in a hospital, outpatient surgical facility or other facility
licensed pursuant to Section 25-3-101 of the Colorado Revised Statutes if the child, in the opinion
of the treating Dentist, satisfies one or more of the following criteria: (a) the child has a physical,
mental, or medically compromising condition; (b) the child has dental needs for which local
anesthesia is ineffective because of acute infection, anatomic variations, or allergy; (c) the child is
an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent
with dental needs deemed sufficiently important that dental care cannot be deferred; or (d) the
child has sustained extensive orofacial and dental trauma.
h) Dental services performed other than by a licensed dentist, licensed physician, his or her
employees, or a licensed Provider acting within the scope of the Providers license.
i) Dental services, appliances or restorations that are necessary to alter, restore or maintain
occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth
structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

90
j) Services or supplies that have the primary purpose of improving the appearance of your teeth.
This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of
the teeth.
k) Restorations placed for preventative or cosmetic purposes.
l) Occlusal or athletic mouth guards
m) Prosthodontic services, such as dentures or bridges {Adult dental: [for members through age
18].
n) Periodontal services {Adult dental: [for members through age 18].
o) Retreatment or additional treatment necessary to correct or relieve the results of treatment
previously covered under the Plan.
p) Separate services billed when they are an inherent component of another covered service.
q) Temporomandibular Joint Disorder (TMJ) except as covered under your medical coverage.
r) Oral hygiene instructions.
s) Surgical exposure of impacted or unerupted teeth for orthodontic reasons, except as listed in this
Booklet.
t) Surgical repositioning of teeth, except as listed in this Booklet.
u) Case presentations, office visits and consultations.
v) Implant services, except as listed in this Booklet.
w) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or non-resorbable filling
material(s) and the procedures used to prepare and place material(s) in the canals (root).
x) Root canal obstruction, internal root repair of perforation defects, incomplete endodontic
treatment and bleaching of discolored teeth.
y) Incomplete root canals.
z) Procedures designed to enable prosthetic or restorative services to be performed such as a
crown lengthening.
aa) Services or supplies that are medical in nature, including dental oral surgery services performed
in a hospital, except as covered under your medical coverage.
bb) Adjunctive diagnostic tests.]
14) Educational Services Services or supplies for teaching, vocational, or self-training purposes, except
as listed in this Booklet.
15) Experimental or Investigational Services Services or supplies that we find are Experimental /
Investigational. This also applies to services related to Experimental / Investigational services,
whether you get them before, during, or after you get the Experimental / Investigational service or
supply.
The fact that a service or supply is the only available treatment will not make it Covered Service if we
conclude it is Experimental / Investigational.
16) Eyeglasses and Contact Lenses Eyeglasses and contact lenses to correct your eyesight unless
listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye
surgery.
17) Eye Exercises Orthoptics and vision therapy.
18) Eye Surgery Eye surgery to fix errors of refraction, such as near-sightedness. This includes, but is
not limited to, LASIK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

91
19) Family Members Services prescribed, ordered, referred by or given by a member of your immediate
family, including your spouse, child, brother, sister, parent, in-law, or self.
20) Foot Care Routine foot care unless Medically Necessary. This Exclusion applies to cutting or
removing corns and calluses; trimming nails; cleaning and preventive foot care, including but not
limited to:
a) Cleaning and soaking the feet.
b) Applying skin creams to care for skin tone.
c) Other services that are given when there is not an illness, injury or symptom involving the foot.
21) Foot Orthotics Foot orthotics, orthopedic shoes or footwear or support items unless used for an
illness affecting the lower limbs, such as severe diabetes.
22) Foot Surgery Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet;
tarsalgia; metatarsalgia; hyperkeratoses.
23) Free Care Services you would not have to pay for if you didnt have this Plan. This includes, but is not
limited to government programs, services during a jail or prison sentence, services you get from
Workers Compensation, and services from free clinics.
If Workers Compensation benefits are not available to you, this Exclusion does not apply. This
Exclusion will apply if you get the benefits in whole or in part.
24) Hearing Aids Hearing aids or exams to prescribe or fit hearing aids, unless listed as covered in this
Booklet. This Exclusion does not apply to cochlear implants.
25) Health Club Memberships and Fitness Services Health club memberships, workout equipment,
charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or
facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health
spas.
26) Intractable Pain and/or Chronic Pain Charges for a pain state in which the cause of the pain cannot
be removed and which in the course of medical practice no relief or cure of the cause of the pain is
possible, or none has been found after reasonable efforts. It is pain that lasts more than 6 months, is
not life threatening, and may continue for a lifetime, and has not responded to current treatment.
27) Maintenance Therapy Treatment given when no further gains are clear or likely to occur.
Maintenance therapy includes care that helps you keep your current level of function and prevents
loss of that function, but does not result in any change for the better.
28) Medical Equipment and Supplies
a) Replacement or repair of purchased or rental equipment because of misuse, or loss.
b) Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury.
c) Non-Medically Necessary enhancements to standard equipment and devices.
29) Medicare For which benefits are payable under Medicare Parts A, B, and/or D, or would have been
payable if you had applied for Parts A and/or B, except as listed in this Booklet or as required by
federal law, as described in the section titled "Medicare" in General Provisions. If you do not enroll in
Medicare Part B, We will calculate benefits as if you had enrolled. You should sign up for Medicare
Part B as soon as possible to avoid large out of pocket costs.
30) Missed or Cancelled Appointments Charges for missed or cancelled appointments.
31) Non-Medically Necessary Services Services we conclude are not Medically Necessary. This
includes services that do not meet our medical policy, clinical coverage, or benefit policy guidelines.
32) Nutritional or Dietary Supplements Nutritional and/or dietary supplements, except as described in
this Booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional

92
formulas and dietary supplements that you can buy over the counter and those you can get without a
written Prescription or from a licensed pharmacist.
33) Oral Surgery Extraction of teeth, surgery for impacted teeth, jaw augmentation or reduction
(orthognathic Surgery), and other oral surgeries to treat the teeth, jaw or bones and gums directly
supporting the teeth, except as listed in this Booklet.
34) Orthodontic Care, unless for Medically Necessary care for cleft palate and cleft conditions as
provided by this Booklet
a) Monthly treatment visits that are inclusive of treatment cost,
b) Repair or replacement of lost/broken/stolen appliances,
c) Orthodontic retention/retainer as a separate service,
d) Retreatment and/or services for any treatment due to relapse,
e) Inpatient or outpatient hospital expenses (please refer to your medical coverage to determine if
this is a covered medical service),
f) Provisional splinting, temporary procedures or interim stabilization of teeth,
g) Dental services or health care services not specifically covered under this Booklet (including any
hospital charges, prescription drug charges and dental services or supplies that are medical in
nature).
35) Personal Care and Convenience
a) Items for personal comfort, convenience, protection, cleanliness such as air conditioners,
humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs,
b) First aid supplies and other items kept in the home for general use (bandages, cotton-tipped
applicators, thermometers, petroleum jelly, tape, non-sterile gloves, heating pads),
c) Home workout or therapy equipment, including treadmills and home gyms,
d) Pools, whirlpools, spas, or hydrotherapy equipment.
e) Hypo-allergenic pillows, mattresses, or waterbeds,
f) Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs,
escalators, elevators, stair glides, emergency alert equipment, handrails).
36) Private Duty Nursing Private Duty Nursing Services, except as specifically stated in this Booklet.
37) Prosthetics Prosthetics for sports or cosmetic purposes. This includes wigs and scalp hair
prosthetics.
38) Sexual Dysfunction Services or supplies for male or female sexual problems.
39) Smoking Cessation Programs Programs to help you stop smoking if the program is not affiliated
with Anthem.
40) Stand-By Charges Stand-by charges of a Doctor or other Provider.
41) Sterilization Services to reverse an elective sterilization.
42) Surrogate Mother Services Services or supplies for a person not covered under this Plan for a
surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an
infertile couple).
43) Temporomandibular Joint Treatment Fixed or removable appliances which move or reposition the
teeth, fillings, or prosthetics (crowns, bridges, dentures).
44) Travel Costs Mileage, lodging, meals, and other Member-related travel costs except as described in
this Plan.

93
45) Vein Treatment Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any
method (including sclerotherapy or other surgeries) for cosmetic purposes.
46) {Pediatric vision exam only: [Vision Services
Vision services for Members age 19 or older, unless listed as covered in this Booklet
Eyeglass lenses, frames, or contact lenses.
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.]
{Pediatric/adult vision: [Vision Services
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.
Safety glasses and accompanying frames.
For two pairs of glasses in lieu of bifocals.
Plano lenses (lenses that have no refractive power)
Lost or broken lenses or frames if the Member has already received benefits during a Benefit
Period.
Vision services not listed as covered in this Booklet.
Cosmetic lenses or options.
Blended lenses.
Oversize lenses.
Sunglasses and accompanying frames.
For Members through age 18, no benefits are available for frames not on the Anthem
formulary.
Certain frames in which the manufacturer imposes a no discount policy.]
47) Weight Loss Programs Programs, whether or not under medical supervision, unless listed as
covered in this Booklet.
This Exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
48) Weight Loss Surgery Bariatric surgery. This includes but is not limited to Roux-en-Y (RNY),
Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgeries lower stomach
capacity and divert partly digested food from the duodenum to the jejunum, the section of the small
intestine extending from the duodenum), or Gastroplasty, (surgeries that reduce stomach size), or
gastric banding procedures.
Whats Not Covered Under Your Prescription Drug Retail or Home
Delivery (Mail Order) Pharmacy Benefit
In addition to the above Exclusions, certain items are not covered under the Prescription Drug Retail or
Home Delivery (Mail Order) Pharmacy benefit:
1. Administration Charges Charges for the administration of any Drug except for covered
immunizations as approved by us or the PBM.

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2. Clinically-Equivalent Alternatives Certain Prescription Drugs may not be covered if you could use a
clinically equivalent Drug, unless required by law. Clinically equivalent means Drugs that for most
Members, will give you similar results for a disease or condition. If you have questions about whether
a certain Drug is covered and which Drugs fall into this group, please call the number on the back of
your Identification Card, or visit our website at www.anthem.com.
3. Compound Drugs Compound Drugs unless its primary ingredient (the highest cost ingredient) is
FDA approved and requires a prescription to dispense, and the Compound Drug is not essentially the
same as an FDA-approved product from a drug manufacturer.
4. Contrary to Approved Medical and Professional Standards Drugs given to you or prescribed in a
way that is against approved medical and professional standards of practice.
5. Delivery Charges Charges for delivery of Prescription Drugs.
6. Drugs Given at the Providers Office / Facility Drugs you take at the time and place where you are
given them or where the Prescription Order is issued. This includes samples given by a Doctor. This
Exclusion does not apply to Drugs used with a diagnostic service, Drugs given during chemotherapy
in the office as described in the Prescription Drugs Administered by a Medical Provider section, or
Drugs covered under the Medical and Surgical Supplies benefit they are Covered Services.
7. Drugs Not on the Anthem Prescription Drug List (a formulary) You can get a copy of the list by
calling us or visiting our website at www.anthem.com.
8. Drugs That Do Not Need a Prescription Drugs that do not need a prescription by federal law
(including Drugs that need a prescription by state law, but not by federal law), except for injectable
insulin or where applicable law requires coverage of the drug.
9. Drugs Over Quantity or Age Limits Drugs in quantities which are over the limits set by the Plan, or
which are over any age limits set by us.
10. Drugs Over the Quantity Prescribed or Refills After One Year Drugs in amounts over the quantity
prescribed, or for any refill given more than one year after the date of the original Prescription Order.
11. Fluoride Treatments Topical and oral fluoride treatments. While these services are not covered
under the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit,
they may be covered under the Pediatric Dental Services for Members through Age 18 benefit.
Please see that section for further details.
12. Infertility Drugs Drugs used in assisted reproductive technology procedures to achieve conception
(e.g., IVF, ZIFT, GIFT).
13. Items Covered as Durable Medical Equipment (DME) Therapeutic DME, devices and supplies
except peak flow meters, spacers, and blood glucose monitors. Items not covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit may be covered
under the Durable Medical Equipment and Medical Devices benefit. Please see that section for
details.
14. Items Covered as Medical Supplies Oral immunizations and biologicals, even if they are federal
legend Drugs, are covered as medical supplies based on where you get the service or item. Over the
counter Drugs, devices or products, are not Covered Services unless we must cover them under
federal law.
15. Items Covered Under the Allergy Services Benefit Allergy desensitization products or allergy
serum. While not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, these items may be covered under the Allergy Services benefit. Please
see that section for details.
16. Lost or Stolen Drugs Refills of lost or stolen Drugs.
17. Mail Order Providers other than the PBMs Home Delivery Mail Order Provider Prescription
Drugs dispensed by any Mail Order Provider other than the PBMs Home Delivery Mail Order
Provider, unless we must cover them by law.

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18. Non-approved Drugs Drugs not approved by the FDA.
19. Off label use Off label use, unless we must cover the use by law or if we, or the PBM, approve it.
20. Onychomycosis Drugs Drugs for Onchomycosis (toenail fungus) except when we allow it to treat
Members who are immuno-compromised or diabetic.
21. Over-the-Counter Items Drugs, devices and products, or Prescription Legend Drugs with over the
counter equivalents and any Drugs, devices or products that are therapeutically comparable to an
over the counter Drug, device, or product. This includes Prescription Legend Drugs when any version
or strength becomes available over the counter.
This Exclusion does not apply to over-the-counter products that we must cover under federal law with
a Prescription.
22. Sexual Dysfunction Drugs Drugs to treat sexual or erectile problems.
23. Syringes Hypodermic syringes except when given for use with insulin and other covered self-
injectable Drugs and medicine.
24. Weight Loss Drugs Any Drug mainly used for weight loss.
Pre-existing Conditions
Not applicable, plan does not impose limitation period for pre-existing conditions.

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Section 9. Member Payment Responsibility
Your Cost-Shares
Your Plan may involve Copayments, Deductibles, and/or Coinsurance, which are charges that you must
pay when receiving Covered Services. Your Plan may also have an Out-of-Pocket Limit, which limits the
cost-shares you must pay. Please read the Schedule of Benefits (Who Pays What) for details on your
cost-shares. Also read the Definitions section for a better understanding of each type of cost share.
Maximum Allowed Amount
General
This section describes how we determine the amount of reimbursement for Covered Services.
Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on this
Booklets Maximum Allowed Amount for the Covered Service that you receive. Please see the Claims
Procedure (How to File a Claim) section for additional information.
The Maximum Allowed Amount for this Booklet is the maximum amount of reimbursement we will allow
for services and supplies:
That meet our definition of Covered Services, to the extent such services and supplies are covered
under your Booklet and are not excluded;
That are Medically Necessary; and
That are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in your Booklet.
You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met
your Deductible or have a Copayment or Coinsurance. In addition, when you receive Covered Services
from an Out-of-Network Provider, you may be responsible for paying any difference between the
Maximum Allowed Amount and the Providers actual charges. This amount can be significant.
When you receive Covered Services from a Provider, we will, to the extent applicable, apply claim
processing rules to the claim submitted for those Covered Services. These rules evaluate the claim
information and, among other things, determine the accuracy and appropriateness of the procedure and
diagnosis codes included in the claim. Applying these rules may affect our determination of the Maximum
Allowed Amount. Our application of these rules does not mean that the Covered Services you received
were not Medically Necessary. It means we have determined that the claim was submitted inconsistent
with procedure coding rules and/or reimbursement policies. For example, your Provider may have
submitted the claim using several procedure codes when there is a single procedure code that includes
all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be
based on the single procedure code rather than a separate Maximum Allowed Amount for each billed
code.
Likewise, when multiple procedures are performed on the same day by the same Doctor or other
healthcare professional, we may reduce the Maximum Allowed Amounts for those secondary and
subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those
procedures would represent duplicative payment for components of the primary procedure that may be
considered incidental or inclusive.

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Provider Network Status
The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider
or an Out-of-Network Provider.
An In-Network Provider is a Provider who is in the managed network for this specific product or in a
special Center of Excellence/or other closely managed specialty network, or who has a participation
contract with us. For Covered Services performed by an In-Network Provider, the Maximum Allowed
Amount for this Booklet is the rate the Provider has agreed with us to accept as reimbursement for the
Covered Services. Because In-Network Providers have agreed to accept the Maximum Allowed Amount
as payment in full for those Covered Services, they should not send you a bill or collect for amounts
above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion
of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or
Coinsurance. Please call Customer Service for help in finding an In-Network Provider or visit
www.anthem.com.
Providers who have not signed any contract with us and are not in any of our networks are Out-of-
Network Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain
ancillary providers.
For Covered Services you receive from an Out-of-Network Provider, the Maximum Allowed Amount for
this Booklet will be one of the following as determined by us:
1. An amount based on Anthems non-participating Provider fee schedule/rate, which is established at
Anthems discretion, and which Anthem may modify from time to time, after considering one or more
of the following: reimbursement amounts accepted by like/similar Providers contracted with Anthem,
reimbursement amounts paid by the Centers for Medicare and Medicaid Services (CMS) for the same
services or supplies, and other industry cost, reimbursement and utilization data; or
2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid
Services (CMS). When basing the Maximum Allowed amount upon the level or method of
reimbursement used by CMS, Anthem will update such information, which is unadjusted for
geographic locality, no less than annually; or
3. An amount based on information provided by a third party vendor, which may reflect one or more of
the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience
required for the treatment; or (3) comparable Providers fees and costs to deliver care, or
4. An amount negotiated by us or a third party vendor which has been agreed to by the Provider. This
may include rates for services coordinated through case management, or
5. An amount based on or derived from the total charges billed by the Out-of-Network Provider.
Unlike In-Network Providers, Out-of-Network Providers may send you a bill and collect for the amount of
the Providers charge that exceeds our Maximum Allowed Amount. You are responsible for paying the
difference between the Maximum Allowed Amount and the amount the Provider charges. This amount
can be significant. Choosing an In-Network Provider will likely result in lower out of pocket costs to you.
Please call Customer Service for help in finding an In-Network Provider or visit our website at
www.anthem.com.
Customer Service is also available to assist you in determining this Booklets Maximum Allowed Amount
for a particular service from an Out-of-Network Provider. In order for us to assist you, you will need to
obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the
Provider will render. You will also need to know the Providers charges to calculate your out of pocket
responsibility. Although Customer Service can assist you with this pre-service information, the final
Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider.

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For Prescription Drugs, the Maximum Allowed Amount is the amount determined by us using Prescription
Drug cost information provided by the Pharmacy Benefits Manager.
Member Cost Share
For certain Covered Services and depending on your Plan design, you may be required to pay a part of
the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or
Coinsurance).
Your cost share amount and Out-of-Pocket Limits may vary depending on whether you received services
from an In-Network or Out-of-Network Provider. Specifically, you may be required to pay higher cost
sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see
the Schedule of Benefits (Who Pays What) in this Booklet for your cost share responsibilities and
limitations, or call Customer Service to learn how this Booklets benefits or cost share amounts may vary
by the type of Provider you use.
We will not provide any reimbursement for non-Covered Services. You may be responsible for the total
amount billed by your Provider for non-Covered Services, regardless of whether such services are
performed by an In-Network or Out-of-Network Provider. Non-covered services include services
specifically excluded from coverage by the terms of your Plan and received after benefits have been
exhausted Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits.
In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use
an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility and
receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or
pathologist who is employed by or contracted with an In-Network Hospital or Facility, you will pay the In-
Network cost share amounts for those Covered Services. You will not have to pay more for the Covered
Services than you would have had to pay if it had been received from an In-Network Provider.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklets cost share amounts; see your Schedule of Benefits (Who Pays What) for
your applicable amounts.
Example: Your Plan has a Coinsurance cost share of 20% for In-Network services, and 30% for Out-of-
Network services after the In-Network or Out-of-Network Deductible has been met.
You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-
Network anesthesiologist to perform the anesthesiology services for the surgery. You have no control
over the anesthesiologist used.
The Out-of-Network anesthesiologists charge for the service is $1200, your coinsurance responsibility
is 20% of $1200, or $240.
You choose an In-Network surgeon. The charge was $2500. The Maximum Allowed Amount for the
surgery is $1500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of
$1500, or $300. We allow 80% of $1500, or $1200. The In-Network surgeon accepts the total of
$1500 as reimbursement for the surgery regardless of the charges. Your total out of pocket
responsibility would be $300.
Authorized Services
In some circumstances, such as where there is no In-Network Provider available, or if we dont have an
In-Network Provider within a reasonable number of miles from your home, for the Covered Service, we
may authorize the In-Network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply
to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstances,
you must contact us in advance of obtaining the Covered Service. If approved, we will pay the Out-of-

99
Network Provider at the In-Network level of benefits and you wont need to pay more for the services than
if the services had been received from an In-Network Provider. A precertification or preauthorization is not
the same thing as an Authorized Service; we must specifically authorize the service from an Out-of-
Network Provider at the In-Network cost share amounts.
Sometimes you may need to travel a reasonable distance to get care from an In-Network Provider. This
does not apply if care is for an Emergency.
If you do not receive a preauthorized network exception to obtain Covered Services from an Out-of-
Network Provider at the In-Network cost share amounts, the claim will be processed using your Out-of-
Network cost shares.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklets cost share amounts; see your Schedule of Benefits (Who Pays What) for
your applicable amounts.
Example:
You require the services of a specialty Provider; but there is no In-Network Provider for that specialty in
your state of residence. You contact us in advance of receiving any Covered Services, and we authorize
you to go to an available Out-of-Network Provider for that Covered Service and we agree that the In-
Network cost share will apply.
Your Plan has a $45 Copayment for Out-of-Network Providers and a $25 Copayment for In-Network
Providers for the Covered Service. The Out-of-Network Providers charge for this service is $500. The
Maximum Allowed Amount is $200.
Because we have authorized the In-Network cost share amount to apply in this situation, you will be
responsible for the In-Network Copayment of $25 and we will be responsible for the remaining $475.
Claims Review
Anthem has processes to review claims before and after payment to detect fraud, waste, abuse and other
inappropriate activity. Members seeking services from Out-of Network Providers could be balance billed
by the Out-of-Network Provider for those services that are determined to be not payable as a result of
these review processes. A claim may also be determined to be not payable due to a Providers failure to
submit medical records with the claims that are under review in these processes.


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Section 10. Claims Procedure (How to File a Claim)
This section describes how we reimburse claims and what information is needed when you submit a
claim. When you receive care from an In-Network Provider, you do not need to file a claim because the
In-Network Provider will do this for you. If you receive care from an Out-of-Network Provider, you will
need to make sure a claim is filed. Many Out-of-Network Hospitals, Doctors and other Providers will file
your claim for you, although they are not required to do so. If you file the claim, use a claim form as
described later in this section.
Notice of Claim & Proof of Loss
After you get Covered Services, we must receive written notice of your claim within 365 days in order for
benefits to be paid. The claim must have the information we need to determine benefits. If the claim
does not include enough information, we will ask for more details and it must be sent to us within the time
listed below or no benefits will be covered, unless required by law.
In certain cases, you may have some extra time to file a claim. If we did not get your claim within 365
days, but it is sent in as soon as reasonably possible and within one year after the 365-day period ends
(i.e., within 24 months), you may still be able to get benefits. However, any claims, or additional
information on claims, sent in more than 24 months after you get Covered Services will be denied.
Claim Forms
Claim forms will usually be available from most Providers. If forms are not available, either send a written
request for a claims form to us, or contact Customer Service and ask for a claims form to be sent to you.
If you do not receive the claims form within 15 days of notifying us, written notice of services rendered
may be submitted to us without the claim form. The same information that would be given on the claim
form must be included in the written notice of claim. This includes:
Name of patient.
Patients relationship with the Subscriber.
Identification number.
Date, type, and place of service.
Your signature and the Providers signature.
Members Cooperation
You will be expected to complete and submit to us all such authorizations, consents, releases,
assignments and other documents that may be needed in order to obtain or assure reimbursement under
Medicare, Workers Compensation or any other governmental program. If you fail to cooperate (including
if you fail to enroll under Part B of the Medicare program where Medicare is the responsible payor), you
will be responsible for any charge for services.
Payment of Benefits
We will make benefit payments directly to Network Providers for Covered Services. If you use an Out-of-
Network Provider, however, we may make benefit payments to you unless if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of
you. We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services. Payments may also be made to, and notice regarding the receipt
and/or adjudication of claims sent to, an Alternate Recipient (any child of a Subscriber who is recognized,
under a Qualified Medical Child Support Order (QMSCO), as having a right to enrollment under the
Groups Contract), or that persons custodial parent or designated representative. Any benefit payments

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made by us will discharge our obligation for Covered Services. You cannot assign your right to benefits
to anyone else, except as required by a Qualified Medical Child Support Order as defined by ERISA or
any applicable state law.
Once a Provider performs a Covered Service, we will not honor a request for us to withhold payment of
the claims submitted.
Inter-Plan Programs
Out-of-Area Services
Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to
generally as Inter-Plan Programs. Whenever you obtain healthcare services outside of Anthems
Service Area, the claims for these services may be processed through one of these Inter-Plan Programs,
which include the BlueCard Program and may include negotiated National Account arrangements
available between Anthem and other Blue Cross and Blue Shield Licensees.
Typically, when accessing care outside Anthems Service Area, you will obtain care from healthcare
Providers that have a contractual agreement (i.e., are participating Providers) with the local Blue Cross
and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may
obtain care from nonparticipating healthcare Providers. Anthems payment practices in both instances are
described below.
BlueCard

Program
Under the BlueCard

Program, when you access covered healthcare services within the geographic area
served by a Host Blue, Anthem will remain responsible for fulfilling Anthems contractual obligations.
However, the Host Blue is responsible for contracting with and generally handling all interactions with its
participating healthcare Providers.
Whenever you access covered healthcare services outside Anthems Service Area and the claim is
processed through the BlueCard Program, the amount you pay for covered healthcare services is
calculated based on the lower of:
The billed covered charges for your Covered Services; or
The negotiated price that the Host Blue makes available to Anthem.
Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays
to your healthcare Provider. Sometimes, it is an estimated price that takes into account special
arrangements with your healthcare Provider or Provider group that may include types of settlements,
incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on
a discount that results in expected average savings for similar types of healthcare Providers after taking
into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for
over- or underestimation of modifications of past pricing for the types of transaction modifications noted
above. However, such adjustments will not affect the price Anthem uses for your claim because they will
not be applied retroactively to claims already paid.
Federal law or the law in a small number of states may require the Host Blue to add a surcharge to your
calculation. If federal law or any state laws mandate other liability calculation methods, including a
surcharge, we would then calculate your liability for any covered healthcare services according to
applicable law.

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Non-Participating Healthcare Providers Outside Our Service Area
Member Liability Calculation
When covered healthcare services are provided outside of our Service Area by non-participating
healthcare providers, the amount you pay for such services will generally be based on either the Host
Blues nonparticipating healthcare provider local payment or the pricing arrangements required by
applicable state law. In these situations, you may be liable for the difference between the amount that the
non-participating healthcare provider bills and the payment we will make for the Covered Services as set
forth in this paragraph.
Exceptions
In certain situations, we may use other payment bases, such as billed covered charges, the payment we
would make if the healthcare services had been obtained within our Service Area, or a special negotiated
payment, as permitted under Inter-Plan Programs Policies, to determine the amount we will pay for
services rendered by nonparticipating healthcare providers. In these situations, you may be liable for the
difference between the amount that the non-participating healthcare provider bills and the payment we
will make for the Covered Services as set forth in this paragraph.
If you obtain services in a state with more than one Blue Plan network, an exclusive network arrangement
may be in place. If you see a Provider who is not part of an exclusive network arrangement, that
Providers service(s) will be considered Non-Network care, and you may be billed the difference between
the charge and the Maximum Allowable Amount. You may call the Customer Service number on your ID
card for more information about such arrangements.


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Section 11. General Policy Provisions
Assignment
The Group cannot legally transfer this Booklet, without obtaining written permission from us. Members
cannot legally transfer the coverage. Benefits available under this Booklet are not assignable by any
Member without obtaining written permission from us, unless in a way described in the How to Access
Your Services and Obtain Approval of Benefits (Applicable to Managed Care Plans) and in Claims
Procedure (How to File a Claim) sections.
Automobile Insurance Provisions
We will coordinate the benefits of this Booklet with the benefits of a complying auto insurance policy.
A complying automobile insurance policy is an auto policy approved by the Colorado Division of
Insurance that provides at least the minimum coverage required by law, and one which is subject to the
Colorado Auto Accident Reparations Act or Colorado Revised Statutes 10-4-601 et seq. Any state or
federal law requiring similar benefits through legislation or regulation is also considered a complying auto
policy.
How We Coordinate Benefits with Auto Policies - Your benefits under this Booklet may be coordinated
with the coverages afforded by an auto policy. After any primary coverages offered by the auto policy
are exhausted, including without limitation any no-fault, personal injury protection, or medical payment
coverages, We will pay benefits subject to the terms and conditions of this Booklet. If there is more than
one auto policy that offers primary coverage, each will pay its maximum coverage before We are liable for
any further payments.
You, your representative, agents and heirs must fully cooperate with Us to make sure that the auto policy
has paid all required benefits. We may require you to take a physical examination in disputed cases. If
there is an auto policy in effect, and you waive or fail to assert your rights to such benefits, this plan will
not pay those benefits that could be available under an auto policy.
We may require proof that the auto policy has paid all primary benefits before making any payments
under this Booklet. On the other hand, we may but are not required to pay benefits under this Booklet,
and later coordinate with or seek reimbursement under the auto policy. In all cases, upon payment, we
are entitled to exercise Our rights under this Booklet and under applicable law against any and all
potentially responsible parties or insurers. In that event, we may exercise the rights found in this section.
What Happens If You Do Not Have Another Policy - We will pay benefits if you are injured while you
are riding in or driving a motor vehicle that you own if it is not covered by an auto policy.
Similarly if not covered by an auto policy, we will also pay benefits for your injuries if as a non-owner or
driver, passenger or when walking you were in a motor vehicle accident. In that event, we may exercise
the rights found in this section.
Clerical Error
A clerical error will never disturb or affect your coverage, as long as your coverage is valid under the rules
of the Plan. This rule applies to any clerical error, regardless of whether it was the fault of the Group or
us.

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Confidentiality and Release of Information
We will use reasonable efforts, and take the same care to preserve the confidentiality of your medical
information. We may use data collected in the course of providing services hereunder for statistical
evaluation and research. If such data is ever released to a third party, it shall be released only in
aggregate statistical form without identifying you. Medical information may be released only with your
written consent or as required by law. It must be signed, dated and must specify the nature of the
information and to which persons and organizations it may be disclosed. You may access your own
medical records.
We may release your medical information to professional peer review organizations and to the Group for
purposes of reporting claims experience or conducting an audit of our operations, provided the
information disclosed is reasonably necessary for the Group to conduct the review or audit.
A statement describing our policies and procedures for preserving the confidentiality of medical records is
available and will be furnished to you upon request.
Conformity with Law
Any term of the Plan which is in conflict with the laws of the state in which the Group Contract is issued,
or with federal law, will hereby be automatically amended to conform with the minimum requirements of
such laws.
Contract with Anthem
The Group, on behalf of itself and its participants, hereby expressly acknowledges its understanding that
this Plan constitutes a Contract solely between the Group and us, Anthem Blue Cross and Blue Shield
(Anthem), and that we are an independent corporation licensed to use the Blue Cross and Blue Shield
names and marks in the state of Colorado. The Blue Cross Blue Shield marks are registered by the Blue
Cross and Blue Shield Association, an association of independently licensed Blue Cross and Blue Shield
plans, with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries. Further, we
are not contracting as the agent of the Blue Cross and Blue Shield Association or any other Blue Cross
and/or Blue Shield plan or licensee. The Group, on behalf of itself and its participants, further
acknowledges and agrees that it has not entered into this Contract based upon representations by any
person other than Anthem Blue Cross and Blue Shield (Anthem) and that no person, entity, or
organization other than Anthem Blue Cross and Blue Shield (Anthem) shall be held accountable or liable
to the Group for any of Anthem Blue Cross and Blue Shield (Anthem)s obligations to the Group created
under the Contract. This paragraph shall not create any additional obligations whatsoever on our part
other than those obligations created under other terms of this agreement.
Entire Contract
Note: The laws of the state in which the Group Contract is issued will apply unless otherwise stated
herein.
This Booklet, any riders, endorsements or attachments, and the individual applications of the Subscriber
and Dependents constitute the entire Contract between the Group and us and as of the Effective Date,
supersede all other agreements. In addition the Group has a Group Contract and Group application
which includes terms that apply to this coverage. Any and all statements made to us by the Group and
any and all statements made to the Group by us are representations and not warranties. No such
statement, unless it is contained in a written application for coverage under this Booklet, shall be used in
defense to a claim under this Booklet.

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Form or Content of Booklet
No agent or employee of ours is authorized to change the form or content of this Booklet. Changes can
only be made through a written authorization, signed by an officer of Anthem. Changes are further noted
in Modifications below this section.
Government Programs
The benefits under this Plan shall not duplicate any benefits that you are entitled to, or eligible for, under
any other governmental program. This does not apply if any particular laws require us to be the primary
payor. If we have duplicated such benefits, all money paid by such programs to you for services you
have or are receiving, shall be returned by or on your behalf to us.
Medical Policy and Technology Assessment
Anthem reviews and evaluates new technology according to its technology evaluation criteria developed
by its medical directors. Technology assessment criteria are used to determine the Experimental /
Investigational status or Medical Necessity of new technology. Guidance and external validation of
Anthems medical policy is provided by the Medical Policy and Technology Assessment Committee
(MPTAC) which consists of approximately 20 Doctors from various medical specialties including Anthems
medical directors, Doctors in academic medicine and Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Medicare
Any benefits covered under both this Plan and Medicare will be covered according to Medicare
Secondary Payor legislation, regulations, and Centers for Medicare & Medicaid Services guidelines,
subject to federal court decisions. Federal law controls whenever there is a conflict among state law,
Booklet terms, and federal law.
Except when federal law requires us to be the primary payor, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Part B. Where Medicare is the responsible payor, all
sums payable by Medicare for services provided to you shall be reimbursed by or on your behalf to us, to
the extent we have made payment for such services. For the purposes of the calculation of benefits, if
you have not enrolled in Medicare Parts B and/or D, we will calculate benefits as if you had enrolled. You
should enroll in Medicare Part B as soon as possible to avoid potential liability. For Medicare Part
D we will calculate benefits as if you had enrolled in the Standard Basic Plan.
Modifications
This Booklet allows the Group to make Plan coverage available to eligible Members. However, this
Booklet shall be subject to amendment, modification, and termination in accordance with any of its terms,
the Group Contract, or by mutual agreement between the Group and us without the permission or
involvement of any Member. Changes will not be effective until the date specified in the written notice we
give to the Group about the change. By electing medical and Hospital coverage under the Plan or
accepting Plan benefits, all Members who are legally capable of entering into a contract, and the legal
representatives of all Members that are incapable of entering into a contract, agree to all terms and
conditions in this Booklet.

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For employer groups of one to 50, if we amend this Booklet to change benefits, notice of the amendment
will be given to the employer no less than 90 days before to the Effective Date of such change and the
amendment(s) will be effective for each group on the renewal or anniversary date of the Group Contract.
For all other changes, such as changes due to state or federal law or regulation, we may amend this
Booklet when authorized by one of our officers and, to the extent required by law, will provide the Group
60 days notice of such changes. We will then provide the Group with any amendments within 60 days
following the effective date of the amendment. If the Group requests a change that reduces or eliminates
coverage, such change must be requested in writing or signed by the Group. The Group will notify you of
such change(s) to coverage. We or the Group will later send or make available to you an amendment to
this Booklet or a new Booklet.
Network Access Plan
We strive to provide Provider networks in Colorado that addresses your health care needs. The Network
Access Plan describes our Provider network standards for network sufficiency in service, access and
availability, as well as assessment procedures we follow in our effort to maintain adequate and accessible
networks. To request a copy of this document, call customer service. This document is also available on
our website or for in-person review at 700 Broadway in Denver, Colorado.
Not Liable for Provider Acts or Omissions
We are not responsible for the actual care you receive from any person. This Booklet does not give
anyone any claim, right, or cause of action against Anthem based on the actions of a Provider of health
care, services, or supplies.
Policies and Procedures
We are able to introduce new policies, procedures, rules and interpretations, as long as they are
reasonable. Such changes are introduced to make the Plan more orderly and efficient. Members must
follow and accept any new policies, procedures, rules, and interpretations.
Under the terms of the Group Contract, we have the authority, in our sole discretion, to introduce or
terminate from time to time, pilot or test programs for disease management or wellness initiatives which
may result in the payment of benefits not otherwise specified in this Booklet. We reserve the right to
discontinue a pilot or test program at any time. We will give thirty (30) days advance written notice to the
Group of the introduction or termination of any such program.
Relationship of Parties (Group-Member-Anthem)
The Group is responsible for passing information to you. For example, if we give notice to the Group, it is
the Groups responsibility to pass that information to you. The Group is also responsible for passing
eligibility data to us in a timely manner. If the Group does not give us with timely enrollment and
termination information, we are not responsible for the payment of Covered Services for Members.
Relationship of Parties (Anthem and In-Network Providers)
The relationship between Anthem and In-Network Providers is an independent contractor relationship. In-
Network Providers are not agents or employees of ours, nor is Anthem, or any employee of Anthem, an
employee or agent of In-Network Providers.
Your health care Provider is solely responsible for all decisions regarding your care and treatment,
regardless of whether such care and treatment is a Covered Service under this Plan. We shall not be

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responsible for any claim or demand on account of damages arising out of, or in any manner connected
with, any injuries suffered by you while receiving care from any In-Network Provider or in any In-Network
Providers Facilities.
Your In-Network Providers agreement for providing Covered Services may include financial incentives or
risk sharing relationships related to the provision of services or referrals to other Providers, including In-
Network Providers, Out-of-Network Providers, and disease management programs. If you have
questions regarding such incentives or risk sharing relationships, please contact your Provider or us.
Reservation of Discretionary Authority
This section only applies when the interpretation of this Booklet is governed by the Employee Retirement
Income Security Act (ERISA), 29 U.S.C. 1001 et seq.
We, or anyone acting on our behalf, shall determine the administration of benefits and eligibility for
participation in such a manner that has a rational relationship to the terms set forth herein. However, we,
or anyone acting on our behalf, have complete discretion to determine the administration of your benefits.
Our determination shall be final and conclusive and may include, without limitation, determination of
whether the services, care, treatment, or supplies are Medically Necessary, Experimental /
Investigational, whether surgery is cosmetic, and whether charges are consistent with the Maximum
Allowable Amount. However, a Member may utilize all applicable complaint and appeals procedures, and
where required by applicable law, Our determination may be reviewed de novo (as if for the first time) in a
later appeal or legal action.
We, or anyone acting on our behalf, shall have all the powers necessary or appropriate to enable us to
carry out the duties in connection with the operation and administration of the Plan. This includes, without
limitation, the power to construe the Contract, to determine all questions arising under the Booklet and to
make, establish and amend the rules, regulations, and procedures with regard to the interpretation and
administration of the provisions of this Plan. However, these powers shall be exercised in such a manner
that has reasonable relationship to the provisions of the Contract, the Booklet, Provider agreements, and
applicable state or federal laws. A specific limitation or exclusion will override more general benefit
language.
Right of Recovery
Whenever payment has been made in error, we will have the right to recover such payment from you or, if
applicable, the Provider. In the event we recover a payment made in error from the Provider, except in
cases of fraud, we will only recover such payment from the Provider during the 24 months after the date
we made the payment on a claim submitted by the Provider, unless the law permits a different timeframe
in which to recover. We reserve the right to deduct or offset any amounts paid in error from any pending
or future claim. The cost share amount shown in your Explanation of Benefits is the final determination
and you will not receive notice of an adjusted cost share amount as a result of such Recovery activity.
We have oversight responsibility for compliance with Provider and vendor contracts. We may enter into a
settlement or compromise regarding enforcement of these contracts and may retain any recoveries made
from a Provider or vendor resulting from these audits if the return of the overpayment is not feasible. We
have established Recovery policies to determine which recoveries are to be pursued, when to incur costs
and expenses and settle or compromise Recovery amounts. We will not pursue recoveries for
overpayments if the cost of collection exceeds the overpayment amount. We may not give you notice of
overpayments made by us or you if the Recovery method makes providing such notice administratively
burdensome.

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Unauthorized Use of Identification Card
If you permit your Identification Card to be used by someone else or if you use the card before coverage
is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting
from the unauthorized use. Fraudulent misuse could also result in termination of the coverage.
Value-Added Programs
We may offer health or fitness related programs to our Members, through which you may access
discounted rates from certain vendors for products and services available to the general public. Products
and services available under this program are not Covered Services under your Plan but are in addition to
Plan benefits. As such, program features are not guaranteed under your health Plan Contract and could
be discontinued at any time. We do not endorse any vendor, product or service associated with this
program. Program vendors are solely responsible for the products and services you receive.
Value of Covered Services
For purposes of subrogation, reimbursement of excess benefits, or reimbursement under any Workers
Compensation or Employer Liability Law, the value of Covered Services shall be the amount we paid for
the Covered Services.
Voluntary Clinical Quality Programs
We may offer additional opportunities to assist you in obtaining certain covered preventive or other care
(e.g., well child check-ups or certain laboratory screening tests) that you have not received in the
recommended timeframe. These opportunities are called voluntary clinical quality programs. They are
designed to encourage you to get certain care when you need it and are separate from Covered Services
under your Plan. These programs are not guaranteed and could be discontinued at any time. We will
give you the choice and if you choose to participate in one of these programs, and obtain the
recommended care within the programs timeframe, you may receive incentives such as gift cards. Under
other clinical quality programs, you may receive a home test kit that allows you to collect the specimen for
certain covered laboratory tests at home and mail it to the laboratory for processing. You may need to
pay any cost shares that normally apply to such covered laboratory tests (e.g., those applicable to the
laboratory processing fee) but will not need to pay for the home test kit. (If you receive a gift card and use
it for purposes other than for qualified medical expenses, this may result in taxable income to you. For
additional guidance, please consult your tax advisor.)
Voluntary Wellness Incentive Programs
We may offer health or fitness related program options for purchase by your Group to help you achieve
your best health. These programs are not Covered Services under your Plan, but are separate
components, which are not guaranteed under this Plan and could be discontinued at any time. If your
Group has selected one of these options to make available to all employees, you may receive incentives
such as gift cards by participating in or completing such voluntary wellness promotion programs as health
assessments, weight management or tobacco cessation coaching. Under other options a Group may
select, you may receive such incentives by achieving specified standards based on health factors under
wellness programs that comply with applicable law. If you think you might be unable to meet the
standard, you might qualify for an opportunity to earn the same reward by different means. You may
contact us at the customer service number on your ID card and we will work with you (and, if you wish,
your Doctor) to find a wellness program with the same reward that is right for you in light of your health
status. (If you receive a gift card as a wellness reward and use it for purposes other than for qualified
medical expenses, this may result in taxable income to you. For additional guidance, please consult your
tax advisor.)

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Waiver
No agent or other person, except an authorized officer of Anthem, is able to disregard any conditions or
restrictions contained in this Booklet, to extend the amount of time for making a payment to us, or to bind
us by making any promise or representation or by giving or receiving any information.
Workers Compensation
The benefits under this Plan are not designed to duplicate benefits that you are eligible for under
Workers Compensation Law. All money paid or owed by Workers Compensation for services provided
to you shall be paid back by you, or on your behalf, to us if we have made or make payment for the
services received. It is understood that coverage under this Plan does not replace or affect any Workers
Compensation coverage requirements.
Subrogation and Reimbursement
This section applies when we pay benefits as a result of injuries or illness and another party or party(ies)
agrees or is ordered to pay money because of these injuries or when the Member received or is entitled
to receive a Recovery because of these injuries or illnesses. Reimbursement or subrogation under this
Booklet may only be permitted if you have been fully compensated, and, the amount recoverable by us
may be reduced by a proportionate share of your attorney fees and costs, if state law so requires.
Subrogation
We have the right to recover payments we make on your behalf. The following apply:
If you have been fully compensated, we have a lien against all or a portion of the benefits that have
been paid to you from the following parties, including, but not limited to, the party or parties who
caused the injuries or illness, the insurer or other indemnifier of the party or parties who caused the
injuries or illness, a guarantor of the party or parties who caused the injuries or illness, your own
insurer (for example, uninsured, underinsured, medical payments or no-fault coverage, or a workers
compensation insurer), or any other person, entity, policy or plan that may be liable or legally
responsible in relation to the injuries or illness. However, our Recovery cannot exceed the amount
actually paid by us under this Booklet as it relates to the injuries or illness that are the subject of the
subrogation action; and
You and your legal representative must do whatever is necessary to enable us to exercise our rights
and do nothing to prejudice them. If you have not pursued a claim against a third party allegedly at
fault for your injuries by the date that is sixty (60) days before to the date on which the applicable
statute of limitations expires, we have a right to bring legal action against the at-fault party.
Reimbursement
If you, a person who represents your legal interest, or beneficiary have been fully compensated and We
have not been repaid for the health insurance benefits we paid on the Members behalf, we shall have a
right to be repaid from the Recovery in the amount of the health insurance benefits we paid on your
behalf and the following apply:
You must reimburse us to the extent of the health insurance benefits we paid on the Members behalf
from any Recovery, including, but not limited to, the party or parties who caused the injuries or illness,
the insurer or other indemnifier of the party or parties who caused the injuries or illness, a guarantor
of the party or parties who caused the injuries or illness, your own insurer (for example, underinsured,
medical payments, or a workers compensation insurer), or any other person, entity, policy or plan
that may be liable or legally responsible in relation to the injuries or illness;

110
Notwithstanding any allocation made in a settlement agreement or court order, we shall have a right
of reimbursement; and
You, a person who represents your legal interest, or beneficiary must hold in trust for us right away
the amount recovered in gross that is to be paid to us. The amount recovered in gross is the total
amount of your Recovery reduced by your lawyer fees and costs.
The Members Duties
You, a person who represents your legal interest, or beneficiary must tell us right away the how, when
and where an accident or event that resulted in your injury or illness. We must find out what
happened and get all the details about the parties involved;
You, a person who represents your legal interest, or beneficiary must work with us in investigating,
settling and protecting rights;
You, a person who represents your legal interest, or beneficiary must send us copies of all police
reports, notices or other papers received in connection with the accident or incident resulting in
personal injury or illness;
You, a person who represents your legal interest, or beneficiary must promptly notify us if you retain
an attorney or if a lawsuit is filed;
If you, a person who represents your legal interest, or beneficiary gets a Recovery that is less than
the sum of all your damages incurred by you, you are required to tell us within 60 days of your receipt
of the Recovery. The notice to us must include:
- Total amount and source of the Recovery;
- Coverage limits applicable to any available insurance policy, contract or benefit plan; and
- The amount of any costs charged to you.
If we receive your notice that you have not been fully paid, we have the right to dispute that
determination;
If we dispute whether your Recovery is less than the sum of all your damages, such dispute must be
resolved through arbitration; and
If you, a person who represents your legal interest, or beneficiary resides in a state where automobile
personal injury protection or medical payment coverage is mandatory, that coverage is primary and
the Booklet takes secondary status. The Booklet will reduce benefits for an amount equal to, but not
less than, that states mandatory minimum personal injury protection or medical payment
requirement.
Coordination of Benefits When Members Are Insured Under More
Than One Plan
We may coordinate benefits when you have coverage with more than one health coverage.
Duplicate Coverage
Duplicate coverage is the term used to describe when you are covered by this Booklet and also covered
by another:
Group or group-type health insurance;
Health benefits coverage; or

111
Blanket coverage.
The total benefits received by you, or on your behalf, from all coverages combined for any claim for
Covered Services will not exceed 100 percent of the total covered charges.
Order of Benefit Determination Rules The following rules are used in the order as listed:
How We Determine Which Coverage is Primary and Which is Secondary
We will determine the primary coverage and secondary coverage according to the following rule: A plan
that does not have order of benefit determination rules or if it has rules will always be primary unless the
provisions of both plans state that the plan is primary.
Non-Dependent or Dependent
The plan that covers the person other than as a dependent, for example as an employee, member,
subscriber or retiree, is primary and the plan that covers the person, as a dependent, is secondary. If the
person is a Medicare beneficiary, please refer to the section below of Determining Primacy Between
Medicare and Us for primary and secondary payer rules.
Active Employee, Retired or Laid-Off Employee
a. The plan that covers a person as an active employee, who is not laid off or retired, or a dependent of
an active employee, is the primary plan.
b. If the secondary, or other plan, does not have this rule, and as result the plans do not agree on the
order of benefits, this rule is ignored.
c. This rule does not apply if the section above of Non-Dependent or Dependent can determine the
order of benefits.
COBRA or State Continuation Coverage
a. If a person whose coverage is provided in accordance with COBRA, or under a right of continuation
according to state or federal law is covered under another plan, the plan covering the person as an
employee, member, subscriber or retiree or covering the person as a dependent of an employee,
member, subscriber, or retiree, is the primary plan and the plan covering that same person in
accordance with COBRA, or under a right of continuation in accordance with state or other federal
law, is the secondary plan.
b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of
benefits, this rule is ignored.
c. This rule does not apply if the section above of Non-Dependent or Dependent can determine the
order of benefits.
Longer or Shorter Length of Coverage
a. If the rules above do not determine the order of benefits, the plan that covered the person for the
longer period of time is primary plan and the plan that covered the person for the shorter period of
time is the secondary plan.
b. To determine the length of time a person has been covered under a plan, two (2) successive plans
will be treated as one if the covered person was eligible under the second within twenty-four (24)
hours after the first ended.
c. The start of a new plan does not include:
(1) A change in the amount or scope of a plans benefits;

112
(2) A change in the entity that pays, provides or administers the plans benefits; or
(3) A change from one type of plan to another (such as, from a single employer plan to that of a
multiple employer plan).
d. The persons length of time covered under a plan is measured from the persons first date of
coverage under that plan. If that date is not readily available for a group plan, the date the person first
became a member of the group will be used as the date from which to determine the length of time
the persons coverage under the present plan has been in force.
If none of the rules above determine the primary plan, the allowable expenses will be shared equally
between the plans.
Dependent Child Covered Under More Than One Plan
Unless there is a court decree stating otherwise, plans covering a dependent child will determine the
order of benefits as follows:
a. For a dependent child whose parents are married or are living together, whether or not they have
been married:
(1) The plan of the parent whose birthday falls earlier in the calendar year, by month and day, is the
primary plan; or
(2) If both parents have the same birthday, the plan that has covered the parent the longest is the
primary plan.
b. For a dependent child whose parents are divorced or separated or are not living together, whether or
not they have ever been married:
(1) If the court decree states that one of the parents is responsible for the dependent childs health
care expenses or health care coverage, and the plan of that parent has actual knowledge of
those terms, that plan is primary. If the parent with financial responsibility has no health care
coverage for the dependent childs health care, but that parents spouse does, the spouses plan
is primary. This item will not apply with respect to a plan year during which benefits are paid or
provided before the entity has actual knowledge of the court decree provision;
(2) If the court decree states that both parents are responsible for the dependent childs health care
expenses or health care coverage, paragraph a above will determine the order of benefits;
(3) If the divorce decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the depend child,
paragraph a above will determine the order of benefits; or
(4) If there is no court decree allocating responsibility for the childs health care expenses of health
care coverage, the order of benefits for the child are as follows:
(a) The plan of the custodial parent;
(b) The plan of the spouse of the custodial parent;
(c) The plan of the noncustodial parent; and then
(d) The plan of the spouse of the noncustodial parent.
c. For a dependent child covered under more than one plan of individuals who are not parents of the
child, the order of benefits will be determined, as applicable, according to paragraph a. or b. above as
if those individuals were the parents of the child.
d. For a dependent child who has coverage under either or both parents' plans and also has his or her
own coverage as a dependent under a spouse's plan, the rule in the section above for Longer or
Shorter Length of Coverage applies.

113
In the event the dependent child's coverage under the spouse's plan began on the same date as the
dependent child's coverage under either or both parents' plans, the order of benefits will be determined by
applying the birthday rule to the dependent child's parent(s) and the dependent's spouse.
Rules for Coordination of Benefits
When a person is covered by two (2) or more plans, the rules for determining the order of benefit
payments are as follows:
1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.
2. If the primary plan is a Closed Panel Plan, and the secondary plan is not a Closed Panel Plan, the
secondary plan will pay or provide benefits as if it were the primary plan when a covered person uses
a non-panel provider, except for emergency services or authorized referrals that are paid or provided
by the primary provider.
3. When multiple contracts providing coordinated coverage are treated as a single plan, this section only
applies to the plan as a whole, and coordination among the component contracts is governed by the
terms of the contracts.
4. If a person is covered by more than one secondary plan, each secondary plan will take into
consideration the benefits of the primary plan, or plans, and the benefits of any other plan, which, has
its benefits determined before those of that secondary plan.
5. Under the terms of a Closed Panel Plan, benefits are not payable if the covered person does not use
the services of a closed panel provider, with the exceptions of medical emergencies and if there are
allowable benefits available. In most instances, Coordination of Benefits does not occur if a covered
person is enrolled in two (2) or more Closed Panel Plans and obtains services from a provider in one
of the Closed Panel Plans because the other Closed Panel Plan (the one whose providers were not
used) has no liability. However, Coordination of Benefits may occur during the claim determination
period when the covered person receives emergency services that would have been covered by both
plans.
Determining Primacy Between Medicare and Us
We will be the primary payer for persons with Medicare age 65 and older if the policyholder is actively
working for an employer who is providing the policy holders health insurance and the employer has 20 or
more employees. Medicare will be the primary payer for persons with Medicare age 65 and older if the
policyholder is not actively working and the Member is enrolled in Medicare. Medicare will be the primary
payer for persons with Medicare age 65 and older if the employer has less than 20 employees and the
Member is enrolled in Medicare.
We will be the primary payer for persons enrolled with Medicare under age 65 when Medicare coverage
is due to disability if the policyholder is actively working for an employer who is providing the
policyholders health insurance and the employer has 100 or more employees. Medicare will be the
primary payer for persons enrolled in Medicare due to disability if the policyholder is not actively working
or the employer has less than 100 employees.
We will be the primary payer for persons with Medicare under age 65 when Medicare coverage is due to
End Stage Renal Disease (ESRD), for the first 30 months from the entitlement to or eligibility for
Medicare (whether or not Medicare is taken at that time). After 30 months, Medicare will become the
primary payer if Medicare is in effect (30-month coordination period).
When a Member becomes eligible for Medicare due to a second entitlement, such as age, We remain
primary. But this will only apply if the group health coverage was primary at the point when the second
entitlement took effect, for the duration of 30 months after becoming Medicare entitled or eligible due to
ESRD. If Medicare was primary at the point of the second entitlement, then Medicare remains primary.
There will be no 30-month coordination period for ESRD.

114
Members with Medicare and Two Group Insurance Policies
Based on the primacy rules, if Medicare is secondary to a group coverage (see Medicare primacy rules),
the primary coverage covering the Member will pay first. Medicare will then pay second, and the
coverage covering the Member as a retiree or inactive employee or Dependent will pay third. The order
of primacy is not based on the policyholder of the group health insurance.
If Medicare is the primary payer due to Medicare primacy rules, then the rules of primacy for employees
and their spouses will be used to determine the coverage that will pay second and third.
Your Obligations
You have an obligation to provide us with current and accurate information regarding the existence of
other coverage.
Benefits payable under another coverage include benefits that would be paid by that coverage, whether
or not a claim is made. It also includes benefits that would have been paid but were refused. This is due
to the claim not being sent to the Provider of other coverage on a timely basis.
Your benefits under this Booklet will be reduced by the amount that such benefits would duplicate
benefits payable under the primary coverage.
Our Rights to Receive and Release Necessary Information
We may release to, or obtain, from any insurance company or other organization or person any
information which we may need to carry out the terms of this Booklet. Members will furnish to us such
information as may be necessary to carry out the terms of this Booklet.
Payment of Benefits to Others
When payments that should have been made under this Booklet were made under any other coverage, we will
have the right to pay to the other coverage any amount we determine to be warranted to satisfy the intent of
this provision. Any amount so paid will be considered to be benefits paid under this Booklet, and with that
payment we will fully satisfy our liability under this provision.
Duplicate Coverage and Coordination of Benefits Overpayment Recovery
If we have overpaid for Covered Services under this section, we will have the right, by offset or otherwise, to
recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were
made.

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Section 12. Termination/Nonrenewal/Continuation
Termination
Except as otherwise provided, your coverage may terminate in the following situations:
When the Contract between the Group and us terminates. If your coverage is through an association,
your coverage will terminate when the Contract between the association and us terminates, or when
your Group leaves the association. It will be the Group's responsibility to notify you of the termination
of coverage.
If you choose to terminate your coverage.
If you or your Dependents cease to meet the eligibility requirements of the Plan, subject to any
applicable continuation requirements. If you cease to be eligible, the Group and/or you must notify us
immediately. The Group and/or you shall be responsible for payment for any services incurred by you
after you cease to meet eligibility requirements.
If you elect coverage under another carriers health benefit plan, which is offered by the Group as an
option instead of this Plan, subject to the consent of the Group. The Group agrees to immediately
notify us that you have elected coverage elsewhere.
If you perform an act, practice, or omission that constitutes fraud or make an intentional
misrepresentation of material fact, as prohibited by the terms of your Plan, your coverage and the
coverage of your Dependents can be retroactively terminated or rescinded. A rescission of coverage
means that the coverage may be legally voided back to the start of your coverage under the Plan, just
as if you never had coverage under the Plan. You will be provided with a 30 calendar day advance
notice with appeal rights before your coverage is retroactively terminated or rescinded. You are
responsible for paying us for the cost of previously received services based on the Maximum Allowable
Amount for such services, less any Copayments made or Premium paid for such services.
If you fail to pay or fail to make satisfactory arrangements to pay your portion of the Premium, we may
terminate your coverage and may also terminate the coverage of your Dependents.
If you permit the fraudulent use of your or any other Members Plan Identification Card by any other
person; use another persons Identification Card; or use an invalid Identification Card to obtain
services, your coverage will terminate immediately upon our written notice to the Group. Anyone
involved in the misuse of a Plan Identification Card will be liable to and must reimburse us for the
Maximum Allowed Amount for services received through such misuse.
If you are a partner to a civil union, recognized domestic partnership, or other relationship recognized
as a spousal relationship in the state where the subscriber resides, on the date such union or
relationship is revoked or terminated. Also, if there is coverage for designated beneficiaries, on the date
a Recorded Designated Beneficiary Agreement is revoked or terminated. Where permitted by law,
such a Dependent may be able to seek COBRA or state continuation coverage, subject to the terms of
this Booklet.
You will be notified in writing of the date your coverage ends by either us or the Group.
Removal of Members
Upon written request through the Group, you may cancel your coverage and/or your Dependents
coverage from the Plan. If this happens, no benefits will be provided for Covered Services after the
termination date even if we have preauthorized the service, unless the Provider confirmed eligibility within
two business days before the service is received.

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Special Rules if Your Group Health Plan is Offered Through an
Exchange
If your Plan is offered through an Exchange, either you or your Group may cancel your coverage and/or
your Dependents coverage through the Exchange. Each Exchange will have rules on how to do this.
You may cancel coverage by sending a written notice to either the Exchange or us. The date that
coverage will end will be either:
The date that you ask for coverage to end, if you provide written notice within 14 days of that date; or
14 days after you ask for coverage to end, if you ask for a termination date more than 14 days before
you gave written notice. We may agree in certain circumstances to allow an earlier termination date
that you request.
Continuation of Coverage Under Federal Law (COBRA)
The following applies if you are covered by a Group that is subject to the requirements of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended.
COBRA continuation coverage can become available to you when you would otherwise lose coverage
under your Group's health Plan. It can also become available to other Members of your family, who are
covered under the Group's health Plan, when they would otherwise lose their health coverage. For
additional information about your rights and duties under federal law, you should contact the Group.
Qualifying events for Continuation Coverage under Federal Law (COBRA)
COBRA continuation coverage is available when your coverage would otherwise end because of certain
qualifying events. After a qualifying event, COBRA continuation coverage must be offered to each
person who is a qualified beneficiary. You, your spouse and your Dependent children could become
qualified beneficiaries if you were covered on the day before the qualifying event and your coverage
would be lost because of the qualifying event. Qualified beneficiaries who elect COBRA must pay for this
COBRA continuation coverage.
This benefit entitles each Member of your family who is enrolled in the Plan to elect continuation
independently. Each qualified beneficiary has the right to make independent benefit elections at the time
of annual enrollment. Covered Subscribers may elect COBRA continuation coverage on behalf of their
spouses, and parents or legal guardians may elect COBRA continuation coverage on behalf of their
children. A child born to, or placed for adoption with, a covered Subscriber during the period of
continuation coverage is also eligible for election of continuation coverage.


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Initial Qualifying Event Length of Availability of Coverage

For Subscribers:

Voluntary or Involuntary Termination (other than
gross misconduct) or Reduction In Hours Worked





18 months


For Dependents:

A Covered Subscribers Voluntary or Involuntary
Termination (other than gross misconduct) or
Reduction In Hours Worked

Covered Subscribers Entitlement to Medicare

Divorce or Legal Separation

Death of a Covered Subscriber






18 months

36 months

36 months

36 months

For Dependent Children:

Loss of Dependent Child Status



36 months


COBRA coverage will end before the end of the maximum continuation period listed above if you become
entitled to Medicare benefits. In that case a qualified beneficiary other than the Medicare beneficiary
is entitled to continuation coverage for no more than a total of 36 months. (For example, if you become
entitled to Medicare prior to termination of employment or reduction in hours, COBRA continuation
coverage for your spouse and children can last up to 36 months after the date of Medicare entitlement.)
If Your Group Offers Retirement Coverage
If you are a retiree under this Plan, filing a proceeding in bankruptcy under Title 11 of the United States
Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your Group, and that
bankruptcy results in the loss of coverage, you will become a qualified beneficiary with respect to the
bankruptcy. Your Dependents will also become qualified beneficiaries if bankruptcy results in the loss of
their coverage under this Plan. If COBRA coverage becomes available to a retiree and his or her covered
family members as a result of a bankruptcy filing, the retiree may continue coverage for life and his or her
Dependents may also continue coverage for a maximum of up to 36 months following the date of the
retirees death.
Second qualifying event
If your family has another qualifying event (such as a legal separation, divorce, etc.) during the initial 18
months of COBRA continuation coverage, your Dependents can receive up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months from the original qualifying event. Such
additional coverage is only available if the second qualifying event would have caused your Dependents
to lose coverage under the Plan had the first qualifying event not occurred.

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Notification Requirements
The Group will offer COBRA continuation coverage to qualified beneficiaries only after the Group has
been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the Subscriber, commencement of a proceeding in
bankruptcy with respect to the employer, or the Subscriber's becoming entitled to Medicare benefits
(under Part A, Part B, or both), the Group will notify the COBRA Administrator (e.g., Human Resources or
their external vendor) of the qualifying event.
You Must Give Notice of Some Qualifying Events
For other qualifying events (e.g., divorce or legal separation of the Subscriber and spouse or a
Dependent childs losing eligibility for coverage as a Dependent child), you must notify the Group within
60 days after the qualifying event occurs.
Electing COBRA Continuation Coverage
To continue your coverage, you or an eligible family Member must make an election within 60 days of the
date your coverage would otherwise end, or the date the companys benefit Plan Administrator notifies
you or your family Member of this right, whichever is later. You must pay the total Premium appropriate
for the type of benefit coverage you choose to continue. If the Premium rate changes for active
associates, your monthly Premium will also change. The Premium you must pay cannot be more than
102% of the Premium charged for Employees with similar coverage, and it must be paid to the companys
benefit plan administrator within 30 days of the date due, except that the initial Premium payment must be
made before 45 days after the initial election for continuation coverage, or your continuation rights will be
forfeited.
Disability extension of 18-month period of continuation coverage
For Subscribers who are determined, at the time of the qualifying event, to be disabled under Title II
(OASDI) or Title XVI (SSI) of the Social Security Act, and Subscribers who become disabled during the
first 60 days of COBRA continuation coverage, coverage may continue from 18 to 29 months. These
Subscribers Dependents are also eligible for the 18- to 29-month disability extension. (This also applies
if any covered family Member is found to be disabled.) This would only apply if the qualified beneficiary
gives notice of disability status within 60 days of the disabling determination. In these cases, the
Employer can charge 150% of Premium for months 19 through 29. This would allow health coverage to
be provided in the period between the end of 18 months and the time that Medicare begins coverage for
the disabled at 29 months. (If a qualified beneficiary is determined by the Social Security Administration to
no longer be disabled, such qualified beneficiary must notify the Plan Administrator of that fact in writing
within 30 days after the Social Security Administrations determination.)
Trade Adjustment Act Eligible Individual
If you dont initially elect COBRA coverage and later become eligible for trade adjustment assistance
under the U.S. Trade Act of 1974 due to the same event which caused you to be eligible initially for
COBRA coverage under this Plan, you will be entitled to another 60-day period in which to elect COBRA
coverage. This second 60-day period will commence on the first day of the month on which you become
eligible for trade adjustment assistance. COBRA coverage elected during this second election period will
be effective on the first day of the election period. You may also be eligible to receive a tax credit equal
to 65% of the cost for health coverage for you and your Dependents charged by the Plan. This tax credit
also may be paid in advance directly to the health coverage Provider, reducing the amount you have to
pay out of pocket.

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When COBRA Coverage Ends
COBRA benefits are available without proof of insurability and coverage will end on the earliest of the
following:
A covered individual reaches the end of the maximum coverage period;
A covered individual fails to pay a required Premium on time;
A covered individual becomes covered under any other group health plan after electing COBRA. If
the other group health plan contains any exclusion or limitation on a pre-existing condition that
applies to you, you may continue COBRA coverage only until these limitations cease;
A covered individual becomes entitled to Medicare after electing COBRA; or
The Group terminates all of its group welfare benefit plans.
If You Have Questions
Questions concerning your Group's health Plan and your COBRA continuation coverage rights should be
addressed to the Group. For more information about your rights under ERISA, including COBRA, the
Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labors Employee Benefits
Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses
and phone numbers of Regional and District EBSA Offices are available through EBSAs website.)
Continuation of Coverage Under State Law
Groups with less than 20 employees who provide health care coverage for their employees are subject to
state law for continuation of coverage. The state continuation coverage period will not exceed 18 months
for you and/or any Dependents. State continuation coverage for you and your Dependents will start on
the date of the earliest of the following qualifying events:
Your termination of employment. To qualify, you must have been covered by the Group health
coverage for at least (6) six straight months;
Your reduction in working hours which results in loss of coverage. Reduction in working hours would
include circumstances resulting from economic conditions, injury, disability, or chronic health
conditions;
Your death; or
Divorce or legal separation of you and the spouse.
State Continuation Coverage Notification
Unless termination or reduction in working hours is the qualifying event, a Subscriber, spouse or
Dependent child must tell the Group of their choice to keep coverage within 30 days after being eligible.
The Group is responsible for telling the Subscriber, spouse and/or Dependent child of how to choose
state continuation. Once the Group has given notice to the Subscriber, spouse and/or Dependent child,
we must get timely notice from the Group that you want state continuation. We must also get timely
payment of Premiums from the Group when paid by the Subscriber.
We should get the notice from the Group and your first no later than 30 days after the qualifying event. If
the group fails to give timely notice to you of your rights, this deadline may extend to 60 days after the
qualifying event. For more, contact your Group.

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When State Continuation Coverage Ends
Your state continuation coverage ends upon the earlier of the following:
A covered individual reaches the end of the maximum coverage period;
The Group Master Contract between Us and your employer ends. If the employer gets other group
coverage, continuation coverage will continue under the new plan;
A covered individual fails to pay Premium timely;
You are eligible for another group health plan unless the other plan does not cover something that is
covered by the continuation coverage. In that case, the state continuation coverage lasts until the
continuation period ends or the other plan covers the excluded condition;
If you are covered as a Designated Beneficiary, on the date the Recorded Designated Beneficiary
Agreement is revoked or terminated;
The date the spouse remarries and becomes eligible for coverage under the new spouses group
health plan;
You get Medicare or Medicaid; or
You tell us in writing to cancel.
Continuation of Coverage Due To Military Service
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the
Subscriber or his / her Dependents may have a right to continue health care coverage under the Plan if
the Subscriber must take a leave of absence from work due to military leave.
Employers must give a cumulative total of five years and in certain instances more than five years, of
military leave.
Military service means performance of duty on a voluntary or involuntary basis and includes active duty,
active duty for training, initial active duty for training, inactive duty training, and full-time National Guard
duty.
During a military leave covered by USERRA, the law requires employers to continue to give coverage
under this Plan to its Members. The coverage provided must be identical to the coverage provided to
similarly situated, active employees and Dependents. This means that if the coverage for similarly
situated, active employees and Dependents is modified, coverage for you (the individual on military leave)
will be modified.
You may elect to continue to cover yourself and your eligible Dependents by notifying your employer in
advance and submitting payment of any required contribution for health coverage. This may include the
amount the employer normally pays on your behalf. If your military service is for a period of time less
than 31 days, you may not be required to pay more than the active Member contribution, if any, for
continuation of health coverage. For military leaves of 31 days or more, you may be required to pay up to
102% of the full cost of coverage, i.e., the employee and employer share.
The amount of time you continue coverage due to USERRA will reduce the amount of time you will be
eligible to continue coverage under COBRA.

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Maximum Period of Coverage During a Military Leave
Continued coverage under USERRA will end on the earlier of the following events:
1. The date you fail to return to work with the Group following completion of your military leave.
Subscribers must return to work within:
a) The first full business day after completing military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service.
b) 14 days after completing military service for leaves of 31 to 180 days,
c) 90 days after completing military service for leaves of more than 180 days; or
2. 24 months from the date your leave began.
Reinstatement of Coverage Following a Military Leave
Regardless of whether you continue coverage during your military leave, if you return to work your health
coverage and that of your eligible Dependents will be reinstated under this Plan if you return within:
1. The first full business day of completing your military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service;
2. 14 days of completing your military service for leaves of 31 to 180 days; or
3. 90 days of completing your military service for leaves of more than 180 days.
If, due to an illness or injury caused or aggravated by your military service, you cannot return to work
within the time frames stated above, you may take up to:
1. Two years; or
2. As soon as reasonably possible if, for reasons beyond your control you cannot return within two years
because you are recovering from such illness or injury.
If your coverage under the Plan is reinstated, all terms and conditions of the Plan will apply to the extent
that they would have applied if you had not taken military leave and your coverage had been continuous.
Any waiting/probationary periods will apply only to the extent that they applied before.
Please note that, regardless of the continuation and/or reinstatement provisions listed above, this Plan
will not cover services for any illness or injury caused or aggravated by your military service, as indicated
in the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions)" section.
Family and Medical Leave Act of 1993
A Subscriber who takes a leave of absence under the Family and Medical Leave Act of 1993 (the Act) will
still be eligible for this Plan during their leave. We will not consider the Subscriber and his or her
Dependents ineligible because the Subscriber is not at work.
If the Subscriber ends their coverage during the leave, the Subscriber and any Dependents who were
covered immediately before the leave may be added back to the Plan when the Subscriber returns to
work without medical underwriting. To be added back to the Plan, the Group may have to give us
evidence that the Family and Medical Leave Act applied to the Subscriber. We may require a copy of the
health care Provider statement allowed by the Act.

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Benefits After Termination Of Coverage
Except as stated below, we will not pay for any services given to you after your coverage ends even if we
preauthorized the service, unless the Provider confirmed your eligibility within two business days before
each service received. Benefits cease on the date your coverage ends as described above. You may be
responsible for benefit payments made by us on your behalf for services provided after your coverage
has ended.
When your coverage ends for any reason other than for nonpayment of Premium, fraud or abuse, We will
continue coverage if you are being treated at an inpatient facility, until you are discharged or transferred
to another level of care. This is subject to the terms of this Booklet. The discharge date is seen as the
first date on which you are discharged from the facility or transferred to another level of care. We will not
cover the services you get after your discharge date.
Unless a law requires, we do not cover services after your date of termination even if:
We approved the services; or
The services were made necessary by an accident, illness or other event that occurred while coverage
was in effect.

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Section 13. Appeals and Complaints
We want your experience with us to be as positive as possible. There may be times, however, when you
have a complaint, problem, or question about your Plan or a service you have received. In those cases,
please contact Customer Service by calling the number on the back of your ID card. We will try to resolve
your complaint informally by talking to your Provider or reviewing your claim. If you are not satisfied with
the resolution of your complaint, you have the right to file a Grievance / Appeal, which is defined as
follows:
We may have turned down your claim for benefits. We may have also denied your request to
preauthorize or receive a service or a supply. If you disagree with Our decision you can:
1. File a complaint
2. File an appeal; or
3. File a grievance.

Complaints
If you want to file a complaint about our customer service or how we processed your claim, please call
customer services. A trained staff member will try to clear up any confusion about the matter. They will
also try to resolve your complaint. If you prefer, you can send a written complaint to this address:
For services that are not dental or vision send to:
Anthem
Customer Services Department
P.O. Box 17549
Denver, CO 80217-0549
For dental benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:
Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
If your complaint isnt solved either by writing or calling, or if you dont want to file a complaint, you can file
an appeal. Well tell you how to do that next, in the Appeals section below.
Note: More details on the complaints and appeals process and time periods can be found in the Appeals
Guide. You may get a copy of the Appeals Guide by visiting www.anthem.com or you can call customer
service.



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Appeals
If we have denied a claim that you feel should have been covered, or handled in a different way, or had
your coverage cancelled retroactively for a reason that it not because of your failure to pay premiums, you
can file an appeal. You can appeal a denial that was made by us before the service is received. You can
also appeal a denial on a service after it is received. You may also appeal an eligibility determination
made by us.
While we encourage you to file an appeal within 60 days of the unfavorable benefit determination, the
written or oral appeal must be received by us within 180 days of the unfavorable benefit determination.
We will assign an employee to help you in the appeal process. An appeal can be filed verbally by calling
customer service.
An appeal can be filed by writing to this address for services that are not a dental or vision
service:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway
Denver, CO 80273
For dental benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
You dont have to file a complaint before you file an appeal. In your appeal, please state as plainly as
possible why you think we shouldnt have denied your claim for benefits. Include any documents you
didnt submit with the original claim or service/supply request. Also send any other documents that
support your appeal. You dont have to file the appeal yourself. Someone else, like your Doctor or
another representative, can file an appeal for you. Just let us know in writing who will be filing the appeal
for you.
The appeals process allows you to request an internal appeal, and in certain cases, an independent
external appeal.
Internal Appeals
We have an internal process that We follow when reviewing your appeal. Members of our staff, who were
not involved when your claim was first denied, will review the appeal. They may also talk with co-workers
to assist in the review.
If your first internal appeal is denied, you can ask for a second level appeal. But you dont have to file a
second level appeal with Us before requesting an independent external review appeal or pursuing legal
action.
Expedited internal appeal - If you have an urgent case, you may request that your internal appeal be
reviewed in a shorter time period. This is called an expedited internal appeal. You or your representative

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can ask for an expedited appeal if you had Emergency services but havent been discharged from the
Facility. Also, you can ask for an expedited appeal if the regular appeal schedule would:
Seriously jeopardize your life or health;
Jeopardize your ability to regain maximum function;
Create an immediate and substantial limitation on your ability to live independently, if youre disabled;
or
In the opinion of a Doctor with knowledge of your condition, would subject you to severe pain that cant
be adequately managed without the service in question.
Independent External Appeals
For claims based on Utilization Review, or a rescission or retroactive cancellation of coverage for reasons
other than nonpayment of premium, you can request an independent external appeal. Utilization Review
includes claims we denied as Experimental or Investigational or not Medically Necessary. It also includes
claims where we reviewed your medical circumstances to decide if an exclusion applied. For these
appeals, your case is reviewed by an external review entity, selected by the Colorado Division of
Insurance.
Your request for independent external review must be made within 4 months of our appeal decision.
Generally, you have to have completed at least the first level internal appeal. But if we fail to handle the
appeal according to applicable Colorado insurance law and regulations, you will be eligible to request
independent external review.
Expedited external appeal You or your representative can request an expedited independent external
review, but only in certain cases:
You had Emergency services but havent been discharged from the Facility.
A Doctor certifies to us that you have a medical condition where following the normal external review
appeal process would seriously jeopardize your life or health, would jeopardize your ability to regain
maximum function or, if youre disabled, would create an imminent and substantial limitation of your
ability to live independently; or
We denied coverage for a requested medical service as being Experimental or Investigational, your
treating physician certifies in writing that the requested service would be significantly less effective if
not promptly initiated and certifies that either:
- Standard health care services or treatments have not been effective in improving your condition
or are not medically appropriate for you; or
- The Doctor is a licensed, board-certified or board-eligible physician qualified to practice in the
area of medicine appropriate to treat your condition, there is no available standard health care
service or treatment covered by this Booklet that is more beneficial than the requested service,
and scientifically valid studies using accepted protocols demonstrate that the requested service is
likely to be more beneficial to you than any available standard services.
If it meets these conditions, your request for expedited external appeal can be filed at the same time as
your request for an expedited internal appeal.
For more information on where and how to request an internal or external appeal, please consult the
Appeals Guide available at www.anthem.com, or call customer service.

126
Grievances
If you have an issue or concern about the quality or services you receive from an In-Network Provider or
Facility, you can file a grievance. The quality management department strives to resolve grievances fairly
and quickly.
You may call customer service or send a written grievance for services that are not a, dental or
vision service to:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway

Denver, CO 80273-0001
For dental benefit issues send to:

Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122

For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
Our quality management department will acknowledge that weve received your grievance. Theyll also
investigate it. We treat every grievance confidentially.
Division of Insurance Inquiries
For inquiries about health care coverage in Colorado, you may call the Division of Insurance between
8:00 a.m. and 5:00 p.m., Monday through Friday, at (303) 894-7490, or write to the Division of Insurance
to the attention of the ICARE Section, 1560 Broadway, Suite 850, Denver, Colorado 80202.
Binding Arbitration
The binding arbitration provision under this Booklet is applicable to claims arising under all individual
plans, governmental plans, church plans, plans or claims to which ERISA preemption does not apply, and
plans maintained outside the United States. Any such arbitration will be governed by the procedures and
rules established by the American Arbitration Association. You may obtain a copy of the Rules of
Arbitration by calling our customer services. The law of the state in which the policy was issued and
delivered to you shall govern the dispute. The arbitration decision is binding on both you and us.
Judgment on the award made in arbitration may be enforced in any court with proper jurisdiction. If any
person subject to this arbitration clause initiates legal action of any kind, the other party may apply for a
court of competent jurisdiction to enjoin, stay or dismiss any such action and direct the parties to arbitrate
in accordance with this section.
Legal Action
Before you take legal action on a claim decision, you must first follow the process found in this section.
You must meet all the requirements of this Booklet.

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No action in law or in equity shall be brought to recover on this Booklet before the expiration of 60
calendar days after a claim has been filed according to the requirements of this Booklet. If you have
exhausted all mandatory levels of review in your appeal, you may be entitled to have the claim decision
reviewed de novo (as if for the first time) in any court with jurisdiction and to a trial by jury.
No such action shall be brought at all unless brought within three years after claim has been filed as
required by the Booklet.

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Section 14. Information on Policy and Rate Changes
Insurance Premiums
How Premiums are Established and Changed Premiums are the monthly charges you and/or the
Group must pay us to get coverage. We figure out and set the required Premiums.
The Group is responsible for paying the employees Premium to us according to the terms of the Group
Contract. Groups may have you contribute to the Premium cost through payroll deduction. Some Groups
may choose to have your Premium determined by the age of the Subscriber, with Premium set by age
brackets. We may change membership Premiums on the annual date on which the Group renews its
coverage, which we may assess when a Subscriber changes to a new five-year increment age bracket,
e.g., age 25 through age 29. If the age of the Subscriber is misstated at enrollment, all amounts payable
for the correct age will be adjusted and billed to the Group.
Grace Period - If a Group fails to submit Premium payments to us in a timely manner, the Group is
entitled to a grace period of 31 days for the payment of such Premium. During the grace period, our
contract with the Group shall continue in force unless the Group gives us written notice of termination of
the contract. If the Group has obtained replacement coverage during the grace period, the contract with
us will be terminated as of the last day for which we have received Premium, and any and all claims paid
during the grace period will be retroactively adjusted to deny. These claims that we retroactively
deny should be submitted to the replacement carrier. If the Group has not obtained replacement
coverage during the grace period, or fails to inform Us that the employer has not obtained replacement
coverage, we will process any and all claims with dates of service during the grace period in accordance
with the terms of this Booklet.

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Section 15. Definitions
If a word or phrase in this Booklet has a special meaning, such as Medical Necessity or Experimental /
Investigational, it will start with a capital letter, and be defined below. If you have questions on any of
these definitions, please call Customer Service at the number on the back of your Identification Card.
Accidental Injury
An unexpected Injury for which you need Covered Services while enrolled in this Plan. It does not include
injuries that you get benefits for under any Workers Compensation, Employers liability or similar law.
Ambulatory Surgical Facility
A freestanding Facility, with a staff of Doctors, that:
1. Is licensed as required;
2. Has permanent facilities and equipment to perform surgical procedures on an Outpatient basis;
3. Gives treatment by or under the supervision of Doctors, and nursing services when the patient is in
the Facility;
4. Does not have Inpatient accommodations; and
5. Is not, other than incidentally, used as an office or clinic for the private practice of a Doctor or other
professional Provider.
Applied Behavioral Analysis
The use of behavior analytic methods and research findings to change socially important behaviors in
meaningful ways.
Authorized Service(s)
A Covered Service you get from an Out-of-Network Provider that we have agreed to cover at the In-
Network level. You will not have to pay any more than the In-Network Deductible, Coinsurance, and/or
Copayment(s) that apply. Please see Claims Procedure (How to File a Claim) for more details.
Autism Services Provider
A person who provides services to a Member with Autism Spectrum Disorders. The Provider must be
licensed, certified, or registered by the applicable state licensing board or by a nationally recognized
organization, and who meets the requirements as defined by state law:
Autism Spectrum Disorders or ASD
Includes the following neurobiological disorders: autistic disorder, Asperger's disorder, and atypical
autism as a diagnosis within pervasive developmental disorder not otherwise specified, as defined in the
most recent edition of the diagnostic and statistical manual of mental disorders, at the time of the
diagnosis.
Autism Treatment Plan
A plan for a Member by an Autism Services Provider and prescribed by a Doctor or psychologist in line
with evaluating or again reviewing a Member's diagnosis; proposed treatment by type, frequency, and
expected treatment; the expected outcomes stated as goals; and the rate by which the treatment plan will
be updated. The treatment plan is in line with the patient-centered medical home as defined in state law.

130
Benefit Period
The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit
Period starts on January 1
st
and ends on December 31
st
. For Plan Year plans, the Benefit Period starts
on your Groups effective or renewal date and lasts for 12 months. (See your Group for details.) The
Schedule of Benefits (Who Pays What) shows if your Plans Benefit Period is a Calendar Year or a Plan
Year. If your coverage ends before the end of the year, then your Benefit Period also ends.
Benefit Period Maximum
The most we will cover for a Covered Service during a Benefit Period.
Booklet
This document (also called the certificate), which describes the terms of your benefits. It is part of the
Group Contract with your Employer, and is also subject to the terms of the Group Contract.
Brand Name Drug
Prescription Drugs that the PBM has classified as Brand Name Drugs through use of an independent
proprietary industry database.
Centers of Excellence (COE) Network
A network of health care facilities, which have been selected to give specific services to our Members
based on their experience, outcomes, efficiency, and effectiveness. An In-Network Provider under this
Plan is not necessarily a COE. To be a COE, the Provider must have signed a Center of Excellence
Agreement with us.
Closed Panel Plan
A health maintenance organization (HMO), preferred provider organization (PPO) or other plan that
provides health benefits to covered persons primarily in the form of services through a panel of providers
that have contracted with either directly, indirectly, or are employed by the plan, and that limits or
excludes benefits for services provided by other providers, except in cases of emergency or referral by a
panel provider.
Coinsurance
Your share of the cost for Covered Services, which is a percent of the Maximum Allowed Amount. You
normally pay Coinsurance after you meet your Deductible. For example, if your Plan lists 20%
Coinsurance on office visits, and the Maximum Allowed Amount is $100, your Coinsurance would be $20
after you meet the Deductible. The Plan would then cover the rest of the Maximum Allowed Amount.
See the Schedule of Benefits (Who Pays What) for details. Your Coinsurance will not be reduced by
any refunds, rebates, or any other form of negotiated post-payment adjustments.
Complications of Pregnancy
Complications of Pregnancy means:

Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but
are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable
severity. This does not include false labor, occasional spotting, physician-prescribed rest during the
period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar

131
conditions associated with the management of a difficult pregnancy not constituting a nosologically
distinct complication of pregnancy;

Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination
of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Congenital Defect
A defect or anomaly existing before birth, such as cleft lip or club foot. Disorders of growth and
development over time are not considered congenital.
Copayment
A fixed amount you pay toward a Covered Service. You normally have to pay the Copayment when you
get health care. The amount can vary by the type of Covered Service you get. For example, you may
have to pay a $15 Copayment for an office visit, but a $150 Copayment for Emergency Room Services.
See the Schedule of Benefits (Who Pays What) for details. Your Copayment will be the lesser of the
amount shown in the Schedule of Benefits (Who Pays What)" or the amount the Provider charges.
Covered Services
Health care services, supplies, or treatment described in this Booklet that are given to you by a Provider.
To be a Covered Service the service, supply or treatment must be:
Medically Necessary or specifically included as a benefit under this Booklet.
Within the scope of the Providers license.
Given while you are covered under the Plan.
Not Experimental / Investigational, excluded, or limited by this Booklet, or by any amendment or rider
to this Booklet.
Approved by us before you get the service if prior authorization is needed.
A charge for a Covered Service will apply on the date the service, supply, or treatment was given to you.
Covered Services do not include services or supplies not described in the Provider records.
Covered Transplant Procedure
Please see the Benefits/Coverage (What is Covered) section for details.
Custodial Care
Any type of care, including room and board, that (a) does not require the skills of professional or technical
workers; (b) is not given to you or supervised by such workers or does not meet the rules for post-
Hospital Skilled Nursing Facility care; (c) is given when you have already reached the greatest level of
physical or mental health and are not likely to improve further.
Custodial Care includes any type of care meant to help you with activities of daily living that does not
require the skill of trained medical or paramedical workers. Examples of Custodial Care include:
Help in walking, getting in and out of bed, bathing, dressing, eating, or using the toilet,
Changing dressings of non-infected wounds, after surgery or chronic conditions,
Preparing meals and/or special diets,
Feeding by utensil, tube, or gastrostomy,

132
Common skin and nail care,
Supervising medicine that you can take yourself,
Catheter care, general colostomy or ileostomy care,
Routine services which we decide can be safely done by you or a non-medical person without the
help of trained medical and paramedical workers,
Residential care and adult day care,
Protective and supportive care, including education,
Rest and convalescent care.
Care can be Custodial even if it is recommended by a professional or performed in a Facility, such as a
Hospital or Skilled Nursing Facility, or at home.
Deductible
The amount you must pay for Covered Services before benefits begin under this Plan. For example, if
your Deductible is $1,000, your Plan wont cover anything until you meet the $1,000 Deductible. The
Deductible may not apply to all Covered Services. Please see the Schedule of Benefits (Who Pays
What) for details.
Dependent
A member of the Subscribers family who meets the rules listed in the Eligibility section and who has
enrolled in the Plan.
{Tiered network:
[Designated Participating Provider
A Physician, advanced nurse practitioner, nurse practitioner, clinical nurse specialist, physician assistant,
or any other Provider licensed by law and allowed under the Plan, who gives, directs, or helps you get a
range of health care services.]
Doctor
See the definition of Physician.
Early Intervention Services
Services, as defined by Colorado law in accordance with part C, that are authorized through an Eligible
Child's IFSP but that exclude: nonemergency medical transportation; respite care; service coordination,
as defined in federal law; and assistive technology (unless covered under this Booklet as durable medical
equipment).
Eligible Child - means an infant or toddler, from birth through two years of age, who is an eligible
Dependent and who, as defined by Colorado law, has significant delays in development or has a
diagnosed physical or mental condition that has a high probability of resulting in significant delays in
development or who is eligible for services pursuant to Colorado law.
Individualized family service plan or IFSP - means a written plan developed pursuant to federal law
that authorizes early intervention services to an Eligible Child and the child's family. An IFSP shall
serve as the individualized plan for an Eligible Child from birth through two years of age.
Effective Date
The date your coverage begins under this Plan.

133
Emergency (Emergency Medical Condition)
Please see the "Benefits/Coverage (What is Covered)" section.
Emergency Care
Please see the "Benefits/Coverage (What is Covered)" section.
Enrollment Date
The first day you are covered under the Plan or, if the Group imposes a waiting period, the first day of
your waiting period.
Excluded Services (Exclusion)
Health care services your Plan doesnt cover.
Experimental or Investigational (Experimental / Investigational)
(a) Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other
health condition which we determine in our sole discretion to be Experimental or Investigational.
We will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or
supply to be Experimental or Investigational if we determine that one or more of the following criteria
apply when the service is rendered with respect to the use for which benefits are sought.
The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA) or any other state or federal regulatory agency, and such final approval has not
been granted;
Has been determined by the FDA to be contraindicated for the specific use;
Is provided as part of a clinical research protocol or clinical trial (except as noted in the Clinical Trials
section under Covered Services in this Booklet as required by state law), or is provided in any other
manner that is intended to evaluate the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply; or is subject to review and
approval of an Institutional Review Board (IRB) or other body serving a similar function; or
Is provided pursuant to informed consent documents that describe the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply as Experimental or
Investigational, or otherwise indicate that the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation.
(b) Any service not deemed Experimental or Investigational based on the criteria in subsection (a) may
still be deemed to be Experimental or Investigational by us. In determining whether a service is
Experimental or Investigational, we will consider the information described in subsection (c) and assess
all of the following:
Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes;
Whether the evidence demonstrates that the service improves the net health outcomes of the total
population for whom the service might be proposed as any established alternatives; or

134
Whether the evidence demonstrates the service has been shown to improve the net health outcomes
of the total population for whom the service might be proposed under the usual conditions of medical
practice outside clinical investigatory settings.
(c) The information we consider or evaluate to determine whether a drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply is Experimental or Investigational under
subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:
Randomized, controlled, clinical trials published in authoritative, peer-reviewed United States medical
or scientific journal;
Evaluations of national medical associations, consensus panels and other technology evaluation
bodies;
Documents issued by and/or filed with the FDA or other federal, state or local agency with the
authority to approve, regulate or investigate the use of the drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply;
Documents of an IRB or other similar body performing substantially the same function;
Consent documentation(s) used by the treating Physicians, other medical professionals or facilities,
or by other treating Physicians, other medical professionals or facilities studying substantially the
same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
The written protocol(s) used by the treating Physicians, other medical professionals or facilities or by
other treating Physicians, other medical professionals or facilities studying substantially the same
drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
Medical records; or
The opinions of consulting Providers and other experts in the field.
(d) We have the sole authority and discretion to identify and weigh all information and determine all
questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is Experimental or Investigational.
Facility
A facility including but not limited to, a Hospital, Ambulatory Surgical Facility, Chemical Dependency
Treatment Facility, Skilled Nursing Facility, Home Health Care Agency or mental health facility, as defined
in this Booklet. The Facility must be licensed, registered or approved by the Joint Commission on
Accreditation of Hospitals or meet specific rules set by us.
Generic Drugs
Prescription Drugs that the PBM has classified as Generic Drugs through use of an independent
proprietary industry database. Generic Drugs have the same active ingredients, must meet the same
FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as
the Brand Name Drug.
Group
The employer or other organization (e.g., association), which has a Group Contract with us, Anthem for
this Plan.

135
Group Contract (or Contract)
The Contract between us, Anthem, and the Group (also known as the Group Master Contract). It
includes this Booklet, your application, any application or change form, your Identification Card, any
endorsements, riders or amendments, and any legal terms added by us to the original Contract.
The Group Master Contract is kept on file by the Group. If a conflict occurs between the Group Master
Contract and this Booklet, the Group Master Contract controls.
Habilitative Services
Habilitative Services help you keep, learn or improve skills and functioning for daily living. Examples
include therapy for a child who isnt walking or talking at the expected age.
Home Health Care Agency
A Facility, licensed in the state in which it is located, that:
1. Gives skilled nursing and other services on a visiting basis in your home; and
2. Supervises the delivery of services under a plan prescribed and approved in writing by the attending
Doctor.
Hospice
A Provider that gives care to terminally ill patients and their families, either directly or on a consulting
basis with the patients Doctor. It must be licensed by the appropriate agency.
Hospital
A Provider licensed and operated as required by law, which has:
1. Room, board, and nursing care;
2. A staff with one or more Doctors on hand at all times;
3. 24 hour nursing service;
4. All the facilities on site are needed to diagnose, care, and treat an illness or injury; and
5. Is fully accredited by the Joint Commission on Accreditation of Health Care Organizations.
The term Hospital does not include a Provider, or that part of a Provider, used mainly for:
1. Nursing care
2. Rest care
3. Convalescent care
4. Care of the aged
5. Custodial Care
6. Educational care
7. Subacute care
8. Treatment of alcohol abuse
9. Treatment of drug abuse
Identification Card
The card we give you that shows your Member identification, Group numbers, and the plan you have.

136
In-Network Provider
A Provider that has a contract, either directly or indirectly, with us, or another organization, to give
Covered Services to Members through negotiated payment arrangements.
In-Network Transplant Provider
Please see the Benefits/Coverage (What is Covered) section for details.
Inpatient
A Member who is treated as a registered bed patient in a Hospital and for whom a room and board
charge is made.
Late Enrollees
Subscribers or Dependents who enroll in the Plan after the initial enrollment period. A person will not be
considered a Late Enrollee if he or she enrolls during a Special Enrollment period. Please see the
Eligibility section for further details.

Maintenance Medications
Please see the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section for
details.
Manipulation Therapy
A system of therapy that includes the therapeutic application of manual manipulation treatment, analysis
and adjustments of the spine and other body structures, and muscle stimulation by any means, including
therapeutic use of heat, cold, and exercise.

Maximum Allowed Amount
The maximum payment that we will allow for Covered Services. For more information, see the Member
Payment Responsibility section.
Medical Necessity (Medically Necessary)
The diagnosis, evaluation and treatment of a condition, illness, disease or injury that we solely decide to be:
Medically appropriate for and consistent with your symptoms and proper diagnosis or treatment of
your condition, illness, disease or injury;
Obtained from a Doctor or Provider;
Provided in line with medical or professional standards;
Known to be effective, as proven by scientific evidence, in improving health;
The most appropriate supply, setting or level of service that can safely be provided to you and which
cannot be omitted. It will need to be consistent with recognized professional standards of care. In
the case of a Hospital stay, also means that safe and adequate care could not be obtained as an
outpatient;
Cost-effective compared to alternative interventions, including no intervention. Cost effective does not
always mean lowest cost. It does mean that as to the diagnosis or treatment of your illness, injury or

137
disease, the service is: (1) not more costly than an alternative service or sequence of services that is
medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate;
Not Experimental or Investigational;
Not primarily for you, your families, or your Providers convenience; and
Not otherwise an exclusion under this Booklet.
The fact that a Doctor or Provider may prescribe, order, recommend or approve care, treatment, services or
supplies does not, of itself, make such care, treatment, services or supplies Medically Necessary.
Member
People, including the Subscriber and his or her Dependents, who have met the eligibility rules, applied for
coverage, and enrolled in the Plan. Members are called you and your in this Booklet.
Mental Health, Biologically Based Mental Illness and Substance Abuse
A condition that is listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) as a mental health or substance abuse condition. Coverage is also provided for Biologically Based
Mental Illness for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive
disorder, specific obsessive-compulsive disorder, and panic disorder. It does not include Autism
Spectrum Disorder, which under state law is considered a medical condition.
Open Enrollment
A period of time in which eligible people or their dependents can enroll without penalty after the initial
enrollment. See the Eligibility section for more details.
Out-of-Network Provider
A Provider that does not have an agreement or contract with us, or our subcontractor(s) to give services
to our Members.
You will often get a lower level of benefits when you use Out-of-Network Providers.
Out-of-Network Transplant Provider
Please see the Benefits/Coverage (What is Covered) section for details.
Out-of-Pocket Limit
The most you pay in Copayments, Deductibles, and Coinsurance during a Benefit Period for Covered
Services. The Out-of-Pocket limit does not include your Premium, amounts over the Maximum Allowed
Amount, or charges for health care that your Plan doesnt cover. Please see the Schedule of Benefits
(Who Pays What) for details.
Pharmacy
A place licensed by state law where you can get Prescription Drugs and other medicines from a licensed
pharmacist when you have a prescription from your Doctor.

138
Pharmacy and Therapeutics (P&T) Process
A process to make clinically based recommendations that will help you access quality, low cost medicines
within your Plan. The process includes health care professionals such as nurses, pharmacists, and
Doctors. The committees of the WellPoint National Pharmacy and Therapeutics Process meet regularly
to talk about and find the clinical and financial value of medicines for our Members. This process first
evaluates the clinical evidence of each product under review. The clinical review is then combined with
an in-depth review of the market dynamics, Member impact and financial value to make choices for the
formulary. Our programs may include, but are not limited to, Drug utilization programs, prior authorization
criteria, therapeutic conversion programs, cross-branded initiatives, and Drug profiling initiatives.
Physician (Doctor)
Includes the following when licensed by law:
Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery,
Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O.,
Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor;
Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and
Doctor of Dental Medicine (D.D.M.), Doctor of Dental Surgery (D.D.S.), legally entitled to provide
dental services.
Optometrists, Clinical Psychologists (PhD), and surgical chiropodists are also Providers when legally
licensed and giving Covered Services within the scope of their licenses.
Plan
The benefit plan your Group has purchased, which is described in this Booklet.
Precertification
Please see the section How to Access Your Services and Obtain Approval of Benefits for details.
Predetermination
Please see the section How to Access Your Services and Obtain Approval of Benefits for details.
Premium
The amount that you and/or the Group must pay to be covered by this Plan. This may be based on your
age and will depend on the Groups Contract with us.
Prescription Drug (Drug)
A medicine that is made to treat illness or injury. Under the Federal Food, Drug & Cosmetic Act, such
substances must bear a message on its original packing label that says, Caution: Federal law prohibits
dispensing without a prescription. This includes the following:
1. Compounded (combination) medications, when the primary ingredient (the highest cost ingredient) is
FDA-approved and requires a prescription to dispense, and is not essentially the same as an FDA-
approved product from a drug manufacturer.
2. Insulin, diabetic supplies, and syringes.

139
Primary Care Physician / Provider (PCP)
A Provider who gives or directs health care services for you. The Provider may work in family practice,
general practice, internal medicine, pediatrics or any other practice allowed by the Plan. A PCP
supervises, directs and gives initial care and basic medical services to you and is in charge of your
ongoing care.
Provider
A professional or Facility licensed by law that gives health care services within the scope of that license
and is approved by us. This includes any Provider that state law says we must cover when they give you
services that state law says we must cover. Providers that deliver Covered Services are described
throughout this Booklet. If you have a question about a Provider not described in this Booklet please call
the number on the back of your Identification Card.
Qualified Early Intervention Service Provider
Means a person or agency, as defined by Colorado law in accordance with part C, who provides Early
Intervention Services and is listed on the registry of early intervention service providers.
Recovery
Recovery is money the Member, the Members legal representative, or beneficiary receives whether by
settlement, verdict, judgment, order or by some other monetary award or determination, from another,
their insurer, or from any uninsured motorist, underinsured motorist, medical payments, personal injury
protection, or any other insurance coverage, to compensate the Member as a result of bodily injury or
illness to the Member. Regardless of how the Member, the Members legal representative, or beneficiary
or any agreement may characterize the money received, it shall be subject to the Subrogation and
Reimbursement under the General Policy Provisions section of this Booklet.
Referral
Please see the How to Access Services and Obtain Approval of Benefits section for details.
Retail Health Clinic
A Facility that gives limited basic health care services to Members on a walk-in basis. These clinics are
often found in major pharmacies or retail stores. Medical services are typically given by Physician
Assistants and Nurse Practitioners.
Service Area
The geographical area where you can get Covered Services from an In-Network Provider.
Skilled Nursing Facility
A Facility operated alone or with a Hospital that cares for you after a Hospital stay when you have a
condition that needs more care than you can get at home. It must be licensed by the appropriate agency
and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or otherwise approved by us. A Skilled Nursing
Facility gives the following:
1. Inpatient care and treatment for people who are recovering from an illness or injury;
2. Care supervised by a Doctor;

140
3. 24 hour per day nursing care supervised by a full-time registered nurse.
A Skilled Nursing Facility is not a place mainly for care of the aged, Custodial Care or domiciliary care,
treatment of alcohol or drug dependency; or a place for rest, educational, or similar services.
Special Enrollment
A period of time in which eligible people or their dependents can enroll after the initial enrollment, typically
due to an event such as marriage, birth, adoption, etc. See the Eligibility section for more details.
Specialist (Specialty Care Physician \ Provider or SCP)
A Specialist is a Doctor who focuses on a specific area of medicine or group of patients to diagnose,
manage, prevent, or treat certain types of symptoms and conditions. A non-Physician Specialist is a
Provider who has added training in a specific area of health care.
Specialty Drugs
Drugs that typically need close supervision and checking of their effect on the patient by a medical
professional. These drugs often need special handling, such as temperature-controlled packaging and
overnight delivery, and are often not available at retail pharmacies. They may be administered in many
forms including, but not limited to, injectable, infused, oral and inhaled.
Subscriber
An employee or member of the Group who is eligible for and has enrolled in the Plan.
Transplant Benefit Period
Please see the Benefits/Coverage (What is Covered) section for details.
Urgent Care Center
A licensed health care Facility that is separate from a Hospital and whose main purpose is giving
immediate, short-term medical care, without an appointment, for urgent care.
Utilization Review
A set of formal techniques to monitor or evaluate the clinical necessity, appropriateness, efficacy or
efficiency of, health care services, procedures or settings. Techniques include ambulatory review,
prospective review, second opinion, certification, concurrent review, Care Management, discharge
planning and/or retrospective review. Utilization Review also includes reviewing whether or not a
procedure or treatment is considered Experimental or Investigational, and reviewing your medical
circumstances when such a review is needed to determine if an exclusion applies.



End of Booklet
Uniform Employee Application CO SG 01 (Revised 05/30/2013)



Division of Insurance



COLORADO UNIFORM EMPLOYEE APPLICATION FOR SMALL GROUP HEALTH BENEFIT PLANS

This form is designed for an employees initial application for coverage. Please contact your agent or the carrier to determine if this form should be used
in other situations once the group is enrolled with the carrier.

COVERAGE INFORMATION
Application Type: New Coverage Change/Modification to Existing Policy Open Enrollment Special Enrollment*
* Proof of eligibility for special enrollment will be required information on eligibility for special enrollment periods is available at: www.dora.colorado.gov/DOI/HealthApp
EMPLOYER INFORMATION
Employee Name: Employer Name:
Proposed Effective Date: Group Number (if known):

EMPLOYEE INFORMATION
Employee Instructions: Please type or print using black or blue ink. Please fill out the entire application for each person for whom coverage is being sought.
First Name: Middle Initial: Last Name:
Social Security #: Date of Birth: / / Current Age: Sex: M F
Address: City:
County: State: Zip:
Mailing Address (If different): City:
County: State: Zip:
Home Phone: Email: Home Work
What is your job title at your current employer? Work Phone:
What was your first day of employment? How many hours, on average, do you work each week?
Are you (check one): Single Married Common Law* Civil Union*
Designated Beneficiary* Legally Separated Divorced Widow or Widower
* A common law, civil union, or designated beneficiary certification may be required by the carrier
Are you on COBRA or State Continuation? Yes No Start Date: Stop Date:

TYPE OF HEALTH COVERAGE
List all dependents (spouse/partner and child(ren)) applying for coverage. If you need additional space, please use a separate sheet of paper and attach it to this application
(please print your name and sign and date the additional sheet).
Please select the type of health insurance coverage for which you are applying: Employee Only Employee & Family

DEPENDENT INFORMATION
(list all dependents to be covered)
Name (First, MI, Last) Sex Social Security Number Relationship Disabled
Birth Date
(MM/DD/YY)

M F

SPOUSE/PARTNER


M F

CHILD
STEPCHILD
Yes
No

M F

CHILD
STEPCHILD
Yes
No

M F

CHILD
STEPCHILD
Yes
No
Employee Name: Employer Name:
Uniform Employee Application CO SG 01 (Revised 05/15/2013) 2
TOBACCO USE
Please answer the following questions to the best of your knowledge. 45 CFR 147.102(a)(1)(iv) "For purposes of this section, tobacco use means use of
tobacco on average four or more times per week within no longer than the past 6 months. This includes all tobacco products, except that tobacco use does
not include religious or ceremonial use of tobacco. Further, tobacco use must be defined in terms of when a tobacco product was last used."
Has anyone named in this application used tobacco or smokeless tobacco during the past 6 months? If yes, provide the information requested below.
Name of Person Used Tobacco Products If Yes, check all that apply Duration Frequency

Yes
No
Cigarettes
Chewing Tobacco
Pipe/Cigars

Yes
No
Cigarettes
Chewing Tobacco
Pipe/Cigars

Yes
No
Cigarettes
Chewing Tobacco
Pipe/Cigars

Yes
No
Cigarettes
Chewing Tobacco
Pipe/Cigars

EMPLOYEE/DEPENDENT WAIVER OF COVERAGE
Complete this section ONLY if you are not enrolling yourself or your spouse/partner or dependents. Waiver must be completed for all of your dependents to be
eligible for enrollment on this plan in the event of changing circumstances. I understand that I am eligible to apply for group health coverage through my employer.
I do NOT want, and hereby waive, group health coverage for:

Name (Last, First, MI)
Birth Date
(Mo/Day/Year)

Employee
Spouse/Partner
Dependent 1
Dependent 2
Dependent 3
I am waiving group health coverage for myself and/or the dependents listed above because (check all that apply, copy of ID card may be required):
I am covered under my spouse/partners group policy.
My spouse/partner is covered under another plan (including this plan, if spouse/partner is also an employee).
My dependents are covered under another plan.
I wish to continue other coverage obtained through an Individual Plan or Medicare
Other (Please explain):
WAIVER: I certify that I have been given the opportunity to apply for group health coverage and decline to enroll as indicated above, on behalf of myself, my
spouse/partner and my dependent child(ren). I understand that by signing this waiver, I, my spouse/partner, and my dependent child(ren) forfeit the right
to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the carrier(s) into waiving or declining the group health coverage.
If in the future I apply for coverage, I, my spouse/partner, or any of my dependent child(ren) may be treated as a late enrollee and subject to postponement
of coverage for up to 12 months.
I understand that if I am declining enrollment for myself, my spouse/partner, or my dependent child(ren) because of other health coverage, I may, in the
future, be able to enroll myself, my spouse/partner, or my dependent child(ren) in this plan, as required by law, provided that I request enrollment within
30 days after my other health coverage ends or a qualifying event occurs. If I do not request enrollment within 30 days of the above events, I understand that
I may not be able to enroll for coverage until my companys Open Enrollment period. I understand that I can obtain information related to my enrollment
eligibility from my employer or small group health carrier.
Signature of Employee: Date Signed:
Employee Name: Employer Name:
Uniform Employee Application CO SG 01 (Revised 05/15/2013) 3
MEDICARE INFORMATION
If you need to complete this section for more than one person, please use a separate sheet of paper and attach it to this application (please sign and date the
additional sheet). A copy of your ID card may be required.
Are you, your spouse/partner or your child(ren) covered by:
Medicare Part A? Yes No Medicare Part B? Yes No Medicare Part D? Yes No
If Yes, reason for Medicare: 65+ Eff. Date_______________ Disability Eff. Date______________
End-Stage Renal Disease (ESRD) Eff. Date______________ Disability and ESRD Eff. Date________________
Name of person covered by Medicare:

CURRENT MEDICAL COVERAGE
Do you, your spouse/partner, or your dependent child(ren) listed in this application currently have health insurance coverage? Yes No
Is the plan information listed below the same for your spouse/partner and all dependents? If yes, skip to next section. Yes No
Your information will help the small employer carrier(s) to coordinate benefits with any other group health coverage you may have.

Name
Carrier Name
Carrier Phone Number
Plan Name
Group Number
Subscriber ID#
Effective Date of
Coverage
(MM/DD/YY)
Termination Date of
Coverage
(MM/DD/YY)
Type of
Coverage
(See Key Below)





Type of Coverage Key: G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical; MS = Medicare Supplement;
H = Hospital Coverage Only; V = Vision Coverage Only O=Other, please explain:_____________________________

HEALTH PROVIDER OR PRODUCT SELECTION, IF APPLICABLE
Please select the type of coverage for which you are applying from the plans offered by your employer and issued by the carrier. This section should be
completed only if the small employer group insurance for which you are applying requires the selection of a primary care provider. A selection should be
made for each individual applying for such coverage and for each carrier from which insurance coverage is being sought. The provider information may be
listed in the provider materials that are supplied by each carrier to your employer. Use additional sheets if necessary.
Covered Persons Name Medical Plan Primary Care Physician Name:
Primary Care Physician Address:
(optional)
Is this your current
provider?





Employee Name: Employer Name:
Uniform Employee Application CO SG 01 (Revised 05/15/2013) 4

TERMS AND CONDITIONS
I acknowledge that I have read all sections of this Colorado Uniform Employee Application for Small Employer Group Health Coverage
(Application), and I certify on behalf of my eligible family dependents and myself that the answers contained in this Application are complete and
accurate to the best of my knowledge. I understand and agree that neither my employer nor any insurance agents have any authority to waive my
complete answer to any question, agree to insurability, alter any contract, or waive any Colorado small employer carriers other rights or
requirements.
I hereby apply for enrollment for myself and for my eligible family dependents listed. On behalf of my eligible family dependents and myself, I
agree to all of the terms and conditions of the group contract(s) with Colorado small employer carrier(s) under which I wish to enroll for coverage.
I have indicated in this Application, if required, what product(s) or provider(s) I have selected. I agree that no coverage will be effective until the
date specified by the Colorado small employer carrier(s) with whom I enroll, after this application has been accepted by such carrier(s).
I understand and agree that any information obtained in connection with this Application will be used by Colorado small employer carrier(s) to
determine eligibility for coverage.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance carrier for the purpose of defrauding or
attempting to defraud the carrier. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance carrier or agent
of an insurance carrier who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
When applicable, I authorize my employer to deduct contributions from my earnings to be applied to the cost of coverage.
I agree to any applicable group contract provisions for the resolution of disagreements and disputes, including arbitration when required and as
allowed by law. Please refer to any arbitration provisions in the group contract(s).
I understand that I may request a copy of this Application. I agree that a photographic copy of this Application shall be as valid as the original. A
legible facsimile signature shall have the same force and effectiveness as the original. This document will become a part of the contract when
coverage is approved and issued.

Signature of Employee: _________________________________________ Date Signed: __________________


DISCLOSURES

COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY APPLICABLE HEALTH BENEFIT PLAN IT MARKETS
IN COLORADO TO ANY SMALL EMPLOYER THAT APPLIES FOR THE PLAN AND AGREES TO MAKE THE REQUIRED PREMIUM PAYMENTS, AND SATISFIES
THE OTHER PROVISIONS OF THE HEALTH BENEFIT PLAN.


This document is a publication of the Colorado Division of Insurance. If you have questions about the content of this document please contact our
offices at 303-894-7499 or visit our website at http://dora.colorado.gov/insurance. For questions regarding coverage or enrollment please see
your employer.
Employee Name: Employer Name:
Uniform Employee Application CO SG 01 (Revised 05/15/2013) 5
This page may be used to provide additional information that was required in the sections above and did not fit in the space provided.






























Signature of Employee: _________________________________________ Date Signed: __________________
COGC2013 (SG) 1 |05/01|


Group Contract

This Group Contract ('Contract) is entered into by and between
('|Employer|) (|'Group|) and HMO Colorado, Inc. or Rocky Mountain Hospital and Medical Service,
Inc. d/b/a Anthem Blue Cross and Blue Shield (collectively, 'Anthem) (individually reIerred to as
'Party and together collectively reIerred to as the 'Parties) upon the Iollowing terms and conditions:

ARTICLE 1 - PURPOSE

|Employer| |Group| has requested Anthem to provide health insurance coverage to its eligible
|Employees| or other individuals as described in the Booklet. Upon Anthem`s receipt and acceptance oI
|Employer`s| |Group`s| signed application and payment oI the Iirst premium, this Contract will be
deemed executed by |Employer| |Group|. This Contract supersedes any prior agreements between the
Parties regarding the subject matter oI this Contract. Anthem`s standard policies and procedures, as they
may be amended Irom time to time, will be used in the perIormance oI services speciIied in this Contract
and the provision oI beneIits contained in the Booklet.

ARTICLE 2 - DEFINITIONS

In this Contract, the Iollowing terms will have the meanings shown below. Capitalized terms used in this
Contract that are not deIined below are deIined in the Booklet.

A. Anniversary Date. The date indicated in Schedule A that this Contract will renew.

B. Booklet. The CertiIicate oI Coverage that describes the medical or other health care beneIits
provided by Anthem, including any amendments or schedules.

C. Contract. The entire agreement between the Parties including: (1) this Contract and any
amendments and schedules; (2) the Booklet and any amendments; (3) the |Employer| |Group|
application; and, (4) any individual enrollment inIormation, as each may be updated Irom time to time.

D. |Employee] Union Member] Association Member] Plan Participant]. Actively employed
individuals, owners, partners or other individuals designated by |Employer| |Group| who meet the
eligibility criteria in the Booklet and any additional eligibility criteria indicated on Schedule A. These
individuals must complete any probationary period required by |Employer| |Group| and satisIy Anthem`s
underwriting rules, consistent with applicable laws. Retirees are also eligible Ior coverage under this
Contract, iI indicated on Schedule A.

E. Group Health Plan or Plan. A beneIits plan established by the |Employer| |Group| as
described in the plan documents, which includes the Booklet.




Anthem Blue Cross and Blue Shield is the trade name oI Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by
HMO Colorado, Inc. Independent licensees oI the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark oI Anthem
Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks oI the Blue Cross and Blue Shield
Association.
COGC2013 (SG) 2 |05/01|

F. !"#$"%& An individual, including the Subscriber and any dependents, that meets the eligibility
criteria and has enrolled Ior coverage under this Contract.

G. ()$*+%,$"%& An |Employee| that meets the eligibility criteria and has enrolled Ior coverage under
this Contract.

-./0123 4 5 67208-/069( 6: -9/;3!

A. Anthem will provide medical or other health care beneIits under the terms oI this Contract and the
Booklet. Anthem will not provide beneIits Ior health care services provided: (1) beIore a Member`s Iirst
day oI coverage under this Contract; (2) aIter the termination oI coverage; or, (3) during any period that
Iull premium has not been paid, except as required by law.

B. Anthem will provide either electronic or paper copy oI materials such as Booklets, ID cards and
provider directories, as permitted under applicable law. |Employer| |Group| will assist in the distribution
oI materials iI requested by Anthem. Anthem will provide paper copies oI electronic materials, upon
request.

C. Anthem will process the enrollment oI eligible individuals, subject to the terms oI this Contract
and receipt oI applicable premium. Anthem will maintain current Member eligibility inIormation
submitted by |Employer| |Group|.

D. Anthem will process claims, including investigating and reviewing the claims to determine what
amount, iI any, is due and payable according to the terms and conditions oI this Contract and the Booklet.
Anthem has the right to make beneIit payments to either Providers or Members as described in the
Booklet. Anthem will coordinate beneIits with other payors, including Medicare. Anthem will give
notice in writing when a claim Ior beneIits has been denied. The notice will provide the reasons Ior the
denial and the right to an appeal oI the denial under the terms oI the Booklet.

E. Anthem is responsible Ior pursuing recoveries oI claim payments as appropriate. Anthem shall
determine which recoveries it will pursue. However, Anthem will not pursue a recovery iI the cost oI
collection is likely to exceed the recovery amount, or iI the recovery is prohibited by law or an agreement
with a Provider or other vendor.

F. |Employer| |Group| is responsible Ior complying with Employee Retirement Income Security
Act ('ERISA) reporting requirements, as applicable; however, Anthem will provide |Employer| |Group|
available data necessary Ior preparation oI the ERISA Form 5500. The Booklet provided by Anthem
does not satisIy all requirements oI ERISA Ior a Summary Plan Description, but may be incorporated into
the Summary Plan Description issued by |Employer| |Group|. Anthem is under no obligation to provide
any other type oI data reports to |Employer| |Group|, except as otherwise agreed to by the Parties or
required by law.

G. In addition to the beneIits described in the Booklet, Anthem may Iacilitate the provision oI
wellness programs oIIered by |Employer| |Group|. |Employer| |Group| will pay any Iees Ior these
wellness programs, iI indicated in Schedule B.

H. Anthem shall not: (1) adjust premiums based on genetic inIormation; (2) request genetic testing,
except to determine medical appropriateness; (3) collect genetic inIormation Irom a Member in
connection with enrollment; or, (4) Ior any other underwriting purpose.
COGC2013 (SG) 3 |05/01|

!"#$%&' ) * +,&$-!#$+./ +0 1'23&+4'"5 1-"+635

A. |Employer| |Group| will provide initial eligibility inIormation in the Iormat agreed to by the
Parties, as well as notice oI additions, deletions, and changes to enrollment. |Employer| |Group| will also
provide any inIormation reasonably required by Anthem to administer this Contract, including
inIormation regarding: (1) eligibility Ior enrollment and termination oI Members; (2) changes in single or
Iamily coverage status; (3) changes due to Medicare eligibility; or, (4) contribution and participation
levels.

B. |Employer| |Group| will notiIy each |Employee| as the |Employee| becomes eligible Ior
enrollment, and will collect and submit to Anthem enrollment or waiver oI coverage inIormation.
|Employer| |Group| will also keep a record oI |Employees| who do not apply. All inIormation provided
by |Employer| |Group| to Anthem will be true, accurate and complete to the best oI its knowledge. In
addition, |Employer| |Group| will provide an open enrollment period as agreed to by the Parties and
consistent with state and Iederal law.

C. |Employer| |Group| will timely notiIy Anthem oI any Member termination or loss oI eligibility
Ior coverage. The |Employer| |Group| will pay premium to Anthem Ior each Member through the date
that the |Employer| |Group| notiIies Anthem that the Member is no longer eligible Ior coverage under
this Contract. Anthem must receive notiIication that a Member is no longer eligible Ior coverage, at the
latest, by the end oI the month that the Member becomes ineligible to be eIIective Ior that month. II
Anthem receives notiIication that a Member is no longer eligible aIter the end oI the month that the
Member becomes ineligible, the termination will be processed as eIIective on the date that Anthem
receives notiIication. Anthem may limit retroactive terminations to a maximum oI
|30||60||90||120||365| days prior to the date notice is received. Also, iI Anthem has provided beneIits
Ior individuals no longer eligible, Anthem may collect Irom |Employer| |Group| any paid claim amounts
not otherwise recovered by Anthem

D. |Employer| |Group| must comply with Anthem`s contribution levels, participation levels, and
other applicable underwriting rules that are consistent with applicable laws.

E. |Employer| |Group| will promptly notiIy Anthem iI there is a change in |Employer`s||Group`s|
status as either a large group or small group, as deIined under applicable law. In such event, |Employer|
|Group| will provide all inIormation requested by Anthem about its status.

F. II |Employer| |Group| maintains a GrandIathered Health Plan, as that term is used in the Patient
Protection and AIIordable Care Act ('PPACA), |Employer| |Group| will not make any changes to such
Plan, including changes to |Employer| |Group| contribution levels, without giving Anthem advance
written notice oI the intent to change such Plan. Also, at Anthem`s request, |Employer| |Group| will
conIirm in writing that it has not made changes to its Plan that would cause the Plan to lose its
grandIathered status. II |Employer| |Group| makes changes to a GrandIathered Health Plan without notice
to Anthem, the Plan may lose grandIathered status, and signiIicant penalties or Iines may be assessed
against |Employer| |Group| and Anthem. II |Employer| |Group| makes changes to its Plan and does not
provide advance notice to Anthem, |Employer| |Group| agrees to reimburse Anthem Ior any penalties,
Iines or other costs assessed against Anthem.

G. |Employer| |Group| agrees to distribute and deliver to its |Employees| and dependents, the
Summary oI BeneIits and Coverage ('SBC) provided by Anthem as required by Iederal law and the
Colorado Supplement as required by state law. The SBC and Colorado Supplement must be provided
with open enrollment materials or, iI |Employer| |Group| does not hold an open enrollment, at least 30
COGC2013 (SG) 4 |05/01|
days prior to the Anniversary Date. |Employer| |Group| will issue an updated SBC and Colorado
Supplement iI the beneIits change between the time oI original distribution and the eIIective date oI
coverage. SBCs and Colorado Supplements must also be provided to new enrollees and special enrollees.
|Employer| |Group| may distribute the SBC and Colorado Supplement either electronically or by paper,
subject to the requirements oI applicable law. II requested by Anthem, |Employer| |Group| will certiIy
its compliance with the SBC and Colorado Supplement distribution requirements. |Employer| |Group|
agrees to reimburse Anthem Ior any penalties, Iines or other costs assessed against Anthem, iI |Employer|
|Group| Iails to comply with these requirements.

|Employer| |Group| will timely notiIy Anthem oI requested beneIit changes prior to the Anniversary
Date. A request Ior beneIit changes aIter the renewal oI this Contract may delay the eIIective date oI the
beneIit changes by at least 60 days and require a notice oI material modiIication.

H. |Employer| |Group| is responsible Ior all applicable requirements pertaining to COBRA and state
continuation, unless otherwise agreed to in writing by Anthem. II Anthem has agreed to perIorm any
COBRA administration duties on behalI oI |Employer| |Group|, such arrangement will be described in a
separate agreement.

I. PPACA requires a small group beneIit design to meet certain minimum levels oI actuarial value.
The amount oI |Employer`s| |Group`s| contribution to any HRA, HSA or Wrap Plan is included in the
calculation oI these actuarial values. |Employer| |Group| must notiIy Anthem iI it changes its
contribution amount to any HRA, HSA or Wrap Plan, and agrees to reimburse Anthem Ior any penalties,
Iines or other costs assessed against Anthem resulting Irom |Employer`s| |Group`s| change in
contribution.

J. II |Employer| |Group| oIIers multiple beneIit plans insured by more than one carrier, |Employer|
|Group| will oIIer Anthem coverage to all Employees at terms and contribution levels that are no less
Iavorable than those oIIered by other carriers.

K. The waiting period elected by |Employer| |Group| may not exceed 90 days.

L. II the |Employer| |Group| reduces the working hours oI Employees to Iewer hours than stated on
the application, coverage will be continued Ior such Employees and their Dependents under the same
conditions and Ior the same premium, iI the Iollowing conditions are met and the |Employer| |Group|
certiIies: (1) the covered Employees are continuously employed as Employees oI the |Employer| |Group|
and are insured under the Contract, or under any contract providing similar beneIits which this Contract
replaces, immediately beIore such reduction in working hours; (2) the |Employer| |Group| has imposed
the reduction in working hours due to economic conditions, or the reduction oI hours is due to the
Employee`s injury, disability, or chronic health condition; and, (3) the |Employer| |Group| intends to
restore the employees to a Iull workweek schedule as soon as economic conditions improve or as soon as
the Employee is able to return to Iull-time work.



!"#$%&' ) * %+!,-'. #/ %/,#"!%# !,0 1//2&'#

A. Anthem may modiIy the terms oI the Booklet by giving at least |30| |60| |90| days
advance written notice prior to the Anniversary Date oI this Contract. |Employer| |Group| can also propose
changes to the terms oI the Booklet at any time by giving written notice oI any such requested
change to Anthem. The eIIective date oI such requested changes to the Booklet shall be agreed to by the
Parties. In addition, Anthem may modiIy the terms oI this Contract, other than the terms oI the Booklet and
the premium rates, by giving |30||60||90| days advance written notice to |Employer| |Group| oI such
changes.
COGC2013 (SG) 5 |05/01|

B. Anthem may change the premium rates or other amounts due under this Contract by providing
written notice to |Employer| |Group| at least |30| |60| |90| days beIore the eIIective date oI such change,
However, such notice requirement will not apply to changes in premium rates that are the result oI
changes in beneIit provisions required by state or Iederal law, or changes requested by |Employer|
|Group|.

C. An amendment to this Contract will not be eIIective unless signed by an oIIicer oI Anthem. II any
change to the Contract or the Booklet, including premium amounts, is unacceptable to |Employer| |Group|,
|Employer| |Group| has the right to terminate coverage under this Contract by giving written notice oI
termination to Anthem beIore the eIIective date oI the change. Payment oI the new amount in the event oI a
premium rate change, or continued payment oI the current amounts in the event oI a Contract or Booklet
change only, will constitute acceptance oI the change by |Employer| |Group|, without the necessity oI
securing |Employer`s| |Group`s| signature on the schedule or amendment. The schedule or amendment will
then become a part oI this Contract.

!"#$%&' ) * +"',$-, !./ 0"!%' +'"$1/

A. The premium rates Ior coverage under this Contract are provided in Schedule B. Premium rates
are based on the data provided by |Employer| |Group|, consistent with applicable laws. Anthem may
retroactively modiIy the premium rates iI the data provided is inaccurate or new data is submitted that
varies Irom the data previously provided to Anthem.

B. The Iull invoice amount, including premium, taxes, Iees or assessments, must be paid in advance
by |Employer| |Group| on or beIore the invoice due date. Anthem does not have an obligation to accept a
partial payment. |Employer| |Group| must make payments regardless oI any contributions to those
payments by Subscribers. Even iI |Employer| |Group| has not received an invoice Irom Anthem,
|Employer| |Group| is still obligated to pay, at a minimum, the prior invoice amount.

C. |Employer| |Group| is entitled to a |31| day period beginning on the invoice due date (the 'Grace
Period), Ior the payment oI any premium or other amounts due. II, during the Grace Period, |Employer|
|Group| pays the Iull amounts owed, this Contract will remain in Iorce. Anthem is not obligated to pay
any claims incurred during the Grace Period, until the Iull amount due is received.

D. Anthem may assess additional Iees or charges iI indicated in Schedule B.

E. For any rebate due and payable by Anthem as a result oI the medical loss ratio ('MLR)
requirements oI PPACA or applicable state law, all such rebates paid will constitute a return oI premium.
|Employer| |Group| will promptly provide Anthem with any inIormation needed to calculate the rebate
amount. Anthem reserves the right to pay the rebate to either |Employer| |Group| or Subscribers.

II Anthem pays the rebate to |Employer| |Group|, |Employer| |Group| will promptly reIund to each
Subscriber his or her proportional share oI the rebate according to the requirements oI PPACA. On
request, |Employer| |Group| will provide to Anthem documentation required under PPACA oI the
distribution oI the rebate to Subscribers. |Employer| |Group| agrees to provide such documentation
within the time Irame designated by Anthem.

II Anthem receives a claim relating to the amount oI the Subscriber`s rebate, |Employer| |Group| will
cooperate with Anthem and provide Anthem with inIormation required to investigate the claim. II
Anthem is required to pay additional amounts to a Subscriber due to |Employer`s| |Group`s| Iailure to
provide accurate inIormation, make a reIund, or reIund less than the amount due, |Employer| |Group|
must reimburse Anthem Ior such additional amounts paid. This provision survives the termination oI the
Contract.
COGC2013 (SG) 6 |05/01|

!"#$%&' ) * #'"+$,!#$-,

A. |Employer| |Group| may terminate this Contract at any time by giving Anthem advance written
notice oI termination; however, the termination will be eIIective at the end oI the month in which notice is
given, except as otherwise agreed to by the Parties. |Employer| |Group| must pay the amounts due Ior
each Subscriber covered through the eIIective date oI termination oI this Contract. Unless |Employer|
|Group| provides advance notice oI termination, this Contract will automatically renew on each
Anniversary Date, upon |Employer`s| |Group`s| payment and Anthem`s acceptance oI premium.

B. The Contract will terminate:

(1) automatically, without notice, on the later oI either the last day oI the Grace Period or the last
day that Anthem remains liable Ior a Member`s claims, as required by applicable law, iI the
Grace Period expires and any amounts due remain unpaid. Anthem`s receipt and deposit oI a
payment through its automatic payment procedures or other procedures will not be deemed
acceptance oI a late payment or waiver oI termination.
(2) with written notice to |Employer| |Group| that the Contract will be terminated due to
|Employer`s| |Group`s| Iailure to comply with Anthem`s contribution or participation
requirements or |Employer`s| |Group`s| Iailure to supply inIormation necessary to
substantiate the contribution or participation levels.
(3) with written notice to |Employer| |Group|, iI |Employer| |Group| commits Iraud or makes an
intentional misrepresentation oI material Iact with respect to this Contract.
(4) with written notice to |Employer| |Group|, as required by applicable law, that the Contract
will be terminated because Anthem is discontinuing the particular type oI health beneIits
product elected by |Employer| |Group|, Anthem will no longer issue group health coverage
within the small or large group market, or Ior any other reason permitted by law.
(5) with written notice to |Employer| |Group|, iI there is no longer any Subscriber under the Plan
who lives or works in Anthem`s service area.
(6) as oI the date |Employer`s| |Group`s| membership in an association, labor union or other
entity applicable to |Employer`| |Group`s| coverage ceases, or the date that entity`s coverage
with Anthem ceases.

C. |Employer| |Group| will promptly notiIy Members that this Contract is or will be terminated,
and will provide any notice regarding a Member`s right to other coverage. Anthem will not provide
beneIits coverage Ior medical services rendered aIter the eIIective date oI termination, except as
otherwise provided in the Booklet or required by law. II Anthem remains liable Ior a Member`s claims
which are incurred aIter termination oI this Contract, the |Employer| |Group| will pay a pro-rata premium
Ior the period oI post-termination coverage.

D. Anthem reserves the right to cancel coverage with 30 days prior written notice to any Member
who engages in material misrepresentation or Iraud.

E. II this Contract terminates Ior nonpayment oI an invoice amount due, |Employer| |Group| may
request reinstatement oI this Contract according to Anthem`s policies and procedures, which may include
the payment oI a reinstatement Iee. Anthem will determine whether the Contract will be reinstated, and
notiIy |Employer| |Group| oI its decision. II Anthem reinstates the Contract, the coverage will resume as
oI the date the Contract terminated. II Anthem does not reinstate the Contract, it will return any unearned
premium to |Employer| |Group|.
COGC2013 (SG) 7 |05/01|

!"#$%&' ) * +,#$%'-

A. Any required notice under this Contract will be deemed suIIicient when made in writing and
delivered by Iirst class mail; personal delivery; electronic mail, as permitted by law; or overnight delivery
with conIirmation capability. Such notice will be deemed to have been given as oI the date oI the
mailing. Anthem will provide notice to |Employer`s| |Group`s| principal place oI business as shown on
Anthem`s records. |Employer| |Group| will provide notice to its designated Anthem representative.

B. II requested by Anthem, |Employer| |Group| will distribute notices and other communications to
Members. |Employer| |Group| will notiIy all Members oI the termination oI this Contract.

!"#$%&' . * &$/$#!#$,+ ,+ !%#$,+- !+0 1,2'"+$+1 &!3

A. No action may be brought to recover beneIits Ior any service covered under this Contract unless
the required notice or prooI oI claim has been given to Anthem within the time Irame required under the
Booklet, and such action is commenced no later than 3 years Iollowing the date that the notice or prooI oI
claim has or should have been provided to Anthem.

B. Except to the extent preempted by ERISA or any other applicable Iederal law, this Contract will
be governed by and construed according to the laws oI Colorado. All claims or actions arising under this
Contract will be heard in a court oI competent jurisdiction in Colorado.

!"#$%&' 45 * +, 3!$2'"

No Iailure or delay by either Party to exercise any right or to enIorce any obligation under this Contract,
in whole or in part, will operate as a waiver to enIorce compliance with such right or obligation in the
Iuture. No course oI dealing between |Employer| |Group| and Anthem will operate as a waiver oI any
right or obligation under this Contract.

!"#$%&' 44 * !--$1+/'+#

Neither Party may assign all or part oI this Contract without Iirst obtaining the written consent oI the other
Party. However, subject to applicable laws, Anthem may assign all or part oI its duties and obligations
to: (1) another qualiIied insurance carrier under an assumption reinsurance arrangement; (2) any aIIiliate or
successor in interest oI Anthem; or, (3) another qualiIied insurance carrier surviving a merger, reorganization,
sale, or similar event involving Anthem or Anthem`s assets. Any assignee under this Contract must continue
to IulIill all Contract obligations.

!"#$%&' 46 * -'"2$%' /!"7-

This Contract constitutes a contract solely between |Employer| |Group| and Anthem. Anthem is an
independent corporation operating under a license with the Blue Cross and Blue Shield Association
('Association), an association oI independent Blue Cross and Blue Shield Plans, permitting Anthem to use
the Blue Cross and/or Blue Shield Service Marks in the State oI Colorado. Anthem is not contracting as the
agent oI the Association. |Employer| |Group| has not entered into this Contract based upon representations
by any person other than Anthem. No person, entity, or organization other than Anthem will be held
accountable or liable to |Employer| |Group| Ior any oI Anthem's obligations provided under this Contract.
This paragraph will not create any additional obligations on the part oI Anthem, other than those obligations
contained in this Contract.
COGC2013 (SG) 8 |05/01|
!"#$%&' )* + %,-#"!%# !./$-$0#"!#$,-

A. Anthem has the authority to determine eligibility Ior beneIits under the Contract. Anthem also
has the authority to resolve all questions arising under the Booklet and to establish and amend the policies
and procedures with regard to the administration oI beneIits under the Booklet. In addition, Anthem has
all powers necessary or appropriate to carry out its duties in connection with the perIormance oI services
under this Contract. Anthem`s authority to determine eligibility Ior beneIits shall be exercised
consistently with the provisions oI the Contract, the Booklet, Provider agreements, and applicable law.

B. Anthem may waive or modiIy any reIerral, authorization, or certiIication requirements, beneIit limits,
or other processes contained in the Booklet iI such waiver is in the best interest oI the Member or will
Iacilitate eIIective and eIIicient claims administration.

C. Anthem may institute, Irom time to time, pilot or test programs regarding disease management,
utilization management, case management or wellness initiatives. A pilot or test program may impact some,
but not all Members. Anthem reserves the right to discontinue a pilot or test program at any time without
notice.

D. Anthem will have sole responsibility Ior resolving appeals Irom claim decisions, consistent with state
and Iederal law. II |Employer| |Group| receives a question or complaint regarding beneIits under this
Contract, |Employer| |Group| will advise the Member to contact Anthem.

E. All statements made by |Employer| |Group| and any Member will be considered representations
and not warranties.

F. Anthem assumes only those responsibilities that are expressly stated in this Contract. Nothing
contained in this Contract will be construed to deem Anthem as Plan Sponsor, Plan Administrator or a
Named Fiduciary Ior purposes oI ERISA.

G. Anthem may delegate any oI its responsibilities under this Contract without the consent oI
|Employer| |Group|. Anthem shall remain responsible to |Employer| |Group| Ior IulIilling its obligations
under this Contract.

!"#$%&' )1 + "'&!#$,-02$3 ,4 #2' 3!"#$'0

|Employer| |Group| and Anthem are separate legal entities. Nothing in this Contract will cause either
Party to be deemed a partner, agent or representatives oI the other Party. Neither Party will have the
expressed or implied right or authority to assume or create any obligation on behalI oI the other Party.

!"#$%&' )5 + $-#'"3&!- 3",6"!/0

A. Anthem has a variety oI relationships with other Blue Cross and/or Blue Shield Licensees,
generally reIerred to as 'Inter-Plan Programs. When Members access Covered Services outside oI
Anthem`s geographic service area, the claims Ior those Covered Services may be processed through one
oI these Inter-Plan Programs. In those cases, the claim will be presented to Anthem Ior payment
according to the rules governing these Inter-Plan Programs. A general description oI the Inter-Plan
Programs is provided below.

Typically, when a Member obtains medical care outside Anthem`s geographic service area, the Member
accesses care Irom a Provider that has a contractual agreement ('Participating Provider) with the local
COGC2013 (SG) 9 |05/01|
Blue Cross and/or Blue Shield Licensee in that other area ('Host Blue). But in some cases, a Member
may obtain care Irom a Provider outside Anthem`s geographic service area that does not have a
contractual agreement with the Host Blue ('Non-Participating Provider). Additionally, depending on the
Member`s beneIits, Anthem may cover only a limited number oI services, such as emergency or urgent
care, outside oI Anthem`s geographic service area. Please reIer to the Booklet Ior more inIormation on
what services are covered outside oI Anthem`s geographic service area.

B. BlueCard Program. Under the BlueCard Program, when a Member receives Covered Services
within the geographic area served by a Host Blue, Anthem is responsible Ior meeting its claims payment
obligations under this Contract. Under these circumstances, the Host Blue is responsible Ior contracting
and handling interactions with Providers in its service area. The Iinancial terms oI the BlueCard Program
are described generally below. There may be some cases that are not directly reIerenced in this
description; however, in those cases, Anthem`s action will be consistent with the spirit oI this description.

(1) The calculation oI a Member`s payment responsibility Ior Covered Services processed through
the BlueCard Program will be based on the lower oI the Participating Provider's billed charges or
the Host Blue`s negotiated price.

(2) Host Blues may use various methods to determine a negotiated price, which depend on the terms
oI their provider contracts. The negotiated price may be based on the actual price which is a
negotiated payment without any other increases or decreases. The negotiated price may also be
based on an estimated price, which is a negotiated payment reduced or increased by a percentage
to take into account; (i.) certain payments negotiated with the Participating Provider; and, (ii.)
other claim and non-claim related transactions. Such transactions may include, but are not
limited to: anti-Iraud and abuse recoveries; Participating Provider reIunds not applied on a claim-
speciIic basis; retrospective settlements; and perIormance-related bonuses or incentives. In
addition, the negotiated price may be based on an average price which is a percent oI the billed
covered charges representing the aggregate payments negotiated by the Host Blue with: (i.) all oI
its Participating Providers; or, (ii) a subgroup oI similar Participating Providers, taking into
account other claim and non-claim related transactions. Such transactions may include the same
ones as noted Ior the estimated price above.

Host Blues using either an estimated price or an average price may prospectively increase or
decrease such prices to correct Ior an over or underestimation oI past prices. In this case, the
actual payment may reIlect additional amounts or credits Ior claims that are: (i.) already paid to
Participating Providers; or, (ii.) anticipated to be paid to or received Irom Participating Providers.
The amount paid is Iinal; no Iuture price adjustment will result in increases or decreases to the
pricing oI past claims. The BlueCard Program requires that the price submitted by a Host Blue to
Anthem remains the Iinal price, regardless oI any Iuture adjustments based on the use oI
estimated or average pricing.

(3) A small number oI states require a Host Blue to either: (i.) use a basis Ior determining a
Member`s cost share that does not reIlect the entire savings realized, or expected to be realized,
on a particular claim; or, (ii.) add a surcharge. Should a state require a cost share calculation
method that diIIers Irom the method described above, or requires a surcharge, Anthem will
calculate a Member`s cost share in accordance with the applicable law.
COGC2013 (SG) 10 |05/01|
(4) Recoveries Irom a Host Blue or a Participating Provider can arise in several ways. These include,
but are not limited to: anti-Iraud and abuse recoveries; Provider audits; credit balance audits;
utilization review reIunds; and unsolicited reIunds. In some cases, the Host Blue will engage a
third party to aid in identiIying and/or collecting recovery amounts. The Iees oI such a third party
may be applied against the recovery. Recovery amounts determined in this way will be applied in
accordance with Inter-Plan Program rules, which generally require correction on a claim-by-claim
or prospective basis.

C. Negotiated National Account Arrangements. As an alternative to the BlueCard Program, claims
Ior Covered Services may be processed through a negotiated national account arrangement with one or
more Host Blues. II Anthem has arranged with one or more Host Blues to provide customized networks,
then the terms oI any such arrangement will determine the payment amount. A Member`s cost share will
be calculated based on the lower oI either: (i.) the billed amount; or, (ii.) the price that Anthem has
negotiated with the Host Blue under the national account arrangement.

D. Non-Participating Providers. When Covered Services are provided outside oI Anthem`s
geographic service area by a Non-Participating Provider, the amount oI a Member`s cost share will
generally be based on either: (i.) the Host Blue`s Non-Participating Provider payment; or, (ii.) the pricing
arrangement required by applicable state law. In these cases, the Member may be responsible Ior the
diIIerence between: (i) the Non-Participating Provider`s billed charges; and, (ii) the payment Anthem will
make Ior the Covered Services.

In some cases, Anthem may pay a claim Irom a Non-Participating Provider based on the Provider`s billed
charges. In other cases, Anthem may pay a claim Irom a Non-Participating Provider based on the
payment Anthem would make to a non-contracting Provider inside Anthem`s geographic service area.
This may happen when the Host Blue`s payment Ior the Covered Services would be more than Anthem`s
payment Ior the same Covered Services. Also, Anthem may negotiate a payment with a Non-
Participating Provider on an exception basis. In any oI these exception cases, the amount oI a Member`s
cost share will be the diIIerence between: (i.) the Non-Participating Provider`s billed charges; and, (ii) the
payment Anthem will make Ior the Covered Services.


!"#$%&' )* + ,'!&#, $-./"!-%' 01"#!2$&$#3 !-4 !%%1/-#!2$&$#3 !%#

A. All capitalized terms used in this Article have the same meaning as deIined in the Health
Insurance Portability and Accountability Act oI 1996 ('HIPAA).

B. Anthem may disclose Summary Health InIormation to |Employer| |Group| Ior purposes oI
obtaining premium bids Irom other carriers or third party payers, or amending or terminating the Plan.

C. Anthem may disclose Personal Health InIormation ('PHI) to |Employer| |Group| Ior it to carry
out Plan administration Iunctions, but such disclosure may occur only aIter receipt oI certiIication Irom
|Employer| |Group| that: (1) |Employer`s| |Group`s| Plan documents comply with the privacy
requirements oI HIPAA; (2) |Employer| |Group| has provided notice to aIIected individuals as required
by HIPAA; and (3) PHI will not be used Ior the purpose oI employment-related actions or other actions
not related to administration oI beneIits under the Plan.

D. Anthem will comply with any additional disclosure restrictions required by state and Iederal law.
COGC2013 (SG) 11 |05/01|

!"#$%&' )* + ,$-%'&&!.'/0-

A. Anthem agrees to treat all proprietary inIormation about |Employer`s| |Group`s| operations and
its Plan in a conIidential manner. |Employer| |Group| agrees to treat all inIormation about Anthem`s
business operations, discount inIormation, and other proprietary data in a conIidential manner. Neither
Party will disclose any such inIormation to any other person without the prior written consent oI the Party
to whom the inIormation pertains. However, Anthem may disclose such inIormation to its legal advisors,
lenders, business advisors, and other third parties Ior commercial or research purposes. Anthem may also
make such disclosures as required or appropriate under applicable securities laws. II a Party is required
by law to make a disclosure oI any proprietary inIormation, the disclosing Party will immediately provide
written notice to the other Party detailing the circumstances oI and extent oI the disclosure.

B. Each Party retains ownership oI the materials and processes it develops in connection with the
services provided under this Contract, and neither conveys ownership rights in its materials and processes
nor acquires ownership rights in the other Party`s materials and processes by entering into this Contract or
perIorming its obligations under this Contract. Nothing in this Contract shall impair or limit a Party`s
right to use and disclose its materials and processes Ior its own lawIul business purposes.

C. By perIorming the services under this Contract, Anthem is not engaged in the practice oI
medicine; it merely makes decisions regarding the coverage oI services. Providers participating in
Anthem networks are not restricted Irom exercising independent medical judgment regarding the
treatment oI their patients, regardless oI Anthem`s coverage determinations.

D. II any provision oI this Contract is Iound to be invalid, illegal or unenIorceable under applicable
law, order, judgment or settlement, such provision will be excluded Irom the Contract and the remainder
oI this Contract will be enIorceable and interpreted as iI such provision is excluded.




!.#1', 2&0' %"/-- !.3 2&0' -1$'&3





(Signature)

|Name oI State President|
President

EIIective Date oI Group Contract:


(Date)
COGC2013 (SG) 12 |05/01|

|Company Name|
|Group Number|
|Association Name|
|EIIective Date: xx/xx/xxxx|





!"#$%&'$ )

EIIective Date oI this Addendum is 12:01 a.m. on: |xx/xx/xxxx|

This Addendum applies to the |Employer| |Group| and its aIIiliated companies as agreed to in writing by Anthem.


!$"*+,- + . )--+/$0!)01 %)*$


The Anniversary Date oI the Contract shall be: |xx/xx|


!$"*+,- ++ . $'+2+3+'+*1

Subscribers who meet the criteria below shall be eligible Ior coverage under this Contract. Family
members oI a Subscriber shall be eligible Ior coverage iI they meet the deIinition oI Dependent contained
in the Booklet.

|Enter |Employer||Group| eligibility inIormation here.|

)-*#$4 3'&$ "0,!! )-% 3'&$ !#+$'%




(Signature)

|Name oI State President|
President



Anthem Blue Cross and Blue Shield is the trade name oI Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by
HMO Colorado, Inc. Independent licensees oI the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark oI Anthem
Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks oI the Blue Cross and Blue Shield
Association.
COGC2013 (SG) 13 |05/01|


|Company Name|
|Group Number|
|Association Name|
|EIIective Date: xx/xx/xxxx|

!"#$%&' )*+!,-! *.$+/ .#0 )*"0-1$2/3 +&+1$+0

/1%+0-&+ 4

EIIective Date oI this Addendum is 12:01 a.m. on: |xx/xx/xxxx|

This Addendum applies to the |Employer| |Group| and its aIIiliated companies as agreed to in writing by
Anthem.



|The |Employer| |Group| will pay a per Subscriber per month Iee calculated by adding the sum oI the rates
Ior each oI the Member categories (subscriber, spouse, up to 3 dependents 20 years and younger, and/or
dependents 21 years and over) set Iorth in the tables below:|

|Enter |Employer||Group| rate table inIormation here.|

.00,$,"#.& 5++/ "* 1%.*6+/

|Billing Fee| |Wellness Programs| |Wellness Incentives| |Payment by Phone|
|Payment by Electronic Funds TransIer| |Reinstatement Fees|
|NSF Charges|
|Late payment Fees|

.#$%+! 4&-+ 1*"// .#0 4&-+ /%,+&0



(Signature)

|Name oI State President| President




Anthem Blue Cross and Blue Shield is the trade name oI Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO
Colorado, Inc. Independent licensees oI the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark oI Anthem Insurance
Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks oI the Blue Cross and Blue Shield Association.
Employer Enrollment Application
For 250 Employee Small Groups
Colorado
38400COEENABS Rev. 5/14
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross and Blue Shield Association.
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
1 of 6
1030830 38400COEENABS SG Employer App File FR 05 14 R5
Please complete in blue or black ink only.
Section A: Company Information
Company name Employer tax ID no. (required)
Company street address
City County State ZIP code
Billing address If different from above
City County State ZIP code
Organization type: Corporation Partnership Proprietorship Government unit/agency Limited Liability Company (LLC)
Organization exempt from Income Tax Labor union trust Other ___________________________
SIC code Required only if applying for Life and Disability coverage
Type of business (be specic) Date business established
Company contact name Title
Primary phone no. Fax no.
Email address
Additional company contact name Title
Primary phone no. Fax no.
Email address
Does group have a cafeteria plan under IRS Section 125? Yes No
Do you have any afliates that qualify as a single employer under subsection (b), (c), (m) or (o) of Internal revenue Code Section 414? Yes No
If yes, please give the legal names, federal tax ID no. and number of employees employed by each.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Section B: Application Type
New enrollment
Change(s) Group No. _____________________
Requested effective date
(MM/DD/YYYY)
2 of 6
Employer tax ID no. (required)
Section C: Type of Coverage
1. Medical Coverage I choose to offer:
Designated Plan 1 3 enrolling employees (choose one plan)
Designated Plan(s) 4+ enrolling employees (choose a single plan or mix of plans, excluding any HRA plan)
NOTE: HRA plans may only be offered as a single option or dual option with an HSA plan. HRA plan selection requires completion of additional HRA-specic forms.
Elements [ (0UP2) Anthem Bronze PPO 5850/30%/6600 Plus]
[ (0UP4) Anthem Silver PPO 3000/30%/4000 Plus]
[ (0UP7) Anthem Silver PPO 2000/30%/4500 Plus]
[ (0USK) Anthem Silver PPO 2000/30%/4500 Plus w/ Dental]
[ (0UP6) Anthem Silver PPO 1500/30%/4250 Plus]
Classic Solutions [ (0UPZ) Anthem Silver PPO 2000/50%/6350]
[ (0UPX) Anthem Gold PPO 2000/40%/4000]
[ (0UPW) Anthem Gold PPO 1500/20%/4000]
[ (0UPV) Anthem Gold PPO 1000/20%/3500]
[ (0UPQ) Anthem Gold PPO 750/20%/4500]
[ (0UP5) Anthem Gold PPO 500/20%/3000 Plus]
[ (0USH) Anthem Gold PPO 500/20%/3000 Plus w/ Dental]
[ (0UPN) Anthem Gold PPO 500/20%/4500]
Consumer-Driven [ (0UQ0) Anthem Bronze PPO 5500/0%/5500 w/ HSA]
[ (0UU4) Anthem Bronze Pathway HMO 4500/50%/6350 Plus
w/ HSA]
[ (0UPA) Anthem Bronze PPO 4500/30%/6350 Plus w/ HSA]
[ (0UP9) Anthem Bronze PPO 2500/50%/6350 Plus w/ HSA]
[ (0UQ6) Anthem Silver PPO 3500/0%/3500 w/ HSA]
[ (0UQ4) Anthem Silver PPO 2500/20%/4500 w/ HSA]
[ (0UU5) Anthem Silver Pathway HMO 2500/20%/4500 Plus
w/ HSA]
[ (1F9F) Anthem Gold PPO 4000/20%/5000 Plus w/ HRA]
[ (1F9E) Anthem Gold PPO 2000/20%/5000 Plus w/ HRA]
High Performance [ (0UNG) Anthem Bronze Blue Priority HMO 6000/30%/6600 Plus]
[ (0USF) Anthem Bronze Blue Priority HMO 6000/30%/6600 Plus
w/ Dental]
[ (0UNE) Anthem Silver Blue Priority HMO 2500/20%/6000 Plus]
[ (0UNF) Anthem Gold Blue Priority HMO 1000/20%/4000 Plus]
NOTE: The Blue Priority HMO plans are only available in specic employer-based geographic areas.
Focused [ (0UNQ) Anthem Silver Pathway HMO 3000/20%/6000 Plus]
[ (0UNZ) Anthem Silver Pathway HMO 2500/20%/6350]
[ (0UNR) Anthem Gold Pathway HMO 1500/20%/4000 Plus]
[ (0UN9) Anthem Gold Pathway HMO 500/20%/5000 Plus]
Choose your medical contribution for each month only one choice is allowed.
Contribution option 1: Traditional option We will contribute: ____% per employee ____% per dependent (optional).
Contribution option 2: Flat dollar amount option $____________
Riders/Optional Benets select additional optional benets
All medical plans listed above are Calendar Year. If you want your Medical plan to be based on Plan Year, then you can select from the list provided below.
NOTE: These plans can not be combined with Calendar Year plans.
[ (0UQC) Anthem Bronze Blue Priority HMO 6000/30%/6600 Plus]
[ (0UQH) Anthem Bronze PPO 5850/30%/6600 Plus]
[ (0UQB) Anthem Silver Pathway HMO 2500/20%/6350]
[ (0UQA) Anthem Gold Pathway HMO 1500/20%/4000 Plus]
NOTE: There are other state mandated plans available, please speak to your broker. Other use: _____________________________________
2. Dental Coverage check all that apply
[ Anthem Dental Family] [ Anthem Dental Family Enhanced]
Choose your dental contribution for each month
____% per employee ____% per dependent (optional).
NOTE: A separate Dental Application is required to enroll in the Dental Prime and Complete products. Please contact your broker to obtain the necessary forms.
3. Vision Coverage select one plan option
Full Service Materials Only Plans
[ Blue View Vision A1]
[ Blue View Vision A2]
[ Blue View Vision A3]
[ Blue View Vision A4]
[ Blue View Vision A5]
[ Blue View Vision B1]
[ Blue View Vision B2]
[ Blue View Vision B3]
[ Blue View Vision B4]
[ Blue View Vision C1]
[ Blue View Vision C2]
[ Blue View Vision C3]
[ Blue View Vision C4]
[ Blue View Vision MO1]
[ Blue View Vision MO2]
Choose your vision contribution for each month
____% per employee ____% per dependent (optional).
3 of 6
Employer tax ID no. (required)
4. Life and Disability Coverage check all that apply.
Life Products Disability Products
Basic Life & Accidental Death & Dismemberment (AD&D) Short Term Disability (STD)
Option A Flat benet amount for all employees
2 9 enrolled employees
$25,000 $30,000 $50,000
10 19 enrolled employees
$25,000 $30,000 $50,000 $100,000
20+ enrolled employees $____________ (specify amount
of $25,000 up to $300,000 maximum in $1,000 increments)
Option B Benet is a percentage of salary; check one of the following
for all employees
2 9 enrolled employees ($25,000 up to $100,000 max.)
1 x annual salary up to $____________
10 19 enrolled employees ($25,000 up to $250,000 max.)
1 x annual salary up to $____________
2 x annual salary up to $____________
20+ enrolled employees ($25,000 up to $300,000 max.)
1 x annual salary up to $____________
2 x annual salary up to $____________
Please provide list of employees and base salaries
Employer Contribution _______%
$250
or
67% of Salary to a Maximum Benet of:
$1,000
$1,350
STD Elimination Period Options:
1/8/13 1/8/26
8/8/13 8/8/26
15/15/13 15/15/26
30/30/13 (20+ Lives Only) 30/30/26 (20+ Lives Only)
Employer Contribution _______%
Basic Dependent Life Long Term Disability (LTD)
2 19 Lives
$10,000 Spouse/$5,000 Child $5,000 Spouse/$2,500 Child
20 50 Lives
$20,000 Spouse/$10,000 Child $5,000 Spouse/$2,500 Child
$15,000 Spouse/$7,500 Child $2,000 Spouse/$1,000 Child
$10,000 Spouse/$5,000 Child
Employer Contribution _______%
Gold - 60% of Salary
Silver - 60% of Salary
Bronze - 60% of Salary
Maximum Benet: $3,000 or $6,000
LTD Elimination Period Options:
Gold: 90 Days or 180 Days
Silver: 90 Days or 180 Days
Bronze: 180 Days
Employer Contribution _______%
Optional Supplemental Life (must be sold with Basic Life)
20 50 Lives Only
Yes No
Prior Coverage
Has this group had coverage within 12 months of this applications signature date? Yes No
Will this plan replace current If yes, carrier name Termination date
Life coverage Yes No
Disability coverage Yes No
Not Actively At Work Requirements for Life & Disability Products
The employees listed below are not presently actively-at-work and/or are not expected to be actively-at-work on the requested group effective date.
Anthem Life may make an exception and assume liability, subject to Underwriting approval, for certain employees. Unless this exception is applied for and
granted as indicated below, they will not be covered until they return to active work. To qualify for this exception, the following conditions must all be satised.
1) The employees absence must be due to illness or injury. 2) The employee must be covered by the prior carrier on the day immediately prior to Anthem Lifes
effective date of coverage for your group. 3) The employee must not be eligible to have coverage continued or extended by the prior carrier after that policy/
contract terminates. In no event will the actively-at work requirement be waived for coverage which provides benets due to total disability, such as short term
disability, waiver of premium or extension of benets. In no event will any increase in coverage or any additional coverage become effective until the employee
returns to work. Coverage approved below will end when your groups coverage under Anthem Lifes policy ends or at the end of any time period shown below,
whichever occurs rst. (Attach additional sheet if necessary.)
Employee name
Amount of
insurance
Date of birth
Last date
worked
Reason not
working
Date expected
to return
Insured by
prior carrier
Request
actively at
work waiver
Waiver
request
approved
Underwriter
approval
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
4 of 6
Employer tax ID no. (required)
Section D: Eligibility
1. Total number of employees
(including employed owners/ofcers): ___________
2. Number of eligible full-time employees
(minimum 30 hours per week): ___________
3. Are employees working 24-29 hours per week covered? Yes No
4. Number of employees enrolling in:
Medical: ___________ Pediatric Dental: ___________
Vision: ___________ Life/Disability: ___________
5. Number of eligible DECLINING employees: ___________
6. Number of INELIGIBLE employees: ___________
7. Number of employees working outside of Colorado ___________
8. Will coverage be restricted to a certain classication
of employees or employees working a certain number
of hours per week? Yes No
If yes, please explain what class(es) or number of
work hours are required (must be between 24 and 40 hours)
___________________________________
9. Probationary period/waiting period for new employees/rehires:
First of month after hire date
30 days 60 days
The standard effective date is rst of the month following the
waiting period/probationary period.
10. Would you like to waive the probation/waiting period for all existing
employees at initial enrollment?
Yes No
11. Under the Medicare Secondary Payer rules, which one applies
for your group?
Medicare is primary (less than 20 employees)
Anthem Blue Cross and Blue Shield is primary (20 or more employees)
Anthem Blue Cross and Blue Shield is primary coverage for groups
with 20 or more total employees on each working day in each of
20 or more calendar weeks in the current calendar year or the
preceding calendar year.
12. Is your company currently subject to COBRA?
(Employed 20 or more total employees on at least
50% of the working days in the previous calendar year)
Yes No
13. Has this group had prior Medical coverage within 12 months of this
application? Yes No
If yes, list carrier name________________________________
Termination Date____________________________________
Section E: Ownership
Please account for 100% of the ownership, regardless of eligibility. Insert an additional sheet if necessary.
Last name First name M.I. Percentage of ownership Eligible
_____% Yes No
_____% Yes No
_____% Yes No
_____% Yes No
Section F: Certicates
The Employer has the option to either access electronic copies or receive printed copies of the employee Certicates. Choose one.
Yes Employer will access electronic copies of the employee Certicates. By marking this option, employer understands that no printed copies of the
Certicates will be mailed to its ofces and agrees to comply with all applicable provisions of the Employee Retirement Income Security Act (ERISA).
Employer shall also make printed copies available to its employees upon request.
No Employer will not access electronic copies of the Certicates. Employer would like to receive printed copies of the Certicates.
5 of 6
Employer tax ID no. (required)
Section G: General Agreement
Please read this section carefully before signing the application.
Please check the box that applies:
We, the employer, as administrator of an Employee Welfare Benet Plan under ERISA (Employee Retirement Income Security Act of 1974), apply to obtain the coverage
indicated. We understand that any dispute involving an adverse benet decision may be subject to voluntary binding arbitration only after the ERISA appeals procedure
has been completed.
We, the employer, as administrator of an Employee Welfare Benet Plan which is a church plan or governmental plan as dened under ERISA (Employee Retirement
Income Security Act of 1974) and therefore not subject to ERISA, apply to obtain the coverage indicated.
To the best of our knowledge and belief, all information on this application is true and complete, and Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO
Colorado may rely on this application in deciding whether to provide coverage. If the application is not complete, Anthem Blue Cross and Blue Shield, Anthem Life and/
or HMO Colorado reserve(s) the right to reject it and notify us in writing. We understand and agree that no coverage will be effective before the date determined by
Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado, and that such coverage will be effective only if we have paid our rst months premium and this
application is accepted. We understand that the premium rates calculated for the employer are contingent on the accuracy of eligibility data submitted on employees
and covered dependents to Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado. Any misstatements on the employees applications or failure to report
new medical information prior to the employees effective dates may result in a material change to the groups coverage or premium rates as of the effective date of the
group coverage. We further understand and agree that we should keep prior coverage in force until notied of acceptance in writing by Anthem Blue Cross and Blue Shield,
Anthem Life and/or HMO Colorado and that no agent has the right to accept this application or bind coverage. If this application is accepted, it becomes a part of our
contract with Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado.
If we decide to cancel our group coverage after coverage has been issued, we understand that the cancellation will become effective on the last day of the month
in which Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado received the written notication of cancellation, and that no premiums will be refunded for
any period between Anthems receipt of the notication and the last day of the month when the cancellation takes effect. If there are any premiums after the cancellation
date, we understand that Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado will refund these premiums after 45 days from the premium deposit date.
Fraudulent Insurance Acts
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment, nes, denial of insurance and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Sign
here
Company ofcer signature
X
Printed name Title Date (MM/DD/YYYY)
Accepted by Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado authorized
representative
Printed name Date (MM/DD/YYYY)
6 of 6
Employer tax ID no. (required)
Section H: Agent/Producer/Broker Certication
1. I am not aware of any information not disclosed by the client in this application that may have bearing on this risk.
2. I have not completed any of the information contained in the application except with the permission of the applicant and as noted by my initials and date
on the application.
3. I have not signed any of the applications for an employer representative or individual applicant. If after submission of this application, I request any additions
or changes to any of the above information, I will do so only with the written consent of the applicant, and I authorize Anthem Blue Cross and Blue Shield,
Anthem Life and/or HMO Colorado to attribute such additions or changes to me.
4. I have advised the employer that a failure to provide complete and accurate information may result in a loss of coverage retroactive to the effective date of
coverage or re-rating of the employers premium retroactive to the coverage effective date and that coverage shall not be effective until Anthem Blue Cross
and Blue Shield, Anthem Life and/or HMO Colorado reviews and approved the application and the employer receives a written notice from Anthem Blue Cross
and Blue Shield Anthem Life and/or HMO Colorado.
5. I am the appointed agent/broker and am receiving commissions for the submission of this client. No portion of my commission payments from Anthem shall
be paid to an agent/broker/producer not appointed/approved by Anthem Blue Cross and Blue Shield, Anthem Life and/or HMO Colorado.
6. I have advised the client not to terminate any existing coverage until receiving written notication from Anthem Blue Cross and Blue Shield, Anthem Life
and/or HMO Colorado that the coverage being applied for by this application is accepted.
Writing payable/sub-agent/producer/broker %
Second writing payable/sub-agent/producer/broker
(Second writing agent not applicable in Maine)
%
Agency name Agency ID no. Agency name Agency ID no.
Agent/producer/broker name Agent/producer/broker name
Agent/producer/broker ID no. Agent/producer/broker ID no.
Payable/sub-agent/producer/broker ID no. if different Payable/sub-agent/producer/broker ID no. if different
Street address Street address
City State ZIP code City State ZIP code
Phone no. Fax no. Phone no. Fax no.
Email address Email address
Signature Date (MM/DD/YYYY) Signature Date (MM/DD/YYYY)
For General Agent/Producer/Broker use only
General agent/producer/broker name Agent/producer/broker ID no.
Street address City State ZIP code
Sales Representative
Sales representative name Sales representative ID no.
Street address City State ZIP code
ANTHEM USE ONLY
Group no. Tracking no. Effective date (MM/DD/YYYY)
S
u
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Division of Insurance
1 of 2

CARRIER ATTESTATION FORM

Instructions:
Review each of the attestation and sign at the end of the document. The Data Submitter must sign
this attestation document.

ATTESTATION YES
1.) Benefit Design Attestations

1. Carrier attests that it will comply with all benefit design standards, federal regulations
and laws, and state mandated benefits for all services including: preventive services,
emergency services, and formulary drug list.

2. Carrier attests that its health benefit plans provide coverage for each of the 10 statutory
categories of essential health benefits (EHBs) in accordance with the applicable EHB
benchmark plan and federal law:
a. Provide benefits and limitations on coverage that are substantially equal to those
covered by the EHB-benchmark plan;
b. Complies with the requirements of 45 CFR 146.136 with regard to mental health
and substance use disorder services, including behavioral health;
c. Provides coverage for preventive services described in 45 CFR 147/130;
d. Complies with EHB requirements with respect to prescription drug coverage;
e. Any benefits substituted are actuarially equivalent to those offered by the EHB
benchmark plan;
f. Complies with the prohibition on discrimination with regard to EHB;
g. Benefits reflect an appropriate balance among the EHB categories, so that
benefits are not unduly weighted toward any category;
h. Include all applicable state required benefits.


2.) Stand-Alone Dental Attestations

1. Carrier attests that all stand-alone dental plans that it offers will comply with all benefit
design standards and federal regulations and laws for stand-alone dental plans, as
applicable, including that:
a. the out-of-pocket maximum for its stand-alone dental plan is reasonable for the
coverage of the pediatric dental EHB;
b. it offers the pediatric dental EHB;
c. it does not include annual and lifetime dollar limits on pediatric dental EHB.

Selecting Yes indicates either:
1) You are attesting to all statements in this section; OR
2) You do not offer Stand-Alone Dental Plans.


3.) Marketing

1. Carrier attests that it will comply with any applicable state laws and regulations regarding
health insurance marketing practices and advertising materials.

2. Carrier attests that it will not employ marketing practices or benefit designs that will
have the effect of discouraging the enrollment of individuals with significant health
needs.



!
!
!



Division of Insurance
2 of 2
4.) Network Adequacy

1. Carrier attests that each of its managed care health benefit plans will maintain a provider
network(s) that is sufficient in number and types of providers, including providers that
specialize in mental health and substance abuse services, to assure that the services will be
accessible without unreasonable delay.

2. Carrier attests that each of its managed care health benefit plans will including in in its
provider network(s) a sufficient number and geographic distribution of essential
community providers (ECPs), where available, to ensure reasonable and timely access to
a broad rand of such providers for low-income, medically underserved individuals in
their service areas.


5.) Meaningful Difference

1. Carrier attests that it will ensure the health benefit plans it offers are meaningfully
different from one another.

Selecting Yes indicates either:
1) You are attesting to all statements in this section; OR
2) You are offering a Stand-Alone Dental Plan, which is not subject to review for
meaningful difference.


6.) Non-Discrimination

1. Carrier will not employ benefit designs that have the effect of discouraging the
enrollment of individuals with significant health needs or pre-existing conditions.
2. Carrier will not discriminate against individuals on the basis of health status, race, color,
national origin, disability, age, sex, gender identity or sexual orientation, consistent with
45 CFR 156.200(e).










Signature Date



Printed Name Title/Position

!
!
!
May 28, 2014
Sherry L. Call VP Indv. Bus. Dev. & Reg. Interface
Digitally signed by Sherry Call
DN: cn=Sherry Call, o=WellPoint, ou=ISG,
email=Sherry.Call@WellPoint.com, c=US
Date: 2014.05.28 13:27:45 -05'00'

Statement oI Variability COSGPPO (1/15)


Statement of VariabiIity for Form Number COSGPPO (1/15) - PPO Off Exchange EOC


n General:
The variable text shown in the text cell submitted in this filing is indicated with bracket. The
bracketed items indicate variable text that may be either used in whole, as combinations of
variables or omitted depending on the requirements of the plan.
Bracketed language or numbers that do not apply to the EOC will be removed prior to
printing the EOC applicable to a specific group.
Any change to plans offered based on bracket variability will be submitted for approval prior
to implementation.
We may change the EOC to correct any minor typographical or formatting errors that exist at
the time of the policy filing.
The use of variable text will be administered in a uniform manner.
This is intended to be a summary of the major items contained in each provision to assist in
the review of the Contract


Bracketed
Language
Location of VariabIe
Text
Comments/ExpIanation
Plan Name Front Cover Options of name values
Benefit Period Schedule of Benefits Options of either calendar or plan year dependent on
requirements of plan
Deductible Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator.
Options for aggregate on non-embedded deductible.
Option for HRA Deductible First plan
Coinsurance Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Out-of-Pocket
Limit
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator.
Options for aggregate or non-embedded out-of-pocket.
Options for what is included in the out-of-pocket
maximum dependent on the benefit offered
Ambulance
Services Air,
Water and
Ground
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Dental Services
for Members
Through Age 18
Schedule of Benefits Option for plans that embed pediatric/adult dental.
Options for plans that have embedded pediatric dental
only.
Dental Services
for Members
Age 19 and
Older
Schedule of Benefits Option for plans that embed pediatric/adult dental.


Statement oI Variability COSGPPO (1/15)

Bracketed
Language
Location of VariabIe
Text
Comments/ExpIanation
Durable Medical
Equipment
(DME) and
Medical
Devices,
Orthotics,
Prosthetics,
Medical and
Surgical
Supplies
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Emergency
Room Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Home Care Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Hospice Care Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
npatient
Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Maternity and
Reproductive
Health Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Mental Health,
Alcohol and
Substance
Abuse Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Office Visits Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator.
Option for tiered provider network
Option for addition for plans that have a copayment for
the first three visits.
Outpatient
Facility Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Outpatient
Freestanding
Facility
Schedule of Benefits Option for plans that have site-of-service cost share
difference.
Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Telemedicine Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator.
Option for tiered provider network
Preventive Care Schedule of Benefits Ranges that are needed for the plan options for out-of-
network services; new or alternate options will be filed
with the regulator
Urgent Care
Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Vision Services
for Members
through Age 18
Schedule of Benefits Option for embedded pediatric vision exam only.
Option for embedded pediatric full coverage.

Statement oI Variability COSGPPO (1/15)

Bracketed
Language
Location of VariabIe
Text
Comments/ExpIanation
Vision Services
for Members
Age 19 and
Older
Schedule of Benefits Option for embedded adult full coverage
Human Organ
and tissue
Transplant
Services
Schedule of Benefits Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator
Prescription
Drug Retail
Pharmacy and
Home Delivery
(Mail Order)
Benefits
Schedule of Benefits Option for separate prescription drug deductible.
Ranges that are needed for the plan options; new or
alternate options will be filed with the regulator.
Option for generic/brand penalty.
Options for waiver of cost shares.
Adult Dental
Services
Notices Required by
State Law
Option for addition when adult dental services are not
covered.
Plan Name Section 2. Title Page Options of name values
High-Deductible
Health Plan for
Use with HSA
Section 3. Contact Us Option for addition with plan is HSA
Narrow network
disclosure
Section 6. How to
Access Your Services
an Obtain Approval of
Benefits How to
Find a Provider in the
Network
Options for plans that use a narrow network
Tiered provider
network
Section 6. How to
Access Your Services
an Obtain Approval of
Benefits How to
Find a Provider in the
Network
Options for plans that use a tiered network of
professional providers
Embedded
pediatric dental
Section 7.
Benefits/Coverage
Pediatric Dental
Option for embedded pediatric dental only
Embedded
pediatric/adult
dental
Section 7.
Benefits/Coverage
Pediatric Dental
Option for embedded pediatric/adult dental
Pediatric vision
(exam only)
Section 7.
Benefits/Coverage
Vision Services for
Members Through
Age 18
Option for embedded pediatric vision exam only
Pediatric/ vision
(full coverage)
Section 7.
Benefits/Coverage
Vision Services for
Members Through
Age 18
Option for embedded pediatric vision full coverage

Statement oI Variability COSGPPO (1/15)

Bracketed
Language
Location of VariabIe
Text
Comments/ExpIanation
Adult vision Section 7.
Benefits/Coverage
Vision Services for
Members Age 19 and
Older
Option for embedded adult vision
Dental
exclusions
Section 8.
Limitations/Exclusions
- Dental Services
Option for addition if coverage is only provided for
pediatric dental. Option for addition when adult dental is
included.
Vision
exclusions
Section 8.
Limitations/Exclusions
- Dental Services
Option for listing exclusions for pediatric exam only or if
embedded full coverage for vision.
Tiered provider
network
definition
Section 15.
Definitions
Option for addition of a definition for plans that use a
tiered network of professional providers


Statement oI Variability COSGPPO (1/15)

Cross WaIk of 2014 Form Number fiIed to 2015 Form Number Change - PPO Off
Exchange

2014 Form FiIing Number 2015 Form FiIing
Number
2014 PIan Name 2015 PIan Name
EOC_ENG_Anthem_87269
CO1060005_20140101
COSGPPO Anthem Essential Direct
Access Plus gnea
Anthem Silver Blue Priority PPO
2500/20%/6000 Plus
EOC_ENG_Anthem_87269
CO1060006_20140101
COSGPPO Anthem Preferred Direct
Access gfga
Anthem Gold PPO
1000/20%/3500
EOC_ENG_Anthem_87269
CO1060018_20140101
COSGPPO Anthem Preferred Direct
Access gjha
Anthem Gold PPO
2000/40%/4000
EOC_ENG_Anthem_87269
CO1060024_20140101
COSGPPO Anthem Essential Direct
Access gyia
Anthem Silver PPO
2000/50%/6350
EOC_ENG_Anthem_87269
CO1060025_20140101
COSGPPO Anthem Preferred Direct
Access ghla
Anthem Gold PPO
750/20%/4500
EOC_ENG_Anthem_87269
CO1060026_20140101
COSGPPO Anthem Preferred Direct
Access gfha
Anthem Gold PPO
1500/20%/4000
EOC_ENG_Anthem_87269
CO1060027_20140101
COSGPPO Anthem Preferred Direct
Access gpka
Anthem Gold PPO
500/20%/4500
EOC_ENG_Anthem_87269
CO1060029_20140101
COSGPPO Anthem Essential Direct
Access Plus w/ Dental ggqa
Anthem Silver PPO
2000/30%/4500 Plus w/Dental
EOC_ENG_Anthem_87269
CO1060030_20140101
COSGPPO Anthem Essential Direct
Access Plus w/ Dental ggqa
Anthem Silver PPO
2000/30%/4500 Plus w/Dental
EOC_ENG_Anthem_87269
CO1060031_20140101
COSGPPO Anthem Essential Direct
Access Plus ggqa
Anthem Silver PPO
2000/30%/4500 Plus
EOC_ENG_Anthem_87269
CO1060032_20140101
COSGPPO Anthem Essential Direct
Access Plus gjpa
Anthem Silver PPO
3000/30%/4000 Plus
EOC_ENG_Anthem_87269
CO1060033_20140101
COSGPPO Anthem Core Direct Access
Plus gtpa
Anthem Bronze PPO
5850/30%/6600 Plus
EOC_ENG_Anthem_87269
CO1060035_20140101
COSGPPO Anthem Preferred Direct
Access Plus w/ Dental gzpa
Anthem Gold PPO
500/20%/3000 Plus w/Dental
EOC_ENG_Anthem_87269
CO1060036_20140101
COSGPPO Anthem Preferred Direct
Access Plus w/ Dental gzpa
Anthem Gold PPO
500/20%/3000 Plus w/Dental
EOC_ENG_Anthem_87269
CO1060037_20140101
COSGPPO Anthem Preferred Direct
Access Plus gzpa
Anthem Gold PPO
500/20%/3000 Plus
EOC_ENG_Anthem_87269
CO1060039_20140101
COSGPPO Anthem Essential Direct
Access Plus gcqa
Anthem Silver PPO
1500/30%/4250 Plus
EOC_ENG_Anthem_87269
CO1060040_20140101
COSGPPO Anthem Core Direct Access
w/ HSA gmua
Anthem Bronze PPO
5500/0%/5500 w/HSA
EOC_ENG_Anthem_87269
CO1060043_20140101
COSGPPO Anthem Essential Direct
Access w/ HSA gdsa
Anthem Silver PPO
3500/0%/3500 w/HSA
EOC_ENG_Anthem_87269
CO1060047_20140101
COSGPPO Anthem Core Direct Access
Plus w/ HSA gpdb
Anthem Bronze PPO
2500/50%/6350 Plus w/HSA
EOC_ENG_Anthem_87269
CO1060050_20140101
COSGPPO Anthem Core Direct Access
Plus w/ HSA ghhb
Anthem Bronze PPO
4500/30%/6350 Plus w/HSA

Statement oI Variability COSGPPO (1/15)

2014 Form FiIing Number 2015 Form FiIing
Number
2014 PIan Name 2015 PIan Name
EOC_ENG_Anthem_87269
CO1060052_20140101
COSGPPO Anthem Essential Direct
Access w/ HSA gpsa
Anthem Silver PPO
2500/20%/4500 w/HSA
EOC_ENG_Anthem_87269
CO1060057_20140101
COSGPPO Anthem Preferred Direct
Access Plus w/ HRA ginb
Anthem Gold PPO
2000/20%/5000 Plus w/HRA
EOC_ENG_Anthem_87269
CO1060059_20140101
COSGPPO Anthem Premier Direct
Access Plus w/ HRA gjnb
Anthem Gold PPO
4000/20%/5000 Plus w/HRA
EOC_ENG_Anthem_87269
CO1060061_20140101
COSGPPO Anthem Core Direct Access
Plus grdf
Anthem Bronze PPO
5900/0%/6600 Plus


!
Statement of Variability COGC2013 (1/15)


Statement of VariabiIity for Form Number COGC2013 SG - Group Contract
n General:
The variable text shown in the text cell submitted in this filing is indicated with bracket. The bracketed
items indicate variable text that may be either used in whole, as combinations of variables or omitted
depending on the requirements of the plan.
Bracketed language or numbers that do not apply to the Employer's Contract will be removed
prior to printing the Contract applicable to a specific group.
Any change to bracket variability will be submitted for approval prior to implementation.
We may change the Contract to correct any minor typographical or formatting errors that
exist at the time of the policy filing.
The use of variable text will be administered in a uniform manner.
This is intended to be a summary of the major items contained in each provision to assist in
the review of the Contract.

Bracketed Language Location of VariabIe
Text
Comments/ExpIanation
Employer and Group Throughout the Document Blank space it provided to insert the name of the entity.
The terms "Employer and "Group are bracketed to
reflect the variability in the type of the Employer. f a
small or large group is a union, trust, or entity other than
an Employer, then Group will be used throughout the
Contract.
Employee definition Article 2 - Definitions D: [Employee] [Union Member] [Association Member]
[Pan Participant].

The standard will be "Employee. A bracketed
alternative will be provided in the Contract if "Employee
is not the correct description. f another term is
selected other than " Employee, that alternative term will
replace the bracketed term "Employee throughout the
Contract. The Booklet provides the information about
eligibility. Schedule A will provide any additional
information about minimum hours worked and other
categories of eligibility criteria (such as Retirees, etc.)
consistent with applicable laws.
Retroactive
terminations
Article 4 Obligations of
[Employer] [Group]
C.: Employer will notify Anthem of any Member's loss
of eligibility for coverage. Occasionally, Employer
requests that Anthem retroactively terminate a Member
from coverage. n that event, Anthem may limit the
amount of time that for that retroactive termination to a
standard of 60 days. As an exception, Anthem may
agree to another number of days that is provided in the
bracketed choices.

!
Statement of Variability COGC2013 (1/15)

Bracketed Language Location of VariabIe
Text
Comments/ExpIanation
Advance Notice of
Changes
Article 5 Changes to
Contract and Booklet
A.: This provision requires Anthem to provide written
notice of changes to the Booklet prior to the Anniversary
Date. The standard notice period is 30 days. As an
exception, Anthem may agree to another time frame
provided in the bracketed choices. This provision also
allows the Employer to propose changes to Anthem
regarding the Booklet at any time. Anthem may also
provide written notice of other changes to Employer. The
standard notice period in these circumstances is 30
days. As an exception, Anthem may agree to another
time frame provided in the bracketed choices.
Advance Notice of
Premium Changes
Article 5 Changes to
Contract and Booklet
B.: This provision requires Anthem to provide written
notice of premium rates. The standard notice period is 30
days.
Grace Period Article 6 Premium and
Grace Period
C.: This provision sets forth the grace period applicable
to a late premium payment.
Effective Date and
Eligibility
Schedule A This section will provide the effective date of the contract,
anniversary date and eligibility as determined by the
employer.
Premiums Monthly Premium Rates
and Product (s) Elected -
Schedule B
This section will provide the premium rate for each product
elected by the Employer.
Premiums Monthly Premium Rates
and Product (s) Elected -
Schedule B
This section provides additional fees that may be charged
to the Employer. Any categories of charges not applicable
to the Employer will be removed prior to issuing the
Contract.




!
Statement of Variability 38400COEENABS Rev. 5/14 (1/15)


Statement of VariabiIity for Form Number 38400COEENABS Rev. 5/14 - EmpIoyer AppIication
n General:
The variable text shown in the text cell submitted in this filing is indicated with bracket. The bracketed
items indicate variable text that may be either used in whole, as combinations of variables or omitted
depending on the requirements of the plan.
Bracketed language or numbers that do not apply to the Employer's Contract will be removed
prior to printing the Contract applicable to a specific group.
Any change to bracket variability will be submitted for approval prior to implementation.
We may change the Contract to correct any minor typographical or formatting errors that
exist at the time of the policy filing.
The use of variable text will be administered in a uniform manner.
This is intended to be a summary of the major items contained in each provision to assist in
the review of the Contract.

Bracketed Language Location of VariabIe
Text
Comments/ExpIanation
Medical Plans Offered Section C: Type of
Coverage, 1. Medical
Coverage
Options of medical plans to be offered
Dental Plans Offered Section C: Type of
Coverage, 2. Dental
Coverage
Options of dental plans to be offered
Vision Plans Offered Section C: Type of
Coverage, 3. Vision
Coverage
Options of vision plans to be offered



State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
Instructions: Please review and respond Yes or No to each of the attestations below and sign the
Statement of Detailed Attestation Responses document. CMS may accept a No response, along
with a justification for any of these No responses, to any of the individual attestations identified
in the Supplemental Updated QHP Attestation Instructions (https://www.regtap.info/). Please
be sure to reference the specific attestation in your justification discussion. If the applicant is
submitting the signed attestation document indicating Yes to all attestations, the justification
document is not required.
Program Attestations
General Issuer Attestations
1. Applicant attests that it will have a license by the end of the certification period, be in good
standing, and be authorized to offer each specific type of insurance coverage offered in
each State in which the issuer offers a QHP.
Yes No
2. Applicant attests that it will be bound by 2 CFR 376 and that no individual or entity that is
a part of the Applicant's organization is excluded by the Department of Health and Human
Services Office of the Inspector General or by the General Services Administration. This
attestation includes any member of the board of directors, key management or executive
staff or major stockholder of the applicant and its affiliated companies, subsidiaries or
subcontractors.
Yes No
3. Applicant attests that it will inform HHS, based on its best information, knowledge and
belief, of any federal or state government current or pending legal actions, criminal or civil,
convictions, administrative actions, investigations or matters subject to arbitration against
the applicant (under a current or former name), its principals, or any of its subcontractors.
The applicant also attests that, based on its best information, knowledge and belief, none of
its principals, nor any of its affiliates is presently debarred, suspended, proposed for
debarment, or declared ineligible to participate in Federal programs by HHS or another
Federal agency under 2 CFR 180.970 or any other applicable statute or regulation, and
should such actions occur, it will inform HHS within 5 working days of learning of such
action.
Yes No
Benefit Design Attestation
1. Applicant attests that it will follow all Actuarial Value requirements.
Yes No
March 2013 1 of 6
State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
Stand-Alone Dental Attestations
1. Applicant attests that it either offers no stand-alone dental plans, or that any stand-alone
dental plans it offers will adhere to the standards set forth by HHS for the administration of
advance payments of the premium tax credit.
Yes No
Financial Management Attestations
1. Applicant attests that it will acknowledge and agree to be bound by Federal statutes and
requirements that govern Federal funds. Federal funds include, but are not limited to,
advance payments of the premium tax credit, cost-sharing reductions, and Federal
payments related to the risk adjustment, reinsurance, and risk corridor programs.
Yes No
2. Applicant attests that it will adhere to the risk corridor standards and requirements set by
HHS as applicable for:
a. risk corridor data standards and annual HHS notice of benefit and payment
parameters for the calendar years 2014, 2015, and 2016 (45 CFR 153.510);
Yes No
b. remit charges to HHS under the circumstances described in 45 CFR 153.510( c).
Yes No
3. Applicant attests that it will adhere to the standards set forth by HHS for the administration
of advance payments of the premium tax credit and cost sharing reductions, including the
provisions at 45 CFR 156.410, 156.425, 156.430, 156.440, 156.460, and 156.470.
Yes No
4. Applicant attests that it will reduce premiums on behalf of eligible individuals if the
Exchange notifies the QHP Issuer that it will receive an APTC on behalf of that individual
pursuant to 156.460.
Yes No
5. Applicant attests that it will adhere to the data standards and reporting for the CSR
reconciliation process pursuant to 45 CFR 156.430(c) for QHPs.
Yes No
March 2013 2 of 6
State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
6. The following applies to applicants participating in the risk adjustment and reinsurance
programs inside and/or outside of the Exchange. Applicant attests that it will:
a. adhere to the risk adjustment standards and requirements set by HHS in the
annual HHS notice of benefit and payment parameters (45 CFR Subparts G and
H);
Yes No
b. remit charges to HHS under the circumstances described in 45 CFR 153.610;
Yes No
c. adhere to the reinsurance standards and requirements set by HHS in the annual
HHS notice of benefit and payment parameters (45 CFR 153.400, 153.405,
153.410, 153.420);
Yes No
d. remit contributions to HHS under the circumstances described in 45 CFR
153.400;
Yes No
e. establish dedicated and secure server environments to host enrollee claims,
encounter, and enrollment information for the purpose of performing risk
adjustment and reinsurance operations for all plans offered;
Yes No
f. allow proper interface between the dedicated server environment and special,
dedicated CMS resources that execute the risk adjustment and reinsurance
operations;
Yes No
g. ensure the transfer of timely, routine, and uniform data from local systems to the
dedicated server environment using CMS-defined standards, including file
formats and processing schedules;
Yes No
h. comply with all information collection and reporting requirements approved
through the Paperwork Reduction Act of 1995 and having a valid OMB control
number for approved collections. The Issuer will submit all required information
in a CMS-established manner and common data format;
Yes No
March 2013 3 of 6
State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
i. cooperate with CMS, or its designee, through a process for establishing the server
environment to implement these functions, including systems testing and
operational readiness;
Yes No
j. use sufficient security procedures to ensure that all data available electronically
are authorized and protect all data from improper access, and ensure that the
operations environment is restricted to only authorized users;
Yes No
k. provide access to all original source documents and medical records related to the
eligible organizations submissions, including the beneficiary's authorization and
signature to CMS or CMS designee, if requested, for audit;
Yes No
l. retain all original source documentation and medical records pertaining to any
such particular claims data for a period of at least 10 years;
Yes No
m. be responsible for all data submitted to CMS by itself, its employees, or its agents
and based on best knowledge, information, and belief, submit data that are
accurate, complete, and truthful;
Yes No
n. all information, in any form whatsoever, exchanged for risk adjustment shall be
employed solely for the purposes of operating the premium stabilization programs
and financial programs associated with state markets, including but not limited to,
the calculation of user fees to fund such programs, oversight, and any validation
and analysis that CMS determines necessary.
Yes No
7. The following attestation applies to applicants participating in the Exchanges and premium
stabilization programs as defined in the Affordable Care Act and applicable regulations.
Under the False Claims Act, 31 U.S.C. 3729-3733, those who knowingly submit, or
cause another person or entity to submit, false claims for payment of government funds are
liable for three times the governments damages plus civil penalties of $5,500 to $11,000
per false claim. 18 U.S.C. 1001 authorizes criminal penalties against an individual who in
any matter within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device, a
material fact, or makes any false, fictitious or fraudulent statements or representations, or
makes any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000
and imprisonment for up to 5 years. Offenders that are organizations are subject to fines up
to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived
March 2013 4 of 6
State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
by the offender if it is greater than the amount specifically authorized by the sentencing
statute. Applicant acknowledges the False Claims Act, 31 U.S.C., 3729-3733.
Yes No
8. The following applies to applicants participating in the Exchanges and premium
stabilization programs as defined in the Affordable Care Act and applicable regulations.
Applicant attests to provide and promptly update when applicable changes occur in its Tax
Identification Number (TIN) and associated legal entity name as registered with the
Internal Revenue Service, financial institution account information, and any other
information needed by CMS in order for the applicant to receive invoices, demand letters,
and payments under the APTC, CSR, user fees, reinsurance, risk adjustment, and risk
corridors programs, as well as, any reconciliations of the aforementioned programs.
Yes No
9. The following applies to applicants participating in the Exchanges and premium
stabilization programs as defined in the Affordable Care Act and applicable regulations.
Applicant attests that it will develop, operate and maintain viable systems, processes,
procedures and communication protocols to accept payment-related information submitted
by CMS.
Yes No
Signature Date
Printed Name Title/Position
March 2013 5 of 6
05/28/2014
Sherry L. Call
VP Individual Business Dev & Regulatory
Interface
Digitally signed by Sherry Call
DN: cn=Sherry Call, o=WellPoint, ou=ISG,
email=Sherry.Call@WellPoint.com, c=US
Date: 2014.05.28 21:33:07 -05'00'
State-based Exchange Issuer Attestations:
Statement of Detailed Attestation Responses
Attestation Justification
Provide a justification for any attestation for which you indicated No. Be sure to reference the
specific attestation in your justification.
March 2013 6 of 6
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[Repository ID/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HIOS ID]_20150101]


Certificate
(Referred to as Booklet in the following pages)

Anthem
[Anthem Silver Blue Priority PPO 2500/20%/6000 Plus]
[Anthem Gold PPO 1000/20%/3500]
[Anthem Gold PPO 2000/40%/4000]
[Anthem Silver PPO 2000/50%/6350]
[Anthem Gold PPO 750/20%/4500]
[Anthem Gold PPO 1500/20%/4000]
[Anthem Gold PPO 500/20%/4500]
[Anthem Silver PPO 2000/30%/4500 Plus w/Dental]
[Anthem Silver PPO 2000/30%/4500 Plus]
[Anthem Silver PPO 3000/30%/4000 Plus]
[Anthem Bronze PPO 5850/30%/6600 Plus]
[Anthem Gold PPO 500/20%/3000 Plus w/Dental]
[Anthem Gold PPO 500/20%/3000 Plus]
[Anthem Silver PPO 1500/30%/4250 Plus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem Silver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 Plus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 Plus w/HSA]
[Anthem Silver PPO 2500/20%/4500 w/HSA]
[Anthem Gold PPO 2000/20%/5000 Plus w/HRA]
[Anthem Gold PPO 4000/20%/5000 Plus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 Plus]

January 1, 2015

[Repository ID/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HIOS ID]_20150101]






Si necesita ayuda en espaol para entender este documento, puede solicitarla sin costo adicional,
llamando al nmero de servicio al cliente.

If you need Spanish-language assistance to understand this document, you may request it at no
additional cost by calling Customer Service at the number on the back of your Identification Card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products are
underwritten by HMO Colorado, Inc. Life and disability products underwritten by Anthem Life Insurance Company. Independent
licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies,
Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association
1
Section 1. Schedule of Benefits (Who Pays What)

In this section you will find an outline of the benefits included in your Plan and a summary of any Deductibles,
Coinsurance, and Copayments that you must pay. Also listed are any Benefit Period Maximums or limits that apply.
Please read the "Benefits/Coverage (What is Covered)"section for more details on the Plans Covered Services. Read
the Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for details on Excluded Services.

All Covered Services are subject to the conditions, Exclusions, limitations, and terms of this Booklet including any
endorsements, amendments, or riders.

To get the highest benefits at the lowest out-of-pocket cost, you must get Covered Services from an In-Network
Provider. Benefits for Covered Services are based on the Maximum Allowed Amount, which is the most the Plan will
allow for a Covered Service. When you use an Out-of-Network Provider you may have to pay the difference between the
Out-of-Network Providers billed charge and the Maximum Allowed Amount in addition to any Coinsurance, Copayments,
Deductibles, and non-covered charges. This amount can be substantial. Please read the Claims Procedure (How to File
a Claim) section for more details.

Deductibles, Coinsurance, and Benefit Period Maximums are calculated based upon the Maximum Allowed Amount, not
the Providers billed charges.

Essential Health Benefits provided within this Booklet are not subject to lifetime or annual dollar maximums.
Certain non-essential health benefits, however, are subject to either a lifetime and/or dollar maximum.

Essential Health Benefits are defined by federal law and refer to benefits in at least the following categories:

Ambulatory patient services,
Emergency services,
Hospitalization,
Maternity and newborn care,
Mental health and substance use disorder services, including behavioral health treatment,
Prescription drugs,
Rehabilitative and Habilitative Services and devices,
Laboratory services,
Preventive and wellness services, and
Chronic disease management and pediatric services, including oral and vision care.

Such benefits shall be consistent with those set forth under the Patient Protection and Affordable Care Act of
2010 and any regulations issued pursuant thereto.

Benefit Period [Calendar][Plan] Year

Dependent Age Limit To the end of the month in which the child attains age 26.

Please see the Eligibility section for further details.

Deductible In-Network Out-of-Network
Per Member [$500 to 5,900] [$1,250 to 14,750]
Per Family
{Aggregate: [(All other Members combined)]
[$1,500 to 11,800] [$2,500 to 29,500]
The In-Network and Out-of-Network Deductibles are separate and cannot be combined.

{Option for Non-Embedded plans of HSA/HRA: [If you, the Subscriber, are the only person covered by this Plan,
only the per Member amounts applies to you. If you also cover Dependents (other family members) under this Plan,
only the per Family amount applies.)]


2
Deductible In-Network Out-of-Network
When the Deductible applies, you must pay it before benefits begin. See the sections below to find out when the
Deductible applies.

{Deductible First for HRA plans: [Note: To meet the In-Network Deductible, your Plan will work as follows:

Step 1 - Upfront In-Network Deductible Members must pay a certain part of the In-Network Deductible
listed above, $[1,000 to 2,000] per Member / $[2,000 to 4,000] per Family, before using their HRA account.
HRA funds cannot be used for this part of the Deductible (known as the upfront Deductible). Amounts paid
toward the upfront Deductible will apply toward the annual In-Network Deductible.

Step 2 - Health Reimbursement Account After meeting the upfront Deductible, Members can use money in
their HRA to help meet the rest of the annual In-Network Deductible.

Step 3 - Traditional Health Coverage - Once the Annual In-Network Deductible has been met, coverage
under this Plan begins.]

Copayments and Coinsurance are separate from and do not apply to the Deductible.

{Deductible First for HRA plans: [HRA funds cannot be used for services listed under Dental Services for Members
age 19 and Older or for services listed under Vision Services for Members age 19 and Older.]


Coinsurance In-Network Out-of-Network
Plan Pays [50 to 100%] [50 to 90]%
Member Pays [0 to 50%] [10 to 50]%
Reminder: Your Coinsurance will be based on the Maximum Allowed Amount. If you use an Out-of-Network Provider,
you may have to pay Coinsurance plus the difference between the Out-of-Network Providers billed charge and the
Maximum Allowed Amount.

Note: The Coinsurance listed above may not apply to all benefits, and some benefits may have a different Coinsurance.
Please see the rest of this Schedule for details.


Out-of-Pocket Limit In-Network Out-of-Network
Per Member $[3,000 to 6,600]

$[6,000 to 19,800]
Per Family
{Aggregate: [(All other Members combined)]
$[6,000 to 13,200] $[18,000 to 39,600]
{Option for Non-Embedded plans of HSA/HRA: [If you, the Subscriber, are the only person covered by this Plan,
only the per Member amount applies to you. If you also cover Dependents (other family members) under this Plan,
only the per Family amount applies.)]

The Out-of-Pocket Limit includes all Deductibles, [[and] Coinsurance], [and Copayments] you pay during a Benefit
Period unless otherwise indicated below. It does not include charges over the Maximum Allowed Amount or amounts
you pay for non-Covered Services.

The Out-of-Pocket Limit does not include amounts you pay for the following benefits:

{Option for embedded adult dental benefit: [Services listed under Dental Services for Members Age 19 and
Older
{Option for embedded adult vision benefit: [Services listed under Vision Services for Members Age 19 and
3
Out-of-Pocket Limit In-Network Out-of-Network
Older]
Out-of-Network Human Organ and Tissue Transplant services.

Once the Out-of- Pocket Limit is satisfied, you will not have to pay additional Deductibles, [[or] Coinsurance], or
Copayments] for the rest of the Benefit Period, except for the services listed above.

The In-Network and Out-of-Network Out-of-Pocket Limits are separate and do not apply toward each other.

Important Notice about Your Cost Shares

In certain cases, if we pay a Provider amounts that are your responsibility, such as Deductibles, Copayments or
Coinsurance, we may collect such amounts directly from you. You agree that we have the right to collect such amounts
from you.

The tables below outline the Plans Covered Services and the cost share(s) you must pay. In many spots you will see the
statement, Benefits are based on the setting in which Covered Services are received. In these cases you should
determine where you will receive the service (i.e., in a doctors office, at an outpatient hospital facility, etc.) and look up
that location to find out which cost share will apply. For example, you might get physical therapy in a doctors office, an
outpatient hospital facility, or during an inpatient hospital stay. For services in the office, look up Office Visits. For
services in the outpatient department of a hospital, look up Outpatient Facility Services. For services during an inpatient
stay, look up Inpatient Services.

Benefits In-Network Out-of-Network
Acupuncture/Nerve Pathway Therapy See Therapy Services.

Allergy Services Benefits are based on the setting in which
Covered Services are received.

Ambulance Services (Air and Water) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an In-Network Provider.

Important Note: Air ambulance services for non-Emergency Hospital to Hospital transfers must be approved through
precertification. Please see How to Access Your Services and Obtain Approval of Benefits for details.


Ambulance Services (Ground) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an In-Network Provider.

Important Note: All scheduled ground ambulance services for non-Emergency transfers, except transfers from one
acute Facility to another, must be approved through precertification. Please see How to Access Your Services and
Obtain Approval of Benefits for details.

Autism Services


Applied Behavioral Analysis Services Benefit Maximum
Benefits are based on the setting in which
Covered Services are received.

The following annual Benefit Period maximums
are effective for Applied Behavior Analysis
services for In- and Out-of-Network services
4
Benefits In-Network Out-of-Network
combined:
From birth to age eight (up to Members ninth
birthday): 550 sessions of 25 minutes for
each session, however we may exceed this
limit if required by state law
Age nine to age eighteen (up to Members
nineteenth birthday): 185 sessions of 25
minutes for each session, however we may
exceed this limit if required by state law
The limits for physical, occupational, and speech therapy will not apply to children between age 3 and 6 with Autism
Spectrum Disorders, if part of a Members Autism Treatment Plan, and determined Medically Necessary by Us.

When you get physical, occupational or speech therapy which also is considered by Us as Applied Behavioral Analysis
for the treatment of autism, the Applied Behavioral Analysis visit limit will apply instead of the Therapy Services limits
listed below.

Behavioral Health Services See Mental Health, Alcohol and Substance
Abuse Services.

Cardiac Rehabilitation See Therapy Services.

Chemotherapy See Therapy Services.

Clinical Trials Benefits are based on the setting in which
Covered Services are received.

Dental Services For Members Through Age 18

Note: To get the In-Network benefit, you must use a participating dental Provider. If you need help finding a
participating dental Provider, please call us at the number on the back of your ID card.
{Embedded Pediatric/Adult Dental plan: [Each Member must pay a Deductible of $50 per Benefit Period for the
dental services below. This Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan.]
Diagnostic and Preventive Services {Embedded Pediatric
Dental: [Deductible
waived, subject to]
10% Coinsurance
30% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Basic Restorative Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Endodontic Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible}
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Periodontal Services Not Covered Not Covered
Oral Surgery Services 50% Coinsurance
{Embedded Pediatric
50% Coinsurance
{Embedded
5
Benefits In-Network Out-of-Network
Dental: [after
Deductible]
Pediatric Dental:
[after Deductible]
Major Restorative Services 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]
Prosthodontic Services Not Covered Not Covered
Dentally Necessary Orthodontic Care 50% Coinsurance
{Embedded Pediatric
Dental: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric Dental:
[after Deductible]

{Embedded Adult Dental:
[Dental Services For Members Age 19 and Older

Note: To get the In-Network benefit, you must use a participating dental Provider. If you need help finding a
participating dental Provider, please call us at the number on the back of your ID card.
Each Member must pay a Deductible of $50 per Benefit Period for the dental services below. This Deductible is
separate and does not apply toward any other Deductible for Covered Services in this Plan.
Diagnostic and Preventive Services No Copayment,
Deductible, or
Coinsurance
50% Coinsurance
Basic Restorative Services 20% Coinsurance 60% Coinsurance
Endodontic Services 50% Coinsurance 75% Coinsurance
Periodontal Services 50% Coinsurance 75% Coinsurance
Oral Surgery Services 50% Coinsurance 75% Coinsurance
Major Restorative Services 50% Coinsurance 75% Coinsurance
Prosthodontic Services 50% Coinsurance 75% Coinsurance
Orthodontic Care Not covered Not covered
Dental Services for Members Age 19 and Older Benefit Maximum $1,000 per Benefit Period
In- and Out-of-Network combined
Orthodontic Care for members age 19 and older may be covered for certain medically necessary conditions. See the
section Dental Services (All Members / All Ages) for more information.]

Dental Services (All Members / All Ages) Benefits are based on the setting in which
Covered Services are received.

Diabetes Equipment, Education, and Supplies Benefits are based on the setting in which
Covered Services are received.
Screenings for gestational diabetes are covered
under Preventive Care.

6
Benefits In-Network Out-of-Network
Diagnostic Services

Benefits are based on the setting in which
Covered Services are received.

Dialysis See Therapy Services.

Durable Medical Equipment (DME) and Medical Devices,
Orthotics, Prosthetics, Medical and Surgical Supplies (Received
from a Supplier)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible

The cost-shares listed above only apply when you get the equipment or supplies from a third-party supplier. If you
receive the equipment or supplies as part of an office or outpatient visit, or during a Hospital stay, benefits will be based
on the setting in which the covered equipment or supplies are received.
Hearing Aid Benefit Maximum for Members under 18 years of age One hearing aid every 5 years
In- and Out-of-Network combined

Emergency Room Services
Emergency Room
Emergency Room Facility Charge

[$[200 to 250] Copayment] [per visit] [plus] [[0 to
50]% Coinsurance] [after Deductible]
[Copayment waived if admitted]
Emergency Room Doctor Charge [0 to 50]% Coinsurance after Deductible
Other Facility Charges (including diagnostic x-ray and lab
services, medical supplies)
[0 to 50]% Coinsurance after Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans) [0 to 50]% Coinsurance after Deductible
For Emergency services from an Out-of-Network Provider you do not need to pay any more than you would have paid
for services from an In-Network Provider.

Home Care
Home Care Visits [$[20 to 60] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Home Dialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Infusion Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Specialty Prescription Drugs [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Home Care Services / Supplies [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Care Benefit Maximum 28 hours of visits per week
7
Benefits In-Network Out-of-Network
In- and Out-of-Network combined
The limit does not apply to Home Infusion
Therapy or Home Dialysis.

Home Infusion Therapy See Home Care.

Hospice Care
Home Care
Respite Hospital Stays

[No Copayment or
Coinsurance after
Deductible] [After
Deductible no
Coinsurance]
[10 to 50]%
Coinsurance after
Deductible

Human Organ and Tissue Transplant (Bone Marrow / Stem Cell)
Services
Please see the separate summary later in this
section.

Infertility Services See Maternity and Reproductive Health
Services.

Inpatient Services
Facility Room & Board Charge:
Hospital / Acute Care Facility

[$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Inpatient Rehabilitation Services Benefit Maximum 2 months per Benefit Period In- and Out-of-
Network combined
Skilled Nursing Facility [$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility / Habilitation Services / Rehabilitation
Services (Includes Services in an Outpatient Day Rehabilitation
Program) Benefit Maximum
160100 days per Benefit Period In- and Out-of-
Network combined
Other Facility Services / Supplies (including diagnostic lab/x-ray,
medical supplies, therapies, anesthesia)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Addition if Copayment cost share: [Hospital Transfers: If you are transferred between Facilities, only one
Copayment will apply. You will not have to pay separate Copayments per Facility.

Hospital Readmissions: If you are readmitted to the Hospital within 72 hours of your discharge for the same medical
diagnosis, you will not have to pay an additional Copayment upon readmission.]
Doctor Services for:
General Medical Care / Evaluation and Management (E&M) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Surgery [0 to 50]% Coinsurance [10 to 50]%
8
Benefits In-Network Out-of-Network
after Deductible Coinsurance after
Deductible

Manipulation Therapy See Therapy Services.

Maternity and Reproductive Health Services
Maternity Visits (Global fee for the ObGyns prenatal, postnatal,
and delivery services)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Inpatient Services (Delivery) See Inpatient Services.
Newborn / Maternity Stays: If the newborn needs services other than routine nursery care or stays in the Hospital
after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission.
Infertility

Benefits are based on the setting in which
Covered Services are received.
Infertility Benefit Maximum Unlimited

Massage Therapy See Therapy Services.

Mental Health, Biologically Based Mental Illness, Alcohol and
Substance Abuse Services

Inpatient Facility Services

[$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Residential Treatment Center Services [$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] after
Deductible]
[50-90]%
Coinsurance after
Deductible
Inpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Outpatient Facility Services

[$250 Copayment per
visit] [plus][[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Outpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Partial Hospitalization Program / Intensive Outpatient Services [$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Office Visits [$[15 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
9
Benefits In-Network Out-of-Network
Mental Health, Biologically Based Mental Illness, Alcohol and Substance Abuse Services will be covered as required by
state and federal law. Please see Mental Health Parity and Addiction Equity Act in the Additional Federal Notices
section for details.

Occupational Therapy See Therapy Services.

Office Visits


Primary Care Physician / Provider (PCP) [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]
Retail Health Clinic Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Online Care Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Counseling Incudes
Family Planning and
Nutritional Counseling
(Other than Eating
Disorders)
[$[10 to 60] Copayment
per visit] [[for the first 3
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Nutritional Counseling for
Eating Disorders
[$[10 to 60] Copayment
per visit] [[for the first [3]
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Allergy Testing [$[10 to 60] Copayment
per visit] [[0 to
50]%Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / Injections (other than allergy serum) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
10
Benefits In-Network Out-of-Network
Deductible
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests (non-preventive; including hearing and EKG) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy Services:
- Acupuncture/Nerve Pathway Therapy, Manipulation
Therapy & Massage Therapy
[$[20 to 30] Copayment
per visit] [for the first 3
visits, then [0 to 50]%
Coinsurance] [after
Deductible]
Not Covered
- Physical, Speech, & Occupational Therapy [$[20 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Dialysis / Hemodialysis

[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Radiation / Chemotherapy / Non-Preventive Infusion &
Injection
[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
- Cardiac Rehabilitation & Pulmonary Therapy [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
See Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
11
Benefits In-Network Out-of-Network
Deductible

{Plans with copay for first 3 visits: [Important Note on Office Visit Copayments: Several services listed above
have a Copayment for the first three visits. This Copayment applies to any combination of services for the first three
visits during the Benefit Period. Starting with the fourth visit, you pay Deductible and Coinsurance, instead of a
Copayment. The three Copayments will not apply to Preventive Care, Maternity Services, or Urgent Care visits. You
will not have to pay any Deductible or Coinsurance when you pay the Copayment.]

Orthotics See Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Outpatient Facility Services
Facility Surgery Charge

[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges (including diagnostic x-ray and
lab services, medical supplies)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Doctor Surgery Charges [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Doctor Charges (including Anesthesiologist, Pathologist,
Radiologist, Surgical Assistant)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Facility Charges (for procedure rooms or other ancillary
services)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests: Hearing, EKG, etc. (Non-Preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
12
Benefits In-Network Out-of-Network
Advanced Diagnostic Imaging (including MRIs, CAT scans) [$250 Copayment [per
service] [per visit] [plus]
[[0 to 50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy:
- Manipulation Therapy

[0 to 50]% Coinsurance
after Deductible
Not Covered
- Physical, Speech, & Occupational Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Radiation / Chemotherapy / Non-Preventive Infusion &
Injection
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Dialysis / Hemodialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
- Cardiac Rehabilitation & Pulmonary Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
See Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in an Outpatient Facility [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Site-of-Service:
[Outpatient Freestanding Facility
Facility Surgery Charge / Ambulatory Surgery Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges/ Ambulatory Surgical Center
(including diagnostic x-ray and lab services, medical supplies)
[0 to 50]% Coinsurance [10 to 50]%
Coinsurance after
Deductible
Doctor Charges in Ambulatory Surgical Center / Freestanding
Radiology Center (including Anesthesiologist, Pathologist,
Radiologist, Surgery, Surgical Assistant)
No Copayment,
Deductible, or
Coinsurance

[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray / Freestanding Radiology Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans)/
Freestanding Radiology Center
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible]]

Physical Therapy See Therapy Services.

Preventive Care


No Copayment,
Deductible, or
Coinsurance
[10 to 50]%
Coinsurance after
Deductible
Preventive care from an Out-of-Network Provider is not subject to the Maximum Allowed Amount.
13
Benefits In-Network Out-of-Network

Prosthetics See Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Pulmonary Therapy See Therapy Services.

Radiation Therapy See Therapy Services.

Rehabilitation Services Benefits are based on the setting in which
Covered Services are received.

Respiratory Therapy See Therapy Services.

Skilled Nursing Facility See Inpatient Services.

Speech Therapy See Therapy Services.

Surgery Benefits are based on the setting in which
Covered Services are received.

Telemedicine
Primary Care Physician / Provider (PCP) $[20 to 60] Copayment
per visit [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) $[20 to 100] Copayment
per visit] [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: If your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]

Temporomandibular and Craniomandibular Joint Treatment Benefits are based on the setting in which
Covered Services are received.

14
Benefits In-Network Out-of-Network
Therapy Services Benefits are based on the setting in which
Covered Services are received.
Benefit Maximum(s): Benefit Maximum(s) are for In- and Out-of-
Network visits combined, for rehabilitative and
habilitative services combined, and for office
and outpatient visits combined.
Physical & Occupational Therapy 420 visits each per Benefit Period for
rehabilitative services
20 visits each per Benefit Period for
habilitative services
Speech Therapy 420 visits per Benefit Period. for rehabilitative
services
20 visits per Benefit Period for habilitative
services
For cleft palate or cleft lip conditions, Medically
necessary speech therapy is not limited, but
those visits lower the number of speech therapy
visits available to treat other problems.
Acupuncture/Nerve Pathway Therapy, Manipulation Therapy &
Massage Therapy
20 visits per Benefit
Period
Limit does not apply to
osteopathic therapy
Not covered
Cardiac Rehabilitation Unlimited
Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice
benefit.

Transgender Services Benefits are based on the setting in which
Covered Services are received.

Transplant Services See Human Organ and Tissue Transplant
(Bone Marrow / Stem Cell) Services.

Urgent Care Services (Office Visits)
Urgent Care Office Visit Charge [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Testing [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / Injections (other than allergy serum) [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to
50]% Coinsurance]
[10 to 50]%
Coinsurance after
Deductible
15
Benefits In-Network Out-of-Network
[after Deductible]
Other Charges (e.g., diagnostic x-ray and lab services, medical
supplies)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic Imaging (including MRIs, CAT scans)

[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75]
Copayment per visit]
[then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]%
Coinsurance after
Deductible
[10 to 50]%
Coinsurance after
Deductible
If you get urgent care at a Hospital or other outpatient Facility, please refer to Outpatient Facility Services for details
on what you will pay.

{Pediatric exam only: [Vision Services For Members Through Age 18

Note: To get the In-Network benefit, you must use an In-Network vision Provider. If you need help finding an In-
Network vision Provider, please call us at the number on the back of your ID card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
Deductible]

{Pediatric vision:
[Vision Services For Members Through Age 18

Note: To get the In-Network benefit, you must use an In-Network vision Provider. If you need help finding an In-
Network vision Provider, please call us at the number on the back of your ID card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
Deductible
Standard Plastic Lenses
Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Progressive $20 Copayment Covered up to $40
Note: In-Network, lenses include factory scratch coating and UV coating at no additional cost. Polycarbonate and
photocromic lenses are also covered at no extra cost In Network
Frames $0 Copayment, Covered
up to $130
Covered up to $45
Limited to one set of frames from the Anthem formulary every other Benefit Period.
Contact Lenses
16
Benefits In-Network Out-of-Network
Limited to one set of contact lenses from the Anthem formulary every other Benefit Period. Available only if the
eyeglass lenses benefit is not used.
Elective Contact Lenses (Conventional or Disposable) $0 Copayment, Covered
up to $80
Covered up to $60
Non-Elective Contact Lenses No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

{Adult vision:
[Vision Services For Members Age 19 and Older
Note: To get the In-Network benefit, you must use an In-Network vision Provider. If y Provider, please call us at the
number on the back of your ID card. ou need help finding an In-Network vision
Routine Eye Exam

Limited to one exam per Benefit Period
$20 Copayment Covered up to $30
Standard Plastic Lenses

Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Photochromic $20 Copayment (in
addition to lens
Copayment)
Not covered
Note: In-Network, lenses include factory scratch coating at no additional cost.
Frames

Limited to one set of frames every other Benefit Period.
Covered up to $130 Covered up to $45
Contact Lenses

Limited to one set of contact lenses every other Benefit Period. Available only if the eyeglass lenses benefit is not
used.
Elective Contact Lenses (Conventional or Disposable) Covered up to $80 Covered up to $60
Non-Elective Contact Lenses


No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

Vision Services (All Members / All Ages)
(For medical and surgical treatment of injuries and/or diseases of
the eye)

Certain vision screenings required by Federal law are covered
under the "Preventive Care" benefit.
Benefits are based on the setting in which
Covered Services are received.


17
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services


Please call our Transplant Department as soon you think you may need a transplant to talk about your benefit
options. You must do this before you have an evaluation and/or work-up for a transplant. To get the most
benefits under your Plan, you must get certain human organ and tissue transplant services from a Network
Transplant Provider. Even if a Hospital is an In-Network Provider for other services, it may not be an In-Network
Transplant Provider for certain transplant services. Please call us to find out which Hospitals are In-Network Transplant
Providers. (When calling Customer Service, ask for the Transplant Case Manager for further details.)

The requirements described below do not apply to the following:

Cornea and kidney transplants, which are covered as any other surgery; and
Any Covered Services related to a Covered Transplant Procedure, that you get before or after the Transplant
Benefit Period. Please note that the initial evaluation, any added tests to determine your eligibility as a candidate
for a transplant by your Provider, and the harvest and storage of bone marrow/stem cells is included in the Covered
Transplant Procedure benefit regardless of the date of service.

Benefits for Covered Services that are not part of the Human Organ and Tissue Transplant benefit will be based on the
setting in which Covered Services are received. Please see the Benefits/Coverage (What is Covered) section for
additional details.

Transplant Benefit Period In-Network Transplant
Provider

Out-of-Network Transplant
Provider
Starts one day before a
Covered Transplant
Procedure and lasts for the
applicable case rate / global
time period. The number of
days will vary depending on
the type of transplant
received and the In-Network
Transplant Provider
agreement. Call the Case
Manager for specific In-
Network Transplant
Provider information for
services received at or
coordinated by an In-
Network Transplant
Provider Facility.
Starts one day before a
Covered Transplant
Procedure and continues to
the date of discharge at an
Out-of- Network Transplant
Provider Facility.

Covered Transplant Procedure during the
Transplant Benefit Period
In-Network Transplant
Provider Facility

Out-of-Network Transplant
Provider Facility

Precertification required


During the Transplant
Benefit Period, [$500
Copayment per admission]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible].

Before and after the
Transplant Benefit Period,
Covered Services will be
covered as Inpatient
Services, Outpatient
Services, Home Visits, or
Office Visits depending
where the service is
During the Transplant Benefit
Period, [10 to 50]%
Coinsurance after Deductible.

During the Transplant Benefit
Period, Covered Transplant
Procedure charges at an Out-
of-Network Transplant
Provider Facility will NOT
apply to your Out-of-Pocket
Limit.

If the Provider is also an In-
Network Provider for this Plan
(for services other than
18
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services

performed. Covered Transplant
Procedures), then you will not
have to pay for Covered
Transplant Procedure charges
over the Maximum Allowed
Amount.

If the Provider is an Out-of-
Network Provider for this
Plan, you will have to pay for
Covered Transplant
Procedure charges over the
Maximum Allowed Amount.

Prior to and after the
Transplant Benefit Period,
Covered Services will be
covered as Inpatient Services,
Outpatient Services, Home
Visits, or Office Visits
depending where the service
is performed.

Covered Transplant Procedure during the
Transplant Benefit Period
In-Network Transplant
Provider Professional and
Ancillary (non-Hospital)
Providers

Out-of-Network Transplant
Provider Professional and
Ancillary (non-Hospital)
Providers
[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Transportation and Lodging

[0 to 50]% Coinsurance
after Deductible
[10 to 50]% Coinsurance after
Deductible

Transportation and Lodging Limit

Covered, as approved by us, up to $10,000 per transplant.
In- and Out-of-Network combined

Unrelated donor searches from an authorized,
licensed registry for bone marrow/stem cell
transplants for a Covered Transplant Procedure

[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Donor Search Limit Covered, as approved by us, up to $30,000 per transplant.
In- and Out-of-Network combined

Live Donor Health Services [0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

19
Human Organ and Tissue Transplant (Bone Marrow
/ Stem Cell) Services

Donor Health Service Limit Donor benefits are limited to benefits not available to the
donor from any other source. Medically Necessary charges
for getting an organ from a live donor are covered up to our
Maximum Allowed Amount, including complications from the
donor procedure for up to six weeks from the date of
procurement.

Prescription Drug Retail Pharmacy and Home
Delivery (Mail Order) Benefits
In-Network Out-of-Network
Each Prescription Drug will be subject to a cost share (e.g., Copayment/Coinsurance) as described below. If your
Prescription Order includes more than one Prescription Drug, a separate cost share will apply to each covered Drug.
You will be required to pay the lesser of your scheduled cost share or the Maximum Allowed Amount.
{Prescription deductible:
[Prescription Drug Deductible
Does not apply to Tier 1
Per Member $[250 to 500] In- and Out-of-Network combined
Per Family $[500 to 1,000] In- and Out-of-Network combined
Note: The Prescription Drug Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan. You must pay the Deductible before you pay any Copayments / Coinsurance listed below. The
Prescription Drug Deductible is included in the Out-of-Pocket Limit.]
Day Supply Limitations Prescription Drugs will be subject to various day supply and quantity limits. Certain
Prescription Drugs may have a lower day-supply limit than the amount shown below due to other Plan requirements
such as prior authorization, quantity limits, and/or age limits and utilization guidelines.
Retail Pharmacy (In-Network and Out-of-Network) 30 days
Home Delivery (Mail Order) Pharmacy 90 days
Specialty Pharmacy (In-Network and Out-of-
Network)
30 days*
*See additional information in the Specialty Drug
Copayments / Coinsurance section below.
Retail Pharmacy Copayments / Coinsurance:

Tier 1 Prescription Drugs

[$15 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 2 Prescription Drugs [$35 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance][ after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 3 Prescription Drugs

[$70 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
[10 to 50]% Coinsurance
[after Deductible]
20
Prescription Drug Retail Pharmacy and Home
Delivery (Mail Order) Benefits
In-Network Out-of-Network
Home Delivery Pharmacy Copayments /
Coinsurance:


Tier 1 Prescription Drugs

[$38 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered

Tier 2 Prescription Drugs [$88 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 3 Prescription Drugs [$175 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
Not covered
Specialty Drug Copayments / Coinsurance:
Please note that certain Specialty Drugs are only available from a Specialty Pharmacy and you will not be able to get
them at a Retail Pharmacy or through the Home Delivery (Mail Order) Pharmacy. Please see Specialty Pharmacy in
the section Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy for further details. When
you get Specialty Drugs from a Specialty Pharmacy, you will have to pay the same Copayments/Coinsurance you pay
for a 30-day supply at a Retail Pharmacy.

{Preferred Generic / Brand Penalty:
[Note: Prescription Drugs will always be dispensed as ordered by your Doctor. You may ask for, or your Doctor may
order, the Brand Name Drug. However, if a Generic Drug is available, you will have to pay the difference in the cost
between the Generic and Brand Name Drug, as well as your Tier 1 Copayment. By law, Generic and Brand Name
Drugs must meet the same standards for safety, strength, and effectiveness. Using generics generally saves money,
yet gives the same quality. We reserve the right, in our sole discretion, to remove certain higher cost Generic Drugs
from this policy.]
{Regular PPO:
[Note: No Copayment, Deductible, or Coinsurance applies to certain diabetic and asthmatic supplies when you get
them from an In-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical Equipment
if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable Prescription
Drug Copayment / Coinsurance.]
{HSA plans:
[Note: Certain diabetic and asthmatic supplies are covered subject to applicable Prescription Drug Copayments when
you get them from an In-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical
Equipment if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable
Prescription Drug Copayment / Coinsurance.]


21
Federal Patient Protection and Affordable Care Act Notices
Choice of Primary Care Physician / Provider
We generally allow the designation of a Primary Care Physician / Provider (PCP). You have the right to designate any
PCP who participates in our network and who is available to accept you or your family members. For information on how
to select a PCP, and for a list of PCPs, contact the telephone number on the back of your Identification Card or refer to
our website, www.anthem.com. For children, you may designate a pediatrician as the PCP.
Access to Obstetrical and Gynecological (ObGyn) Care
You do not need referral or authorization from us or from any other person (including a PCP) in order to obtain access to
obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or
gynecology. The health care professional, however, may be required to comply with certain procedures, including
obtaining prior authorization for certain services or following a pre-approved treatment plan. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of your
Identification Card or refer to our website, www.anthem.com.
22
Additional Federal Notices
Statement of Rights under the Newborns and Mothers Health Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the
mothers or newborns attending Provider, after consulting with the mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that
a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
Statement of Rights under the Womens Cancer Rights Act of 1998
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Womens Health and
Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in
a manner determined in consultation with the attending Physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other medical and surgical
benefits provided under this Plan. (See the Schedule of Benefits (Who Pays What) for details.) If you would like more
information on WHCRA benefits, call us at the number on the back of your Identification Card.
Coverage for a Child Due to a Qualified Medical Support Order (QMCSO)
If you or your spouse are required, due to a QMCSO, to provide coverage for your child(ren), you may ask the Group to
provide you, without charge, a written statement outlining the procedures for getting coverage for such child(ren).
Mental Health Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate treatment limitations
(day or visit limits) on mental health and substance abuse benefits with day or visit limits on medical and surgical benefits.
In general, group health plans offering mental health and substance abuse benefits cannot set day/visit limits on mental
health or substance abuse benefits that are lower than any such day or visit limits for medical and surgical benefits. A plan
that does not impose day or visit limits on medical and surgical benefits may not impose such day or visit limits on mental
health and substance abuse benefits offered under the plan. Also, the plan may not impose Deductibles, Copayment,
Coinsurance, and out of pocket expenses on mental health and substance abuse benefits that are more restrictive than
Deductibles, Copayment, Coinsurance and out of pocket expenses applicable to other medical and surgical benefits.
Medical Necessity criteria are available upon request.
Special Enrollment Notice
If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance
coverage, you may in the future be able to enroll yourself or your Dependents in this Plan if you or your Dependents lose
eligibility for that other coverage (or if the employer stops contributing towards your or your Dependents other coverage).
However, you must request enrollment within 31 days after your or your Dependents other coverage ends (or after the
employer stops contributing toward the other coverage.
In addition, if you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and Your Dependents. However, you must request enrollment within 31 days after the marriage,
birth, adoption, or placement for adoption.
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
23
The Subscribers or Dependents Medicaid or Childrens Health Insurance Program (CHIP) coverage is terminated as
a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program).
The Subscriber or Dependent must request Special Enrollment within 60 days of the loss of Medicaid/CHIP or of the
eligibility determination.
To request special enrollment or obtain more information, call us at the Customer Service telephone number on your
Identification Card, or contact the Group.
Statement of ERISA Rights
Please note: This section applies to employer sponsored plans other than Church employer groups and government
groups. If you have questions about whether this Plan is governed by ERISA, please contact the Plan Administrator (the
Group).
The Employee Retirement Income Security Act of 1974 (ERISA) entitles you, as a Member of the Group under this
Contract, to:
Examine, without charge, at the Plan Administrators office and at other specified locations such as worksites and
union halls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed by this plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions;
Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for these copies; and
Receive a summary of the plans annual financial report. The Plan Administrator is required by law to furnish each
participant with a copy of this summary financial report.
In addition to creating rights for you and other employees, ERISA imposes duties on the people responsible for the
operation of your employee benefit plan. The people who operate your plan are called plan fiduciaries. They must handle
your plan prudently and in the best interest of you and other plan participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you
from obtaining a welfare benefit or exercising your right under ERISA. If your claim for welfare benefits is denied, in whole
or in part, you must receive a written explanation of the reason for the denial. You have the right to have your claims
reviewed and reconsidered.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the
Plan Administrator and do not receive them within 30 days, you may file suit in a federal court. In such case, the court
may require the Plan Administrator to provide you the materials and pay you up to $110 a day until you receive the
materials, unless the materials are not sent because of reasons beyond the control of the Plan Administrator. If your
claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. If plan fiduciaries
misuse the plans money or if you are discriminated against for asserting your rights, you may seek assistance from the
U.S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal
fees. It may order you to pay these expenses, for example, if it finds your claim is frivolous. If you have any questions
about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your
rights under ERISA, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee
Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
24
Notices Required by State Law
Cancer Screenings
At Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado, Inc., we believe cancer screenings
provide important preventive care that supports our mission: to improve the lives of the people we serve and the health of
our communities. We cover cancer screenings as described below.
Pap Tests
All Plans provide coverage under the preventive care benefits for a routine annual Pap test and the related office visit.
Payment for the routine Pap test is based on the Plans provisions for preventive care service. Payment for the related
office visit is based on the Plans preventive care provisions.
Mammogram Screenings
All Plans provide coverage under the preventive care benefits for routine screening or diagnostic mammogram regardless
of age. Payment for the mammogram screening benefit is based on the Plans provisions for preventive care.
Prostate Cancer Screenings
All Plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for
the prostate cancer screening is based on the Plans provisions for preventive care.
Colorectal Cancer Screenings
Several types of colorectal cancer screening methods exist. All Plans provide coverage for routine colorectal cancer
screenings, such as fecal occult blood tests, barium enema, sigmoidoscopies and colonoscopies. Depending on the type
of colorectal cancer screening received, payment for the benefit is based on where the services are rendered and if
rendered as a screening or medical procedure. Colorectal cancer screenings are covered under preventive care as long
as the services provided are for a preventive screening. Payment for preventive colorectal cancer screenings based on
the Plans provisions for preventive care.
The information above is only a summary of the benefits described. The rest of this Booklet includes important additional
information about limitations, exclusions and covered benefits. The Schedule of Benefits (Who Pays What) section
includes additional information about Copayments, Deductibles and Coinsurance. If you have any questions, please call
Customer Service at the number on the back of your Identification Card.
{No adult dental:
[No-Adult Dental Services

This policy does not provide any dental benefits to individuals age nineteen (19) or older, except as specifically provided
in the benefit booklet. This policy is being offered so the purchaser will have pediatric dental coverage as required by the
Affordable Care Act. If you want adult dental benefits, you will need to buy a plan that has adult dental benefits. Except as
stated in the benefit booklet, this plan will not pay for any adult dental care, so you will have to pay the full price of any
care you receive.]




25
Notice of
Protection Provided by
Life and Health Insurance Protection Association
This notice provides a brief summary of the Life and Health Insurance Protection Association (the Association) and the
protection it provides for policyholders. This safety net was created under Colorado law, which determines who and what
is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or health insurance
company becomes financially unable to meet its obligations and is taken over by its Insurance Department. If this should
happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Colorado law, with
funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
Life Insurance
- $300,000 in death benefits
- $100,000 in cash surrender or withdrawal values
Health Insurance
- $500,000 in hospital, medical and surgical insurance benefits
- $300,000 in disability insurance benefits
- $300,000 in long-term care insurance benefits
- $100,000 in other types of health insurance benefits
Annuities
- $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000.
Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to
any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the
account value of a variable life insurance policy or a variable annuity contract. There are also various residency
requirements and other limitations under Colorado law.
To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please
visit the Associations website http://colorado.lhiga.com, email jkelldorf@aol.com or contact:
Colorado Life and Health
Insurance Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 292-5022
Colorado Division of Insurance
1560 Broadway, Suite 850
Denver, CO 80202

(303) 894-7499
Insurance companies and agents are not allowed by Colorado law to use the existence of the Association or its
coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you
should not rely on Association coverage. If there is any inconsistency between this notice and Colorado law,
then Colorado law will control.
26
Section 2. Title Page (Cover Page)

Anthem Blue Cross and Blue Shield


[Anthem Silver Blue Priority PPO 2500/20%/6000 Plus]
[Anthem Gold PPO 1000/20%/3500]
[Anthem Gold PPO 2000/40%/4000]
[Anthem Silver PPO 2000/50%/6350]
[Anthem Gold PPO 750/20%/4500]
[Anthem Gold PPO 1500/20%/4000]
[Anthem Gold PPO 500/20%/4500]
[Anthem Silver PPO 2000/30%/4500 Plus w/Dental]
[Anthem Silver PPO 2000/30%/4500 Plus]
[Anthem Silver PPO 3000/30%/4000 Plus]
[Anthem Bronze PPO 5850/30%/6600 Plus]
[Anthem Gold PPO 500/20%/3000 Plus w/Dental]
[Anthem Gold PPO 500/20%/3000 Plus]
[Anthem Silver PPO 1500/30%/4250 Plus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem Silver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 Plus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 Plus w/HSA]
[Anthem Silver PPO 2500/20%/4500 w/HSA]
[Anthem Gold PPO 2000/20%/5000 Plus w/HRA]
[Anthem Gold PPO 4000/20%/5000 Plus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 Plus]




27

Section 3. Contact Us
Welcome to Anthem!
We are pleased that you have become a Member of our health insurance Plan. We want to make sure
that our services are easy to use. Weve designed this Booklet to give a clear description of your
benefits, as well as our rules and procedures.
The Booklet explains many of the rights and duties between you and us. It also describes how to get
health care, what services are covered, and what part of the costs you will need to pay. Many parts of
this Booklet are related. Therefore, reading just one or two sections may not give you a full understanding
of your coverage. You should read the whole Booklet to know the terms of your coverage.
This Booklet replaces any Booklet issued to you in the past. The coverage described is based upon the
terms of the Group Contract issued to your Group, and the Plan that your Group chose for you. This
Booklet, and any endorsements, amendments or riders attached, form the entire legal contract under
which Covered Services are available. In addition the Group has a Group Contract and Group
Application which includes terms that apply to this coverage.
Many words used in the Booklet have special meanings (e.g., Group, Covered Services, and Medical
Necessity). These words are capitalized and are defined in the "Definitions" section. See these
definitions for the best understanding of what is being stated. Throughout this Booklet you will also see
references to we, us, our, you, and your. The words we, us, and our mean Anthem Blue
Cross and Blue Shield. The words you and your mean the Member, Subscriber and each covered
Dependent.
If you have any questions about your Plan, please be sure to call Customer Service at the number on the
back of your Identification Card. You can also contact us at:
800-234-0111
Anthem Blue Cross and Blue Shield
700 Broadway
Denver, CO 80273
Also be sure to check our website, www.anthem.com for details on how to find a Provider, get answers to
questions, and access valuable health and wellness tips. Thank you again for enrolling in the Plan!
{HSA plans:
[High-Deductible Health Plan for Use with Health Savings Accounts
This Plan is meant to be federally tax qualified and used with a qualified health savings account. Approval
by the Division of Insurance does not guarantee tax qualification and this Plan has not been submitted for
approval by the IRS. Please seek the advice of a tax advisor.]
How to Get Language Assistance
Anthem is committed to communicating with our Members about their health Plan, no matter what their
language is. Anthem employs a language line interpretation service for use by all of our Customer Service
call centers. Simply call the Customer Service phone number on the back of your Identification Card and
a representative will be able to help you. Translation of written materials about your benefits can also
be asked for by contacting Customer Service. TTY/TDD services also are available by dialing 711. A
special operator will get in touch with us to help with your needs.


28


Mike Ramseier
President and General Manager
Anthem Blue Cross and Blue Shield
29

Your Rights and Responsibilities as an Anthem Blue Cross and Blue
Shield Member
As a Member you have certain rights and responsibilities when receiving your health care. You also have
a responsibility to take an active role in your care. As your health care partner, were committed to making
sure your rights are respected while providing your health benefits. That also means giving you access to
our In-Network Providers and the information you need to make the best decisions for your health and
welfare.

You have the right to:
Speak freely and privately with your Doctors and other health Providers about all health care
options and treatment needed for your condition. This is no matter what the cost or whether its
covered under your Plan.
Work with your Doctors in making choices about your health care.
Be treated with respect and dignity.
Expect us to keep your personal health information private. This is as long as it follows state and
Federal laws and our privacy policies.
Get the information you need to help make sure you get the most from your health Plan, and share
your feedback. This includes information on:
- Our company and services.
- Our network of Doctors and other health care Providers.
- Your rights and responsibilities.
- The rules of your health care Plan.
- The way your health Plan works.
Make a complaint or file an appeal about:
- Your Plan.
- Any care you get.
- Any Covered Service or benefit ruling that your Plan makes.
Say no to any care, for any condition, sickness or disease, without it affecting any care you may get in
the future. This includes the right to have your Doctor tell you how that may affect your health now
and in the future.
Get all of the most up-to-date information from a Doctor or other health care professional Provider
about the cause of your illness, your treatment and what may result from it. If you dont understand
certain information, you can choose a person to be with you to help you understand.

You have the responsibility to:
Read and understand, to the best of your ability, all information about your health benefits or ask for
help if you need it.
Follow all Plan rules and policies.
Choose an In-Network Primary Care Physician (Doctor) / Provider, also called a PCP, if your health
care Plan requires it.
Treat all Doctors, health care Providers and staff with courtesy and respect.
Keep all scheduled appointments with your health care Providers. Call their office if you may be late
or need to cancel.
Understand your health problems as well as you can and work with your Doctors or other health care
Providers to make a treatment plan that you all agree on.
Tell your Doctors or other health care Providers if you dont understand any type of care youre
getting or what they want you to do as part of your care plan.

30
Follow the care plan that you have agreed on with your Doctors or health care Providers.
Give us, your Doctors and other health care professionals the information needed to help you get the
best possible care and all the benefits you are entitled to. This may include information about other
health and insurance benefits you have in addition to your coverage with us.
Let our customer service department know if you have any changes to your name, address or family
members covered under your Plan.

We are committed to providing quality benefits and customer service to our Members. Benefits and
coverage for services provided under the benefit program are governed by the Booklet and not by this
Member Rights and Responsibilities statement.
We value your feedback regarding the benefits and service provided under Our policies and your overall
thoughts and concerns regarding Our operations. If you have any concerns regarding how your benefits
were applied or any concerns about services you requested which were not covered under this Booklet,
you are free to file a complaint or appeal as explained in this Booklet. If you have any concerns regarding
a participating Provider or facility, you can file a grievance as explained in this Booklet. And if you have
any concerns or suggestions on how we can improve Our overall operations and service, We encourage
you to contact customer service.
If you need more information or would like to contact us, please go to anthem.com and select Customer
Support > Contact Us. Or call the Member Services number on your ID card.




31

Section 4. Table of Contents
Section 1. Schedule of Benefits (Who Pays What) .................................................................................. 1
Section 2. Title Page (Cover Page) .......................................................................................................... 26
Section 3. Contact Us ............................................................................................................................... 27
Welcome to Anthem! ............................................................................................................................... 27
[High-Deductible Health Plan for Use with Health Savings Accounts ..................................................... 27
How to Get Language Assistance ........................................................................................................... 27
Your Rights and Responsibilities as an Anthem Blue Cross and Blue Shield Member .......................... 29
Section 4. Table of Contents .................................................................................................................... 31
Section 5. Eligibility .................................................................................................................................. 36
Who is Eligible for Coverage ................................................................................................................... 36
The Subscriber ..................................................................................................................................... 36
Dependents .......................................................................................................................................... 36
Types of Coverage ............................................................................................................................... 37
When You Can Enroll .............................................................................................................................. 37
Initial Enrollment .................................................................................................................................. 37
Open Enrollment .................................................................................................................................. 38
Special Enrollment Periods .................................................................................................................. 38
Special Rules if Your Group Health Plan is Offered Through an Exchange ....................................... 38
Medicaid and Childrens Health Insurance Program Special Enrollment ............................................ 39
Late Enrollees ...................................................................................................................................... 39
Members Covered Under the Groups Prior Plan ................................................................................ 39
Enrolling Dependent Children ................................................................................................................. 39
Newborn Children ................................................................................................................................ 39
Adopted Children ................................................................................................................................. 39
Adding a Child due to Award of Legal Custody or Guardianship ........................................................ 40
Qualified Medical Child Support Order ................................................................................................ 40
Updating Coverage and/or Removing Dependents ................................................................................ 40
Nondiscrimination .................................................................................................................................... 40
Statements and Forms ............................................................................................................................ 40
Section 6. How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) ................................................................................................................................................. 41
Introduction .............................................................................................................................................. 41
In-Network Services ................................................................................................................................ 41
Out-of-Network Services ......................................................................................................................... 42
How to Find a Provider in the Network .................................................................................................... 42
[Designated Participating Provider Program ........................................................................................... 42
Continuity of Care .................................................................................................................................... 43
Crediting Prior Plan Coverage ................................................................................................................. 43
The BlueCard Program ............................................................................................................................ 43
Identification Card .................................................................................................................................... 44
Obtain Approval of Benefits ..................................................................................................................... 45
Types of Requests ................................................................................................................................... 45
Request Categories ................................................................................................................................. 46
Decision and Notice Requirements ......................................................................................................... 47
Health Plan Individual Case Management .............................................................................................. 48
Section 7. Benefits/Coverage (What is Covered) ................................................................................... 49
Acupuncture/Nerve Pathway ................................................................................................................... 49
Allergy Services ....................................................................................................................................... 49
Ambulance Services ................................................................................................................................ 49

32
Autism Services ....................................................................................................................................... 50
Behavioral Health Services ..................................................................................................................... 51
Cardiac Rehabilitation ............................................................................................................................. 51
Chemotherapy ......................................................................................................................................... 51

Clinical Trials ........................................................................................................................................... 51
Dental Services ....................................................................................................................................... 52
Your Dental Benefits ............................................................................................................................ 52
Pretreatment Estimate ......................................................................................................................... 53
[Pediatric Dental for Members through Age 18 ................................................................................... 53
[Dental Services ...................................................................................................................................... 56
Dental Services for Members through Age 18 ..................................................................................... 56
Diagnostic and Preventive Services .................................................................................................... 56
Basic Restorative Services .................................................................................................................. 56
Major Restorative Services .................................................................................................................. 57
Oral Surgery ......................................................................................................................................... 57
Orthodontic Care .................................................................................................................................. 57
Dental Services for Members Age 19 and Older ................................................................................. 58
Diagnostic and Preventive Services .................................................................................................... 58
Basic Restorative Services .................................................................................................................. 59
Endodontic Services ............................................................................................................................ 59
Periodontal Services ............................................................................................................................ 59
Oral Surgery Services .......................................................................................................................... 60
Major Restorative Services .................................................................................................................. 61
Prosthodontic Services ........................................................................................................................ 61
Dental Services (All Members / All Ages) ................................................................................................ 63
Preparing the Mouth for Medical Treatments ...................................................................................... 63
Accident-Related Dental Services ....................................................................................................... 63
Cleft Palate and Cleft Lip Conditions ................................................................................................... 63
Dental Anesthesia for Children ............................................................................................................ 63
Diabetes Equipment, Education, and Supplies ....................................................................................... 63
Diagnostic Services ................................................................................................................................. 64
Diagnostic Laboratory and Pathology Services ................................................................................... 64
Diagnostic Imaging Services and Electronic Diagnostic Tests ............................................................ 64
Advanced Imaging Services ................................................................................................................ 64
Dialysis .................................................................................................................................................... 64
Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies ................................................................................................................................................... 64
Durable Medical Equipment and Medical Devices .............................................................................. 64
Hearing Aid Services ........................................................................................................................... 65
Orthotics ............................................................................................................................................... 65
Prosthetics ........................................................................................................................................... 65
Medical and Surgical Supplies ............................................................................................................. 66
Blood and Blood Products ................................................................................................................... 66
Emergency Care Services ....................................................................................................................... 66
Emergency Services ............................................................................................................................ 66
Home Care Services ............................................................................................................................... 67
Home Infusion Therapy ........................................................................................................................... 67
Hospice Care ........................................................................................................................................... 67
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services ........................................... 68
Prior Approval and Precertification ...................................................................................................... 69
Infertility Services .................................................................................................................................... 70
Inpatient Services .................................................................................................................................... 70
Inpatient Hospital Care ........................................................................................................................ 70
Inpatient Professional Services ........................................................................................................... 71
Maternity and Reproductive Health Services .......................................................................................... 71

33
Maternity Services ............................................................................................................................... 71
Contraceptive Benefits ......................................................................................................................... 72
Sterilization Services ............................................................................................................................ 72
Abortion Services ................................................................................................................................. 72
Infertility Services ................................................................................................................................. 72
Mental Health, Alcohol and Substance Abuse Services ......................................................................... 72
Occupational Therapy ............................................................................................................................. 74
Office Visits and Doctor Services ............................................................................................................ 74
Orthotics .................................................................................................................................................. 74
Outpatient Facility Services ..................................................................................................................... 74
Physical Therapy ..................................................................................................................................... 75
Preventive Care ....................................................................................................................................... 75
Prosthetics ............................................................................................................................................... 76
Pulmonary Therapy ................................................................................................................................. 76
Radiation Therapy ................................................................................................................................... 76
Rehabilitation Services ............................................................................................................................ 76
Habilitative Services ............................................................................................................................. 76
Respiratory Therapy ................................................................................................................................ 76
Skilled Nursing Facility ............................................................................................................................ 76
Smoking Cessation .................................................................................................................................. 77
Speech Therapy ...................................................................................................................................... 77
Surgery .................................................................................................................................................... 77
Oral Surgery ......................................................................................................................................... 77
Reconstructive Surgery........................................................................................................................ 77
Transgender Surgery ........................................................................................................................... 78
Telemedicine ........................................................................................................................................... 78
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services ................................................. 78
Therapy Services ..................................................................................................................................... 79
Physical Medicine Therapy Services ................................................................................................... 79
Early Intervention Services .................................................................................................................. 79
Other Therapy Services ....................................................................................................................... 80
Transplant Services ................................................................................................................................. 80
Urgent Care Services .............................................................................................................................. 80
Routine Eye Exam ............................................................................................................................... 81
Eyeglass Lenses .................................................................................................................................. 81
Frames ................................................................................................................................................. 81
Contact Lenses .................................................................................................................................... 81
[Vision Services for Members Age 19 and Older .................................................................................... 82
Routine Eye Exam ............................................................................................................................... 82
Eyeglass Lenses .................................................................................................................................. 82
Frames ................................................................................................................................................. 82
Contact Lenses .................................................................................................................................... 82
Vision Services (All Members / All Ages) ................................................................................................ 83
Prescription Drugs Administered by a Medical Provider ......................................................................... 84
Important Details About Prescription Drug Coverage .......................................................................... 84
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy ..................................... 85
Prescription Drug Benefits ................................................................................................................... 85
Section 8. Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) .................. 89
Whats Not Covered Under Your Prescription Drug Retail or Home Delivery (Mail Order) Pharmacy
Benefit ...................................................................................................................................................... 94
Pre-existing Conditions ............................................................................................................................ 96
Section 9. Member Payment Responsibility........................................................................................... 97
Your Cost-Shares .................................................................................................................................... 97
Maximum Allowed Amount ...................................................................................................................... 97
Claims Review ....................................................................................................................................... 100

34
Section 10. Claims Procedure (How to File a Claim) ........................................................................... 101
Notice of Claim & Proof of Loss ............................................................................................................ 101
Claim Forms .......................................................................................................................................... 101
Members Cooperation .......................................................................................................................... 101
Payment of Benefits .............................................................................................................................. 101
Inter-Plan Programs .............................................................................................................................. 102
Out-of-Area Services ............................................................................................................................. 102
BlueCard

Program ........................................................................................................................... 102

Non-Participating Healthcare Providers Outside Our Service Area .................................................. 103
Section 11. General Policy Provisions .................................................................................................. 104
Assignment ............................................................................................................................................ 104
Automobile Insurance Provisions .......................................................................................................... 104
Clerical Error .......................................................................................................................................... 104
Confidentiality and Release of Information............................................................................................ 105
Conformity with Law .............................................................................................................................. 105
Contract with Anthem ............................................................................................................................ 105
Entire Contract ....................................................................................................................................... 105
Form or Content of Booklet ................................................................................................................... 106
Government Programs .......................................................................................................................... 106
Medical Policy and Technology Assessment ........................................................................................ 106
Medicare ................................................................................................................................................ 106
Modifications .......................................................................................................................................... 106
Network Access Plan ............................................................................................................................. 107
Not Liable for Provider Acts or Omissions ............................................................................................. 107
Policies and Procedures ........................................................................................................................ 107
Relationship of Parties (Group-Member-Anthem) ................................................................................. 107
Relationship of Parties (Anthem and In-Network Providers) ................................................................. 107
Reservation of Discretionary Authority .................................................................................................. 108
Right of Recovery .................................................................................................................................. 108
Unauthorized Use of Identification Card ................................................................................................ 109
Value-Added Programs ......................................................................................................................... 109
Value of Covered Services .................................................................................................................... 109
Voluntary Clinical Quality Programs ...................................................................................................... 109
Voluntary Wellness Incentive Programs ................................................................................................ 109
Waiver .................................................................................................................................................... 110
Workers Compensation ........................................................................................................................ 110
Subrogation and Reimbursement .......................................................................................................... 110
Subrogation ........................................................................................................................................ 110
Reimbursement .................................................................................................................................. 110
The Members Duties ......................................................................................................................... 111
Coordination of Benefits When Members Are Insured Under More Than One Plan ............................ 111
Section 12. Termination/Nonrenewal/Continuation ............................................................................. 116
Termination ............................................................................................................................................ 116
Removal of Members ............................................................................................................................ 116
Special Rules if Your Group Health Plan is Offered Through an Exchange ......................................... 117
Continuation of Coverage Under Federal Law (COBRA) ...................................................................... 117
Qualifying events for Continuation Coverage under Federal Law (COBRA) ..................................... 117
If Your Group Offers Retirement Coverage ....................................................................................... 118
Second qualifying event ..................................................................................................................... 118
Notification Requirements .................................................................................................................. 119
Disability extension of 18-month period of continuation coverage .................................................... 119
Trade Adjustment Act Eligible Individual ........................................................................................... 119
When COBRA Coverage Ends .......................................................................................................... 120
If You Have Questions ....................................................................................................................... 120
Continuation of Coverage Under State Law .......................................................................................... 120

35
Continuation of Coverage Due To Military Service ............................................................................... 121
Maximum Period of Coverage During a Military Leave ..................................................................... 122
Reinstatement of Coverage Following a Military Leave .................................................................... 122
Family and Medical Leave Act of 1993 ................................................................................................. 122
Benefits After Termination Of Coverage ............................................................................................... 123
Section 13. Appeals and Complaints .................................................................................................... 124
Complaints ............................................................................................................................................. 124
Appeals .................................................................................................................................................. 125
Grievances ............................................................................................................................................ 127
Division of Insurance Inquiries ........................................................................................................... 127
Binding Arbitration .............................................................................................................................. 127
Legal Action ....................................................................................................................................... 127
Section 14. Information on Policy and Rate Changes ......................................................................... 129
Insurance Premiums .............................................................................................................................. 129
Section 15. Definitions ............................................................................................................................ 130

36
Section 5. Eligibility
In this section you will find information on who is eligible for coverage under this Plan and when Members
can be added to your coverage. Eligibility requirements are described in general terms below. For more
specific information, please see your Human Resources or Benefits Department.
Who is Eligible for Coverage
The Subscriber
To be eligible to enroll as a Subscriber, the individual must:
Be an employee of the Group, and;
Be entitled to participate in the benefit Plan arranged by the Group, and;
Have satisfied any probationary or waiting period established by the Group and perform the duties of
your principal occupation for the Group.
Dependents
To be eligible to enroll as a Dependent, you must be listed on the enrollment form completed by the
Subscriber, meet all Dependent eligibility criteria established by the Group, and be one of the following:
The Subscribers spouse, including the partner to a civil union as recognized by Colorado law. For
information on spousal eligibility please contact the Group.
Common-law spouse. A Common-Law Marriage Affidavit is needed to enroll a common-law spouse.
You can get the affidavit from your employer or you can call us. All references to spouse in this
Booklet include a common-law spouse.
A common law spouse is an eligible Dependent who has a valid common-law marriage in Colorado.
This is the same as any other marriage and can only end by death or divorce.
Designated beneficiary. Your Group may have decided to offer benefits under this plan to designated
beneficiaries. Check with your Group to learn more. If they are recognized by the Group, all
references to spouse in this Booklet include a designated beneficiary. A Recorded Designated
Beneficiary Agreement will need to be provided. A designated beneficiary is not eligible for COBRA
under this Booklet.
A designated beneficiary is an agreement entered into by two people for the purpose of making each
a beneficiary of the other and which has been recorded with the county clerk and recorder in the
county in which one of the person lives. The agreement is based on the Colorado Designated
Beneficiary Act.
Same-sex domestic partner. Domestic Partner, or Domestic Partnership means a person of the same
sex who has signed the Domestic Partner Affidavit certifying that he or she is the Subscribers sole
Domestic Partner; he or she is mentally competent; he or she is not related to the Subscriber by
blood closer than permitted by state law for marriage; he or she is not married to anyone else; and he
or she is financially interdependent with the Subscriber.
For purposes of this Plan, a Domestic Partner or partner to a recognized civil union shall be treated
the same as a spouse, and that partners child, adopted child, or child for whom he or she has legal
guardianship shall be treated the same as any other child. The coverage of a Domestic Partner, civil
union partner, or the child of any such partner ends on the date of dissolution of the Domestic
Partnership or civil union.
While this Booklet will recognize and provide benefits for a Member who is a spouse or child in
connection with a Domestic Partner or recognized civil union relationship, not every federal or state

37
law that applies to a Member who is a spouse or child under this Plan will also apply to a Domestic
Partner or a partner under a civil union. This includes but is not limited to, COBRA and FMLA.
We reserve the right to make the ultimate decision in determining eligibility of the Domestic Partner.
The children of the Subscriber or the Subscribers spouse, including natural children, stepchildren,
newborn and legally adopted children and children who the Group has determined are covered under
a Qualified Medical Child Support Order as defined by ERISA or any applicable state law.
Children, including grandchildren, for whom the Subscriber or the Subscribers spouse is a permanent
legal guardian or as otherwise required by law.
All enrolled eligible children will continue to be covered until the age limit listed in the Schedule of
Benefits (Who Pays What). Coverage may be continued past the age limit in the following circumstances:
For unmarried children of any age who are medically certified as disabled and dependent upon the
parent. The Dependents disability must start before the end of the period they would become
ineligible for coverage. We must be informed of the Dependents eligibility for continuation of
coverage within 31 days after the Dependent would normally become ineligible. You must then give
proof as often as we require. This will not be more often than once a year after the two-year period
following the child reaching the limiting age. You must give the proof at no cost to us. You must
notify us if the Dependents marital status changes and they are no longer eligible for continued
coverage.
We may require you to give proof of continued eligibility for any enrolled child. Your failure to give this
information could result in termination of a childs coverage.
To obtain coverage for children, we may require you to give us a copy of any legal documents awarding
permanent guardianship of such child(ren) to you.

Your group may have limited or excluded the eligibility of certain Dependent types and so not all
Dependents listed in this Plan may be entitled to enroll. For more specific information, please see your
Human Resources or Benefits Department.
Types of Coverage
Your Group offers some or all of the enrollment options listed below. After reviewing the available options,
you may choose the option that best meets your needs. The options may include:
Subscriber only (also referred to as single coverage);
Subscriber and spouse; or Domestic Partner;
Subscriber and child(ren);
Subscriber and family.
When You Can Enroll
Initial Enrollment
The Group will offer an initial enrollment period to new Subscribers and their Dependents when the
Subscriber is first eligible for coverage. Coverage will be effective based on the waiting period chosen by
the Group, and will not exceed 90 days.
If you did not enroll yourself and/or your Dependents during the initial enrollment period you will only be
able to enroll during an Open Enrollment period or during a Special Enrollment period, as described
below.

38
Open Enrollment
Open Enrollment refers to a period of time, usually 60 days, during which eligible Subscribers and
Dependents can apply for or change coverage. Open Enrollment occurs only once per year. The Group
will notify you when Open Enrollment is available.
Special Enrollment Periods
If a Subscriber or Dependent does not apply for coverage when they were first eligible, they may be able
to join the Plan prior to Open Enrollment if they qualify for Special Enrollment. Except as noted otherwise
below, the Subscriber or Dependent must request Special Enrollment within 31 days of a qualifying event.
Special Enrollment is available for eligible individuals who:
Lost eligibility under a prior health plan for reasons other than non-payment of premium or due to
fraud or intentional misrepresentation of a material fact;
Lost coverage due to death of a covered employee; the termination or reduction in number of hours of
the covered employees employment (regardless of eligibility for COBRA or state continuation
coverage); involuntary termination of coverage; lost eligibility under the Colorado Medical Assistance
Act or the Childrens Basic Health Plan; or the covered employee becoming eligible for benefits under
Title XVIII of the Federal Social Security Act, as amended;
Lost coverage under a health benefit plan due to the divorce or legal separation of the covered
employee from the covered employees spouse or partner in civil union, or due to the termination of a
recognized domestic partnership;
Is now eligible for coverage due to marriage (including a civil union where recognized in the state
where the Subscriber resides), birth, adoption, placement for adoption, by entering into a Designated
Beneficiary Agreement, or pursuant to a QMCSO or other court or administrative order mandating
that the individual be covered;
Exhausted COBRA or state continuation benefits or stopped receiving group contributions toward the
cost of the prior health plan; or
Lost employer contributions towards the cost of the other coverage.

Important Notes about Special Enrollment:
Members who enroll during Special Enrollment are not considered Late Enrollees.
Individuals must request coverage within 31 days of a qualifying event (i.e., marriage, exhaustion of
COBRA, etc.).
If the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Special Rules if Your Group Health Plan is Offered Through an Exchange
If your Plan is offered through a public exchange operated by the state or federal government as part of
the Patient Protection and Affordable Care Act (Exchange), all enrollment changes must be made
through the Exchange by you or your Group. Each Exchange will have rules on how to do this. For plans
offered on the Exchange there are additional opportunities for Special Enrollment. They include:
Your enrollment or non-enrollment in another qualified health plan was unintentional, inadvertent or
erroneous and was a result of an error, misrepresentation, or inaction by an employee or
representative of the Exchange;
You adequately demonstrate to the Exchange that the health plan under which you are enrolled has
substantially violated a material provision of its contract with you;
You move and become eligible for new qualified health plans;

39
You are a Native American Indian, as defined by section 4 of the Indian Health Care Improvement
Act, and allowed to change from one qualified health plan to another as often as once per month; or
The Exchange determines, under federal law, that you meet other exceptional circumstances that
warrant a Special Enrollment.
You must give the Exchange notice within 30 days of the above events if you wish to enroll.
Medicaid and Childrens Health Insurance Program Special Enrollment
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
The Subscribers or Dependents Medicaid or Childrens Health Insurance Program (CHIP) coverage
is terminated as a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program)
The Subscriber or Dependent must request Special Enrollment within 60 days of the above events.
Late Enrollees
If the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Members Covered Under the Groups Prior Plan
Members who were previously enrolled under another plan offered by the Group that is being replaced by
this Plan are eligible for coverage on the Effective Date of this coverage.
Enrolling Dependent Children
Newborn Children
Newborn children are covered automatically from the moment of birth. Following the birth of a child, you
should submit an application / change form to the Group within 31, but no more than 60, days to add the
newborn to your Plan. During the first 31 days after birth, a newborn child will be covered for Medically
Necessary care. This includes well child care and treatment of medically diagnosed congenital defects
and birth abnormalities. This is regardless of the limitations and exclusions applicable to other conditions
or procedures of this Booklet.
Even if no additional Premium is required, you should still submit an application / change form to the
Group to add the newborn to your Plan, to make sure we have accurate records and are able to cover
your claims.
Adopted Children
A child will be considered adopted from the earlier of: (1) the moment of placement in your home; or (2)
the date of an entry of an order granting custody of the child to you. The placement begins when you
assume or retain a legal obligation to partially or totally support a child in anticipation of the child's
adoption. A placement terminates at the time such legal obligation terminates. The child will continue to
be considered adopted unless the child is removed from your home prior to issuance of a legal decree of
adoption.
Your Dependents Effective Date will be the date of the adoption or placement for adoption if you send us
the completed application / change form within 31 days of the event.

40
Adding a Child due to Award of Legal Custody or Guardianship
If you or your spouse is awarded permanent legal custody or permanent guardianship for a child, an
application must be submitted within 31 days of the date legal custody or guardianship is awarded by the
court. Coverage will be effective on the date the court granted legal custody or guardianship.
Qualified Medical Child Support Order
If you are required by a qualified medical child support order or court order, as defined by ERISA and/or
applicable state or federal law, to enroll your child in this Plan, we will permit the child to enroll at any time
without regard to any Open Enrollment limits and will provide the benefits of this Plan according to the
applicable requirements of such order. However, a child's coverage will not extend beyond any
Dependent Age Limit listed in the Schedule of Benefits (Who Pays What).
Updating Coverage and/or Removing Dependents
You are required to notify the Group of any changes that affect your eligibility or the eligibility of your
Dependents for this Plan. When any of the following occurs, contact the Group and complete the
appropriate forms:
Changes in address;
Marriage or divorce or entering into or terminating a recognized civil union or domestic partnership;
Death of an enrolled family member (a different type of coverage may be necessary);
Enrollment in another health plan or in Medicare;
Eligibility for Medicare;
Dependent child reaching the Dependent Age Limit (see Termination/Nonrenewal/Continuation);
Enrolled Dependent child either becomes totally or permanently disabled, or is no longer disabled.
Failure to notify us of individuals no longer eligible for services will not obligate us to cover such services,
even if Premium is received for those individuals. All notifications must be in writing and on approved
forms.
Nondiscrimination
No person who is eligible to enroll will be refused enrollment based on health status, health care needs,
genetic information, previous medical information, disability, sexual orientation or identity, gender or age.
Statements and Forms
All Members must complete and submit applications or other forms or statements that we may reasonably
request.
Any rights to benefits under this Plan are subject to the condition that all such information is true, correct,
and complete. Any intentional material misrepresentation by you may result in termination of coverage as
provided in the "Termination/Nonrenewal/Continuation" section. We will not use a statement made by you
to void or reduce your coverage after that coverage has been in effect for two years, unless such
statement is contained in a written instrument signed by you making such statement and a copy of that
instrument is or has been given to you or your beneficiary.


41
Section 6. How to Access Your Services and Obtain Approval
of Benefits (Applicable to managed care plans)
Introduction
Your Plan is a PPO plan. The Plan has two sets of benefits: In-Network and Out-of-Network. If you
choose an In-Network Provider, you will pay less in out-of-pocket costs, such as Copayments,
Deductibles, and Coinsurance. If you use an Out-of-Network Provider, you will have to pay more out-of-
pocket costs.
In-Network Services
When you use an In-Network Provider or get care as part of an Authorized Service, Covered Services will
be covered at the In-Network level. Regardless of Medical Necessity, benefits will be denied for care that
is not a Covered Service. We have final authority to decide the Medical Necessity of the service.
In-Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for you. Referrals are never needed to visit an In-Network Specialist, including behavioral
health Providers.
To see a Doctor, call their office:
Tell them you are an Anthem Member,
Have your Member Identification Card handy. The Doctors office may ask you for your group or
Member ID number.
Tell them the reason for your visit.
When you go to the office, be sure to bring your Member Identification Card with you.
For services from In-Network Providers:
1. You will not need to file claims. In-Network Providers will file claims for Covered Services for you.
(You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be
billed by your In-Network Provider(s) for any non-Covered Services you get or when you have not
followed the terms of this Booklet.
2. Precertification will be done by the In-Network Provider. (See this section for further details.)
We do not guarantee that an In-Network Provider is available for all services and supplies covered under
your PPO plan. For some services and supplies We may not have arrangements with In-Network
Providers. For example, some Hospital-based labs are not part of our Reference Lab Network. Please
read the Member Payment Responsibility section for additional information on Authorized Services.
After Hours Care
If you need care after normal business hours, your Doctor may have several options for you. You should
call your Doctors office for instructions if you need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. If you have an Emergency, call 911 or go to the nearest
Emergency Room.

42
Out-of-Network Services
When you do not use an In-Network Provider or get care as part of an Authorized Service, Covered
Services are covered at the Out-of-Network level, unless otherwise indicated in this Booklet.
For services from an Out-of-Network Provider:
1. In addition to any Deductible and/or Coinsurance/Copayments, the Out-of-Network Provider can
charge you the difference between their bill and the Plans Maximum Allowed Amount;
2. You may have higher cost sharing amounts (i.e., Deductibles, Coinsurance, and/or Copayments);
3. You will have to pay for services that are not Medically Necessary;
4. You will have to pay for non-Covered Services;
5. You may have to file claims; and
6. You must make sure any necessary Precertification is done. (Please see this section for more
details.)
We will not deny or restrict Covered Services just because you get treatment from an Out-of-Network
Provider; however, you may have to pay more.
We pay the benefits of this Booklet directly to Out-of-Network Providers, if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of you.
We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services.
How to Find a Provider in the Network
There are three ways you can find out if a Provider or Facility is in the network for this Plan. You can also
find out where they are located and details about their license or training.
See your Plans directory of In-Network Providers at www.anthem.com, which lists the Doctors,
Providers, and Facilities that participate in this Plans network.
Call Customer Service to ask for a list of Doctors and Providers that participate in this Plans network,
based on specialty and geographic area.
Check with your Doctor or Provider.
If you need help choosing a Doctor who is right for you, call the Customer Service number on the back of
your Member Identification Card. TTY/TDD services also are available by dialing 711. A special operator
will get in touch with us to help with your needs.
{Narrow network:
[Please note that we have several networks, and that a Provider that is In-Network for one plan may not
be In-Network for another. Be sure to check your Identification Card or call Customer Service to find out
which network this Plan uses.]

{Tiered plan:
[Designated Participating Provider Program
Certain Providers are part of our Designated Participating Provider Program, a program aimed at
improving the quality of our Members health care. Providers in this program agree to coordinate much of
your care and will prepare care plans for Members who have multiple, complex health conditions.]

43
Continuity of Care
If you are getting ongoing care for a medical condition when you first enroll in this coverage, We may be
able to help ease the transition. Examples of ongoing care are prenatal/obstetrical care, Home Care or
Hospice Care. We try to avoid disruption of a new Members care through Our transition of care policy. If
interested, you or your Provider must review the reference sheet, complete a Transition of Care Form
and submit them to Us for review. You or your Provider can get these materials by calling Our Customer
Service.
Crediting Prior Plan Coverage
If you were covered by the Groups prior carrier / plan immediately before the Group signs up with us, with
no break in coverage, then you will get credit for any accrued Deductible and, if applicable and approved
by us, Out of Pocket amounts under that other plan. This does not apply to people who were not covered
by the prior carrier or plan on the day before the Groups coverage with us began, or to people who join
the Group later.
If your Group moves from one of our plans to another, (for example, changes its coverage from HMO to
PPO), and you were covered by the other product immediately before enrolling in this product with no
break in coverage, then you may get credit for any accrued Deductible and Out of Pocket amounts, if
applicable and approved by us. Any maximums, when applicable, will be carried over and charged
against the maximums under this Plan.
If your Group offers more than one of our products, and you change from one product to another with no
break in coverage, you will get credit for any accrued Deductible and, if applicable, Out of Pocket
amounts and any maximums will be carried over and charged against maximums under this Plan.
If your Group offers coverage through other products or carriers in addition to ours, and you change
products or carriers to enroll in this product with no break in coverage, you will get credit for any accrued
Deductible, Out of Pocket, and any maximums under this Plan.
This Section Does Not Apply To You If:
Your Group moves to this Plan at the beginning of a Benefit Period.
You change from one of our individual policies to a group plan;
You change employers; or
You are a new Member of the Group who joins the Group after the Group's initial enrollment with us.
The BlueCard Program
Like all Blue Cross & Blue Shield plans throughout the country, we participate in a program called
"BlueCard." This program lets you get Covered Services at the In-Network cost-share when you are
traveling out of state and need health care, as long as you use a BlueCard Provider. All you have to do is
show your Identification Card to a participating Blue Cross & Blue Shield Provider, and they will send your
claims to us.
If you are out of state and an Emergency or urgent situation arises, you should get care right away.
In a non-Emergency situation, you can find the nearest contracted Provider by visiting the BlueCard
Doctor and Hospital Finder website (www.BCBS.com) or call the number on the back of your Identification
Card.
You can also access Doctors and Hospitals outside of the U.S. The BlueCard program is recognized in
more than 200 countries throughout the world.

44
Care Outside the United States BlueCard

Worldwide
Before you travel outside the United States, check with your Group or call Customer Service at the
number on your Identification Card to find out if your plan has BlueCard Worldwide benefits. Your
coverage outside the United States may be different and we suggest:
Before you leave home, call the Customer Service number on your Identification Card for coverage
details.
Always carry your up to date Anthem Identification Card.
In an Emergency, go straight to the nearest Hospital.
The BlueCard Worldwide Service Center is on hand 24 hours a day, seven days a week toll-free at
(800) 810-BLUE (2583) or by calling collect at (804) 673-1177. An assistance coordinator, along with
a health care professional, will arrange a Doctor visit or Hospital stay, if needed.
Call the Service Center in these non-emergency situations:
You need to find a Doctor or Hospital or need health care. An assistance coordinator, along with a
medical professional, will arrange a Doctor visit or Hospital stay, if needed.
You need Inpatient care. After calling the Service Center, you must also call us to get approval for
benefits at the phone number on your Identification Card. Note: this number is different than the
phone numbers listed above for BlueCard Worldwide.
Payment Details
Participating BlueCard Worldwide Hospitals. In most cases, when you make arrangements for a
Hospital stay through BlueCard Worldwide, you should not need to pay upfront for Inpatient care at
participating BlueCard Worldwide hospitals except for the out-of-pocket costs (non-Covered Services,
Deductible, Copayments and Coinsurance) you normally pay. The Hospital should send in your claim
for you.
Doctors and/or non-participating Hospitals. You will need to pay upfront for outpatient services,
care received from a Doctor, and Inpatient care not arranged through the BlueCard Worldwide
Service Center. Then you can fill out a BlueCard Worldwide claim form and send it with the original
bill(s) to the BlueCard Worldwide Service Center (the address is on the form).
Claim Filing
The Hospital will file your claim if the BlueCard Worldwide Service Center arranged your Hospital
stay. You will need to pay the Hospital for the out-of-pocket costs you normally pay.
You must file the claim for outpatient and Doctor care, or Inpatient care not arranged through the
BlueCard Worldwide Service Center. You will need to pay the Provider and subsequently send an
international claim form with the original bills to us.
Claim Forms
You can get international claim forms from us, the BlueCard Worldwide Service Center, or online at
www.bcbs.com/bluecardworldwide. The address for sending in claims is on the form.
Identification Card
We will give an Identification Card to each Member enrolled in the Plan. When you get care, you must
show your Identification Card. Only a Member who has paid the Premiums for this Plan has the right to
services or benefits under this Booklet. If anyone gets services or benefits to which they are not entitled to
under the terms of this Booklet, he/she must pay for the actual cost of the services.

45
Obtain Approval of Benefits
Your Plan includes the processes of Precertification, Predetermination and Post Service Clinical Claims
Review to decide when services should be covered by your Plan. Their purpose is to aid the delivery of
cost-effective health care by reviewing the use of treatments and, when proper, the setting or place of
service that they are performed. Covered Services must be Medically Necessary for benefits to be
covered. When setting or place of service is part of the review, services that can be safely given to you in
a lower cost setting will not be Medically Necessary if they are given in a higher cost setting.
Prior Authorization: In-Network Providers must obtain prior authorization in order for you to get benefits
for certain services. Prior authorization criteria will be based on many sources including medical policy,
clinical guidelines, and pharmacy and therapeutics guidelines. Anthem may decide that a service that was
first prescribed or asked for is not Medically Necessary if you have not tried other treatments which are
more cost effective.
If you have any questions about the information in this section, you may call the Customer Service phone
number on the back of your Identification Card.
Types of Requests
Precertification A required review of a service, treatment or admission for a benefit coverage
determination which must be done before the service, treatment or admission start date. For
Emergency admissions, you, your authorized representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a reasonable period of time. For labor / childbirth
admissions, Precertification is not needed unless there is a problem and/or the mother and baby are
not sent home at the same time.
Predetermination An optional, voluntary Prospective or Continued Stay Review request for a
benefit coverage determination for a service or treatment. We will check your Booklet to find out if
there is an Exclusion for the service or treatment. If there is a related clinical coverage guideline, the
benefit coverage review will include a review to decide whether the service meets the definition of
Medical Necessity under this Booklet or is Experimental / Investigational as that term is defined in this
Booklet.
Post Service Clinical Claims Review A Retrospective review for a benefit coverage determination
to decide the Medical Necessity or Experimental / Investigational nature of a service, treatment or
admission that did not need Precertification and did not have a Predetermination review performed.
Medical reviews are done for a service, treatment or admission in which we have a related clinical
coverage guideline and are typically initiated by us.
Typically, In-Network Providers know which services need Precertification and will get any Precertification
or ask for a Predetermination when needed. Your Primary Care Physician / Provider and other In-
Network Providers have been given detailed information about these procedures and are responsible for
meeting these requirements. Generally, the ordering Provider, Facility or attending Doctor will get in touch
with us to ask for a Precertification or Predetermination review (requesting Provider). We will work with
the requesting Provider for the Precertification request. However, you may choose an authorized
representative to act on your behalf for a specific request. The authorized representative can be anyone
who is 18 years of age or older.

46
Who is responsible for Precertification
Services given by an In-
Network Provider
Services given by a BlueCard/Out-of-Network/Non-
Participating Provider
Provider
Member must get Precertification.
If Member fails to get Precertification, Member may be
financially responsible for service and/or setting in
whole or in part.
For Emergency admissions, you, your authorized
representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a
reasonable period of time.

We use our clinical coverage guidelines, such as medical policy, clinical guidelines, preventative care
clinical coverage guidelines and other applicable policies and procedures to help make our Medical
Necessity decisions, including decisions about Prescription and Specialty Drug services. Medical policies
and clinical guidelines reflect the standards of practice and medical interventions identified as proper
medical practice. We reserve the right to review and update these clinical coverage guidelines from time
to time. Your Booklet and Group Contract take precedence over these guidelines.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning your
request. To ask for this information, call the Precertification phone number on the back of your
Identification Card.
Anthem may, from time to time, waive, enhance, change or end certain medical management processes
(including utilization management, case management, and disease management) if in our discretion,
such change furthers the provision of cost effective, value based and/or quality services.
We may also select certain qualifying Providers to take part in a program that exempts them from certain
procedural or medical management processes that would otherwise apply. We may also exempt your
claim from medical review if certain conditions apply.
Just because Anthem exempts a process, Provider or Claim from the standards which otherwise would
apply, it does not mean that Anthem will do so in the future, or will do so in the future for any other
Provider, claim or Member. Anthem may stop or change any such exemption with or without advance
notice.
You may find out whether a Provider is taking part in certain programs by checking your on-line Provider
Directory or contacting the Customer Service number on the back of your ID card.

We also may identify certain Providers to review for potential fraud, waste, abuse or other inappropriate
activity if the claims data suggests there may be inappropriate billing practices. If a Provider is selected
under this program, then we may use one or more clinical utilization management guidelines in the review
of claims submitted by this Provider, even if those guidelines are not used for all Providers delivering
services to this Plans Members.
Request Categories
Expedited A request for Precertification or Predetermination that, in the view of the treating
Provider or any Doctor with knowledge of your medical condition, could; without such care or
treatment, seriously threaten your life or health or your ability to regain maximum function; or subject
you to severe pain that cannot be adequately managed without such care or treatment; or if you have

47
a physical or mental disability, create an imminent and substantial limitation on your existing ability to
live independently.
Prospective A request for Precertification or Predetermination that is conducted before the service,
treatment or admission.
Continued Stay Review - A request for Precertification or Predetermination that is conducted during
the course of outpatient treatment or during an Inpatient admission.
Retrospective - A request for Precertification that is conducted after the service, treatment or
admission has happened. Post Service Clinical Claims Reviews are also retrospective.
Retrospective review does not include a review that is limited to an evaluation of reimbursement
levels, veracity of documentation, accuracy of coding or adjudication of payment.
Decision and Notice Requirements
We will review requests for benefits according to the timeframes listed below. The timeframes and
requirements listed are based on state and federal laws. Where state laws are stricter than federal laws,
we will follow state laws. If you live in and/or get services in a state other than the state where your
Contract was issued other state-specific requirements may apply. You may call the phone number on the
back of your Identification Card for more details.
Request Category Timeframe Requirement for Decision and
Notification
Prospective Expedited 72 hours from the receipt of request
Prospective Non-Expedited 15 calendar days from the receipt of the request
Continued Stay Review when hospitalized
at the time of the request
72 hours from the receipt of the request and prior to
expiration of current certification.
Continued Stay Review Expedited when
request is received more than 24 hours
before the end of the previous authorization
24 hours from the receipt of the request
Continued Stay Review Expedited when
request is received less than 24 hours
before the end of the previous authorization
or no previous authorization exists
72 hours from the receipt of the request
Continued Stay Review Non-Expedited 15 calendar days from the receipt of the request
Retrospective 30 calendar days from the receipt of the request
If more information is needed to make our decision, we will tell the requesting Provider and send written
notice to you or your authorized representative of the specific information needed to finish the review. If
we do not get the specific information we need or if the information is not complete by the timeframe
identified in the written notice, we will make a decision based upon the information we have.
We will give notice of our decision as required by state and federal law. Notice may be given by the
following methods:
Verbal: Oral notice given to the requesting Provider by phone or by electronic means if agreed to by
the Provider.
Written: Mailed letter or electronic means including email and fax given to, at a minimum, the
requesting Provider and you or your authorized representative
For benefits to be covered, Precertification will consider the following:
1. You must be eligible for benefits;

48
2. Premium must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under your Plan;
4. The service cannot be subject to an Exclusion under your Plan;
5. You must not have exceeded any applicable limits under your Plan; and
6. You did not perform an act, practice, or omission that constitutes fraud or abuse when requesting the
Precertification.
Health Plan Individual Case Management
Our health plan case management programs (Case Management) help coordinate services for Members
with health care needs due to serious, complex, and/or chronic health conditions. Our programs
coordinate benefits and educate Members who agree to take part in the Case Management program to
help meet their health-related needs.
Our Case Management programs are confidential and voluntary and are made available at no extra cost
to you. These programs are provided by, or on behalf of and at the request of, your health plan case
management staff. These Case Management programs are separate from any Covered Services you are
receiving.
If you meet program criteria and agree to take part, we will help you meet your identified health care
needs. This is reached through contact and team work with you and/or your chosen authorized
representative, treating Doctor(s), and other Providers.
In addition, we may assist in coordinating care with existing community-based programs and services to
meet your needs. This may include giving you information about external agencies and community-
based programs and services.
In certain cases of severe or chronic illness or injury, we may provide benefits for alternate care that is not
listed as a Covered Service through our Case Management program. We may also extend Covered
Services beyond the Benefit Maximums of this Plan. We will make our decision case-by-case, if in our
discretion the alternate or extended benefit is in the best interest of the Member and Anthem. A decision
to provide extended benefits or approve alternate care in one case does not obligate us to provide the
same benefits again to you or to any other Member. We reserve the right, at any time, to alter or stop
providing extended benefits or approving alternate care. In such case, we will notify you or your
authorized representative in writing.


49
Section 7. Benefits/Coverage (What is Covered)
This section describes the Covered Services available under your Plan. Covered Services are subject to
all the terms and conditions listed in this Booklet, including, but not limited to, Benefit Maximums,
Deductibles, Copayments, Coinsurance, Exclusions and Medical Necessity requirements. Please read
the Schedule of Benefits (Who Pays What)" for details on the amounts you must pay for Covered
Services and for details on any Benefit Maximums. Also be sure to read "How to Access Your Services
and Obtain Approval of Benefits (Applicable to managed care plans)" for more information on your Plans
rules. Read the Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for
important details on Excluded Services.
Your benefits are described below. Benefits are listed alphabetically to make them easy to find. Please
note that several sections may apply to your claims. For example, if you have inpatient surgery, benefits
for your Hospital stay will be described under Inpatient Hospital Care "and benefits for your Doctors
services will be described under Inpatient Professional Services. As a result, you should read all
sections that might apply to your claims.
You should also know that many of Covered Services can be received in several settings, including a
Doctors office, an Urgent Care Facility, an Outpatient Facility, or an Inpatient Facility. Benefits will often
vary depending on where you choose to get Covered Services, and this can result in a change in the
amount you need to pay. Please see the Schedule of Benefits (Who Pays What) for more details on
how benefits vary in each setting.
Acupuncture/Nerve Pathway Therapy
Please see Therapy Service later in this section.
Allergy Services
Your Plan includes benefits for Medically Necessary allergy testing and treatment, including allergy serum
and allergy shots.
Ambulance Services
Medically Necessary ambulance services are a Covered Service when one or more of the following
criteria are met:
You are transported by a state licensed vehicle that is designed, equipped, and used only to transport
the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other
certified medical professionals. This includes ground, water, fixed wing, and rotary wing air
transportation.
For ground ambulance, you are taken:
- From your home, the scene of an accident or medical Emergency to a Hospital;
- Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an In-Network Hospital
- Between a Hospital and a Skilled Nursing Facility or other approved Facility.
For air or water ambulance, you are taken:
- From the scene of an accident or medical Emergency to a Hospital;
- Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an In-Network Hospital
- Between a Hospital and an approved Facility.

50
Emergency ambulance services do not require prior authorization and are allowed regardless of whether
the Provider is an In-Network or Out-of-Network Provider. However non-Emergency ambulance services
are subject to Medical Necessity reviews by us. When using an air ambulance for non-Emergency
services, we reserve the right to select the air ambulance Provider. For non-Emergency ambulance
services if you do not use the air ambulance Provider we select, the Out-of-Network Provider may bill you
for any charges that exceed the Plans Maximum Allowed Amount.
You must be taken to the nearest Facility that can give care for your condition. In certain cases we may
approve benefits for transportation to a Facility that is not the nearest Facility.
Benefits also include Medically Necessary treatment of a sickness or injury by medical professionals from
an ambulance service, even if you are not taken to a Facility.
Ambulance services are not covered when another type of transportation can be used without
endangering your health. Ambulance services for your convenience or the convenience of your family or
Doctor are not a Covered Service.
Other non-covered ambulance services, include but are not limited to, trips to:
A Doctors office or clinic;
A morgue or funeral home.
Important Notes on Air Ambulance Benefits
Benefits are only available for air ambulance when it is not appropriate to use a ground or water
ambulance. For example, if using a ground ambulance would endanger your health and your medical
condition requires a more rapid transport to a Facility than the ground ambulance can provide, the Plan
will cover the air ambulance. Air ambulance will also be covered if you are in an area that a ground or
water ambulance cannot reach.
Air ambulance will not be covered if you are taken to a Hospital that is not an acute care Hospital (such
as a Skilled Nursing Facility), or if you are taken to a Physicians office or your home.
Hospital to Hospital Transport
If you are moving from one Hospital to another, air ambulance will only be covered if using a ground
ambulance would endanger your health and if the Hospital that first treats cannot give you the medical
services you need. Certain specialized services are not available at all Hospitals. For example, burn
care, cardiac care, trauma care, and critical care are only available at certain Hospitals. To be covered,
you must be taken to the closest Hospital that can treat you. Coverage is not available for air
ambulance transfers simply because you, your family, or your Provider prefers a specific Hospital
or Physician.
Autism Services
Covered Services are provided for the assessment, diagnosis, and treatment of Autism Spectrum
Disorders (ASD) for a covered child. The following treatments will not be considered Experimental or
Investigational and will be considered appropriate, effective, or efficient for the treatment of Autism
Spectrum Disorders where We determine such services are Medically Necessary:
Evaluation and assessment services;
Behavior training and behavior management and Applied Behavior Analysis, including but not limited
to consultations, direct care, supervision, or treatment, or any combination thereof, for Autism
Spectrum Disorders provided by Autism Services Providers;

51
Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy,
or speech therapy, or any combination of those therapies;
Prescription Drugs;
Psychiatric care;
Psychological care, including family counseling; and
Therapeutic care.
Treatment for Autism Spectrum Disorders must be prescribed or ordered by a Doctor or psychologist, and
services must be provided by a Provider covered under this Plan and approved to provide those services.
However, behavior training, behavior management, or Applied Behavior Analysis services (whether
provided directly or as part of Therapeutic Care), must be provided by an Autism Services Provider.
Coverage of Autism Spectrum Disorders in this section is in addition to coverage provided for early
intervention and Congenital Defects and Birth Abnormality. Autism services and the Autism Treatment
Plan are subject to review under the How to Access Your Services and Obtain Approval of Benefits
(Applicable to managed care plans) section.
Behavioral Health Services
See Mental Health, Alcohol and Substance Abuse Services later in this section.
Cardiac Rehabilitation
Please see Therapy Services later in this section.
Chemotherapy
Please see Therapy Services later in this section.

Clinical Trials
Benefits include coverage for services given to you as a participant in an approved clinical trial if the
services are Covered Services under this Plan. An approved clinical trial means a phase I, phase II,
phase III, or phase IV clinical trial that studies the prevention, detection, or treatment of cancer or other
life-threatening conditions. The term life-threatening condition means any disease or condition from which
death is likely unless the disease or condition is treated.
Benefits are limited to the following trials:
1. Federally funded trials approved or funded by one of the following:
a. The National Institutes of Health.
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.
e. Cooperative group or center of any of the entities described in (a) through (d) or the Department
of Defense or the Department of Veterans Affairs.

52
f. A qualified non-governmental research entity identified in the guidelines issued by the National
Institutes of Health for center support grants.
g. Any of the following in i-iii below if the study or investigation has been reviewed and approved
through a system of peer review that the Secretary determines 1) to be comparable to the system
of peer review of studies and investigations used by the National Institutes of Health, and 2)
assures unbiased review of the highest scientific standards by qualified individuals who have no
interest in the outcome of the review.
i. The Department of Veterans Affairs.
ii. The Department of Defense.
iii. The Department of Energy.
2. Studies or investigations done as part of an investigational new drug application reviewed by the
Food and Drug Administration;
3. Studies or investigations done for drug trials which are exempt from the investigational new drug
application.
Your Plan may require you to use an In-Network Provider to maximize your benefits.
When a requested service is part of an approved clinical trial, it is a Covered Service even though it might
otherwise be Investigational as defined by this Plan. All other requests for clinical trials services that are
not part of approved clinical trials will be reviewed according to our Clinical Coverage Guidelines, related
policies and procedures.
Your Plan is not required to provide benefits for the following services. We reserve our right to exclude
any of the following services:
i. The Investigational item, device, or service, itself; or
ii. Items and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
Dental Services
Your Dental Benefits
Anthem does not determine whether dental services listed in this section are medically necessary to treat
your specific condition or restore your dentition. There is a preset schedule of dental services that are
covered under this Plan. We evaluate the procedures submitted to us on your claim to determine if they
are a covered service under this Plan.

Exception: Claims for orthodontic care will be reviewed to determine if it was Dentally Necessary
Orthodontic Care. See the section Orthodontic Care for more information.
Your dentist may recommend or prescribe other dental care services that are not covered, are cosmetic in
nature, or exceed the benefit frequencies of this Plan. While these services may be necessary for your
dental condition, they may not be covered by us. There may be an alternative dental care service
available to you that is covered under your Plan. These alternative services are called optional
treatments. If an allowance for an optional treatment is available, you may apply this allowance to the
initial dental service prescribed by your dentist. You are responsible for any costs that exceed the
allowance, in addition to any coinsurance or deductible you may have.

53
The decision as to what dental care treatment is best for you is solely between you and your dentist.
Pretreatment Estimate
A pretreatment estimate is a valuable tool for you and your dentist. It provides you and the dentist with an
idea of what your out of pocket costs will be for the dental care treatment. This will allow the dentist and
you to make any necessary financial arrangements before treatment begins. It is a good idea to get a
pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or
orthodontic care
The pretreatment estimate is recommended, but not required for you to receive benefits for covered
dental care services.
A pretreatment estimate does not authorize treatment or determine its medical necessity (except for
orthodontics), and does not guarantee benefits. The estimate will be based on your current eligibility and
the Plan benefits in effect at the time the estimate is submitted to us. This is an estimate only. Our final
payment will be based on the claim that is submitted at the time of the completed dental care service(s).
Submission in other claims, changes to your eligibility or changes to the Plan may affect our final
payment.
You can ask your dentist to submit a pretreatment estimate for you, or you can send it to us yourself.
Please include the procedure codes for the services to be performed (your dentist can tell you what
procedure codes). Pretreatment estimate requests can be sent to the address on your dental ID card.
{Pediatric dental:
[Pediatric Dental for Members through Age 18

This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.

Diagnostic and Preventive Services

Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive

Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s)
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.

Dental Cleaning (Prophylaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.

Fluoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.


54
Sealants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.

Space Maintainers and Recementation of Space Maintainer - Covered only for premature loss of
primary posterior (back) teeth.

Emergency (Palliative) Treatment (for pain relief).

Basic Restorative Services

Amalgam (silver) Restoration Treatment to restore decayed or fractured permanent or primary
posterior (back) teeth. Covered once in a 24 month period per tooth surface.

Composite (white) Resin Restorations Covered once in a 24 month period for the same amalgam
restoration.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.

Major Restorative Services

Recement Crown.

Prefabricated Stainless Steel or Resin Crown - Covered once per tooth in a 24 month period.

Sedative Filling.

Pin Retention per tooth in addition to restoration.

Oral Surgery

Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

Complex Surgical Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth

Note: Surgical removal of 3rd molars are covered only if the removal is associated with symptoms of oral
pathology.

Endodontic Services

Therapeutic Pulpotomy - Covered for primary teeth only.

Root Canal Therapy - Covered for permanent teeth only .


55
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

Dentally Necessary Orthodontic Care
To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:
a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth when
you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores at a
level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem that
interferes with the biting function.

Orthodontic treatment may include the following:
Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
Interceptive Treatment - A limited (phase I) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments
Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive ongoing
payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate of
Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued. A
new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve as
the claim form to be submitted 6 months from the date of appliance placement.]


56
{Pediatric/Adult dental:
[Dental Services
Dental Services for Members through Age 18
This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.
Diagnostic and Preventive Services
Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive
Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s) 4 single x-rays per 12-month period.
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.
Dental Cleaning (Prophylaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.
Fluoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.
Sealants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.
Space Maintainers and Recementation of Space Maintainer. Covered only for premature loss of
primary posterior (back) teeth.
Emergency (Palliative) Treatment (for pain relief).
Basic Restorative Services
Amalgam (silver) Restoration Treatment to restore decayed or fractured permanent or primary teeth
posterior (back) teeth. Covered once in a 24 month period per tooth surface.
Composite (white) Resin Restorations Covered once in a 24 month period per tooth surface.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be

57
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.
Major Restorative Services
Recement Crown.
Prefabricated Stainless Steel or Resin Crown. Covered once per tooth in a 24 month period.
Sedative Filling.
Pin Retention per tooth in addition to restoration.
Oral Surgery
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

Complex Surgical Extractions

Surgical removal of impacted tooth

Note: Surgical removal of 3
rd
molars are covered only if the removal is associated with symptoms
of oral pathology.

Endodontic Services

Therapeutic Pulpotomy. Covered only for primary teeth.

Root Canal Therapy. Covered for permanent teeth only.
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

Dentally Necessary Orthodontic Care

To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:

a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth
when you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores
at a level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem
that interferes with the biting function.


58
Orthodontic treatment may include the following:

Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
Interceptive Treatment - A limited (phase I) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments

Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive
ongoing payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate
of Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued.
A new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve
as the claim form to be submitted 6 months from the date of appliance placement.]
Dental Services for Members Age 19 and Older
This Plan covers the dental services below for Members age 19 and older when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. If there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive treatment.
Diagnostic and Preventive Services
Oral Evaluations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Radiographs (X-rays)
Bitewings - 1 series per 24-month period.
Full Mouth (Complete Series) or Panoramic - Once per 60-month period.
Periapical(s) - 4 single x-rays per 12-month period.
Occlusal - 2 series per 24-month period.

59
Dental Cleaning (Prophylaxis) Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain
from teeth. Any combination of this procedure and periodontal maintenance (See Periodontal Services
below) are covered 2 times per calendar year.
Basic Restorative Services
Emergency Treatment Emergency (palliative) treatment for the temporary relief of pain or infection.
Amalgam (silver) Restorations Treatment to restore decayed or fractured permanent or primary teeth.
Composite (white) Resin Restorations
Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anterior
(front) teeth.
Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posterior
(back) teeth.
Benefits will be limited to the same surfaces and allowances for amalgam (silver filling). You must pay
the difference in cost between the Maximum Allowed Amount for the Covered Service and the optional
treatment plus any Deductible and/or Coinsurance.
Benefits for amalgam or composite restorations will be limited to one service per tooth surface per 24-
month period.
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root
Brush Biopsy - Covered once per 36-month period for Members age 20 to 39. Covered once per 12-
month period for Members age 40 and older.
Endodontic Services
Endodontic Therapy on Primary Teeth
Pulpal Therapy
Therapeutic Pulpotomy
Endodontic Therapy on Permanent Teeth
Root Canal Therapy
Root Canal Retreatment
All of the above endodontic services are limited to once per tooth per lifetime.
Periodontal Services
Periodontal Maintenance A procedure that includes removal of bacteria from the gum pocket areas,
scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patients who
have completed periodontal treatment.

60
Benefits for any combination of this procedure and dental cleanings (see Diagnostic and Preventive
Services section) are limited to 2 times per calendar year.
Basic Non-Surgical Periodontal Care Treatment of diseases of the gingival (gums) and bone
supporting the teeth.
Periodontal scaling & root planning is covered once per 36 months if the tooth has a pocket depth of
4 millimeters or greater.
Full mouth debridement is covered once per lifetime.
Complex Surgical Periodontal Care Surgical treatment of diseases of the gingival (gums) and bone
supporting the teeth. The following services are considered complex surgical periodontal services:
Gingivectomy/gingivoplasty;
Gingival flap;
Apically positioned flap;
Osseous surgery;
Bone replacement graft;
Pedicle soft tissue graft;
Free soft tissue graft;
Subepithelial connective tissue graft;
Soft tissue allograft;
Combined connective tissue and double pedicle graft;
Distal/proximal wedge - Covered on natural teeth only
Complex surgical periodontal services are limited as follows:
Only one complex surgical periodontal service is covered per 36-month period per single tooth; or
Only one complex surgical periodontal service is covered per 36-month period for multiple teeth in the
same quadrant if the pocket depth of the tooth is 5 millimeters or greater.
Oral Surgery Services
Complex Surgical Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth
Surgical removal of residual tooth roots
Surgical removals of third molars are only covered if the removal is associated with symptoms of oral
pathology.
Other Complex Surgical Procedures Covered only when required to prepare for dentures and limited to
once in a 60-month period:
Alveoloplasty
Vestibuloplasty
Removal of exostosis-per site
Surgical reduction of osseous tuberosity
Surgical Reduction of Fibrous Tuberosity Covered once every 6 months.

61
Adjunctive General Services
Intravenous Conscious Sedation, IV Sedation, and General Anesthesia Covered only when given
with covered complex surgical services. Benefits are not available when given with non-surgical
dental care.
Major Restorative Services
Gold foil restorations The Plan will cover an amalgam (silver filling) benefit equal to the same number of
surfaces and allowances.
You must pay the difference in cost between the Maximum Allowed Amount for the Covered Services and
optional treatment plus any Deductible and/or Coinsurance that applies. Covered once per 24-month
period.
Inlays Benefit will equal an amalgam (silver) restoration for the same number of surfaces.
If an inlay is performed to restore a posterior (back) tooth with a metal, porcelain, or any composite
(white) based resin material, the patient must pay the difference in cost between the Maximum Allowed
Amount for the Covered Service and inlay, plus any Deductible and/or Coinsurance that applies.
Onlays and/or Permanent Crowns Covered once every 7 years if the tooth has extensive loss of natural
tooth structure due to decay or tooth fracture such that a restoration cannot be used to restore the tooth.
We will pay up to the Maximum Allowed Amount for a porcelain to noble metal crown. You must pay the
difference in cost between the porcelain to noble metal crown and the optional treatment, plus any
Deductible and/or Coinsurance that applies.
Implant Crowns See Prosthodontic Services.
Recement Inlay, Onlay, and Crowns Covered 6 months after initial placement.
Crown/Inlay/Onlay Repair Covered once per 12-month period per tooth when the submitted narrative
from the treating dentist supports the procedure.
Restorative cast post and core build-up, including 1 post per tooth and 1 pin per surface Covered
once every 7 years when necessary to retain an indirectly fabricated restoration due to extensive loss of
actual tooth structure due to caries or fracture.
Prosthodontic Services
Tissue Conditioning Covered once per 24-month period.
Reline and Rebase Covered once per 24-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge).
Repairs, Replacement of Broken Artificial Teeth, Replacement of Broken Clasp(s) Covered once per
6-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance;

62
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge); and
When the submitted narrative from the treating dentist supports the procedure.
Denture Adjustments Covered 2 times per 12-month period when:
The denture is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the denture.
Partial and Bridge Adjustments Covered 2 times per 24-month period when:
The partial or bridge is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the partial or bridge.
Removable Prosthetic Services (Dentures and Partials) Covered once per 7 year period:
For the replacement of extracted (removed) permanent teeth;
If 7 years have passed since the last covered removable prosthetic appliance (denture or partial) and
the existing denture or partial cannot be repaired or adjusted.
Fixed Prosthetic Services (Bridge) Covered once every 7 years:
For the replacement of extracted (removed) permanent teeth;
If no more than 3 teeth are missing in the same arch;
A natural, healthy, sound tooth is present to serve as the anterior and posterior retainer;
No other missing teeth in the same arch that have not been replaced with a removable partial
denture;
If none of the individual units of the bridge has been covered previously as a crown or cast restoration
in the last 7 years;
If 7 years have passed since the last covered removable prosthetic appliance (bridge) and the
existing bridge cannot be repaired or adjusted.
If there are multiple missing teeth, benefits may only be paid for a removable partial denture if it would be
the least costly, commonly performed course of treatment. Any optional benefits are subject to all
contract limits on the Covered Service.
Recement Fixed Prosthetic Covered once per 12 months.
Single Tooth Implant Body, Abutment and Crown Covered once per 7 year period. Coverage includes
only the single surgical placement of the implant body, implant abutment and implant/abutment supported
crown.
Some adjunctive implant services may not be covered. We recommend that you get a
pretreatment estimate to estimate the amount of payment before you begin treatment.

Orthodontic Services
Orthodontic services for members age 19 and older is not covered, except as provided under the Dental
Services (All Members / All Ages) section below.]

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Dental Services (All Members / All Ages)
Preparing the Mouth for Medical Treatments
Your Plan includes coverage for dental services to prepare the mouth for medical services and treatments
such as radiation therapy to treat cancer and prepare for transplants. Covered Services include:
Evaluation
Dental x-rays
Extractions, including surgical extractions
Anesthesia
Accident-Related Dental Services
Benefits are also available for dental work needed to treat injuries to the jaw, sound natural teeth, mouth
or face as a result of an accident. An injury that results from chewing or biting is not considered an
Accidental Injury under this Plan, unless the chewing or biting results from a medical or mental condition.
Treatment must begin within 90 days of the injury to be a Covered Service under this Plan.
Cleft Palate and Cleft Lip Conditions
Benefits are available for inpatient care and outpatient care, including:
Orofacial surgery
Surgical care and follow-up care by plastic surgeons and oral surgeons
Orthodontics and prosthodontic treatment
Prosthetic treatment such as obturators, speech appliances, and prosthodontic
Prosthodontic and surgical reconstruction for the treatment of cleft palate and/or cleft lip
If you have a dental plan, the dental plan would be the main plan and must fully cover orthodontics and
dental care for cleft palate and cleft lip conditions.
Dental Anesthesia for Children
Benefits are available for general anesthesia from a Hospital, outpatient surgical Facility or other Facility,
and for the Hospital or Facility charges needed for dental care for a covered Dependent child who:
Has a physical, mental or medically compromising condition
Has dental needs for which local anesthesia is not effective because of acute infection, anatomic
variation or allergy
Is extremely uncooperative, unmanageable, uncommunicative or anxious and whose dental needs
are deemed sufficiently important that dental care cannot be deferred
Has sustained extensive orofacial and dental trauma.
Diabetes Equipment, Education, and Supplies
Your Plan covers diabetes training and medical nutrition therapy if you have diabetes (whether or not it is
insulin dependent), or if you have raised blood glucose levels caused by pregnancy. Other medical
conditions may also qualify. But the services need to be ordered by a Doctor and given by a Provider
who is certified, registered or with training in diabetes. Diabetes training sessions must be provided by a
Provider in an outpatient Facility or in a Doctors office.

64
Screenings for gestational diabetes are covered under Preventive Care later in this section.
Diagnostic Services
Your Plan includes benefits for tests or procedures to find or check a condition when specific symptoms
exist. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or
Hospital admission. Benefits include the following services:
Diagnostic Laboratory and Pathology Services
Diagnostic Imaging Services and Electronic Diagnostic Tests
X-rays / regular imaging services
Ultrasound
Electrocardiograms (EKG)
Electroencephalography (EEG)
Echocardiograms
Hearing and vision tests for a medical condition or injury (not for screenings or preventive care)
Tests ordered before a surgery or admission.
Advanced Imaging Services
Benefits are also available for advanced imaging services, which include but are not limited to:
CT scan
CTA scan
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Angiography (MRA)
Magnetic resonance spectroscopy (MRS)
Nuclear Cardiology
PET scans
PET/CT Fusion scans
QTC Bone Densitometry
Diagnostic CT Colonography
The list of advanced imaging services may change as medical technologies change.
Dialysis
See Therapy Services later in this section.
Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies
Durable Medical Equipment and Medical Devices
Your Plan includes benefits for durable medical equipment and medical devices when the equipment
meets the following criteria:
Is meant for repeated use and is not disposable.
Is used for a medical purpose and is of no further use when medical need ends.
Is meant for use outside a medical Facility.

65
Is only for the use of the patient.
Is made to serve a medical use.
Is ordered by a Provider.
Benefits include purchase-only equipment and devices (e.g., crutches and customized equipment),
purchase or rent-to-purchase equipment and devices (e.g., Hospital beds and wheelchairs), and
continuous rental equipment and devices (e.g., oxygen concentrator, ventilator, and negative pressure
wound therapy devices). Continuous rental equipment must be approved by us. We may limit the
amount of coverage for ongoing rental of equipment. We may not cover more in rental costs than the cost
of simply purchasing the equipment.
Benefits include repair and replacement costs as well as supplies and equipment needed for the use of
the equipment or device, for example, a battery for a powered wheelchair.
Oxygen and equipment for its administration are also Covered Services. Benefits are also available for
cochlear implants.
Hearing Aid Services
For children under 18, subject to the terms of the Booklet, your Plan covers the following hearing aids and
the services that go with them when provided by or purchased as a result of a written recommendation
from an otolaryngologist or a state-certified audiologist:
Audiological testing to measure the level of hearing loss and to choose the proper make and model of
a hearing aid. These evaluations will be provided under the prior Diagnostic Services of this
section;
Hearing aids (monaural or binaural) including ear mold(s), the hearing aid instrument, batteries, cords
and other ancillary equipment. The Plan covers auditory training when it is offered using approved
professional standards. Initial and replacement hearing aids will be supplied every 5 years, a new
hearing aid may be a covered service when alterations to your existing hearing aid cannot adequately
meet your needs or be repaired; and
Visits for fitting, counseling, adjustments and repairs after receiving the covered hearing aid.
Orthotics
Benefits are available for certain types of orthotics (braces, boots, splints). Covered Services include the
initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support,
align, prevent, or correct deformities or to improve the function of movable parts of the body, or which
limits or stops motion of a weak or diseased body part.
Prosthetics
Your Plan also includes benefits for prosthetics, which are artificial substitutes for body parts for functional
or therapeutic purposes, when they are required to adequately meet your needs.
Benefits include the purchase, fitting, adjustments, repairs and replacements. Covered Services may
include, but are not limited to:
1) Artificial limbs and accessories. For prosthetic arms and legs we cover up to the benefits amounts
provide by federal laws for Medicare or where needed to meet state insurance laws;
2) One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes);
3) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Womens
Health and Cancer Rights Act;

66
4) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to
ostomy care;
5) Restoration prosthesis (composite facial prosthesis);
Medical and Surgical Supplies
Your Plan includes coverage for medical and surgical supplies that serve only a medical purpose, are
used once, and are purchased (not rented). Covered supplies include syringes, needles, surgical
dressings, splints, diabetic supplies, and other similar items that serve only a medical purpose. Covered
Services do not include items often stocked in the home for general use like Band-Aids, thermometers,
and petroleum jelly.
Blood and Blood Products
Your Plan also includes coverage for the administration of blood products unless they are received from a
community source, such as blood donated through a blood bank.
Emergency Care Services
Emergency Services
Benefits are available in a Hospital Emergency Room for services and supplies to treat the onset of
symptoms, screen and stabilize an Emergency, which is defined below:
Emergency (Emergency Medical Condition)
Emergency or Emergency Medical Condition means health care services provided in connection with
any event that a prudent layperson having average knowledge of health services and medicine and acting
reasonably would believe threatens his or her life or limb in such a manner that a need for immediate
medical care is created to prevent death or serious impairment of health.
Emergency Care
Emergency Care means a medical exam done in the Emergency Department of a Hospital, and
includes services routinely available in the Emergency Department to evaluate an Emergency Condition.
It includes any further medical exams and treatment required to stabilize the patient.
If you are experiencing an Emergency please call 911 or visit the nearest Hospital for treatment.
Medically Necessary services will be covered whether you get care from an In-Network or Out-of-Network
Provider. Emergency Care you get from an Out-of-Network Provider will be covered as an In-Network
service, you will not need to pay more than what you would have if you had seen an In-Network Provider.
If you are admitted to the Hospital from the Emergency Room, be sure that you or your Doctor calls us as
soon as possible. We will review your care to decide if a Hospital stay is needed and how many days you
should stay. See How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) for more details. If you or your Doctor do not call us, you may have to pay for services that
are determined to be not Medically Necessary.
With respect to an Emergency, stabilize means to provide such medical treatment of the condition as may
be necessary to assure, within reasonable medical probability, that no material deterioration of the
condition is likely to result from or occur during the transfer of the Member from a facility. With respect to
a pregnant woman who is having contractions, the term stabilize also means to deliver (including the

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placenta), if there is inadequate time to effect a safe transfer to another Hospital before delivery or
transfer may pose a threat to the health or safety of the woman or the unborn child. Treatment you get
after your condition has stabilized is not Emergency Care. If you continue to get care from an Out-of-
Network Provider, Covered Services will be covered at the Out-of-Network level unless we agree to cover
it as an Authorized Service.
Home Care Services
Benefits are available for Covered Services performed by a Home Health Care Agency or other Provider
in your home. Home care benefits are an alternative to a Hospital stay, and you must be physically
unable to get needed medical services on an outpatient basis. Services must be prescribed by a Doctor
and the services must be so inherently complex that they can be safely and effectively performed only by
qualified, technical, or professional health staff. Home care is covered only when such care is
necessary as an alternative to Hospital stay. Prior Hospital stay is not required. Home care must
be prescribed by a Doctor, under a plan of care established by the Doctor in collaboration with a
Home Health Care Agency. We must preauthorize all care and reserve the right to review
treatment plans at periodic intervals.
Covered Services include but are not limited to:
Intermittent skilled nursing services by an R.N. or L.P.N.
Medical / social services
Diagnostic services
Nutritional guidance
Training of the patient and/or family/caregiver
Home health aide services. You must be receiving skilled nursing or therapy. Services must be given
by appropriately trained staff working for the Home Health Care Provider. Other organizations may
give services only when approved by us, and their duties must be assigned and supervised by a
professional nurse on the staff of the Home Health Care Provider.
Therapy Services of physical, occupational, speech and language, respiratory and inhalation (except
for Manipulation Therapy which will not be covered when given in the home)
Medical supplies
Durable medical equipment, prosthetics and orthopedic appliances
Private duty nursing in the home
Home Infusion Therapy
See Therapy Services later in this section.
Hospice Care
The services and supplies listed below are Covered Services when given by a Hospice for the palliative
care of pain and other symptoms that are part of a terminal disease. Palliative care means care that
controls pain and relieves symptoms, but is not meant to cure a terminal illness. Hospice care includes
routine home care, constant home care, inpatient Hospice and inpatient respite. Covered Services
include:
Care from an interdisciplinary team with the development and maintenance of an appropriate plan of
care.
Short-term Inpatient Hospital care when needed in periods of crisis or as respite care.
Skilled nursing services, home health aide services, and homemaker services given by or under the
supervision of a registered nurse.
Doctor services and diagnostic testing.

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Social services and counseling services from a licensed social worker.
Nutritional support such as intravenous feeding and feeding tubes and nutritional counseling.
Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed
therapist.
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition,
including oxygen and related respiratory therapy supplies.
Prosthetics and orthopedic appliances.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Members death.
Bereavement services are available to the patient/family consisting of those individuals who are
closely linked to the patient, including the immediate family, the primary or designated care giver and
individuals with significant personal ties.
Transportation.
Your Doctor and Hospice medical director must certify that you are terminally ill and likely have less than
six months to live. Your Doctor must agree to care by the Hospice and must be consulted in the
development of the care plan. The Hospice must keep a written care plan on file and give it to us upon
request.
Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy
given as palliative care, are available to a Member in Hospice. These additional Covered Services will be
covered under other parts of this Plan. Any care you get that has to do with an unrelated illness or
medical condition will be subject to the provisions of this plan that deals with that illness.
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell)
Services
Your Plan includes coverage for Medically Necessary human organ and tissue transplants. Certain
transplants (e.g., cornea and kidney) are covered like any other surgery, under the regular inpatient and
outpatient benefits described elsewhere in this Booklet.
This section describes benefits for certain Covered Transplant Procedures that you get during the
Transplant Benefit Period. Any Covered Services related to a Covered Transplant Procedure, received
before or after the Transplant Benefit Period, are covered under the regular Inpatient and outpatient
benefits described elsewhere in this Booklet.
In this section you will see some key terms, which are defined below:
Covered Transplant Procedure
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage.
It also includes Medically Necessary myeloablative or reduced intensity preparative chemotherapy,
radiation therapy, or a combination of these therapies.
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and transfusions including necessary acquisition procedures, harvest and storage, and
including Medically Necessary preparatory myeloablative therapy.
In-Network Transplant Provider
A Provider that we have chosen as a Center of Excellence and/or a Provider selected to take part as an
In-Network Transplant Provider by a designee. The Provider has entered into a Transplant Provider

69
Agreement to give Covered Transplant Procedures to you and take care of certain administrative duties
for the transplant network. A Provider may be an In-Network Transplant Provider for:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
Out-of-Network Transplant Provider
Any Provider that has NOT been chosen as a Center of Excellence by us or has not been selected to
take part as an In-Network Transplant Provider by a designee.
Transplant Benefit Period
At an In-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts for the applicable case rate / global time period. The number of
days will vary depending on the type of transplant received and the In-Network Transplant Provider
agreement. Call the Case Manager for specific In-Network Transplant Provider details for services
received at or coordinated by an In-Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
Prior Approval and Precertification
To maximize your benefits, you should call our Transplant Department as soon as you think you
may need a transplant to talk about your benefit options. You must do this before you have an
evaluation and/or work-up for a transplant. We will help you maximize your benefits by giving you
coverage information, including details on what is covered and if any clinical coverage guidelines, medical
policies, In-Network Transplant Provider rules, or Exclusions apply. Call the Customer Service phone
number on the back of your Identification Card and ask for the transplant coordinator. Even if we give a
prior approval for the Covered Transplant Procedure, you or your Provider must call our Transplant
Department for Precertification prior to the transplant whether this is performed in an Inpatient or
Outpatient setting.
Precertification is required before we will cover benefits for a transplant. Your Doctor must certify, and we
must agree, that the transplant is Medically Necessary. Your Doctor should send a written request for
Precertification to us as soon as possible to start this process. Not getting Precertification will result in a
denial of benefits.
Please note that there are cases where your Provider asks for approval for HLA testing, donor searches
and/or a harvest and storage of stem cells prior to the final decision as to what transplant procedure will
be needed. In these cases, the HLA testing and donor search charges will be covered as routine
diagnostic tests. The harvest and storage request will be reviewed for Medical Necessity and may be
approved. However, such an approval for HLA testing, donor search and/or harvest and storage is NOT
an approval for the later transplant. A separate Medical Necessity decision will be needed for the
transplant.
Donor Benefits
Benefits for an organ donor are as follows:
When both the person donating the organ and the person getting the organ are our covered
Members, each will get benefits under their Plan.

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When the person getting the organ is our covered Member, but the person donating the organ is not,
benefits under this Plan are limited to benefits not available to the donor from any other source. This
includes, but is not limited to, other insurance, grants, foundations, and government programs.
If our covered Member is donating the organ to someone who is not a covered Member, benefits are
not available under this Plan.
Transportation and Lodging
We will cover the cost of reasonable and necessary travel costs when you get prior approval and need to
travel more than 75 miles from your permanent home to reach the Facility where the Covered Transplant
Procedure will be performed. Our help with travel costs includes transportation to and from the Facility,
and lodging for the patient and one companion. If the Member receiving care is a minor, then reasonable
and necessary costs for transportation and lodging may be allowed for two companions. You must send
itemized receipts for transportation and lodging costs in a form satisfactory to us when claims are filed.
Call us for complete information.
For lodging and ground transportation benefits, we will cover costs up to the current limits set forth in the
Internal Revenue Code.
Non-Covered Services for transportation and lodging include, but are not limited to:
Child care,
Mileage within the medical transplant Facility city,
Rental cars, buses, taxis, or shuttle service, except as specifically approved by us,
Frequent Flyer miles,
Coupons, Vouchers, or Travel tickets,
Prepayments or deposits,
Services for a condition that is not directly related, or a direct result, of the transplant,
Phone calls,
Laundry,
Postage,
Entertainment,
Travel costs for donor companion/caregiver,
Return visits for the donor for a treatment of an illness found during the evaluation,
Meals.
Infertility Services
Please see Maternity and Reproductive Health Services later in this section.
Inpatient Services
Inpatient Hospital Care
Covered Services include acute care in a Hospital setting.
Benefits for room, board, and nursing services include:
A room with two or more beds.

71
A private room. The most the Plan will cover for private rooms is the Hospitals average semi-private
room rate unless it is Medically Necessary that you use a private room for isolation and no isolation
facilities are available.
A room in a special care unit approved by us. The unit must have facilities, equipment, and supportive
services for intensive care or critically ill patients.
Routine nursery care for newborns during the mothers normal Hospital stay.
Newborn care for during and after the mothers maternity Hospital stay for treatment of injury and
sickness and medically diagnosed Congenital Defects and Birth Abnormalities.
Meals, special diets.
General nursing services.
Benefits for ancillary services include:
Operating, childbirth, and treatment rooms and equipment.
Prescribed Drugs.
Anesthesia, anesthesia supplies and services given by the Hospital or other Provider.
Medical and surgical dressings and supplies, casts, and splints.
Diagnostic services.
Therapy services.
Inpatient Professional Services
Covered Services include:
Medical care visits.
Intensive medical care when your condition requires it.
Treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for
surgery. Benefits include treatment by two or more Doctors during one Hospital stay when the nature
or severity of your health problem calls for the skill of separate Doctors.
A personal bedside exam by another Doctor when asked for by your Doctor. Benefits are not
available for staff consultations required by the Hospital, consultations asked for by the patient,
routine consultations, phone consultations, or EKG transmittals by phone.
Surgery and general anesthesia.
Newborn exam. A Doctor other than the one who delivered the child must do the exam.
Professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology.
Manipulation Therapy
Please see Therapy Services later in this section.
Maternity and Reproductive Health Services
Maternity Services
Covered Services include services needed during a normal or complicated pregnancy, Complications of
Pregnancy, and for services needed for a miscarriage. Covered maternity services include:
Professional and Facility services for childbirth in a Facility or the home including the services of an
appropriately licensed nurse midwife;
Routine nursery care for the newborn during the mothers normal Hospital stay, including circumcision
of a covered male Dependent;
Prenatal and postnatal services; and
Fetal screenings, which are genetic or chromosomal tests of the fetus, as allowed by us.

72
If you are pregnant on your Effective Date and in the first trimester of the pregnancy, you must change to
an In-Network Provider to have Covered Services covered at the In-Network level. If you are pregnant on
your Effective Date and in your second or third trimester of pregnancy (13 weeks or later) as of the
Effective Date, benefits for obstetrical care will be available at the In-Network level even if an Out-of-
Network Provider is used if you fill out a Continuation of Care Request Form and send it to us. Covered
Services will include the obstetrical care given by that Provider through the end of the pregnancy and the
immediate post-partum period.
Important Note About Maternity Admissions: Under federal law, we may not limit benefits for any
Hospital length of stay for childbirth for the mother or newborn to less than 48 hours after vaginal birth, or
less than 96 hours after a cesarean section (C-section). If the baby is born between 8:00 p.m. and 8:00
a.m., coverage will continue until 8:00 a.m. on the morning after the 48 or 96 hours timeframe. However,
federal law as a rule does not stop the mothers or newborns attending Provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours, or 96 hours, as applicable. In
any case, as provided by federal law, we may not require a Provider to get authorization from us before
prescribing a length of stay which is not more than 48 hours for a vaginal birth or 96 hours after a C-
section.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain
contraceptives are covered under the Preventive Care benefit. Please see that section for further
details.
Sterilization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the Preventive Care benefit.
Abortion Services
Benefits include services for therapeutic or elective abortion regardless if Medically Necessary, unless
applicable law or regulation prohibits the Group from providing such coverage (in which case, Covered
Services are provided only to the extent necessary to prevent the death of the mother or unborn baby).
Infertility Services
Important Note: Although this Plan offers limited coverage of certain infertility services, it does not cover
all forms of infertility treatment. Benefits do not include assisted reproductive technologies (ART) or the
diagnostic tests and Drugs to support it. Examples of ART include artificial insemination, in-vitro
fertilization, zygote intrafallopian transfer (ZIFT), or gamete intrafallopian transfer (GIFT).
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy,
endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical
conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
Fertility treatments such as artificial insemination and in-vitro fertilization are not a Covered Service.
Medical Foods
Covered Services include Medically Necessary medical foods for home use for metabolic disorders which
may be taken by mouth or enterally. A Provider must have prescribed the medical foods that are

73
designed and manufactured for the treatment of inherited enzymatic disorders caused by single gene
defects involved in the metabolism of amino, organic, and fatty acids. Such disorders include:
Phenylketonuria, if you are 21 or younger (35 or younger for women of child-bearing age);
Maternal phenylketonuria;
Maple syrup urine disease;
Tyrosinemia;
Homocystinuria;
Histidinemia;
Urea cycle disorders;
Hyperlysinemia;
Glutaric acidemias;
Methylmalonic academia; and
Propionic acidemia.
Covered Services do not include enteral nutrition therapy or medical foods for Members with cystic
fibrosis or lactose- or soy- intolerance. Also all covered medical foods must be obtained through a
Pharmacy and are subject to the pharmacy payment requirements. Please see Prescription Drug Benefit
at a Retail or Home Delivery (Mail Order) Pharmacy later in this section.
Mental Health, Biologically Based Mental Illness, Alcohol and
Substance Abuse Services
Covered Services include the following:

Inpatient Services in a Hospital or any facility that we must cover per state law. Inpatient benefits
include psychotherapy, psychological testing, electroconvulsive therapy, and detoxification.

Outpatient Services including office visits and treatment in an outpatient department of a Hospital or
outpatient Facility, such as partial hospitalization programs and intensive outpatient programs.

Residential Treatment which is specialized 24-hour treatment in a licensed residential treatment
center. It offers individualized and intensive treatment and includes:

Observation and assessment by a psychiatrist weekly or more often,
Rehabilitation, therapy, and education.

You can get Covered Services under this section from the following Providers:

Psychiatrist,
Psychologist,
Neuropsychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
Licensed professional counselor (L.P.C) or
Any agency licensed by the state to give these services, when we have to cover them by law.

74
Occupational Therapy
Please see Therapy Services later in this section.
Office Visits and Doctor Services
Covered Services include:
Office Visits for medical care (including second surgical opinions) to examine, diagnose, and treat an
illness or injury.
Home Visits for medical care to examine, diagnose, and treat an illness or injury. Please note that
Doctor visits in the home are different than the Home Care Services benefit described earlier in this
Booklet.
Retail Health Clinic Care for limited basic health care services to Members on a walk-in basis. These
clinics are normally found in major pharmacies or retail stores. Health care services are typically given by
Physicians Assistants or Nurse Practitioners. Services are limited to routine care and treatment of
common illnesses for adults and children.
Walk-In Doctors Office for services limited to routine care and treatment of common illnesses for adults
and children. You do not have to be an existing patient or have an appointment to use a walk-in Doctors
office.
Urgent Care as described in Urgent Care Services later in this section.
Online Care Visits when available in your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online care visits do not include reporting normal lab or
other test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Hearing Exams and tests to determine the need for hearing correction. For additional information on
hearing aid services, please see Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies earlier in this section.
Prescription Drugs Administered in the Office
Orthotics
See Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies earlier in this section.
Outpatient Facility Services
Your Plan includes Covered Services in an:
Outpatient Hospital,
Ambulatory Surgical Facility,
Mental Health / Substance Abuse Facility, or
Other Facilities approved by us.
Benefits include Facility and related (ancillary) charges, when proper, such as:

75
Surgical rooms and equipment,
Prescription Drugs, including Specialty Drugs,
Anesthesia and anesthesia supplies and services given by the Hospital or other Facility,
Medical and surgical dressings and supplies, casts, and splints,
Diagnostic services,
Therapy services.
Physical Therapy
Please see Therapy Services later in this section.
Preventive Care
Preventive care includes screenings and other services for adults and children with no current symptoms
or history of a health problem.
Members who have current symptoms or a diagnosed health problem will get benefits under the
Diagnostic Services benefit, not this benefit.
Preventive care services will meet the requirements of federal and state law. Many preventive care
services are covered with no Deductible, Copayments or Coinsurance when you use an In-Network
Provider. That means we cover 100% of the Maximum Allowed Amount. Covered Services fall under
four broad groups:
1. Services with an A or B rating from the United States Preventive Services Task Force. Examples
include screenings for:
a. Breast cancer,
b. Cervical cancer,
c. Colorectal cancer,
d. High blood pressure,
e. Type 2 Diabetes Mellitus,
f. Cholesterol,
g. Child and adult obesity.
Tobacco use screening and tobacco cessation counseling and intervention is also covered.
2. Immunizations for children, adolescents, and adults, including cervical cancer vaccinations for
females, where recommended by the Advisory Committee on Immunization Practices of the Centers
for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as listed in the guidelines
supported by the Health Resources and Services Administration; and
4. Preventive care and screening for women as listed in the guidelines supported by the Health
Resources and Services Administration, including:
a. Womens contraceptives, sterilization treatments, and counseling. This includes Generic and
single-source Brand Drugs as well as injectable contraceptives and patches. Contraceptive
devices such as diaphragms, intra uterine devices (IUDs), and implants are also covered. Multi-
source Brand Drugs will be covered under the Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy.
b. Breastfeeding support, supplies, and counseling. Benefits for breast pumps are limited to one
pump per pregnancy.

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c. Gestational diabetes screening.
You may call Customer Service at the number on your Identification Card for more details about these
services or view the federal governments web sites,https://www.healthcare.gov/what-are-my-preventive-
care-benefits, http://www.ahrq.gov, and http://www.cdc.gov/vaccines/acip/index.html.
Prosthetics
See Durable Medical Equipment and Medical Devices, Orthotics, and Medical and Surgical Supplies
earlier in this section.
Pulmonary Therapy
Please see Therapy Services later in this section.
Radiation Therapy
Please see Therapy Services later in this section.
Rehabilitation Services
Benefits include services in a Hospital, free-standing Facility, Skilled Nursing Facility, or in an outpatient
day rehabilitation program.
Covered Services involve a coordinated team approach and several types of treatment, including skilled
nursing care, physical, occupational, and speech therapy, and services of a social worker or psychologist.
To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period
of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing
toward those goals.
Habilitative Services
Benefits also include Habilitative Services that help you keep, learn or improve skills and functioning for
daily living. Examples include therapy for a child who isnt walking or talking at the expected age. These
services may include physical and occupational therapy, speech-language pathology and other services
for people with disabilities in a variety of inpatient and/or outpatient settings.
Respiratory Therapy
Please see Therapy Services later in this section.
Skilled Nursing Facility
When you require Inpatient skilled nursing and related services for convalescent and rehabilitative or
habilitative care, Covered Services are available if the Facility is licensed or certified under state law as a
Skilled Nursing Facility, or is otherwise licensed to provide the services. Custodial Care is not a Covered
Service.

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Smoking Cessation
Please see Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy later in this
Booklet.
Speech Therapy
Please see Therapy Services later in this section.
Surgery
Your Plan covers surgical services on an Inpatient or outpatient basis, including office surgeries.
Covered Services include:
Accepted operative and cutting procedures;
Other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain
or spine;
Endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Treatment of fractures and dislocations;
Anesthesia and surgical support when Medically Necessary;
Medically Necessary pre-operative and post-operative care.
Oral Surgery
Important Note: Although this Plan covers certain oral surgeries, many oral surgeries (e.g. removal of
wisdom teeth) are not covered, except as listed in this Booklet.
Benefits are limited to certain oral surgeries including:
Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;
Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or
lower jaw and is Medically Necessary to attain functional capacity of the affected part.
Oral / surgical correction of accidental injuries as indicated in the Dental Services (All Members/All
Ages) section.
Treatment of non-dental lesions, such as removal of tumors and biopsies.
Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses
Your Plan also covers certain oral surgeries for children. Please refer to Pediatric Dental Services for
Members through Age 18 for details.
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or
developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal
appearance. Benefits include surgery performed to restore symmetry after a mastectomy. Reconstructive
services needed as a result of an earlier treatment are covered only if the first treatment would have been
a Covered Service under this Plan.
Note: This section does not apply to orthognathic surgery. See the Oral Surgery section above for that
benefit.

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Mastectomy Notice
A Member who is getting benefits for a mastectomy or for follow-up care for a mastectomy and who
chooses breast reconstruction, will also get coverage for:
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to give a symmetrical appearance; and
Prostheses and treatment of physical problems of all stages of mastectomy, including lymphedemas.
When due to breast cancer, reconstructive and surgical coverage will be provided in a manner
determined in consultation with the attending Physician and the Member. Members will have to pay the
same Deductible, Coinsurance, and/or Copayments that normally apply to surgeries in this Plan.
Transgender Surgery
This Plan provides benefits for many of the charges for transgender surgery (also known as sex
reassignment surgery). Benefits must be approved by us for the type of transgender surgery requested
and must be authorized prior to being performed. Changes for services that are not authorized for the
transgender surgery requested will not be considered Covered Services. Some conditions apply,
and all services must be authorized by us as outlined in the "How to Access Your Services and
Obtain Approval of Benefits" section.
Telemedicine
When you can!t travel to a Provider!s office, telemedicine benefits might be available when provided by
covered Providers. Telemedicine is the real-time transfer of health data and help. Services include the
use of interactive audio, video, or other electronic media to discuss and treat your health problem.
Typically, you communicate through an interactive means that is enough to start a link to the Provider
who is working at a different location from you. These services are covered if they would be Covered
Services when given in a face-to-face meeting with the Provider.
There are limits. Telemedicine does not include the use of phones or fax machines. It also is not
covered if you can go into the office of an In-Network Provider in the area where you live. Telemedicine
benefits may also be limited to only certain areas in Colorado. Please check with Customer Services to
see if your area is eligible.
Non-covered services are:
Reporting normal lab or other test results;
Office appointment requests;
Billing, insurance coverage or payment questions;
Requests for referrals to doctors outside the online care panel;
Benefit Preauthorization; Doctor talking to another Doctor.
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services
Benefits are available to treat temporomandibular and craniomandibular disorders. The
temporomandibular joint connects the lower jaw to the temporal bone at the side of the head and the
craniomandibular joint involves the head and neck muscles.
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care,
and diagnostic services. Covered Services do not include fixed or removable appliances that involve
movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).

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Therapy Services
Physical Medicine Therapy Services
Your Plan includes coverage for the therapy services described below. To be a Covered Service, the
therapy must improve your level of function within a reasonable period of time.
For children under age 6, your Plan covers at least 20 visits, each, of physical, speech and occupational
therapy. Benefits include the treatment of Congenital Defects and Birth Abnormalities, even if it is a long
term condition. It also doesn!t matter if the reason for the therapy is to maintain (not improve) the child!s
skills.
Covered Services include:
Physical therapy The treatment by physical means to ease pain, restore health, and to avoid
disability after an illness, injury, or loss of an arm or a leg. It includes hydrotherapy, heat, physical
agents, bio-mechanical and neuro-physiological principles and devices.
Speech therapy and speech-language pathology (SLP) services Services to identify, assess,
and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or
treat communication or swallowing skills to correct a speech impairment.
Occupational therapy Treatment to restore a physically disabled persons ability to do activities of
daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a
bed, and bathing. It also includes therapy for tasks needed for the persons job. Occupational therapy
does not include recreational or vocational therapies, such as hobbies, arts and crafts.
Osteopathic / Manipulation Therapy Includes therapy to treat problems of the bones, joints, and
the back. The two therapies are similar, but Manipulation Therapy focuses on the joints of the spine
and the nervous system, while osteopathic therapy also focuses on the joints and surrounding
muscles, tendons and ligaments.
Massage therapy - Injury or illness for which massage has a therapeutic result. Coverage is provided
for up to a 60 minute session per visit. Some Covered Services include acupressure and deep tissue
massage, or other approved services.
Acupuncture/Nerve Pathway therapy Is limited to the treatment of neuromusculoskeletal pain,
through the use of needles inserted along specific nerve pathways to ease pain.
Early Intervention Services
From the Members birth until the Members third (3rd) birthday, this Plan covers Early Intervention
Services (as defined in this Booklet and by Colorado law in accordance with part C), that are authorized
through an eligible child's individualized family service plan (IFSP) and delivered by a Qualified Early
Intervention Service Provider to an eligible child, to the extent required by applicable law. The services
stated in an IFSP will be considered Medically Necessary. Coverage for early intervention services does
not include: nonemergency medical transportation; respite care; service coordination, as defined in
federal law; or assistive technology (unless covered under the applicable insurance policy as durable
medical equipment). Coverage is limited to up to 45 visits, in 15 minute increments, per Benefit Period.
A 45 minute visit counts as 3 billing increments.
This visit limit does not apply to rehabilitation or therapeutic services that are necessary as the result of
an acute medical condition or post-surgical rehabilitation or services provided to a child who is not
participating in part C. The coverage for Early Intervention Services is in addition to any other coverage
provided under this Booklet for congenital defects or birth abnormalities.

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Other Therapy Services
Benefits are also available for:
Cardiac Rehabilitation Medical evaluation, training, supervised exercise, and psychosocial
support to care for you after a cardiac event (heart problem). Benefits do not include home programs,
on-going conditioning, or maintenance care.
Chemotherapy Treatment of an illness by chemical or biological antineoplastic agents. See the
section Prescription Drugs Administered by a Medical Provider for more details.
Dialysis Services for acute renal failure and chronic (end-stage) renal disease, including
hemodialysis, home intermittent peritoneal dialysis (IPD), home continuous cycling peritoneal dialysis
(CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Covered Services include
dialysis treatments in an outpatient dialysis Facility. Covered Services also include home dialysis and
training for you and the person who will help you with home self-dialysis.
Infusion Therapy Nursing, durable medical equipment and Drug services that are delivered and
administered to you through an I.V. in your home. Also includes Total Parenteral Nutrition (TPN),
Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections
(intra-muscular, subcutaneous, continuous subcutaneous). See the section Prescription Drugs
Administered by a Medical Provider for more details.
Pulmonary Rehabilitation Includes outpatient short-term respiratory care to restore your health
after an illness or injury.
Radiation Therapy Treatment of an illness by x-ray, radium, or radioactive isotopes. Covered
Services include treatment (teletherapy, brachytherapy and intraoperative radiation, photon or high
energy particle sources), materials and supplies needed, and treatment planning.
Respiratory Therapy Includes the use of dry or moist gases in the lungs, nonpressurized
inhalation treatment; intermittent positive pressure breathing treatment, air or oxygen, with or without
nebulized medication, continuous positive pressure ventilation (CPAP); continuous negative pressure
ventilation (CNP); chest percussion; therapeutic use of medical gases or Drugs in the form of
aerosols, and equipment such as resuscitators, oxygen tents, and incentive spirometers; broncho-
pulmonary drainage and breathing exercises.
Transplant Services
See Human Organ and Tissue Transplant earlier in this section.
Urgent Care Services
Often an urgent rather than an Emergency health problem exists. An urgent health problem is an
unexpected illness or injury that calls for care that cannot wait until a regularly scheduled office visit.
Urgent health problems are not life threatening and do not call for the use of an Emergency Room.
Urgent health problems include earache, sore throat, and fever (not above 104 degrees).
Benefits for urgent care include:
X-ray services;
Care for broken bones;
Tests such as flu, urinalysis, pregnancy test, rapid strep;
Lab services;
Stitches for simple cuts; and
Draining an abscess.


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{Pediatric vision exam only:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.]

{Pediatric vision full coverage:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
Eyeglass Lenses
This Plan also covers a choice of eyeglass lenses. Benefits include polycarbonate, photochromic and
factory scratch coating when In-Network.

Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:

Single vision
Bifocal
Trifocal (FT 25-28)
Progressive
Frames
A selection of frames is covered under this Plan. Members must choose a frame from the Anthem
formulary.
Contact Lenses
The Plan offers the following benefits for contact lenses:

Elective Contact Lenses Contacts chosen for comfort or appearance;

Non-Elective Contact Lenses Only for the following medical conditions:

Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.

Special Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASIK.

82

This Plan only covers a choice of contact lenses or eyeglasses, but not both. If you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglasses until the next Benefit Period. If
you choose eyeglasses during a Benefit Period, no benefits will be available for contact lenses until the
next Benefit Period.]

{Adult vision:
[Vision Services for Members Age 19 and Older
The vision benefits described in this section only apply to Members age 19 or older.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
Eyeglass Lenses
This Plan also covers a choice of eyeglass lenses. Lens benefits include factory scratch coating when In-
Network. Photochromic lenses are also available.
Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:
Single vision
Bifocal
Trifocal (FT 25-28)
Frames
A selection of frames is covered under this Plan. Members will get a benefit allowance toward the
purchase of any frame. If the frame you choose costs more than the Plans allowance, you will have to
pay the amount over the Plans allowance.
Contact Lenses
The Plan offers the following benefits for contact lenses:
Elective Contact Lenses Contacts chosen for comfort or appearance;
Non-Elective Contact Lenses Only for the following medical conditions:
Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.
Special Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASIK.
This Plan only covers a choice of contact lenses or eyeglass lenses, but not both. If you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglass lenses until the next Benefit
Period. If you choose eyeglass lenses during a Benefit Period, no benefits will be available for contact
lenses until the next Benefit Period.]

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Vision Services (All Members / All Ages)
Benefits include medical and surgical treatment of injuries and illnesses of the eye. Certain vision
screenings required by Federal law are covered under the Preventive Care benefit.
Benefits do not include glasses or contact lenses except as listed in the Prosthetics benefit.

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Prescription Drugs Administered by a Medical Provider
Your Plan covers Prescription Drugs when they are administered to you as part of a doctors visit, home
care visit, or at an outpatient Facility. This includes Drugs for infusion therapy, chemotherapy, Specialty
Drugs, blood products, and office-based injectables that must be administered by a Provider. This
section applies when your Provider orders the Drug and administers it to you. Benefits for Drugs that you
can inject or get at a Pharmacy (i.e., self-administered injectable Drugs) are not covered under this
section. Benefits for those Drugs are described in the Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy section.
Note: When Prescription Drugs are covered under this benefit, they will not also be covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit. Also, if
Prescription Drugs are covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, they will not be covered under this benefit.
Important Details About Prescription Drug Coverage
Your Plan includes certain features to determine when Prescription Drugs should be covered, which are
described below. As part of these features, your prescribing Doctor may be asked to give more details
before we can decide if the Drug is Medically Necessary. We may also set quantity and/or age limits for
specific Prescription Drugs or use recommendations made as part of our Medical Policy and Technology
Assessment Committee and/or Pharmacy and Therapeutics Process.
Prior Authorization
Prior authorization may be needed for certain Prescription Drugs to make sure proper use and guidelines
for Prescription Drug coverage are followed. We will contact your Provider to get the details we need to
decide if prior authorization should be given. We will give the results of our decision to both you and your
Provider.
If prior authorization is denied you have the right to file a Grievance as outlined in the Appeals and
Complaints section of this Booklet.
For a list of Drugs that need prior authorization, please call the phone number on the back of your
Identification Card. The list will be reviewed and updated from time to time. Including a Drug or related
item on the list does not promise coverage under your Plan. Your Provider may check with us to verify
Drug coverage, to find out whether any quantity (amount) and/or age limits apply, and to find out which
brand or generic Drugs are covered under the Plan.
Step Therapy
Step therapy is a process in which you may need to use one type of Drug before we will cover another.
We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These
guidelines help you get high quality and cost effective Prescription Drugs. If a Doctor decides that a
certain Drug is needed, the prior authorization will apply.
Therapeutic Substitution
Therapeutic substitution is an optional program that tells you and your Doctors about alternatives to
certain prescribed Drugs. We may contact you and your Doctor to make you aware of these choices.
Only you and your Doctor can determine if the therapeutic substitute is right for you. We have a
therapeutic Drug substitutes list, which we review and update from time to time. For questions or issues
about therapeutic Drug substitutes, call Customer Service at the phone number on the back of your
Identification Card.

85
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order)
Pharmacy
Your Plan also includes benefits for Prescription Drugs you get at a Retail or Mail Order Pharmacy. We
use a Pharmacy Benefits Manager (PBM) to manage these benefits. The PBM has a network of Retail
Pharmacies, a Home Delivery (Mail Order) Pharmacy, and a Specialty Pharmacy. The PBM works to
make sure Drugs are used properly. This includes checking that Prescriptions are based on recognized
and appropriate doses and checking for Drug interactions or pregnancy concerns.
Please note: Benefits for Prescription Drugs, including Specialty Drugs, which are administered to you in
a medical setting (e.g., doctors office, home care visit, or outpatient Facility) are covered under the
Prescription Drugs Administered by a Medical Provider benefit. Please read that section for important
details.
Prescription Drug Benefits
As described in the Prescription Drugs Administered by a Medical Provider section, Prescription Drug
benefits may depend on reviews to decide when Drugs should be covered. These reviews may include
prior authorization, step therapy, use of a Prescription Drug List, Therapeutic Substitution, day / supply
limits, and other utilization reviews. Your In-Network Pharmacist will be told of any rules when you fill a
Prescription, and will be also told about any details we need to decide benefits.
Covered Prescription Drugs
To be a Covered Service, Prescription Drugs must be approved by the Food and Drug Administration
(FDA) and, under federal law, require a Prescription. Prescription Drugs must be prescribed by a
licensed Provider and you must get them from a licensed Pharmacy.
Benefits are available for the following:
Prescription Legend Drugs from either a Retail Pharmacy or the PBMs Home Delivery Pharmacy;
Specialty Drugs;
Self-administered injectable Drugs. These are Drugs that do not need administration or monitoring by
a Provider in an office or Facility. Office-based injectables and infused Drugs that need Provider
administration and/or supervision are covered under the Prescription Drugs Administered by a
Medical Provider benefit;
Self-injectable insulin and supplies and equipment used to administer insulin;
Self-administered contraceptives, including oral contraceptive Drugs, self-injectable contraceptive
Drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the
Preventive Care benefit. Please see that section for more details;
Special food products or supplements, including metabolic formulas, when prescribed by a Doctor if
we agree they are Medically Necessary,
Flu Shots (including administration). These will be covered under the Preventive Care benefit;
Prescription Drugs that help you stop smoking or reduce your dependence on tobacco products.
These Drugs will be covered under the Preventive Care benefit;
FDA-approved smoking cessation products, including over the counter nicotine replacement
products, when obtained with a Prescription for a Member age 18 or older. These products will be
covered under the Preventive Care benefit.
Certain Legend Drugs, including orally administered anticancer medication, may also be used for
treatment of cancer even though it has not been approved by the Food and Drug Administration (FDA) for
treatment of a specific type of cancer, if the following conditions are met:

86
the off-label use of the FDA approved drug is supported for the treatment of cancer by the
authoritative reference compendia identified by the Department of Health and Human Services; and
the condition being treated is covered under this Booklet.
Where You Can Get Prescription Drugs
In-Network Pharmacy
You can visit one of the local Retail Pharmacies in our network. Give the Pharmacy the prescription from
your Doctor and your Identification Card and they will file your claim for you. You will need to pay any
Copayment, Coinsurance, and/or Deductible that applies when you get the Drug. If you do not have your
Identification Card, the Pharmacy will charge you the full retail price of the Prescription and will not be
able to file the claim for you. You will need to ask the Pharmacy for a detailed receipt and send it to us
with a written request for payment.
Specialty Pharmacy
If you need a Specialty Drug, you or your Doctor should order it from the PBMs Specialty Pharmacy. We
keep a list of Specialty Drugs that may be covered based upon clinical findings from the Pharmacy and
Therapeutics (P&T) Process, and where appropriate, certain clinical economic reasons. This list will
change from time to time.
The PBMs Specialty Pharmacy has dedicated patient care coordinators to help you take charge of your
health problem and offers toll-free twenty-four hour access to nurses and pharmacists to answer your
questions about Specialty Drugs.
When you use the PBMs Specialty Pharmacy a patient care coordinator will work with you and your
Doctor to get prior authorization and to ship your Specialty Drugs to you or your Doctors office. Your
patient care coordinator will also tell you when it is time to refill your prescription.
You can get the list of covered Specialty Drugs by calling Customer Service at the phone number on the
back of your Identification Card or check our website at www.anthem.com.
Home Delivery Pharmacy
The PBM also has a Home Delivery Pharmacy which lets you get certain Drugs by mail if you take them
on a regular basis. You will need to contact the PBM to sign up when you first use the service. You can
mail written prescriptions from your Doctor or have your Doctor send the prescription to the Home
Delivery Pharmacy. Your Doctor may also call the Home Delivery Pharmacy. You will need to send in
any Copayments, Deductible, or Coinsurance amounts that apply when you ask for a prescription or refill.
Out-of-Network Pharmacy
You may also use a Pharmacy that is not in our network. You will be charged the full retail price of the
Drug and you will have to send your claim for the Drug to us. (Out-of-Network Pharmacies wont file the
claim for you.) You can get a claims form from us or the PBM. You must fill in the top section of the form
and ask the Out-of-Network Pharmacy to fill in the bottom section. If the bottom section of this form
cannot be filled out by the pharmacist, you must attach a detailed receipt to the claim form. The receipt
must show:
Name and address of the Out-of-Network Pharmacy;
Patients name;
Prescription number;
Date the prescription was filled;
Name of the Drug;

87
Cost of the Drug;
Quantity (amount) of each covered Drug or refill dispensed.
You must pay the amount shown in the Schedule of Benefits (Who Pays What). This is based on the
Maximum Allowed Amount as determined by our normal or average contracted rate with network
pharmacies on or near the date of service.
What You Pay for Prescription Drugs
Tiers
Your share of the cost for Prescription Drugs may vary based on the tier the Drug is in.
Tier 1 Drugs have the lowest Coinsurance or Copayment. This tier contains low cost and preferred
Drugs that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.
Tier 2 Drugs have a higher Coinsurance or Copayment than those in Tier 1. This tier contains
preferred Drugs that may be Generic, single source, or multi-source Brand Drugs.
Tier 3 Drugs have a higher Coinsurance or Copayment than those in Tier 2. This tier contains non-
preferred and high cost Drugs. This includes Drugs considered Generic, single source brands, and
multi-source brands.
Tier 4 Drugs have a higher Coinsurance or Copayment than those in Tier 3.
We assign drugs to tiers based on clinical findings from the Pharmacy and Therapeutics (P&T) Process.
We retain the right, at our discretion, to decide coverage for doses and administration (i.e., by mouth,
shots, topical, or inhaled). We may cover one form of administration instead of another, or put other forms
of administration in a different tier.
Prescription Drug List
We also have an Anthem Prescription Drug List, (a formulary), which is a list of FDA-approved Drugs that
have been reviewed and recommended for use based on their quality and cost effectiveness. Benefits
may not be covered for certain Drugs if they are not on the Prescription Drug List.
The Drug List is developed by us based upon clinical findings, and where proper, the cost of the Drug
relative to other Drugs in its therapeutic class or used to treat the same or similar condition. It is also
based on the availability of over the counter medicines, Generic Drugs, the use of one Drug over another
by our Members, and where proper, certain clinical economic reasons.
We retain the right, at our discretion, to decide coverage for doses and administration methods (i.e., by
mouth, shots, topical, or inhaled) and may cover one form of administration instead of another as
Medically Necessary.
Additional Features of Your Prescription Drug Pharmacy Benefit
Day Supply and Refill Limits
Certain day supply limits apply to Prescription Drugs as listed in the Schedule of Benefits (Who Pays
What). In most cases, you must use a certain amount of your prescription before it can be refilled. In
some cases we may let you get an early refill. For example, we may let you refill your prescription early if
it is decided that you need a larger dose. We will work with the Pharmacy to decide when this should
happen.

88
If you are going on vacation and you need more than the day supply allowed, you should ask your
pharmacist to call our PBM and ask for an override for one early refill. If you need more than one early
refill, please call Customer Service at the number on the back of your Identification Card.
Half-Tablet Program
The Half-Tablet Program lets you pay a reduced Copayment on selected once daily dosage Drugs on
our approved list. The program lets you get a 30-day supply (15 tablets) of the higher strength Drug
when the Doctor tells you to take a ! tablet daily. The Half-Tablet Program is strictly voluntary and you
should talk to your Doctor about the choice when it is available. To get a list of the Drugs in the program
call the number on the back of your Identification Card.
Special Programs
From time to time we may offer programs to support the use of more cost-effective or clinically effective
Prescription Drugs including Generic Drugs, Home Delivery Drugs, over the counter Drugs or preferred
products. Such programs may reduce or waive Copayments or Coinsurance for a limited time. We may
discontinue a program at any time. If you are participating in a program that We discontinue, We will
provide you at least a 30 day advance written notice of the discontinuance.

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Section 8. Limitations/Exclusions (What is Not Covered and
Pre-Existing Conditions)
In this section you will find a review of items that are not covered by your Plan. Excluded items will not be
covered even if the service, supply, or equipment is Medically Necessary. This section is only meant to be
an aid to point out certain items that may be misunderstood as Covered Services. This section is not
meant to be a complete list of all the items that are excluded by your Plan.

We will have the right to make the final decision about whether services or supplies are Medically
Necessary and if they will be covered by your Plan.
1) Acts of War, Disasters, or Nuclear Accidents In the event of a major disaster, epidemic, war, or
other event beyond our control, we will make a good faith effort to give you Covered Services. We will
not be responsible for any delay or failure to give services due to lack of available Facilities or staff.
Benefits will not be given for any illness or injury that is a result of war, service in the armed forces, a
nuclear explosion, nuclear accident, release of nuclear energy, a riot, or civil disobedience.
2) Administrative Charges
a) Charges to complete claim forms,
b) Charges to get medical records or reports,
c) Membership, administrative, or access fees charged by Doctors or other Providers. Examples
include, but are not limited to, fees for educational brochures or calling you to give you test
results.
3) Alternative / Complementary Medicine Services or supplies for alternative or complementary
medicine, regardless of the Provider rendering such services or supplies. This includes, but is not
limited to:
a. Holistic medicine,
b. Homeopathic medicine,
c. Hypnosis,
d. Aroma therapy,
e. Reiki therapy,
f. Herbal, vitamin or dietary products or therapies,
g. Naturopathy,
h. Thermography,
i. Orthomolecular therapy,
j. Contact reflex analysis,
k. Bioenergial synchronization technique (BEST),
l. Iridology-study of the iris,
m. Auditory integration therapy (AIT),
n. Colonic irrigation,
o. Magnetic innervation therapy,
p. Electromagnetic therapy,
q. Neurofeedback / Biofeedback.
4) Before Effective Date or After Termination Date Charges for care you get before your Effective
Date or after your coverage ends, except as written in this Plan.

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5) Certain Providers Services you get from Providers that are not licensed by law to provide Covered
Services as defined in this Booklet. .
6) Charges Over the Maximum Allowed Amount Charges over the Maximum Allowed Amount for
Covered Services, except as written in this Plan.
7) Charges Not Supported by Medical Records Charges for services not described in your medical
records.
8) Complications of Non-Covered Services Care for problems directly related to a service that is not
covered by this Plan. Directly related means that the care took place as a direct result of the non-
Covered Service and would not have taken place without the non-Covered Service.
9) Cosmetic Services Treatments, services, Prescription Drugs, equipment, or supplies given for
cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or
are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or
treatments to change the texture or look of your skin or to change the size, shape or look of facial or
body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).
10) Court Ordered Testing Court ordered testing or care unless the testing or care is Medically
Necessary and otherwise a Covered Service under this Booklet.
11) Crime Treatment of an injury or illness that results from a crime you committed, or tried to commit.
This Exclusion does not apply if your involvement in the crime was solely the result of a medical or
mental condition, or where you were the victim of a crime, including domestic violence.
12) Custodial Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to
Hospice services.
13) [Dental Services
a) {Pediatric dental: [Dental services for Members age 19 or older, unless listed as covered in this
Booklet]
b) Dental services not listed as covered in this Booklet.
c) New, experimental or investigational dental techniques or services may be denied until there is, to
our satisfaction, an established scientific basis for recommendation.
d) Dental services completed prior to the date the member became eligible for coverage.
e) Services of anesthesiologists.
f) Analgesia, analgesia agents, anxiolysis, nitrous oxide, medicines, or drugs for non-surgical or
dental care
g) Intravenous conscious sedation, IV sedation and general anesthesia are not covered when given
with non-surgical dental care. EXCEPTION: General anesthesia for dental services for members
under age 19 years of age when rendered in a hospital, outpatient surgical facility or other facility
licensed pursuant to Section 25-3-101 of the Colorado Revised Statutes if the child, in the opinion
of the treating Dentist, satisfies one or more of the following criteria: (a) the child has a physical,
mental, or medically compromising condition; (b) the child has dental needs for which local
anesthesia is ineffective because of acute infection, anatomic variations, or allergy; (c) the child is
an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent
with dental needs deemed sufficiently important that dental care cannot be deferred; or (d) the
child has sustained extensive orofacial and dental trauma.
h) Dental services performed other than by a licensed dentist, licensed physician, his or her
employees, or a licensed Provider acting within the scope of the Providers license.
i) Dental services, appliances or restorations that are necessary to alter, restore or maintain
occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth
structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

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j) Services or supplies that have the primary purpose of improving the appearance of your teeth.
This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of
the teeth.
k) Restorations placed for preventative or cosmetic purposes.
l) Occlusal or athletic mouth guards
m) Prosthodontic services, such as dentures or bridges {Adult dental: [for members through age
18].
n) Periodontal services {Adult dental: [for members through age 18].
o) Retreatment or additional treatment necessary to correct or relieve the results of treatment
previously covered under the Plan.
p) Separate services billed when they are an inherent component of another covered service.
q) Temporomandibular Joint Disorder (TMJ) except as covered under your medical coverage.
r) Oral hygiene instructions.
s) Surgical exposure of impacted or unerupted teeth for orthodontic reasons, except as listed in this
Booklet.
t) Surgical repositioning of teeth, except as listed in this Booklet.
u) Case presentations, office visits and consultations.
v) Implant services, except as listed in this Booklet.
w) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or non-resorbable filling
material(s) and the procedures used to prepare and place material(s) in the canals (root).
x) Root canal obstruction, internal root repair of perforation defects, incomplete endodontic
treatment and bleaching of discolored teeth.
y) Incomplete root canals.
z) Procedures designed to enable prosthetic or restorative services to be performed such as a
crown lengthening.
aa) Services or supplies that are medical in nature, including dental oral surgery services performed
in a hospital, except as covered under your medical coverage.
bb) Adjunctive diagnostic tests.]
14) Educational Services Services or supplies for teaching, vocational, or self-training purposes, except
as listed in this Booklet.
15) Experimental or Investigational Services Services or supplies that we find are Experimental /
Investigational. This also applies to services related to Experimental / Investigational services,
whether you get them before, during, or after you get the Experimental / Investigational service or
supply.
The fact that a service or supply is the only available treatment will not make it Covered Service if we
conclude it is Experimental / Investigational.
16) Eyeglasses and Contact Lenses Eyeglasses and contact lenses to correct your eyesight unless
listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye
surgery.
17) Eye Exercises Orthoptics and vision therapy.
18) Eye Surgery Eye surgery to fix errors of refraction, such as near-sightedness. This includes, but is
not limited to, LASIK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

92
19) Family Members Services prescribed, ordered, referred by or given by a member of your immediate
family, including your spouse, child, brother, sister, parent, in-law, or self.
20) Foot Care Routine foot care unless Medically Necessary. This Exclusion applies to cutting or
removing corns and calluses; trimming nails; cleaning and preventive foot care, including but not
limited to:
a) Cleaning and soaking the feet.
b) Applying skin creams to care for skin tone.
c) Other services that are given when there is not an illness, injury or symptom involving the foot.
21) Foot Orthotics Foot orthotics, orthopedic shoes or footwear or support items unless used for an
illness affecting the lower limbs, such as severe diabetes.
22) Foot Surgery Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet;
tarsalgia; metatarsalgia; hyperkeratoses.
23) Free Care Services you would not have to pay for if you didnt have this Plan. This includes, but is not
limited to government programs, services during a jail or prison sentence, services you get from
Workers Compensation, and services from free clinics.
If Workers Compensation benefits are not available to you, this Exclusion does not apply. This
Exclusion will apply if you get the benefits in whole or in part.
24) Hearing Aids Hearing aids or exams to prescribe or fit hearing aids, unless listed as covered in this
Booklet. This Exclusion does not apply to cochlear implants.
25) Health Club Memberships and Fitness Services Health club memberships, workout equipment,
charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or
facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health
spas.
26) Intractable Pain and/or Chronic Pain Charges for a pain state in which the cause of the pain cannot
be removed and which in the course of medical practice no relief or cure of the cause of the pain is
possible, or none has been found after reasonable efforts. It is pain that lasts more than 6 months, is
not life threatening, and may continue for a lifetime, and has not responded to current treatment.
27) Maintenance Therapy Treatment given when no further gains are clear or likely to occur.
Maintenance therapy includes care that helps you keep your current level of function and prevents
loss of that function, but does not result in any change for the better.
28) Medical Equipment and Supplies
a) Replacement or repair of purchased or rental equipment because of misuse, or loss.
b) Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury.
c) Non-Medically Necessary enhancements to standard equipment and devices.
29) Medicare For which benefits are payable under Medicare Parts A, B, and/or D, or would have been
payable if you had applied for Parts A and/or B, except as listed in this Booklet or as required by
federal law, as described in the section titled "Medicare" in General Provisions. If you do not enroll in
Medicare Part B, We will calculate benefits as if you had enrolled. You should sign up for Medicare
Part B as soon as possible to avoid large out of pocket costs.
30) Missed or Cancelled Appointments Charges for missed or cancelled appointments.
31) Non-Medically Necessary Services Services we conclude are not Medically Necessary. This
includes services that do not meet our medical policy, clinical coverage, or benefit policy guidelines.
32) Nutritional or Dietary Supplements Nutritional and/or dietary supplements, except as described in
this Booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional

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formulas and dietary supplements that you can buy over the counter and those you can get without a
written Prescription or from a licensed pharmacist.
33) Oral Surgery Extraction of teeth, surgery for impacted teeth, jaw augmentation or reduction
(orthognathic Surgery), and other oral surgeries to treat the teeth, jaw or bones and gums directly
supporting the teeth, except as listed in this Booklet.
34) Orthodontic Care, unless for Medically Necessary care for cleft palate and cleft conditions as
provided by this Booklet
a) Monthly treatment visits that are inclusive of treatment cost,
b) Repair or replacement of lost/broken/stolen appliances,
c) Orthodontic retention/retainer as a separate service,
d) Retreatment and/or services for any treatment due to relapse,
e) Inpatient or outpatient hospital expenses (please refer to your medical coverage to determine if
this is a covered medical service),
f) Provisional splinting, temporary procedures or interim stabilization of teeth,
g) Dental services or health care services not specifically covered under this Booklet (including any
hospital charges, prescription drug charges and dental services or supplies that are medical in
nature).
35) Personal Care and Convenience
a) Items for personal comfort, convenience, protection, cleanliness such as air conditioners,
humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs,
b) First aid supplies and other items kept in the home for general use (bandages, cotton-tipped
applicators, thermometers, petroleum jelly, tape, non-sterile gloves, heating pads),
c) Home workout or therapy equipment, including treadmills and home gyms,
d) Pools, whirlpools, spas, or hydrotherapy equipment.
e) Hypo-allergenic pillows, mattresses, or waterbeds,
f) Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs,
escalators, elevators, stair glides, emergency alert equipment, handrails).
36) Private Duty Nursing Private Duty Nursing Services, except as specifically stated in this Booklet.
37) Prosthetics Prosthetics for sports or cosmetic purposes. This includes wigs and scalp hair
prosthetics.
38) Sexual Dysfunction Services or supplies for male or female sexual problems.
39) Smoking Cessation Programs Programs to help you stop smoking if the program is not affiliated
with Anthem.
40) Stand-By Charges Stand-by charges of a Doctor or other Provider.
41) Sterilization Services to reverse an elective sterilization.
42) Surrogate Mother Services Services or supplies for a person not covered under this Plan for a
surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an
infertile couple).
43) Temporomandibular Joint Treatment Fixed or removable appliances which move or reposition the
teeth, fillings, or prosthetics (crowns, bridges, dentures).
44) Travel Costs Mileage, lodging, meals, and other Member-related travel costs except as described in
this Plan.

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45) Vein Treatment Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any
method (including sclerotherapy or other surgeries) for cosmetic purposes.
46) {Pediatric vision exam only: [Vision Services
Vision services for Members age 19 or older, unless listed as covered in this Booklet
Eyeglass lenses, frames, or contact lenses.
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.]
{Pediatric/adult vision: [Vision Services
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.
Safety glasses and accompanying frames.
For two pairs of glasses in lieu of bifocals.
Plano lenses (lenses that have no refractive power)
Lost or broken lenses or frames if the Member has already received benefits during a Benefit
Period.
Vision services not listed as covered in this Booklet.
Cosmetic lenses or options.
Blended lenses.
Oversize lenses.
Sunglasses and accompanying frames.
For Members through age 18, no benefits are available for frames not on the Anthem
formulary.
Certain frames in which the manufacturer imposes a no discount policy.]
47) Weight Loss Programs Programs, whether or not under medical supervision, unless listed as
covered in this Booklet.
This Exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
48) Weight Loss Surgery Bariatric surgery. This includes but is not limited to Roux-en-Y (RNY),
Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgeries lower stomach
capacity and divert partly digested food from the duodenum to the jejunum, the section of the small
intestine extending from the duodenum), or Gastroplasty, (surgeries that reduce stomach size), or
gastric banding procedures.
Whats Not Covered Under Your Prescription Drug Retail or Home
Delivery (Mail Order) Pharmacy Benefit
In addition to the above Exclusions, certain items are not covered under the Prescription Drug Retail or
Home Delivery (Mail Order) Pharmacy benefit:
1. Administration Charges Charges for the administration of any Drug except for covered
immunizations as approved by us or the PBM.

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2. Clinically-Equivalent Alternatives Certain Prescription Drugs may not be covered if you could use a
clinically equivalent Drug, unless required by law. Clinically equivalent means Drugs that for most
Members, will give you similar results for a disease or condition. If you have questions about whether
a certain Drug is covered and which Drugs fall into this group, please call the number on the back of
your Identification Card, or visit our website at www.anthem.com.
3. Compound Drugs Compound Drugs unless its primary ingredient (the highest cost ingredient) is
FDA approved and requires a prescription to dispense, and the Compound Drug is not essentially the
same as an FDA-approved product from a drug manufacturer.
4. Contrary to Approved Medical and Professional Standards Drugs given to you or prescribed in a
way that is against approved medical and professional standards of practice.
5. Delivery Charges Charges for delivery of Prescription Drugs.
6. Drugs Given at the Providers Office / Facility Drugs you take at the time and place where you are
given them or where the Prescription Order is issued. This includes samples given by a Doctor. This
Exclusion does not apply to Drugs used with a diagnostic service, Drugs given during chemotherapy
in the office as described in the Prescription Drugs Administered by a Medical Provider section, or
Drugs covered under the Medical and Surgical Supplies benefit they are Covered Services.
7. Drugs Not on the Anthem Prescription Drug List (a formulary) You can get a copy of the list by
calling us or visiting our website at www.anthem.com.
8. Drugs That Do Not Need a Prescription Drugs that do not need a prescription by federal law
(including Drugs that need a prescription by state law, but not by federal law), except for injectable
insulin or where applicable law requires coverage of the drug.
9. Drugs Over Quantity or Age Limits Drugs in quantities which are over the limits set by the Plan, or
which are over any age limits set by us.
10. Drugs Over the Quantity Prescribed or Refills After One Year Drugs in amounts over the quantity
prescribed, or for any refill given more than one year after the date of the original Prescription Order.
11. Fluoride Treatments Topical and oral fluoride treatments. While these services are not covered
under the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit,
they may be covered under the Pediatric Dental Services for Members through Age 18 benefit.
Please see that section for further details.
12. Infertility Drugs Drugs used in assisted reproductive technology procedures to achieve conception
(e.g., IVF, ZIFT, GIFT).
13. Items Covered as Durable Medical Equipment (DME) Therapeutic DME, devices and supplies
except peak flow meters, spacers, and blood glucose monitors. Items not covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit may be covered
under the Durable Medical Equipment and Medical Devices benefit. Please see that section for
details.
14. Items Covered as Medical Supplies Oral immunizations and biologicals, even if they are federal
legend Drugs, are covered as medical supplies based on where you get the service or item. Over the
counter Drugs, devices or products, are not Covered Services unless we must cover them under
federal law.
15. Items Covered Under the Allergy Services Benefit Allergy desensitization products or allergy
serum. While not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, these items may be covered under the Allergy Services benefit. Please
see that section for details.
16. Lost or Stolen Drugs Refills of lost or stolen Drugs.
17. Mail Order Providers other than the PBMs Home Delivery Mail Order Provider Prescription
Drugs dispensed by any Mail Order Provider other than the PBMs Home Delivery Mail Order
Provider, unless we must cover them by law.

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18. Non-approved Drugs Drugs not approved by the FDA.
19. Off label use Off label use, unless we must cover the use by law or if we, or the PBM, approve it.
20. Onychomycosis Drugs Drugs for Onchomycosis (toenail fungus) except when we allow it to treat
Members who are immuno-compromised or diabetic.
21. Over-the-Counter Items Drugs, devices and products, or Prescription Legend Drugs with over the
counter equivalents and any Drugs, devices or products that are therapeutically comparable to an
over the counter Drug, device, or product. This includes Prescription Legend Drugs when any version
or strength becomes available over the counter.
This Exclusion does not apply to over-the-counter products that we must cover under federal law with
a Prescription.
22. Sex Change Drugs Drugs for sex change surgery, unless we must cover such drugs under
applicable law.
23.22. Sexual Dysfunction Drugs Drugs to treat sexual or erectile problems.
24.23. Syringes Hypodermic syringes except when given for use with insulin and other covered self-
injectable Drugs and medicine.
25.24. Weight Loss Drugs Any Drug mainly used for weight loss.
Pre-existing Conditions
Not applicable, plan does not impose limitation period for pre-existing conditions.

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Section 9. Member Payment Responsibility
Your Cost-Shares
Your Plan may involve Copayments, Deductibles, and/or Coinsurance, which are charges that you must
pay when receiving Covered Services. Your Plan may also have an Out-of-Pocket Limit, which limits the
cost-shares you must pay. Please read the Schedule of Benefits (Who Pays What) for details on your
cost-shares. Also read the Definitions section for a better understanding of each type of cost share.
Maximum Allowed Amount
General
This section describes how we determine the amount of reimbursement for Covered Services.
Reimbursement for services rendered by In-Network and Out-of-Network Providers is based on this
Booklets Maximum Allowed Amount for the Covered Service that you receive. Please see the Claims
Procedure (How to File a Claim) section for additional information.
The Maximum Allowed Amount for this Booklet is the maximum amount of reimbursement we will allow
for services and supplies:
That meet our definition of Covered Services, to the extent such services and supplies are covered
under your Booklet and are not excluded;
That are Medically Necessary; and
That are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in your Booklet.
You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met
your Deductible or have a Copayment or Coinsurance. In addition, when you receive Covered Services
from an Out-of-Network Provider, you may be responsible for paying any difference between the
Maximum Allowed Amount and the Providers actual charges. This amount can be significant.
When you receive Covered Services from a Provider, we will, to the extent applicable, apply claim
processing rules to the claim submitted for those Covered Services. These rules evaluate the claim
information and, among other things, determine the accuracy and appropriateness of the procedure and
diagnosis codes included in the claim. Applying these rules may affect our determination of the Maximum
Allowed Amount. Our application of these rules does not mean that the Covered Services you received
were not Medically Necessary. It means we have determined that the claim was submitted inconsistent
with procedure coding rules and/or reimbursement policies. For example, your Provider may have
submitted the claim using several procedure codes when there is a single procedure code that includes
all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be
based on the single procedure code rather than a separate Maximum Allowed Amount for each billed
code.
Likewise, when multiple procedures are performed on the same day by the same Doctor or other
healthcare professional, we may reduce the Maximum Allowed Amounts for those secondary and
subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those
procedures would represent duplicative payment for components of the primary procedure that may be
considered incidental or inclusive.

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Provider Network Status
The Maximum Allowed Amount may vary depending upon whether the Provider is an In-Network Provider
or an Out-of-Network Provider.
An In-Network Provider is a Provider who is in the managed network for this specific product or in a
special Center of Excellence/or other closely managed specialty network, or who has a participation
contract with us. For Covered Services performed by an In-Network Provider, the Maximum Allowed
Amount for this Booklet is the rate the Provider has agreed with us to accept as reimbursement for the
Covered Services. Because In-Network Providers have agreed to accept the Maximum Allowed Amount
as payment in full for those Covered Services, they should not send you a bill or collect for amounts
above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion
of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or
Coinsurance. Please call Customer Service for help in finding an In-Network Provider or visit
www.anthem.com.
Providers who have not signed any contract with us and are not in any of our networks are Out-of-
Network Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain
ancillary providers.
For Covered Services you receive from an Out-of-Network Provider, the Maximum Allowed Amount for
this Booklet will be one of the following as determined by us:
1. An amount based on Anthems non-participating Provider fee schedule/rate, which is established at
Anthems discretion, and which Anthem may modify from time to time, after considering one or more
of the following: reimbursement amounts accepted by like/similar Providers contracted with Anthem,
reimbursement amounts paid by the Centers for Medicare and Medicaid Services (CMS) for the same
services or supplies, and other industry cost, reimbursement and utilization data; or
2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid
Services (CMS). When basing the Maximum Allowed amount upon the level or method of
reimbursement used by CMS, Anthem will update such information, which is unadjusted for
geographic locality, no less than annually; or
3. An amount based on information provided by a third party vendor, which may reflect one or more of
the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience
required for the treatment; or (3) comparable Providers fees and costs to deliver care, or
4. An amount negotiated by us or a third party vendor which has been agreed to by the Provider. This
may include rates for services coordinated through case management, or
5. An amount based on or derived from the total charges billed by the Out-of-Network Provider.
Unlike In-Network Providers, Out-of-Network Providers may send you a bill and collect for the amount of
the Providers charge that exceeds our Maximum Allowed Amount. You are responsible for paying the
difference between the Maximum Allowed Amount and the amount the Provider charges. This amount
can be significant. Choosing an In-Network Provider will likely result in lower out of pocket costs to you.
Please call Customer Service for help in finding an In-Network Provider or visit our website at
www.anthem.com.
Customer Service is also available to assist you in determining this Booklets Maximum Allowed Amount
for a particular service from an Out-of-Network Provider. In order for us to assist you, you will need to
obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the
Provider will render. You will also need to know the Providers charges to calculate your out of pocket
responsibility. Although Customer Service can assist you with this pre-service information, the final
Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider.

99
For Prescription Drugs, the Maximum Allowed Amount is the amount determined by us using Prescription
Drug cost information provided by the Pharmacy Benefits Manager.
Member Cost Share
For certain Covered Services and depending on your Plan design, you may be required to pay a part of
the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or
Coinsurance).
Your cost share amount and Out-of-Pocket Limits may vary depending on whether you received services
from an In-Network or Out-of-Network Provider. Specifically, you may be required to pay higher cost
sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see
the Schedule of Benefits (Who Pays What) in this Booklet for your cost share responsibilities and
limitations, or call Customer Service to learn how this Booklets benefits or cost share amounts may vary
by the type of Provider you use.
We will not provide any reimbursement for non-Covered Services. You may be responsible for the total
amount billed by your Provider for non-Covered Services, regardless of whether such services are
performed by an In-Network or Out-of-Network Provider. Non-covered services include services
specifically excluded from coverage by the terms of your Plan and received after benefits have been
exhausted Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits.
In some instances you may only be asked to pay the lower In-Network cost sharing amount when you use
an Out-of-Network Provider. For example, if you go to an In-Network Hospital or Provider Facility and
receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or
pathologist who is employed by or contracted with an In-Network Hospital or Facility, you will pay the In-
Network cost share amounts for those Covered Services. You will not have to pay more for the Covered
Services than you would have had to pay if it had been received from an In-Network Provider.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklets cost share amounts; see your Schedule of Benefits (Who Pays What) for
your applicable amounts.
Example: Your Plan has a Coinsurance cost share of 20% for In-Network services, and 30% for Out-of-
Network services after the In-Network or Out-of-Network Deductible has been met.
You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-
Network anesthesiologist to perform the anesthesiology services for the surgery. You have no control
over the anesthesiologist used.
The Out-of-Network anesthesiologists charge for the service is $1200, your coinsurance responsibility
is 20% of $1200, or $240.
You choose an In-Network surgeon. The charge was $2500. The Maximum Allowed Amount for the
surgery is $1500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of
$1500, or $300. We allow 80% of $1500, or $1200. The In-Network surgeon accepts the total of
$1500 as reimbursement for the surgery regardless of the charges. Your total out of pocket
responsibility would be $300.
Authorized Services
In some circumstances, such as where there is no In-Network Provider available, or if we dont have an
In-Network Provider within a reasonable number of miles from your home, for the Covered Service, we
may authorize the In-Network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply
to a claim for a Covered Service you receive from an Out-of-Network Provider. In such circumstances,
you must contact us in advance of obtaining the Covered Service. If approved, we will pay the Out-of-

100
Network Provider at the In-Network level of benefits and you wont need to pay more for the services than
if the services had been received from an In-Network Provider. A precertification or preauthorization is not
the same thing as an Authorized Service; we must specifically authorize the service from an Out-of-
Network Provider at the In-Network cost share amounts.
Sometimes you may need to travel a reasonable distance to get care from an In-Network Provider. This
does not apply if care is for an Emergency.
If you do not receive a preauthorized network exception to obtain Covered Services from an Out-of-
Network Provider at the In-Network cost share amounts, the claim will be processed using your Out-of-
Network cost shares.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklets cost share amounts; see your Schedule of Benefits (Who Pays What) for
your applicable amounts.
Example:
You require the services of a specialty Provider; but there is no In-Network Provider for that specialty in
your state of residence. You contact us in advance of receiving any Covered Services, and we authorize
you to go to an available Out-of-Network Provider for that Covered Service and we agree that the In-
Network cost share will apply.
Your Plan has a $45 Copayment for Out-of-Network Providers and a $25 Copayment for In-Network
Providers for the Covered Service. The Out-of-Network Providers charge for this service is $500. The
Maximum Allowed Amount is $200.
Because we have authorized the In-Network cost share amount to apply in this situation, you will be
responsible for the In-Network Copayment of $25 and we will be responsible for the remaining $475.
Claims Review
Anthem has processes to review claims before and after payment to detect fraud, waste, abuse and other
inappropriate activity. Members seeking services from Out-of Network Providers could be balance billed
by the Out-of-Network Provider for those services that are determined to be not payable as a result of
these review processes. A claim may also be determined to be not payable due to a Providers failure to
submit medical records with the claims that are under review in these processes.


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Section 10. Claims Procedure (How to File a Claim)
This section describes how we reimburse claims and what information is needed when you submit a
claim. When you receive care from an In-Network Provider, you do not need to file a claim because the
In-Network Provider will do this for you. If you receive care from an Out-of-Network Provider, you will
need to make sure a claim is filed. Many Out-of-Network Hospitals, Doctors and other Providers will file
your claim for you, although they are not required to do so. If you file the claim, use a claim form as
described later in this section.
Notice of Claim & Proof of Loss
After you get Covered Services, we must receive written notice of your claim within 365 days in order for
benefits to be paid. The claim must have the information we need to determine benefits. If the claim
does not include enough information, we will ask for more details and it must be sent to us within the time
listed below or no benefits will be covered, unless required by law.
In certain cases, you may have some extra time to file a claim. If we did not get your claim within 365
days, but it is sent in as soon as reasonably possible and within one year after the 365-day period ends
(i.e., within 24 months), you may still be able to get benefits. However, any claims, or additional
information on claims, sent in more than 24 months after you get Covered Services will be denied.
Claim Forms
Claim forms will usually be available from most Providers. If forms are not available, either send a written
request for a claims form to us, or contact Customer Service and ask for a claims form to be sent to you.
If you do not receive the claims form within 15 days of notifying us, written notice of services rendered
may be submitted to us without the claim form. The same information that would be given on the claim
form must be included in the written notice of claim. This includes:
Name of patient.
Patients relationship with the Subscriber.
Identification number.
Date, type, and place of service.
Your signature and the Providers signature.
Members Cooperation
You will be expected to complete and submit to us all such authorizations, consents, releases,
assignments and other documents that may be needed in order to obtain or assure reimbursement under
Medicare, Workers Compensation or any other governmental program. If you fail to cooperate (including
if you fail to enroll under Part B of the Medicare program where Medicare is the responsible payor), you
will be responsible for any charge for services.
Payment of Benefits
We will make benefit payments directly to Network Providers for Covered Services. If you use an Out-of-
Network Provider, however, we may make benefit payments to you unless if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of
you. We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services. Payments may also be made to, and notice regarding the receipt
and/or adjudication of claims sent to, an Alternate Recipient (any child of a Subscriber who is recognized,
under a Qualified Medical Child Support Order (QMSCO), as having a right to enrollment under the
Groups Contract), or that persons custodial parent or designated representative. Any benefit payments

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made by us will discharge our obligation for Covered Services. You cannot assign your right to benefits
to anyone else, except as required by a Qualified Medical Child Support Order as defined by ERISA or
any applicable state law.
Once a Provider performs a Covered Service, we will not honor a request for us to withhold payment of
the claims submitted.
Inter-Plan Programs
Out-of-Area Services
Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to
generally as Inter-Plan Programs. Whenever you obtain healthcare services outside of Anthems
Service Area, the claims for these services may be processed through one of these Inter-Plan Programs,
which include the BlueCard Program and may include negotiated National Account arrangements
available between Anthem and other Blue Cross and Blue Shield Licensees.
Typically, when accessing care outside Anthems Service Area, you will obtain care from healthcare
Providers that have a contractual agreement (i.e., are participating Providers) with the local Blue Cross
and/or Blue Shield Licensee in that other geographic area (Host Blue). In some instances, you may
obtain care from nonparticipating healthcare Providers. Anthems payment practices in both instances are
described below.
BlueCard

Program
Under the BlueCard

Program, when you access covered healthcare services within the geographic area
served by a Host Blue, Anthem will remain responsible for fulfilling Anthems contractual obligations.
However, the Host Blue is responsible for contracting with and generally handling all interactions with its
participating healthcare Providers.
Whenever you access covered healthcare services outside Anthems Service Area and the claim is
processed through the BlueCard Program, the amount you pay for covered healthcare services is
calculated based on the lower of:
The billed covered charges for your Covered Services; or
The negotiated price that the Host Blue makes available to Anthem.
Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays
to your healthcare Provider. Sometimes, it is an estimated price that takes into account special
arrangements with your healthcare Provider or Provider group that may include types of settlements,
incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on
a discount that results in expected average savings for similar types of healthcare Providers after taking
into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for
over- or underestimation of modifications of past pricing for the types of transaction modifications noted
above. However, such adjustments will not affect the price Anthem uses for your claim because they will
not be applied retroactively to claims already paid.
Federal law or the law in a small number of states may require the Host Blue to add a surcharge to your
calculation. If federal law or any state laws mandate other liability calculation methods, including a
surcharge, we would then calculate your liability for any covered healthcare services according to
applicable law.

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Non-Participating Healthcare Providers Outside Our Service Area
Member Liability Calculation
When covered healthcare services are provided outside of our Service Area by non-participating
healthcare providers, the amount you pay for such services will generally be based on either the Host
Blues nonparticipating healthcare provider local payment or the pricing arrangements required by
applicable state law. In these situations, you may be liable for the difference between the amount that the
non-participating healthcare provider bills and the payment we will make for the Covered Services as set
forth in this paragraph.
Exceptions
In certain situations, we may use other payment bases, such as billed covered charges, the payment we
would make if the healthcare services had been obtained within our Service Area, or a special negotiated
payment, as permitted under Inter-Plan Programs Policies, to determine the amount we will pay for
services rendered by nonparticipating healthcare providers. In these situations, you may be liable for the
difference between the amount that the non-participating healthcare provider bills and the payment we
will make for the Covered Services as set forth in this paragraph.
If you obtain services in a state with more than one Blue Plan network, an exclusive network arrangement
may be in place. If you see a Provider who is not part of an exclusive network arrangement, that
Providers service(s) will be considered Non-Network care, and you may be billed the difference between
the charge and the Maximum Allowable Amount. You may call the Customer Service number on your ID
card for more information about such arrangements.


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Section 11. General Policy Provisions
Assignment
The Group cannot legally transfer this Booklet, without obtaining written permission from us. Members
cannot legally transfer the coverage. Benefits available under this Booklet are not assignable by any
Member without obtaining written permission from us, unless in a way described in the How to Access
Your Services and Obtain Approval of Benefits (Applicable to Managed Care Plans) and in Claims
Procedure (How to File a Claim) sections.
Automobile Insurance Provisions
We will coordinate the benefits of this Booklet with the benefits of a complying auto insurance policy.
A complying automobile insurance policy is an auto policy approved by the Colorado Division of
Insurance that provides at least the minimum coverage required by law, and one which is subject to the
Colorado Auto Accident Reparations Act or Colorado Revised Statutes 10-4-601 et seq. Any state or
federal law requiring similar benefits through legislation or regulation is also considered a complying auto
policy.
How We Coordinate Benefits with Auto Policies - Your benefits under this Booklet may be coordinated
with the coverages afforded by an auto policy. After any primary coverages offered by the auto policy
are exhausted, including without limitation any no-fault, personal injury protection, or medical payment
coverages, We will pay benefits subject to the terms and conditions of this Booklet. If there is more than
one auto policy that offers primary coverage, each will pay its maximum coverage before We are liable for
any further payments.
You, your representative, agents and heirs must fully cooperate with Us to make sure that the auto policy
has paid all required benefits. We may require you to take a physical examination in disputed cases. If
there is an auto policy in effect, and you waive or fail to assert your rights to such benefits, this plan will
not pay those benefits that could be available under an auto policy.
We may require proof that the auto policy has paid all primary benefits before making any payments
under this Booklet. On the other hand, we may but are not required to pay benefits under this Booklet,
and later coordinate with or seek reimbursement under the auto policy. In all cases, upon payment, we
are entitled to exercise Our rights under this Booklet and under applicable law against any and all
potentially responsible parties or insurers. In that event, we may exercise the rights found in this section.
What Happens If You Do Not Have Another Policy - We will pay benefits if you are injured while you
are riding in or driving a motor vehicle that you own if it is not covered by an auto policy.
Similarly if not covered by an auto policy, we will also pay benefits for your injuries if as a non-owner or
driver, passenger or when walking you were in a motor vehicle accident. In that event, we may exercise
the rights found in this section.
Clerical Error
A clerical error will never disturb or affect your coverage, as long as your coverage is valid under the rules
of the Plan. This rule applies to any clerical error, regardless of whether it was the fault of the Group or
us.

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Confidentiality and Release of Information
We will use reasonable efforts, and take the same care to preserve the confidentiality of your medical
information. We may use data collected in the course of providing services hereunder for statistical
evaluation and research. If such data is ever released to a third party, it shall be released only in
aggregate statistical form without identifying you. Medical information may be released only with your
written consent or as required by law. It must be signed, dated and must specify the nature of the
information and to which persons and organizations it may be disclosed. You may access your own
medical records.
We may release your medical information to professional peer review organizations and to the Group for
purposes of reporting claims experience or conducting an audit of our operations, provided the
information disclosed is reasonably necessary for the Group to conduct the review or audit.
A statement describing our policies and procedures for preserving the confidentiality of medical records is
available and will be furnished to you upon request.
Conformity with Law
Any term of the Plan which is in conflict with the laws of the state in which the Group Contract is issued,
or with federal law, will hereby be automatically amended to conform with the minimum requirements of
such laws.
Contract with Anthem
The Group, on behalf of itself and its participants, hereby expressly acknowledges its understanding that
this Plan constitutes a Contract solely between the Group and us, Anthem Blue Cross and Blue Shield
(Anthem), and that we are an independent corporation licensed to use the Blue Cross and Blue Shield
names and marks in the state of Colorado. The Blue Cross Blue Shield marks are registered by the Blue
Cross and Blue Shield Association, an association of independently licensed Blue Cross and Blue Shield
plans, with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries. Further, we
are not contracting as the agent of the Blue Cross and Blue Shield Association or any other Blue Cross
and/or Blue Shield plan or licensee. The Group, on behalf of itself and its participants, further
acknowledges and agrees that it has not entered into this Contract based upon representations by any
person other than Anthem Blue Cross and Blue Shield (Anthem) and that no person, entity, or
organization other than Anthem Blue Cross and Blue Shield (Anthem) shall be held accountable or liable
to the Group for any of Anthem Blue Cross and Blue Shield (Anthem)s obligations to the Group created
under the Contract. This paragraph shall not create any additional obligations whatsoever on our part
other than those obligations created under other terms of this agreement.
Entire Contract
Note: The laws of the state in which the Group Contract is issued will apply unless otherwise stated
herein.
This Booklet, any riders, endorsements or attachments, and the individual applications of the Subscriber
and Dependents constitute the entire Contract between the Group and us and as of the Effective Date,
supersede all other agreements. In addition the Group has a Group Contract and Group application
which includes terms that apply to this coverage. Any and all statements made to us by the Group and
any and all statements made to the Group by us are representations and not warranties. No such
statement, unless it is contained in a written application for coverage under this Booklet, shall be used in
defense to a claim under this Booklet.

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Form or Content of Booklet
No agent or employee of ours is authorized to change the form or content of this Booklet. Changes can
only be made through a written authorization, signed by an officer of Anthem. Changes are further noted
in Modifications below this section.
Government Programs
The benefits under this Plan shall not duplicate any benefits that you are entitled to, or eligible for, under
any other governmental program. This does not apply if any particular laws require us to be the primary
payor. If we have duplicated such benefits, all money paid by such programs to you for services you
have or are receiving, shall be returned by or on your behalf to us.
Medical Policy and Technology Assessment
Anthem reviews and evaluates new technology according to its technology evaluation criteria developed
by its medical directors. Technology assessment criteria are used to determine the Experimental /
Investigational status or Medical Necessity of new technology. Guidance and external validation of
Anthems medical policy is provided by the Medical Policy and Technology Assessment Committee
(MPTAC) which consists of approximately 20 Doctors from various medical specialties including Anthems
medical directors, Doctors in academic medicine and Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Medicare
Any benefits covered under both this Plan and Medicare will be covered according to Medicare
Secondary Payor legislation, regulations, and Centers for Medicare & Medicaid Services guidelines,
subject to federal court decisions. Federal law controls whenever there is a conflict among state law,
Booklet terms, and federal law.
Except when federal law requires us to be the primary payor, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Part B. Where Medicare is the responsible payor, all
sums payable by Medicare for services provided to you shall be reimbursed by or on your behalf to us, to
the extent we have made payment for such services. For the purposes of the calculation of benefits, if
you have not enrolled in Medicare Parts B and/or D, we will calculate benefits as if you had enrolled. You
should enroll in Medicare Part B as soon as possible to avoid potential liability. For Medicare Part
D we will calculate benefits as if you had enrolled in the Standard Basic Plan.
Modifications
This Booklet allows the Group to make Plan coverage available to eligible Members. However, this
Booklet shall be subject to amendment, modification, and termination in accordance with any of its terms,
the Group Contract, or by mutual agreement between the Group and us without the permission or
involvement of any Member. Changes will not be effective until the date specified in the written notice we
give to the Group about the change. By electing medical and Hospital coverage under the Plan or
accepting Plan benefits, all Members who are legally capable of entering into a contract, and the legal
representatives of all Members that are incapable of entering into a contract, agree to all terms and
conditions in this Booklet.

107
For employer groups of one to 50, if we amend this Booklet to change benefits, notice of the amendment
will be given to the employer no less than 90 days before to the Effective Date of such change and the
amendment(s) will be effective for each group on the renewal or anniversary date of the Group Contract.
For all other changes, such as changes due to state or federal law or regulation, we may amend this
Booklet when authorized by one of our officers and, to the extent required by law, will provide the Group
60 days notice of such changes. We will then provide the Group with any amendments within 60 days
following the effective date of the amendment. If the Group requests a change that reduces or eliminates
coverage, such change must be requested in writing or signed by the Group. The Group will notify you of
such change(s) to coverage. We or the Group will later send or make available to you an amendment to
this Booklet or a new Booklet.
Network Access Plan
We strive to provide Provider networks in Colorado that addresses your health care needs. The Network
Access Plan describes our Provider network standards for network sufficiency in service, access and
availability, as well as assessment procedures we follow in our effort to maintain adequate and accessible
networks. To request a copy of this document, call customer service. This document is also available on
our website or for in-person review at 700 Broadway in Denver, Colorado.
Not Liable for Provider Acts or Omissions
We are not responsible for the actual care you receive from any person. This Booklet does not give
anyone any claim, right, or cause of action against Anthem based on the actions of a Provider of health
care, services, or supplies.
Policies and Procedures
We are able to introduce new policies, procedures, rules and interpretations, as long as they are
reasonable. Such changes are introduced to make the Plan more orderly and efficient. Members must
follow and accept any new policies, procedures, rules, and interpretations.
Under the terms of the Group Contract, we have the authority, in our sole discretion, to introduce or
terminate from time to time, pilot or test programs for disease management or wellness initiatives which
may result in the payment of benefits not otherwise specified in this Booklet. We reserve the right to
discontinue a pilot or test program at any time. We will give thirty (30) days advance written notice to the
Group of the introduction or termination of any such program.
Relationship of Parties (Group-Member-Anthem)
The Group is responsible for passing information to you. For example, if we give notice to the Group, it is
the Groups responsibility to pass that information to you. The Group is also responsible for passing
eligibility data to us in a timely manner. If the Group does not give us with timely enrollment and
termination information, we are not responsible for the payment of Covered Services for Members.
Relationship of Parties (Anthem and In-Network Providers)
The relationship between Anthem and In-Network Providers is an independent contractor relationship. In-
Network Providers are not agents or employees of ours, nor is Anthem, or any employee of Anthem, an
employee or agent of In-Network Providers.
Your health care Provider is solely responsible for all decisions regarding your care and treatment,
regardless of whether such care and treatment is a Covered Service under this Plan. We shall not be

108
responsible for any claim or demand on account of damages arising out of, or in any manner connected
with, any injuries suffered by you while receiving care from any In-Network Provider or in any In-Network
Providers Facilities.
Your In-Network Providers agreement for providing Covered Services may include financial incentives or
risk sharing relationships related to the provision of services or referrals to other Providers, including In-
Network Providers, Out-of-Network Providers, and disease management programs. If you have
questions regarding such incentives or risk sharing relationships, please contact your Provider or us.
Reservation of Discretionary Authority
This section only applies when the interpretation of this Booklet is governed by the Employee Retirement
Income Security Act (ERISA), 29 U.S.C. 1001 et seq.
We, or anyone acting on our behalf, shall determine the administration of benefits and eligibility for
participation in such a manner that has a rational relationship to the terms set forth herein. However, we,
or anyone acting on our behalf, have complete discretion to determine the administration of your benefits.
Our determination shall be final and conclusive and may include, without limitation, determination of
whether the services, care, treatment, or supplies are Medically Necessary, Experimental /
Investigational, whether surgery is cosmetic, and whether charges are consistent with the Maximum
Allowable Amount. However, a Member may utilize all applicable complaint and appeals procedures, and
where required by applicable law, Our determination may be reviewed de novo (as if for the first time) in a
later appeal or legal action.
We, or anyone acting on our behalf, shall have all the powers necessary or appropriate to enable us to
carry out the duties in connection with the operation and administration of the Plan. This includes, without
limitation, the power to construe the Contract, to determine all questions arising under the Booklet and to
make, establish and amend the rules, regulations, and procedures with regard to the interpretation and
administration of the provisions of this Plan. However, these powers shall be exercised in such a manner
that has reasonable relationship to the provisions of the Contract, the Booklet, Provider agreements, and
applicable state or federal laws. A specific limitation or exclusion will override more general benefit
language.
Right of Recovery
Whenever payment has been made in error, we will have the right to recover such payment from you or, if
applicable, the Provider. In the event we recover a payment made in error from the Provider, except in
cases of fraud, we will only recover such payment from the Provider during the 24 months after the date
we made the payment on a claim submitted by the Provider, unless the law permits a different timeframe
in which to recover. We reserve the right to deduct or offset any amounts paid in error from any pending
or future claim. The cost share amount shown in your Explanation of Benefits is the final determination
and you will not receive notice of an adjusted cost share amount as a result of such Recovery activity.
We have oversight responsibility for compliance with Provider and vendor contracts. We may enter into a
settlement or compromise regarding enforcement of these contracts and may retain any recoveries made
from a Provider or vendor resulting from these audits if the return of the overpayment is not feasible. We
have established Recovery policies to determine which recoveries are to be pursued, when to incur costs
and expenses and settle or compromise Recovery amounts. We will not pursue recoveries for
overpayments if the cost of collection exceeds the overpayment amount. We may not give you notice of
overpayments made by us or you if the Recovery method makes providing such notice administratively
burdensome.

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Unauthorized Use of Identification Card
If you permit your Identification Card to be used by someone else or if you use the card before coverage
is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting
from the unauthorized use. Fraudulent misuse could also result in termination of the coverage.
Value-Added Programs
We may offer health or fitness related programs to our Members, through which you may access
discounted rates from certain vendors for products and services available to the general public. Products
and services available under this program are not Covered Services under your Plan but are in addition to
Plan benefits. As such, program features are not guaranteed under your health Plan Contract and could
be discontinued at any time. We do not endorse any vendor, product or service associated with this
program. Program vendors are solely responsible for the products and services you receive.
Value of Covered Services
For purposes of subrogation, reimbursement of excess benefits, or reimbursement under any Workers
Compensation or Employer Liability Law, the value of Covered Services shall be the amount we paid for
the Covered Services.
Voluntary Clinical Quality Programs
We may offer additional opportunities to assist you in obtaining certain covered preventive or other care
(e.g., well child check-ups or certain laboratory screening tests) that you have not received in the
recommended timeframe. These opportunities are called voluntary clinical quality programs. They are
designed to encourage you to get certain care when you need it and are separate from Covered Services
under your Plan. These programs are not guaranteed and could be discontinued at any time. We will
give you the choice and if you choose to participate in one of these programs, and obtain the
recommended care within the programs timeframe, you may receive incentives such as gift cards. Under
other clinical quality programs, you may receive a home test kit that allows you to collect the specimen for
certain covered laboratory tests at home and mail it to the laboratory for processing. You may need to
pay any cost shares that normally apply to such covered laboratory tests (e.g., those applicable to the
laboratory processing fee) but will not need to pay for the home test kit. (If you receive a gift card and use
it for purposes other than for qualified medical expenses, this may result in taxable income to you. For
additional guidance, please consult your tax advisor.)
Voluntary Wellness Incentive Programs
We may offer health or fitness related program options for purchase by your Group to help you achieve
your best health. These programs are not Covered Services under your Plan, but are separate
components, which are not guaranteed under this Plan and could be discontinued at any time. If your
Group has selected one of these options to make available to all employees, you may receive incentives
such as gift cards by participating in or completing such voluntary wellness promotion programs as health
assessments, weight management or tobacco cessation coaching. Under other options a Group may
select, you may receive such incentives by achieving specified standards based on health factors under
wellness programs that comply with applicable law. If you think you might be unable to meet the
standard, you might qualify for an opportunity to earn the same reward by different means. You may
contact us at the customer service number on your ID card and we will work with you (and, if you wish,
your Doctor) to find a wellness program with the same reward that is right for you in light of your health
status. (If you receive a gift card as a wellness reward and use it for purposes other than for qualified
medical expenses, this may result in taxable income to you. For additional guidance, please consult your
tax advisor.)

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Waiver
No agent or other person, except an authorized officer of Anthem, is able to disregard any conditions or
restrictions contained in this Booklet, to extend the amount of time for making a payment to us, or to bind
us by making any promise or representation or by giving or receiving any information.
Workers Compensation
The benefits under this Plan are not designed to duplicate benefits that you are eligible for under
Workers Compensation Law. All money paid or owed by Workers Compensation for services provided
to you shall be paid back by you, or on your behalf, to us if we have made or make payment for the
services received. It is understood that coverage under this Plan does not replace or affect any Workers
Compensation coverage requirements.
Subrogation and Reimbursement
This section applies when we pay benefits as a result of injuries or illness and another party or party(ies)
agrees or is ordered to pay money because of these injuries or when the Member received or is entitled
to receive a Recovery because of these injuries or illnesses. Reimbursement or subrogation under this
Booklet may only be permitted if you have been fully compensated, and, the amount recoverable by us
may be reduced by a proportionate share of your attorney fees and costs, if state law so requires.
Subrogation
We have the right to recover payments we make on your behalf. The following apply:
If you have been fully compensated, we have a lien against all or a portion of the benefits that have
been paid to you from the following parties, including, but not limited to, the party or parties who
caused the injuries or illness, the insurer or other indemnifier of the party or parties who caused the
injuries or illness, a guarantor of the party or parties who caused the injuries or illness, your own
insurer (for example, uninsured, underinsured, medical payments or no-fault coverage, or a workers
compensation insurer), or any other person, entity, policy or plan that may be liable or legally
responsible in relation to the injuries or illness. However, our Recovery cannot exceed the amount
actually paid by us under this Booklet as it relates to the injuries or illness that are the subject of the
subrogation action; and
You and your legal representative must do whatever is necessary to enable us to exercise our rights
and do nothing to prejudice them. If you have not pursued a claim against a third party allegedly at
fault for your injuries by the date that is sixty (60) days before to the date on which the applicable
statute of limitations expires, we have a right to bring legal action against the at-fault party.
Reimbursement
If you, a person who represents your legal interest, or beneficiary have been fully compensated and We
have not been repaid for the health insurance benefits we paid on the Members behalf, we shall have a
right to be repaid from the Recovery in the amount of the health insurance benefits we paid on your
behalf and the following apply:
You must reimburse us to the extent of the health insurance benefits we paid on the Members behalf
from any Recovery, including, but not limited to, the party or parties who caused the injuries or illness,
the insurer or other indemnifier of the party or parties who caused the injuries or illness, a guarantor
of the party or parties who caused the injuries or illness, your own insurer (for example, underinsured,
medical payments, or a workers compensation insurer), or any other person, entity, policy or plan
that may be liable or legally responsible in relation to the injuries or illness;

111
Notwithstanding any allocation made in a settlement agreement or court order, we shall have a right
of reimbursement; and
You, a person who represents your legal interest, or beneficiary must hold in trust for us right away
the amount recovered in gross that is to be paid to us. The amount recovered in gross is the total
amount of your Recovery reduced by your lawyer fees and costs.
The Members Duties
You, a person who represents your legal interest, or beneficiary must tell us right away the how, when
and where an accident or event that resulted in your injury or illness. We must find out what
happened and get all the details about the parties involved;
You, a person who represents your legal interest, or beneficiary must work with us in investigating,
settling and protecting rights;
You, a person who represents your legal interest, or beneficiary must send us copies of all police
reports, notices or other papers received in connection with the accident or incident resulting in
personal injury or illness;
You, a person who represents your legal interest, or beneficiary must promptly notify us if you retain
an attorney or if a lawsuit is filed;
If you, a person who represents your legal interest, or beneficiary gets a Recovery that is less than
the sum of all your damages incurred by you, you are required to tell us within 60 days of your receipt
of the Recovery. The notice to us must include:
- Total amount and source of the Recovery;
- Coverage limits applicable to any available insurance policy, contract or benefit plan; and
- The amount of any costs charged to you.
If we receive your notice that you have not been fully paid, we have the right to dispute that
determination;
If we dispute whether your Recovery is less than the sum of all your damages, such dispute must be
resolved through arbitration; and
If you, a person who represents your legal interest, or beneficiary resides in a state where automobile
personal injury protection or medical payment coverage is mandatory, that coverage is primary and
the Booklet takes secondary status. The Booklet will reduce benefits for an amount equal to, but not
less than, that states mandatory minimum personal injury protection or medical payment
requirement.
Coordination of Benefits When Members Are Insured Under More
Than One Plan
We may coordinate benefits when you have coverage with more than one health coverage.
Duplicate Coverage
Duplicate coverage is the term used to describe when you are covered by this Booklet and also covered
by another:
Group or group-type health insurance;
Health benefits coverage; or

112
Blanket coverage.
The total benefits received by you, or on your behalf, from all coverages combined for any claim for
Covered Services will not exceed 100 percent of the total covered charges.
Order of Benefit Determination Rules The following rules are used in the order as listed:
How We Determine Which Coverage is Primary and Which is Secondary
We will determine the primary coverage and secondary coverage according to the following rule: A plan
that does not have order of benefit determination rules or if it has rules will always be primary unless the
provisions of both plans state that the plan is primary.
Non-Dependent or Dependent
The plan that covers the person other than as a dependent, for example as an employee, member,
subscriber or retiree, is primary and the plan that covers the person, as a dependent, is secondary. If the
person is a Medicare beneficiary, please refer to the section below of Determining Primacy Between
Medicare and Us for primary and secondary payer rules.
Active Employee, Retired or Laid-Off Employee
a. The plan that covers a person as an active employee, who is not laid off or retired, or a dependent of
an active employee, is the primary plan.
b. If the secondary, or other plan, does not have this rule, and as result the plans do not agree on the
order of benefits, this rule is ignored.
c. This rule does not apply if the section above of Non-Dependent or Dependent can determine the
order of benefits.
COBRA or State Continuation Coverage
a. If a person whose coverage is provided in accordance with COBRA, or under a right of continuation
according to state or federal law is covered under another plan, the plan covering the person as an
employee, member, subscriber or retiree or covering the person as a dependent of an employee,
member, subscriber, or retiree, is the primary plan and the plan covering that same person in
accordance with COBRA, or under a right of continuation in accordance with state or other federal
law, is the secondary plan.
b. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of
benefits, this rule is ignored.
c. This rule does not apply if the section above of Non-Dependent or Dependent can determine the
order of benefits.
Longer or Shorter Length of Coverage
a. If the rules above do not determine the order of benefits, the plan that covered the person for the
longer period of time is primary plan and the plan that covered the person for the shorter period of
time is the secondary plan.
b. To determine the length of time a person has been covered under a plan, two (2) successive plans
will be treated as one if the covered person was eligible under the second within twenty-four (24)
hours after the first ended.
c. The start of a new plan does not include:
(1) A change in the amount or scope of a plans benefits;

113
(2) A change in the entity that pays, provides or administers the plans benefits; or
(3) A change from one type of plan to another (such as, from a single employer plan to that of a
multiple employer plan).
d. The persons length of time covered under a plan is measured from the persons first date of
coverage under that plan. If that date is not readily available for a group plan, the date the person first
became a member of the group will be used as the date from which to determine the length of time
the persons coverage under the present plan has been in force.
If none of the rules above determine the primary plan, the allowable expenses will be shared equally
between the plans.
Dependent Child Covered Under More Than One Plan
Unless there is a court decree stating otherwise, plans covering a dependent child will determine the
order of benefits as follows:
a. For a dependent child whose parents are married or are living together, whether or not they have
been married:
(1) The plan of the parent whose birthday falls earlier in the calendar year, by month and day, is the
primary plan; or
(2) If both parents have the same birthday, the plan that has covered the parent the longest is the
primary plan.
b. For a dependent child whose parents are divorced or separated or are not living together, whether or
not they have ever been married:
(1) If the court decree states that one of the parents is responsible for the dependent childs health
care expenses or health care coverage, and the plan of that parent has actual knowledge of
those terms, that plan is primary. If the parent with financial responsibility has no health care
coverage for the dependent childs health care, but that parents spouse does, the spouses plan
is primary. This item will not apply with respect to a plan year during which benefits are paid or
provided before the entity has actual knowledge of the court decree provision;
(2) If the court decree states that both parents are responsible for the dependent childs health care
expenses or health care coverage, paragraph a above will determine the order of benefits;
(3) If the divorce decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the depend child,
paragraph a above will determine the order of benefits; or
(4) If there is no court decree allocating responsibility for the childs health care expenses of health
care coverage, the order of benefits for the child are as follows:
(a) The plan of the custodial parent;
(b) The plan of the spouse of the custodial parent;
(c) The plan of the noncustodial parent; and then
(d) The plan of the spouse of the noncustodial parent.
c. For a dependent child covered under more than one plan of individuals who are not parents of the
child, the order of benefits will be determined, as applicable, according to paragraph a. or b. above as
if those individuals were the parents of the child.
d. For a dependent child who has coverage under either or both parents' plans and also has his or her
own coverage as a dependent under a spouse's plan, the rule in the section above for Longer or
Shorter Length of Coverage applies.

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In the event the dependent child's coverage under the spouse's plan began on the same date as the
dependent child's coverage under either or both parents' plans, the order of benefits will be determined by
applying the birthday rule to the dependent child's parent(s) and the dependent's spouse.
Rules for Coordination of Benefits
When a person is covered by two (2) or more plans, the rules for determining the order of benefit
payments are as follows:
1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.
2. If the primary plan is a Closed Panel Plan, and the secondary plan is not a Closed Panel Plan, the
secondary plan will pay or provide benefits as if it were the primary plan when a covered person uses
a non-panel provider, except for emergency services or authorized referrals that are paid or provided
by the primary provider.
3. When multiple contracts providing coordinated coverage are treated as a single plan, this section only
applies to the plan as a whole, and coordination among the component contracts is governed by the
terms of the contracts.
4. If a person is covered by more than one secondary plan, each secondary plan will take into
consideration the benefits of the primary plan, or plans, and the benefits of any other plan, which, has
its benefits determined before those of that secondary plan.
5. Under the terms of a Closed Panel Plan, benefits are not payable if the covered person does not use
the services of a closed panel provider, with the exceptions of medical emergencies and if there are
allowable benefits available. In most instances, Coordination of Benefits does not occur if a covered
person is enrolled in two (2) or more Closed Panel Plans and obtains services from a provider in one
of the Closed Panel Plans because the other Closed Panel Plan (the one whose providers were not
used) has no liability. However, Coordination of Benefits may occur during the claim determination
period when the covered person receives emergency services that would have been covered by both
plans.
Determining Primacy Between Medicare and Us
We will be the primary payer for persons with Medicare age 65 and older if the policyholder is actively
working for an employer who is providing the policy holders health insurance and the employer has 20 or
more employees. Medicare will be the primary payer for persons with Medicare age 65 and older if the
policyholder is not actively working and the Member is enrolled in Medicare. Medicare will be the primary
payer for persons with Medicare age 65 and older if the employer has less than 20 employees and the
Member is enrolled in Medicare.
We will be the primary payer for persons enrolled with Medicare under age 65 when Medicare coverage
is due to disability if the policyholder is actively working for an employer who is providing the
policyholders health insurance and the employer has 100 or more employees. Medicare will be the
primary payer for persons enrolled in Medicare due to disability if the policyholder is not actively working
or the employer has less than 100 employees.
We will be the primary payer for persons with Medicare under age 65 when Medicare coverage is due to
End Stage Renal Disease (ESRD), for the first 30 months from the entitlement to or eligibility for
Medicare (whether or not Medicare is taken at that time). After 30 months, Medicare will become the
primary payer if Medicare is in effect (30-month coordination period).
When a Member becomes eligible for Medicare due to a second entitlement, such as age, We remain
primary. But this will only apply if the group health coverage was primary at the point when the second
entitlement took effect, for the duration of 30 months after becoming Medicare entitled or eligible due to
ESRD. If Medicare was primary at the point of the second entitlement, then Medicare remains primary.
There will be no 30-month coordination period for ESRD.

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Members with Medicare and Two Group Insurance Policies
Based on the primacy rules, if Medicare is secondary to a group coverage (see Medicare primacy rules),
the primary coverage covering the Member will pay first. Medicare will then pay second, and the
coverage covering the Member as a retiree or inactive employee or Dependent will pay third. The order
of primacy is not based on the policyholder of the group health insurance.
If Medicare is the primary payer due to Medicare primacy rules, then the rules of primacy for employees
and their spouses will be used to determine the coverage that will pay second and third.
Your Obligations
You have an obligation to provide us with current and accurate information regarding the existence of
other coverage.
Benefits payable under another coverage include benefits that would be paid by that coverage, whether
or not a claim is made. It also includes benefits that would have been paid but were refused. This is due
to the claim not being sent to the Provider of other coverage on a timely basis.
Your benefits under this Booklet will be reduced by the amount that such benefits would duplicate
benefits payable under the primary coverage.
Our Rights to Receive and Release Necessary Information
We may release to, or obtain, from any insurance company or other organization or person any
information which we may need to carry out the terms of this Booklet. Members will furnish to us such
information as may be necessary to carry out the terms of this Booklet.
Payment of Benefits to Others
When payments that should have been made under this Booklet were made under any other coverage, we will
have the right to pay to the other coverage any amount we determine to be warranted to satisfy the intent of
this provision. Any amount so paid will be considered to be benefits paid under this Booklet, and with that
payment we will fully satisfy our liability under this provision.
Duplicate Coverage and Coordination of Benefits Overpayment Recovery
If we have overpaid for Covered Services under this section, we will have the right, by offset or otherwise, to
recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were
made.

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Section 12. Termination/Nonrenewal/Continuation
Termination
Except as otherwise provided, your coverage may terminate in the following situations:
When the Contract between the Group and us terminates. If your coverage is through an association,
your coverage will terminate when the Contract between the association and us terminates, or when
your Group leaves the association. It will be the Group's responsibility to notify you of the termination
of coverage.
If you choose to terminate your coverage.
If you or your Dependents cease to meet the eligibility requirements of the Plan, subject to any
applicable continuation requirements. If you cease to be eligible, the Group and/or you must notify us
immediately. The Group and/or you shall be responsible for payment for any services incurred by you
after you cease to meet eligibility requirements.
If you elect coverage under another carriers health benefit plan, which is offered by the Group as an
option instead of this Plan, subject to the consent of the Group. The Group agrees to immediately
notify us that you have elected coverage elsewhere.
If you perform an act, practice, or omission that constitutes fraud or make an intentional
misrepresentation of material fact, as prohibited by the terms of your Plan, your coverage and the
coverage of your Dependents can be retroactively terminated or rescinded. A rescission of coverage
means that the coverage may be legally voided back to the start of your coverage under the Plan, just
as if you never had coverage under the Plan. You will be provided with a 30 calendar day advance
notice with appeal rights before your coverage is retroactively terminated or rescinded. You are
responsible for paying us for the cost of previously received services based on the Maximum Allowable
Amount for such services, less any Copayments made or Premium paid for such services.
If you fail to pay or fail to make satisfactory arrangements to pay your portion of the Premium, we may
terminate your coverage and may also terminate the coverage of your Dependents.
If you permit the fraudulent use of your or any other Members Plan Identification Card by any other
person; use another persons Identification Card; or use an invalid Identification Card to obtain
services, your coverage will terminate immediately upon our written notice to the Group. Anyone
involved in the misuse of a Plan Identification Card will be liable to and must reimburse us for the
Maximum Allowed Amount for services received through such misuse.
If you are a partner to a civil union, recognized domestic partnership, or other relationship recognized
as a spousal relationship in the state where the subscriber resides, on the date such union or
relationship is revoked or terminated. Also, if there is coverage for designated beneficiaries, on the date
a Recorded Designated Beneficiary Agreement is revoked or terminated. Where permitted by law,
such a Dependent may be able to seek COBRA or state continuation coverage, subject to the terms of
this Booklet.
You will be notified in writing of the date your coverage ends by either us or the Group.
Removal of Members
Upon written request through the Group, you may cancel your coverage and/or your Dependents
coverage from the Plan. If this happens, no benefits will be provided for Covered Services after the
termination date even if we have preauthorized the service, unless the Provider confirmed eligibility within
two business days before the service is received.

117
Special Rules if Your Group Health Plan is Offered Through an
Exchange
If your Plan is offered through an Exchange, either you or your Group may cancel your coverage and/or
your Dependents coverage through the Exchange. Each Exchange will have rules on how to do this.
You may cancel coverage by sending a written notice to either the Exchange or us. The date that
coverage will end will be either:
The date that you ask for coverage to end, if you provide written notice within 14 days of that date; or
14 days after you ask for coverage to end, if you ask for a termination date more than 14 days before
you gave written notice. We may agree in certain circumstances to allow an earlier termination date
that you request.
Continuation of Coverage Under Federal Law (COBRA)
The following applies if you are covered by a Group that is subject to the requirements of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended.
COBRA continuation coverage can become available to you when you would otherwise lose coverage
under your Group's health Plan. It can also become available to other Members of your family, who are
covered under the Group's health Plan, when they would otherwise lose their health coverage. For
additional information about your rights and duties under federal law, you should contact the Group.
Qualifying events for Continuation Coverage under Federal Law (COBRA)
COBRA continuation coverage is available when your coverage would otherwise end because of certain
qualifying events. After a qualifying event, COBRA continuation coverage must be offered to each
person who is a qualified beneficiary. You, your spouse and your Dependent children could become
qualified beneficiaries if you were covered on the day before the qualifying event and your coverage
would be lost because of the qualifying event. Qualified beneficiaries who elect COBRA must pay for this
COBRA continuation coverage.
This benefit entitles each Member of your family who is enrolled in the Plan to elect continuation
independently. Each qualified beneficiary has the right to make independent benefit elections at the time
of annual enrollment. Covered Subscribers may elect COBRA continuation coverage on behalf of their
spouses, and parents or legal guardians may elect COBRA continuation coverage on behalf of their
children. A child born to, or placed for adoption with, a covered Subscriber during the period of
continuation coverage is also eligible for election of continuation coverage.


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Initial Qualifying Event Length of Availability of Coverage

For Subscribers:

Voluntary or Involuntary Termination (other than
gross misconduct) or Reduction In Hours Worked





18 months


For Dependents:

A Covered Subscribers Voluntary or Involuntary
Termination (other than gross misconduct) or
Reduction In Hours Worked

Covered Subscribers Entitlement to Medicare

Divorce or Legal Separation

Death of a Covered Subscriber






18 months

36 months

36 months

36 months

For Dependent Children:

Loss of Dependent Child Status



36 months


COBRA coverage will end before the end of the maximum continuation period listed above if you become
entitled to Medicare benefits. In that case a qualified beneficiary other than the Medicare beneficiary
is entitled to continuation coverage for no more than a total of 36 months. (For example, if you become
entitled to Medicare prior to termination of employment or reduction in hours, COBRA continuation
coverage for your spouse and children can last up to 36 months after the date of Medicare entitlement.)
If Your Group Offers Retirement Coverage
If you are a retiree under this Plan, filing a proceeding in bankruptcy under Title 11 of the United States
Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your Group, and that
bankruptcy results in the loss of coverage, you will become a qualified beneficiary with respect to the
bankruptcy. Your Dependents will also become qualified beneficiaries if bankruptcy results in the loss of
their coverage under this Plan. If COBRA coverage becomes available to a retiree and his or her covered
family members as a result of a bankruptcy filing, the retiree may continue coverage for life and his or her
Dependents may also continue coverage for a maximum of up to 36 months following the date of the
retirees death.
Second qualifying event
If your family has another qualifying event (such as a legal separation, divorce, etc.) during the initial 18
months of COBRA continuation coverage, your Dependents can receive up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months from the original qualifying event. Such
additional coverage is only available if the second qualifying event would have caused your Dependents
to lose coverage under the Plan had the first qualifying event not occurred.

119
Notification Requirements
The Group will offer COBRA continuation coverage to qualified beneficiaries only after the Group has
been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the Subscriber, commencement of a proceeding in
bankruptcy with respect to the employer, or the Subscriber's becoming entitled to Medicare benefits
(under Part A, Part B, or both), the Group will notify the COBRA Administrator (e.g., Human Resources or
their external vendor) of the qualifying event.
You Must Give Notice of Some Qualifying Events
For other qualifying events (e.g., divorce or legal separation of the Subscriber and spouse or a
Dependent childs losing eligibility for coverage as a Dependent child), you must notify the Group within
60 days after the qualifying event occurs.
Electing COBRA Continuation Coverage
To continue your coverage, you or an eligible family Member must make an election within 60 days of the
date your coverage would otherwise end, or the date the companys benefit Plan Administrator notifies
you or your family Member of this right, whichever is later. You must pay the total Premium appropriate
for the type of benefit coverage you choose to continue. If the Premium rate changes for active
associates, your monthly Premium will also change. The Premium you must pay cannot be more than
102% of the Premium charged for Employees with similar coverage, and it must be paid to the companys
benefit plan administrator within 30 days of the date due, except that the initial Premium payment must be
made before 45 days after the initial election for continuation coverage, or your continuation rights will be
forfeited.
Disability extension of 18-month period of continuation coverage
For Subscribers who are determined, at the time of the qualifying event, to be disabled under Title II
(OASDI) or Title XVI (SSI) of the Social Security Act, and Subscribers who become disabled during the
first 60 days of COBRA continuation coverage, coverage may continue from 18 to 29 months. These
Subscribers Dependents are also eligible for the 18- to 29-month disability extension. (This also applies
if any covered family Member is found to be disabled.) This would only apply if the qualified beneficiary
gives notice of disability status within 60 days of the disabling determination. In these cases, the
Employer can charge 150% of Premium for months 19 through 29. This would allow health coverage to
be provided in the period between the end of 18 months and the time that Medicare begins coverage for
the disabled at 29 months. (If a qualified beneficiary is determined by the Social Security Administration to
no longer be disabled, such qualified beneficiary must notify the Plan Administrator of that fact in writing
within 30 days after the Social Security Administrations determination.)
Trade Adjustment Act Eligible Individual
If you dont initially elect COBRA coverage and later become eligible for trade adjustment assistance
under the U.S. Trade Act of 1974 due to the same event which caused you to be eligible initially for
COBRA coverage under this Plan, you will be entitled to another 60-day period in which to elect COBRA
coverage. This second 60-day period will commence on the first day of the month on which you become
eligible for trade adjustment assistance. COBRA coverage elected during this second election period will
be effective on the first day of the election period. You may also be eligible to receive a tax credit equal
to 65% of the cost for health coverage for you and your Dependents charged by the Plan. This tax credit
also may be paid in advance directly to the health coverage Provider, reducing the amount you have to
pay out of pocket.

120
When COBRA Coverage Ends
COBRA benefits are available without proof of insurability and coverage will end on the earliest of the
following:
A covered individual reaches the end of the maximum coverage period;
A covered individual fails to pay a required Premium on time;
A covered individual becomes covered under any other group health plan after electing COBRA. If
the other group health plan contains any exclusion or limitation on a pre-existing condition that
applies to you, you may continue COBRA coverage only until these limitations cease;
A covered individual becomes entitled to Medicare after electing COBRA; or
The Group terminates all of its group welfare benefit plans.
If You Have Questions
Questions concerning your Group's health Plan and your COBRA continuation coverage rights should be
addressed to the Group. For more information about your rights under ERISA, including COBRA, the
Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labors Employee Benefits
Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses
and phone numbers of Regional and District EBSA Offices are available through EBSAs website.)
Continuation of Coverage Under State Law
Groups with less than 20 employees who provide health care coverage for their employees are subject to
state law for continuation of coverage. The state continuation coverage period will not exceed 18 months
for you and/or any Dependents. State continuation coverage for you and your Dependents will start on
the date of the earliest of the following qualifying events:
Your termination of employment. To qualify, you must have been covered by the Group health
coverage for at least (6) six straight months;
Your reduction in working hours which results in loss of coverage. Reduction in working hours would
include circumstances resulting from economic conditions, injury, disability, or chronic health
conditions;
Your death; or
Divorce or legal separation of you and the spouse.
State Continuation Coverage Notification
Unless termination or reduction in working hours is the qualifying event, a Subscriber, spouse or
Dependent child must tell the Group of their choice to keep coverage within 30 days after being eligible.
The Group is responsible for telling the Subscriber, spouse and/or Dependent child of how to choose
state continuation. Once the Group has given notice to the Subscriber, spouse and/or Dependent child,
we must get timely notice from the Group that you want state continuation. We must also get timely
payment of Premiums from the Group when paid by the Subscriber.
We should get the notice from the Group and your first no later than 30 days after the qualifying event. If
the group fails to give timely notice to you of your rights, this deadline may extend to 60 days after the
qualifying event. For more, contact your Group.

121
When State Continuation Coverage Ends
Your state continuation coverage ends upon the earlier of the following:
A covered individual reaches the end of the maximum coverage period;
The Group Master Contract between Us and your employer ends. If the employer gets other group
coverage, continuation coverage will continue under the new plan;
A covered individual fails to pay Premium timely;
You are eligible for another group health plan unless the other plan does not cover something that is
covered by the continuation coverage. In that case, the state continuation coverage lasts until the
continuation period ends or the other plan covers the excluded condition;
If you are covered as a Designated Beneficiary, on the date the Recorded Designated Beneficiary
Agreement is revoked or terminated;
The date the spouse remarries and becomes eligible for coverage under the new spouses group
health plan;
You get Medicare or Medicaid; or
You tell us in writing to cancel.
Continuation of Coverage Due To Military Service
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the
Subscriber or his / her Dependents may have a right to continue health care coverage under the Plan if
the Subscriber must take a leave of absence from work due to military leave.
Employers must give a cumulative total of five years and in certain instances more than five years, of
military leave.
Military service means performance of duty on a voluntary or involuntary basis and includes active duty,
active duty for training, initial active duty for training, inactive duty training, and full-time National Guard
duty.
During a military leave covered by USERRA, the law requires employers to continue to give coverage
under this Plan to its Members. The coverage provided must be identical to the coverage provided to
similarly situated, active employees and Dependents. This means that if the coverage for similarly
situated, active employees and Dependents is modified, coverage for you (the individual on military leave)
will be modified.
You may elect to continue to cover yourself and your eligible Dependents by notifying your employer in
advance and submitting payment of any required contribution for health coverage. This may include the
amount the employer normally pays on your behalf. If your military service is for a period of time less
than 31 days, you may not be required to pay more than the active Member contribution, if any, for
continuation of health coverage. For military leaves of 31 days or more, you may be required to pay up to
102% of the full cost of coverage, i.e., the employee and employer share.
The amount of time you continue coverage due to USERRA will reduce the amount of time you will be
eligible to continue coverage under COBRA.

122
Maximum Period of Coverage During a Military Leave
Continued coverage under USERRA will end on the earlier of the following events:
1. The date you fail to return to work with the Group following completion of your military leave.
Subscribers must return to work within:
a) The first full business day after completing military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service.
b) 14 days after completing military service for leaves of 31 to 180 days,
c) 90 days after completing military service for leaves of more than 180 days; or
2. 24 months from the date your leave began.
Reinstatement of Coverage Following a Military Leave
Regardless of whether you continue coverage during your military leave, if you return to work your health
coverage and that of your eligible Dependents will be reinstated under this Plan if you return within:
1. The first full business day of completing your military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service;
2. 14 days of completing your military service for leaves of 31 to 180 days; or
3. 90 days of completing your military service for leaves of more than 180 days.
If, due to an illness or injury caused or aggravated by your military service, you cannot return to work
within the time frames stated above, you may take up to:
1. Two years; or
2. As soon as reasonably possible if, for reasons beyond your control you cannot return within two years
because you are recovering from such illness or injury.
If your coverage under the Plan is reinstated, all terms and conditions of the Plan will apply to the extent
that they would have applied if you had not taken military leave and your coverage had been continuous.
Any waiting/probationary periods will apply only to the extent that they applied before.
Please note that, regardless of the continuation and/or reinstatement provisions listed above, this Plan
will not cover services for any illness or injury caused or aggravated by your military service, as indicated
in the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions)" section.
Family and Medical Leave Act of 1993
A Subscriber who takes a leave of absence under the Family and Medical Leave Act of 1993 (the Act) will
still be eligible for this Plan during their leave. We will not consider the Subscriber and his or her
Dependents ineligible because the Subscriber is not at work.
If the Subscriber ends their coverage during the leave, the Subscriber and any Dependents who were
covered immediately before the leave may be added back to the Plan when the Subscriber returns to
work without medical underwriting. To be added back to the Plan, the Group may have to give us
evidence that the Family and Medical Leave Act applied to the Subscriber. We may require a copy of the
health care Provider statement allowed by the Act.

123
Benefits After Termination Of Coverage
Except as stated below, we will not pay for any services given to you after your coverage ends even if we
preauthorized the service, unless the Provider confirmed your eligibility within two business days before
each service received. Benefits cease on the date your coverage ends as described above. You may be
responsible for benefit payments made by us on your behalf for services provided after your coverage
has ended.
When your coverage ends for any reason other than for nonpayment of Premium, fraud or abuse, We will
continue coverage if you are being treated at an inpatient facility, until you are discharged or transferred
to another level of care. This is subject to the terms of this Booklet. The discharge date is seen as the
first date on which you are discharged from the facility or transferred to another level of care. We will not
cover the services you get after your discharge date.
Unless a law requires, we do not cover services after your date of termination even if:
We approved the services; or
The services were made necessary by an accident, illness or other event that occurred while coverage
was in effect.

124
Section 13. Appeals and Complaints
We want your experience with us to be as positive as possible. There may be times, however, when you
have a complaint, problem, or question about your Plan or a service you have received. In those cases,
please contact Customer Service by calling the number on the back of your ID card. We will try to resolve
your complaint informally by talking to your Provider or reviewing your claim. If you are not satisfied with
the resolution of your complaint, you have the right to file a Grievance / Appeal, which is defined as
follows:
We may have turned down your claim for benefits. We may have also denied your request to
preauthorize or receive a service or a supply. If you disagree with Our decision you can:
1. File a complaint
2. File an appeal; or
3. File a grievance.

Complaints
If you want to file a complaint about our customer service or how we processed your claim, please call
customer services. A trained staff member will try to clear up any confusion about the matter. They will
also try to resolve your complaint. If you prefer, you can send a written complaint to this address:
For services that are not dental or vision send to:
Anthem
Customer Services Department
P.O. Box 17549
Denver, CO 80217-0549
For dental benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:
Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
If your complaint isnt solved either by writing or calling, or if you dont want to file a complaint, you can file
an appeal. Well tell you how to do that next, in the Appeals section below.
Note: More details on the complaints and appeals process and time periods can be found in the Appeals
Guide. You may get a copy of the Appeals Guide by visiting www.anthem.com or you can call customer
service.



125
Appeals
If we have denied a claim that you feel should have been covered, or handled in a different way, or had
your coverage cancelled retroactively for a reason that it not because of your failure to pay premiums, you
can file an appeal. You can appeal a denial that was made by us before the service is received. You can
also appeal a denial on a service after it is received. You may also appeal an eligibility determination
made by us.
While we encourage you to file an appeal within 60 days of the unfavorable benefit determination, the
written or oral appeal must be received by us within 180 days of the unfavorable benefit determination.
We will assign an employee to help you in the appeal process. An appeal can be filed verbally by calling
customer service.
An appeal can be filed by writing to this address for services that are not a dental or vision
service:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway
Denver, CO 80273
For dental benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
You dont have to file a complaint before you file an appeal. In your appeal, please state as plainly as
possible why you think we shouldnt have denied your claim for benefits. Include any documents you
didnt submit with the original claim or service/supply request. Also send any other documents that
support your appeal. You dont have to file the appeal yourself. Someone else, like your Doctor or
another representative, can file an appeal for you. Just let us know in writing who will be filing the appeal
for you.
The appeals process allows you to request an internal appeal, and in certain cases, an independent
external appeal.
Internal Appeals
We have an internal process that We follow when reviewing your appeal. Members of our staff, who were
not involved when your claim was first denied, will review the appeal. They may also talk with co-workers
to assist in the review.
If your first internal appeal is denied, you can ask for a second level appeal. But you dont have to file a
second level appeal with Us before requesting an independent external review appeal or pursuing legal
action.
Expedited internal appeal - If you have an urgent case, you may request that your internal appeal be
reviewed in a shorter time period. This is called an expedited internal appeal. You or your representative

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can ask for an expedited appeal if you had Emergency services but havent been discharged from the
Facility. Also, you can ask for an expedited appeal if the regular appeal schedule would:
Seriously jeopardize your life or health;
Jeopardize your ability to regain maximum function;
Create an immediate and substantial limitation on your ability to live independently, if youre disabled;
or
In the opinion of a Doctor with knowledge of your condition, would subject you to severe pain that cant
be adequately managed without the service in question.
Independent External Appeals
For claims based on Utilization Review, or a rescission or retroactive cancellation of coverage for reasons
other than nonpayment of premium, you can request an independent external appeal. Utilization Review
includes claims we denied as Experimental or Investigational or not Medically Necessary. It also includes
claims where we reviewed your medical circumstances to decide if an exclusion applied. For these
appeals, your case is reviewed by an external review entity, selected by the Colorado Division of
Insurance.
Your request for independent external review must be made within 4 months of our appeal decision.
Generally, you have to have completed at least the first level internal appeal. But if we fail to handle the
appeal according to applicable Colorado insurance law and regulations, you will be eligible to request
independent external review.
Expedited external appeal You or your representative can request an expedited independent external
review, but only in certain cases:
You had Emergency services but havent been discharged from the Facility.
A Doctor certifies to us that you have a medical condition where following the normal external review
appeal process would seriously jeopardize your life or health, would jeopardize your ability to regain
maximum function or, if youre disabled, would create an imminent and substantial limitation of your
ability to live independently; or
We denied coverage for a requested medical service as being Experimental or Investigational, your
treating physician certifies in writing that the requested service would be significantly less effective if
not promptly initiated and certifies that either:
- Standard health care services or treatments have not been effective in improving your condition
or are not medically appropriate for you; or
- The Doctor is a licensed, board-certified or board-eligible physician qualified to practice in the
area of medicine appropriate to treat your condition, there is no available standard health care
service or treatment covered by this Booklet that is more beneficial than the requested service,
and scientifically valid studies using accepted protocols demonstrate that the requested service is
likely to be more beneficial to you than any available standard services.
If it meets these conditions, your request for expedited external appeal can be filed at the same time as
your request for an expedited internal appeal.
For more information on where and how to request an internal or external appeal, please consult the
Appeals Guide available at www.anthem.com, or call customer service.

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Grievances
If you have an issue or concern about the quality or services you receive from an In-Network Provider or
Facility, you can file a grievance. The quality management department strives to resolve grievances fairly
and quickly.
You may call customer service or send a written grievance for services that are not a, dental or
vision service to:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway

Denver, CO 80273-0001
For dental benefit issues send to:

Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122

For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
Our quality management department will acknowledge that weve received your grievance. Theyll also
investigate it. We treat every grievance confidentially.
Division of Insurance Inquiries
For inquiries about health care coverage in Colorado, you may call the Division of Insurance between
8:00 a.m. and 5:00 p.m., Monday through Friday, at (303) 894-7490, or write to the Division of Insurance
to the attention of the ICARE Section, 1560 Broadway, Suite 850, Denver, Colorado 80202.
Binding Arbitration
The binding arbitration provision under this Booklet is applicable to claims arising under all individual
plans, governmental plans, church plans, plans or claims to which ERISA preemption does not apply, and
plans maintained outside the United States. Any such arbitration will be governed by the procedures and
rules established by the American Arbitration Association. You may obtain a copy of the Rules of
Arbitration by calling our customer services. The law of the state in which the policy was issued and
delivered to you shall govern the dispute. The arbitration decision is binding on both you and us.
Judgment on the award made in arbitration may be enforced in any court with proper jurisdiction. If any
person subject to this arbitration clause initiates legal action of any kind, the other party may apply for a
court of competent jurisdiction to enjoin, stay or dismiss any such action and direct the parties to arbitrate
in accordance with this section.
Legal Action
Before you take legal action on a claim decision, you must first follow the process found in this section.
You must meet all the requirements of this Booklet.

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No action in law or in equity shall be brought to recover on this Booklet before the expiration of 60
calendar days after a claim has been filed according to the requirements of this Booklet. If you have
exhausted all mandatory levels of review in your appeal, you may be entitled to have the claim decision
reviewed de novo (as if for the first time) in any court with jurisdiction and to a trial by jury.
No such action shall be brought at all unless brought within three years after claim has been filed as
required by the Booklet.

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Section 14. Information on Policy and Rate Changes
Insurance Premiums
How Premiums are Established and Changed Premiums are the monthly charges you and/or the
Group must pay us to get coverage. We figure out and set the required Premiums.
The Group is responsible for paying the employees Premium to us according to the terms of the Group
Contract. Groups may have you contribute to the Premium cost through payroll deduction. Some Groups
may choose to have your Premium determined by the age of the Subscriber, with Premium set by age
brackets. We may change membership Premiums on the annual date on which the Group renews its
coverage, which we may assess when a Subscriber changes to a new five-year increment age bracket,
e.g., age 25 through age 29. If the age of the Subscriber is misstated at enrollment, all amounts payable
for the correct age will be adjusted and billed to the Group.
Grace Period - If a Group fails to submit Premium payments to us in a timely manner, the Group is
entitled to a grace period of 31 days for the payment of such Premium. During the grace period, our
contract with the Group shall continue in force unless the Group gives us written notice of termination of
the contract. If the Group has obtained replacement coverage during the grace period, the contract with
us will be terminated as of the last day for which we have received Premium, and any and all claims paid
during the grace period will be retroactively adjusted to deny. These claims that we retroactively
deny should be submitted to the replacement carrier. If the Group has not obtained replacement
coverage during the grace period, or fails to inform Us that the employer has not obtained replacement
coverage, we will process any and all claims with dates of service during the grace period in accordance
with the terms of this Booklet.

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Section 15. Definitions
If a word or phrase in this Booklet has a special meaning, such as Medical Necessity or Experimental /
Investigational, it will start with a capital letter, and be defined below. If you have questions on any of
these definitions, please call Customer Service at the number on the back of your Identification Card.
Accidental Injury
An unexpected Injury for which you need Covered Services while enrolled in this Plan. It does not include
injuries that you get benefits for under any Workers Compensation, Employers liability or similar law.
Ambulatory Surgical Facility
A freestanding Facility, with a staff of Doctors, that:
1. Is licensed as required;
2. Has permanent facilities and equipment to perform surgical procedures on an Outpatient basis;
3. Gives treatment by or under the supervision of Doctors, and nursing services when the patient is in
the Facility;
4. Does not have Inpatient accommodations; and
5. Is not, other than incidentally, used as an office or clinic for the private practice of a Doctor or other
professional Provider.
Applied Behavioral Analysis
The use of behavior analytic methods and research findings to change socially important behaviors in
meaningful ways.
Authorized Service(s)
A Covered Service you get from an Out-of-Network Provider that we have agreed to cover at the In-
Network level. You will not have to pay any more than the In-Network Deductible, Coinsurance, and/or
Copayment(s) that apply. Please see Claims Procedure (How to File a Claim) for more details.
Autism Services Provider
A person who provides services to a Member with Autism Spectrum Disorders. The Provider must be
licensed, certified, or registered by the applicable state licensing board or by a nationally recognized
organization, and who meets the requirements as defined by state law:
Autism Spectrum Disorders or ASD
Includes the following neurobiological disorders: autistic disorder, Asperger's disorder, and atypical
autism as a diagnosis within pervasive developmental disorder not otherwise specified, as defined in the
most recent edition of the diagnostic and statistical manual of mental disorders, at the time of the
diagnosis.
Autism Treatment Plan
A plan for a Member by an Autism Services Provider and prescribed by a Doctor or psychologist in line
with evaluating or again reviewing a Member's diagnosis; proposed treatment by type, frequency, and
expected treatment; the expected outcomes stated as goals; and the rate by which the treatment plan will
be updated. The treatment plan is in line with the patient-centered medical home as defined in state law.

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Benefit Period
The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit
Period starts on January 1
st
and ends on December 31
st
. For Plan Year plans, the Benefit Period starts
on your Groups effective or renewal date and lasts for 12 months. (See your Group for details.) The
Schedule of Benefits (Who Pays What) shows if your Plans Benefit Period is a Calendar Year or a Plan
Year. If your coverage ends before the end of the year, then your Benefit Period also ends.
Benefit Period Maximum
The most we will cover for a Covered Service during a Benefit Period.
Booklet
This document (also called the certificate), which describes the terms of your benefits. It is part of the
Group Contract with your Employer, and is also subject to the terms of the Group Contract.
Brand Name Drug
Prescription Drugs that the PBM has classified as Brand Name Drugs through use of an independent
proprietary industry database.
Centers of Excellence (COE) Network
A network of health care facilities, which have been selected to give specific services to our Members
based on their experience, outcomes, efficiency, and effectiveness. An In-Network Provider under this
Plan is not necessarily a COE. To be a COE, the Provider must have signed a Center of Excellence
Agreement with us.
Closed Panel Plan
A health maintenance organization (HMO), preferred provider organization (PPO) or other plan that
provides health benefits to covered persons primarily in the form of services through a panel of providers
that have contracted with either directly, indirectly, or are employed by the plan, and that limits or
excludes benefits for services provided by other providers, except in cases of emergency or referral by a
panel provider.
Coinsurance
Your share of the cost for Covered Services, which is a percent of the Maximum Allowed Amount. You
normally pay Coinsurance after you meet your Deductible. For example, if your Plan lists 20%
Coinsurance on office visits, and the Maximum Allowed Amount is $100, your Coinsurance would be $20
after you meet the Deductible. The Plan would then cover the rest of the Maximum Allowed Amount.
See the Schedule of Benefits (Who Pays What) for details. Your Coinsurance will not be reduced by
any refunds, rebates, or any other form of negotiated post-payment adjustments.
Complications of Pregnancy
Complications of Pregnancy means:

Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but
are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable
severity. This does not include false labor, occasional spotting, physician-prescribed rest during the
period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar

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conditions associated with the management of a difficult pregnancy not constituting a nosologically
distinct complication of pregnancy;

Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination
of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

Congenital Defect
A defect or anomaly existing before birth, such as cleft lip or club foot. Disorders of growth and
development over time are not considered congenital.
Copayment
A fixed amount you pay toward a Covered Service. You normally have to pay the Copayment when you
get health care. The amount can vary by the type of Covered Service you get. For example, you may
have to pay a $15 Copayment for an office visit, but a $150 Copayment for Emergency Room Services.
See the Schedule of Benefits (Who Pays What) for details. Your Copayment will be the lesser of the
amount shown in the Schedule of Benefits (Who Pays What)" or the amount the Provider charges.
Covered Services
Health care services, supplies, or treatment described in this Booklet that are given to you by a Provider.
To be a Covered Service the service, supply or treatment must be:
Medically Necessary or specifically included as a benefit under this Booklet.
Within the scope of the Providers license.
Given while you are covered under the Plan.
Not Experimental / Investigational, excluded, or limited by this Booklet, or by any amendment or rider
to this Booklet.
Approved by us before you get the service if prior authorization is needed.
A charge for a Covered Service will apply on the date the service, supply, or treatment was given to you.
Covered Services do not include services or supplies not described in the Provider records.
Covered Transplant Procedure
Please see the Benefits/Coverage (What is Covered) section for details.
Custodial Care
Any type of care, including room and board, that (a) does not require the skills of professional or technical
workers; (b) is not given to you or supervised by such workers or does not meet the rules for post-
Hospital Skilled Nursing Facility care; (c) is given when you have already reached the greatest level of
physical or mental health and are not likely to improve further.
Custodial Care includes any type of care meant to help you with activities of daily living that does not
require the skill of trained medical or paramedical workers. Examples of Custodial Care include:
Help in walking, getting in and out of bed, bathing, dressing, eating, or using the toilet,
Changing dressings of non-infected wounds, after surgery or chronic conditions,
Preparing meals and/or special diets,
Feeding by utensil, tube, or gastrostomy,

133
Common skin and nail care,
Supervising medicine that you can take yourself,
Catheter care, general colostomy or ileostomy care,
Routine services which we decide can be safely done by you or a non-medical person without the
help of trained medical and paramedical workers,
Residential care and adult day care,
Protective and supportive care, including education,
Rest and convalescent care.
Care can be Custodial even if it is recommended by a professional or performed in a Facility, such as a
Hospital or Skilled Nursing Facility, or at home.
Deductible
The amount you must pay for Covered Services before benefits begin under this Plan. For example, if
your Deductible is $1,000, your Plan wont cover anything until you meet the $1,000 Deductible. The
Deductible may not apply to all Covered Services. Please see the Schedule of Benefits (Who Pays
What) for details.
Dependent
A member of the Subscribers family who meets the rules listed in the Eligibility section and who has
enrolled in the Plan.
{Tiered network:
[Designated Participating Provider
A Physician, advanced nurse practitioner, nurse practitioner, clinical nurse specialist, physician assistant,
or any other Provider licensed by law and allowed under the Plan, who gives, directs, or helps you get a
range of health care services.]
Doctor
See the definition of Physician.
Early Intervention Services
Services, as defined by Colorado law in accordance with part C, that are authorized through an Eligible
Child's IFSP but that exclude: nonemergency medical transportation; respite care; service coordination,
as defined in federal law; and assistive technology (unless covered under this Booklet as durable medical
equipment).
Eligible Child - means an infant or toddler, from birth through two years of age, who is an eligible
Dependent and who, as defined by Colorado law, has significant delays in development or has a
diagnosed physical or mental condition that has a high probability of resulting in significant delays in
development or who is eligible for services pursuant to Colorado law.
Individualized family service plan or IFSP - means a written plan developed pursuant to federal law
that authorizes early intervention services to an Eligible Child and the child's family. An IFSP shall
serve as the individualized plan for an Eligible Child from birth through two years of age.
Effective Date
The date your coverage begins under this Plan.

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Emergency (Emergency Medical Condition)
Please see the "Benefits/Coverage (What is Covered)" section.
Emergency Care
Please see the "Benefits/Coverage (What is Covered)" section.
Enrollment Date
The first day you are covered under the Plan or, if the Group imposes a waiting period, the first day of
your waiting period.
Excluded Services (Exclusion)
Health care services your Plan doesnt cover.
Experimental or Investigational (Experimental / Investigational)
(a) Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other
health condition which we determine in our sole discretion to be Experimental or Investigational.
We will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or
supply to be Experimental or Investigational if we determine that one or more of the following criteria
apply when the service is rendered with respect to the use for which benefits are sought.
The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA) or any other state or federal regulatory agency, and such final approval has not
been granted;
Has been determined by the FDA to be contraindicated for the specific use;
Is provided as part of a clinical research protocol or clinical trial (except as noted in the Clinical Trials
section under Covered Services in this Booklet as required by state law), or is provided in any other
manner that is intended to evaluate the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply; or is subject to review and
approval of an Institutional Review Board (IRB) or other body serving a similar function; or
Is provided pursuant to informed consent documents that describe the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply as Experimental or
Investigational, or otherwise indicate that the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation.
(b) Any service not deemed Experimental or Investigational based on the criteria in subsection (a) may
still be deemed to be Experimental or Investigational by us. In determining whether a service is
Experimental or Investigational, we will consider the information described in subsection (c) and assess
all of the following:
Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes;
Whether the evidence demonstrates that the service improves the net health outcomes of the total
population for whom the service might be proposed as any established alternatives; or

135
Whether the evidence demonstrates the service has been shown to improve the net health outcomes
of the total population for whom the service might be proposed under the usual conditions of medical
practice outside clinical investigatory settings.
(c) The information we consider or evaluate to determine whether a drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply is Experimental or Investigational under
subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:
Randomized, controlled, clinical trials published in authoritative, peer-reviewed United States medical
or scientific journal;
Evaluations of national medical associations, consensus panels and other technology evaluation
bodies;
Documents issued by and/or filed with the FDA or other federal, state or local agency with the
authority to approve, regulate or investigate the use of the drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply;
Documents of an IRB or other similar body performing substantially the same function;
Consent documentation(s) used by the treating Physicians, other medical professionals or facilities,
or by other treating Physicians, other medical professionals or facilities studying substantially the
same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
The written protocol(s) used by the treating Physicians, other medical professionals or facilities or by
other treating Physicians, other medical professionals or facilities studying substantially the same
drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
Medical records; or
The opinions of consulting Providers and other experts in the field.
(d) We have the sole authority and discretion to identify and weigh all information and determine all
questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is Experimental or Investigational.
Facility
A facility including but not limited to, a Hospital, Ambulatory Surgical Facility, Chemical Dependency
Treatment Facility, Skilled Nursing Facility, Home Health Care Agency or mental health facility, as defined
in this Booklet. The Facility must be licensed, registered or approved by the Joint Commission on
Accreditation of Hospitals or meet specific rules set by us.
Generic Drugs
Prescription Drugs that the PBM has classified as Generic Drugs through use of an independent
proprietary industry database. Generic Drugs have the same active ingredients, must meet the same
FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as
the Brand Name Drug.
Group
The employer or other organization (e.g., association), which has a Group Contract with us, Anthem for
this Plan.

136
Group Contract (or Contract)
The Contract between us, Anthem, and the Group (also known as the Group Master Contract). It
includes this Booklet, your application, any application or change form, your Identification Card, any
endorsements, riders or amendments, and any legal terms added by us to the original Contract.
The Group Master Contract is kept on file by the Group. If a conflict occurs between the Group Master
Contract and this Booklet, the Group Master Contract controls.
Habilitative Services
Habilitative Services help you keep, learn or improve skills and functioning for daily living. Examples
include therapy for a child who isnt walking or talking at the expected age.
Home Health Care Agency
A Facility, licensed in the state in which it is located, that:
1. Gives skilled nursing and other services on a visiting basis in your home; and
2. Supervises the delivery of services under a plan prescribed and approved in writing by the attending
Doctor.
Hospice
A Provider that gives care to terminally ill patients and their families, either directly or on a consulting
basis with the patients Doctor. It must be licensed by the appropriate agency.
Hospital
A Provider licensed and operated as required by law, which has:
1. Room, board, and nursing care;
2. A staff with one or more Doctors on hand at all times;
3. 24 hour nursing service;
4. All the facilities on site are needed to diagnose, care, and treat an illness or injury; and
5. Is fully accredited by the Joint Commission on Accreditation of Health Care Organizations.
The term Hospital does not include a Provider, or that part of a Provider, used mainly for:
1. Nursing care
2. Rest care
3. Convalescent care
4. Care of the aged
5. Custodial Care
6. Educational care
7. Subacute care
8. Treatment of alcohol abuse
9. Treatment of drug abuse
Identification Card
The card we give you that shows your Member identification, Group numbers, and the plan you have.

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In-Network Provider
A Provider that has a contract, either directly or indirectly, with us, or another organization, to give
Covered Services to Members through negotiated payment arrangements.
In-Network Transplant Provider
Please see the Benefits/Coverage (What is Covered) section for details.
Inpatient
A Member who is treated as a registered bed patient in a Hospital and for whom a room and board
charge is made.
Late Enrollees
Subscribers or Dependents who enroll in the Plan after the initial enrollment period. A person will not be
considered a Late Enrollee if he or she enrolls during a Special Enrollment period. Please see the
Eligibility section for further details.

Maintenance Medications
Please see the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section for
details.
Manipulation Therapy
A system of therapy that includes the therapeutic application of manual manipulation treatment, analysis
and adjustments of the spine and other body structures, and muscle stimulation by any means, including
therapeutic use of heat, cold, and exercise.

Maximum Allowed Amount
The maximum payment that we will allow for Covered Services. For more information, see the Member
Payment Responsibility section.
Medical Necessity (Medically Necessary)
The diagnosis, evaluation and treatment of a condition, illness, disease or injury that we solely decide to be:
Medically appropriate for and consistent with your symptoms and proper diagnosis or treatment of
your condition, illness, disease or injury;
Obtained from a Doctor or Provider;
Provided in line with medical or professional standards;
Known to be effective, as proven by scientific evidence, in improving health;
The most appropriate supply, setting or level of service that can safely be provided to you and which
cannot be omitted. It will need to be consistent with recognized professional standards of care. In
the case of a Hospital stay, also means that safe and adequate care could not be obtained as an
outpatient;
Cost-effective compared to alternative interventions, including no intervention. Cost effective does not
always mean lowest cost. It does mean that as to the diagnosis or treatment of your illness, injury or

138
disease, the service is: (1) not more costly than an alternative service or sequence of services that is
medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate;
Not Experimental or Investigational;
Not primarily for you, your families, or your Providers convenience; and
Not otherwise an exclusion under this Booklet.
The fact that a Doctor or Provider may prescribe, order, recommend or approve care, treatment, services or
supplies does not, of itself, make such care, treatment, services or supplies Medically Necessary.
Member
People, including the Subscriber and his or her Dependents, who have met the eligibility rules, applied for
coverage, and enrolled in the Plan. Members are called you and your in this Booklet.
Mental Health, Biologically Based Mental Illness and Substance Abuse
A condition that is listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) as a mental health or substance abuse condition. Coverage is also provided for Biologically Based
Mental Illness for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive
disorder, specific obsessive-compulsive disorder, and panic disorder. It does not include Autism
Spectrum Disorder, which under state law is considered a medical condition.
Open Enrollment
A period of time in which eligible people or their dependents can enroll without penalty after the initial
enrollment. See the Eligibility section for more details.
Out-of-Network Provider
A Provider that does not have an agreement or contract with us, or our subcontractor(s) to give services
to our Members.
You will often get a lower level of benefits when you use Out-of-Network Providers.
Out-of-Network Transplant Provider
Please see the Benefits/Coverage (What is Covered) section for details.
Out-of-Pocket Limit
The most you pay in Copayments, Deductibles, and Coinsurance during a Benefit Period for Covered
Services. The Out-of-Pocket limit does not include your Premium, amounts over the Maximum Allowed
Amount, or charges for health care that your Plan doesnt cover. Please see the Schedule of Benefits
(Who Pays What) for details.
Pharmacy
A place licensed by state law where you can get Prescription Drugs and other medicines from a licensed
pharmacist when you have a prescription from your Doctor.

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Pharmacy and Therapeutics (P&T) Process
A process to make clinically based recommendations that will help you access quality, low cost medicines
within your Plan. The process includes health care professionals such as nurses, pharmacists, and
Doctors. The committees of the WellPoint National Pharmacy and Therapeutics Process meet regularly
to talk about and find the clinical and financial value of medicines for our Members. This process first
evaluates the clinical evidence of each product under review. The clinical review is then combined with
an in-depth review of the market dynamics, Member impact and financial value to make choices for the
formulary. Our programs may include, but are not limited to, Drug utilization programs, prior authorization
criteria, therapeutic conversion programs, cross-branded initiatives, and Drug profiling initiatives.
Physician (Doctor)
Includes the following when licensed by law:
Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery,
Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O.,
Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor;
Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and
Doctor of Dental Medicine (D.D.M.), Doctor of Dental Surgery (D.D.S.), legally entitled to provide
dental services.
Optometrists, Clinical Psychologists (PhD), and surgical chiropodists are also Providers when legally
licensed and giving Covered Services within the scope of their licenses.
Plan
The benefit plan your Group has purchased, which is described in this Booklet.
Precertification
Please see the section How to Access Your Services and Obtain Approval of Benefits for details.
Predetermination
Please see the section How to Access Your Services and Obtain Approval of Benefits for details.
Premium
The amount that you and/or the Group must pay to be covered by this Plan. This may be based on your
age and will depend on the Groups Contract with us.
Prescription Drug (Drug)
A medicine that is made to treat illness or injury. Under the Federal Food, Drug & Cosmetic Act, such
substances must bear a message on its original packing label that says, Caution: Federal law prohibits
dispensing without a prescription. This includes the following:
1. Compounded (combination) medications, when the primary ingredient (the highest cost ingredient) is
FDA-approved and requires a prescription to dispense, and is not essentially the same as an FDA-
approved product from a drug manufacturer.
2. Insulin, diabetic supplies, and syringes.

140
Primary Care Physician / Provider (PCP)
A Provider who gives or directs health care services for you. The Provider may work in family practice,
general practice, internal medicine, pediatrics or any other practice allowed by the Plan. A PCP
supervises, directs and gives initial care and basic medical services to you and is in charge of your
ongoing care.
Provider
A professional or Facility licensed by law that gives health care services within the scope of that license
and is approved by us. This includes any Provider that state law says we must cover when they give you
services that state law says we must cover. Providers that deliver Covered Services are described
throughout this Booklet. If you have a question about a Provider not described in this Booklet please call
the number on the back of your Identification Card.
Qualified Early Intervention Service Provider
Means a person or agency, as defined by Colorado law in accordance with part C, who provides Early
Intervention Services and is listed on the registry of early intervention service providers.
Recovery
Recovery is money the Member, the Members legal representative, or beneficiary receives whether by
settlement, verdict, judgment, order or by some other monetary award or determination, from another,
their insurer, or from any uninsured motorist, underinsured motorist, medical payments, personal injury
protection, or any other insurance coverage, to compensate the Member as a result of bodily injury or
illness to the Member. Regardless of how the Member, the Members legal representative, or beneficiary
or any agreement may characterize the money received, it shall be subject to the Subrogation and
Reimbursement under the General Policy Provisions section of this Booklet.
Referral
Please see the How to Access Services and Obtain Approval of Benefits section for details.
Retail Health Clinic
A Facility that gives limited basic health care services to Members on a walk-in basis. These clinics are
often found in major pharmacies or retail stores. Medical services are typically given by Physician
Assistants and Nurse Practitioners.
Service Area
The geographical area where you can get Covered Services from an In-Network Provider.
Skilled Nursing Facility
A Facility operated alone or with a Hospital that cares for you after a Hospital stay when you have a
condition that needs more care than you can get at home. It must be licensed by the appropriate agency
and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or otherwise approved by us. A Skilled Nursing
Facility gives the following:
1. Inpatient care and treatment for people who are recovering from an illness or injury;
2. Care supervised by a Doctor;

141
3. 24 hour per day nursing care supervised by a full-time registered nurse.
A Skilled Nursing Facility is not a place mainly for care of the aged, Custodial Care or domiciliary care,
treatment of alcohol or drug dependency; or a place for rest, educational, or similar services.
Special Enrollment
A period of time in which eligible people or their dependents can enroll after the initial enrollment, typically
due to an event such as marriage, birth, adoption, etc. See the Eligibility section for more details.
Specialist (Specialty Care Physician \ Provider or SCP)
A Specialist is a Doctor who focuses on a specific area of medicine or group of patients to diagnose,
manage, prevent, or treat certain types of symptoms and conditions. A non-Physician Specialist is a
Provider who has added training in a specific area of health care.
Specialty Drugs
Drugs that typically need close supervision and checking of their effect on the patient by a medical
professional. These drugs often need special handling, such as temperature-controlled packaging and
overnight delivery, and are often not available at retail pharmacies. They may be administered in many
forms including, but not limited to, injectable, infused, oral and inhaled.
Subscriber
An employee or member of the Group who is eligible for and has enrolled in the Plan.
Transplant Benefit Period
Please see the Benefits/Coverage (What is Covered) section for details.
Urgent Care Center
A licensed health care Facility that is separate from a Hospital and whose main purpose is giving
immediate, short-term medical care, without an appointment, for urgent care.
Utilization Review
A set of formal techniques to monitor or evaluate the clinical necessity, appropriateness, efficacy or
efficiency of, health care services, procedures or settings. Techniques include ambulatory review,
prospective review, second opinion, certification, concurrent review, Care Management, discharge
planning and/or retrospective review. Utilization Review also includes reviewing whether or not a
procedure or treatment is considered Experimental or Investigational, and reviewing your medical
circumstances when such a review is needed to determine if an exclusion applies.



End of Booklet
[Repository D/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HOS D]_20150101]


Certificate
(Referred to as "Booklet in the following pages)

Anthem
[Anthem SiIver BIue Priority PPO 2500/20%/6000 PIus]
[Anthem GoId PPO 1000/20%/3500]
[Anthem GoId PPO 2000/40%/4000]
[Anthem SiIver PPO 2000/50%/6350]
[Anthem GoId PPO 750/20%/4500]
[Anthem GoId PPO 1500/20%/4000]
[Anthem GoId PPO 500/20%/4500]
[Anthem SiIver PPO 2000/30%/4500 PIus w/DentaI]
[Anthem SiIver PPO 2000/30%/4500 PIus]
[Anthem SiIver PPO 3000/30%/4000 PIus]
[Anthem Bronze PPO 5850/30%/6600 PIus]
[Anthem GoId PPO 500/20%/3000 PIus w/DentaI]
[Anthem GoId PPO 500/20%/3000 PIus]
[Anthem SiIver PPO 1500/30%/4250 PIus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem SiIver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 PIus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 PIus w/HSA]
[Anthem SiIver PPO 2500/20%/4500 w/HSA]
[Anthem GoId PPO 2000/20%/5000 PIus w/HRA]
[Anthem GoId PPO 4000/20%/5000 PIus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 PIus]

January 1, 2015

[Repository D/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HOS D]_20150101]






Si necesita ayuda en espaoI para entender este documento, puede soIicitarIa sin costo adicionaI,
IIamando aI nmero de servicio aI cIiente.

f you need Spanish-language assistance to understand this document, you may request it at no
additional cost by calling Customer Service at the number on the back of your dentification Card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, nc. HMO products are
underwritten by HMO Colorado, nc. Life and disability products underwritten by Anthem Life nsurance Company. ndependent
licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem nsurance Companies,
nc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association
1
Section 1. ScheduIe of Benefits (Who Pays What)

n this section you will find an outline of the benefits included in your Plan and a summary of any Deductibles,
Coinsurance, and Copayments that you must pay. Also listed are any Benefit Period Maximums or limits that apply.
Please read the "Benefits/Coverage (What is Covered)"section for more details on the Plan's Covered Services. Read
the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for details on Excluded Services.

All Covered Services are subject to the conditions, Exclusions, limitations, and terms of this Booklet including any
endorsements, amendments, or riders.

To get the highest benefits at the Iowest out-of-pocket cost, you must get Covered Services from an In-Network
Provider. Benefits for Covered Services are based on the Maximum Allowed Amount, which is the most the Plan will
allow for a Covered Service. When you use an Out-of-Network Provider you may have to pay the difference between the
Out-of-Network Provider's billed charge and the Maximum Allowed Amount in addition to any Coinsurance, Copayments,
Deductibles, and non-covered charges. This amount can be substantial. Please read the "Claims Procedure (How to File
a Claim) section for more details.

Deductibles, Coinsurance, and Benefit Period Maximums are calculated based upon the Maximum Allowed Amount, not
the Provider's billed charges.

EssentiaI HeaIth Benefits provided within this BookIet are not subject to Iifetime or annuaI doIIar maximums.
Certain non-essentiaI heaIth benefits, however, are subject to either a Iifetime and/or doIIar maximum.

EssentiaI HeaIth Benefits are defined by federaI Iaw and refer to benefits in at Ieast the foIIowing categories:

AmbuIatory patient services,
Emergency services,
HospitaIization,
Maternity and newborn care,
MentaI heaIth and substance use disorder services, incIuding behavioraI heaIth treatment,
Prescription drugs,
RehabiIitative and HabiIitative Services and devices,
Laboratory services,
Preventive and weIIness services, and
Chronic disease management and pediatric services, incIuding oraI and vision care.

Such benefits shaII be consistent with those set forth under the Patient Protection and AffordabIe Care Act of
2010 and any reguIations issued pursuant thereto.

Benefit Period [Calendar][Plan] Year

Dependent Age Limit To the end of the month in which the child attains age 26.

Please see the "Eligibility section for further details.

DeductibIe In-Network Out-of-Network
Per Member [$500 to 5,900] [$1,250 to 14,750]
Per Family
{Aggregate: [(All other Members combined)]
[$1,500 to 11,800] [$2,500 to 29,500]
The n-Network and Out-of-Network Deductibles are separate and cannot be combined.

{Option for Non-Embedded pIans of HSA/HRA: [f you, the Subscriber, are the only person covered by this Plan,
only the "per Member amounts applies to you. f you also cover Dependents (other family members) under this Plan,
only the "per Family amount applies.)]


2
DeductibIe In-Network Out-of-Network
When the Deductible applies, you must pay it before benefits begin. See the sections below to find out when the
Deductible applies.

{DeductibIe First for HRA pIans: [Note: To meet the n-Network Deductible, your Plan will work as follows:

Step 1 - Upfront In-Network DeductibIe Members must pay a certain part of the n-Network Deductible
listed above, $[1,000 to 2,000] per Member / $[2,000 to 4,000] per Family, before using their HRA account.
HRA funds cannot be used for this part of the Deductible (known as the "upfront Deductible). Amounts paid
toward the upfront Deductible will apply toward the annual n-Network Deductible.

Step 2 - HeaIth Reimbursement Account After meeting the upfront Deductible, Members can use money in
their HRA to help meet the rest of the annual n-Network Deductible.

Step 3 - TraditionaI HeaIth Coverage - Once the Annual n-Network Deductible has been met, coverage
under this Plan begins.]

Copayments and Coinsurance are separate from and do not apply to the Deductible.

{DeductibIe First for HRA pIans: [HRA funds cannot be used for services listed under "Dental Services for Members
age 19 and Older or for services listed under "Vision Services for Members age 19 and Older.]


Coinsurance In-Network Out-of-Network
Plan Pays [50 to 100%] [50 to 90]%
Member Pays [0 to 50%] [10 to 50]%
Reminder: Your Coinsurance will be based on the Maximum Allowed Amount. f you use an Out-of-Network Provider,
you may have to pay Coinsurance plus the difference between the Out-of-Network Provider's billed charge and the
Maximum Allowed Amount.

Note: The Coinsurance listed above may not apply to all benefits, and some benefits may have a different Coinsurance.
Please see the rest of this Schedule for details.


Out-of-Pocket Limit In-Network Out-of-Network
Per Member $[3,000 to 6,600]

$[6,000 to 19,800]
Per Family
{Aggregate: [(All other Members combined)]
$[6,000 to 13,200] $[18,000 to 39,600]
{Option for Non-Embedded pIans of HSA/HRA: [f you, the Subscriber, are the only person covered by this Plan,
only the "per Member amount applies to you. f you also cover Dependents (other family members) under this Plan,
only the "per Family amount applies.)]

The Out-of-Pocket Limit includes all Deductibles, [[and] Coinsurance], [and Copayments] you pay during a Benefit
Period unless otherwise indicated below. t does not include charges over the Maximum Allowed Amount or amounts
you pay for non-Covered Services.

The Out-of-Pocket Limit does not include amounts you pay for the following benefits:

{Option for embedded aduIt dentaI benefit: [Services listed under "Dental Services for Members Age 19 and
Older
{Option for embedded aduIt vision benefit: [Services listed under "Vision Services for Members Age 19 and
3
Out-of-Pocket Limit In-Network Out-of-Network
Older]
Out-of-Network Human Organ and Tissue Transplant services.

Once the Out-of- Pocket Limit is satisfied, you will not have to pay additional Deductibles, [[or] Coinsurance], or
Copayments] for the rest of the Benefit Period, except for the services listed above.

The n-Network and Out-of-Network Out-of-Pocket Limits are separate and do not apply toward each other.

Important Notice about Your Cost Shares

n certain cases, if we pay a Provider amounts that are your responsibility, such as Deductibles, Copayments or
Coinsurance, we may collect such amounts directly from you. You agree that we have the right to collect such amounts
from you.

The tables below outline the Plan's Covered Services and the cost share(s) you must pay. n many spots you will see the
statement, "Benefits are based on the setting in which Covered Services are received. n these cases you should
determine where you will receive the service (i.e., in a doctor's office, at an outpatient hospital facility, etc.) and look up
that location to find out which cost share will apply. For example, you might get physical therapy in a doctor's office, an
outpatient hospital facility, or during an inpatient hospital stay. For services in the office, look up "Office Visits. For
services in the outpatient department of a hospital, look up "Outpatient Facility Services. For services during an inpatient
stay, look up "npatient Services.

Benefits In-Network Out-of-Network
Acupuncture/Nerve Pathway Therapy See "Therapy Services.

AIIergy Services Benefits are based on the setting in which
Covered Services are received.

AmbuIance Services (Air and Water) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an n-Network Provider.

Important Note: Air ambulance services for non-Emergency Hospital to Hospital transfers must be approved through
precertification. Please see "How to Access Your Services and Obtain Approval of Benefits for details.


AmbuIance Services (Ground) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an n-Network Provider.

Important Note: All scheduled ground ambulance services for non-Emergency transfers, except transfers from one
acute Facility to another, must be approved through precertification. Please see "How to Access Your Services and
Obtain Approval of Benefits for details.

Autism Services


Applied Behavioral Analysis Services Benefit Maximum
Benefits are based on the setting in which
Covered Services are received.

The following annual Benefit Period maximums
are effective for Applied Behavior Analysis
services for n- and Out-of-Network services
4
Benefits In-Network Out-of-Network
combined:
From birth to age eight (up to Member's ninth
birthday): 550 sessions of 25 minutes for
each session, however we may exceed this
limit if required by state law
Age nine to age eighteen (up to Member's
nineteenth birthday): 185 sessions of 25
minutes for each session, however we may
exceed this limit if required by state law
The limits for physical, occupational, and speech therapy will not apply to children between age 3 and 6 with Autism
Spectrum Disorders, if part of a Member's Autism Treatment Plan, and determined Medically Necessary by Us.

When you get physical, occupational or speech therapy which also is considered by Us as Applied Behavioral Analysis
for the treatment of autism, the Applied Behavioral Analysis visit limit will apply instead of the Therapy Services limits
listed below.

BehavioraI HeaIth Services See "Mental Health, Alcohol and Substance
Abuse Services.

Cardiac RehabiIitation See "Therapy Services.

Chemotherapy See "Therapy Services.

Chiropractor Services See "Therapy Services.

CIinicaI TriaIs Benefits are based on the setting in which
Covered Services are received.

DentaI Services For Members Through Age 18

Note: To get the n-Network benefit, you must use a participating dental Provider. f you need help finding a
participating dental Provider, please call us at the number on the back of your D card.
{Embedded Pediatric/AduIt DentaI pIan: [Each Member must pay a Deductible of $50 per Benefit Period for the
dental services below. This Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan.]
Diagnostic and Preventive Services {Embedded Pediatric
DentaI: [Deductible
waived, subject to]
10% Coinsurance
30% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Basic Restorative Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Endodontic Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible}
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Periodontal Services Not Covered Not Covered
5
Benefits In-Network Out-of-Network
Oral Surgery Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Major Restorative Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Prosthodontic Services Not Covered Not Covered
Dentally Necessary Orthodontic Care 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]

{Embedded AduIt DentaI:
[DentaI Services For Members Age 19 and OIder

Note: To get the n-Network benefit, you must use a participating dental Provider. f you need help finding a
participating dental Provider, please call us at the number on the back of your D card.
Each Member must pay a Deductible of $50 per Benefit Period for the dental services below. This Deductible is
separate and does not apply toward any other Deductible for Covered Services in this Plan.
Diagnostic and Preventive Services No Copayment,
Deductible, or
Coinsurance
50% Coinsurance
Basic Restorative Services 20% Coinsurance 60% Coinsurance
Endodontic Services 50% Coinsurance 75% Coinsurance
Periodontal Services 50% Coinsurance 75% Coinsurance
Oral Surgery Services 50% Coinsurance 75% Coinsurance
Major Restorative Services 50% Coinsurance 75% Coinsurance
Prosthodontic Services 50% Coinsurance 75% Coinsurance
Orthodontic Care Not covered Not covered
Dental Services for Members Age 19 and Older Benefit Maximum $1,000 per Benefit Period
n- and Out-of-Network combined]
Orthodontic Care for members age 19 and older may be covered for certain medically necessary conditions. See the
section Dental Services (All Members / All Ages) for more information.]

DentaI Services (AII Members / AII Ages) Benefits are based on the setting in which
Covered Services are received.

Diabetes Equipment, Education, and SuppIies Benefits are based on the setting in which
Covered Services are received.
Screenings for gestational diabetes are covered
under "Preventive Care.

6
Benefits In-Network Out-of-Network
Diagnostic Services

Benefits are based on the setting in which
Covered Services are received.

DiaIysis See "Therapy Services.

DurabIe MedicaI Equipment (DME) and MedicaI Devices,
Orthotics, Prosthetics, MedicaI and SurgicaI SuppIies (Received
from a Supplier)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible

The cost-shares listed above only apply when you get the equipment or supplies from a third-party supplier. f you
receive the equipment or supplies as part of an office or outpatient visit, or during a Hospital stay, benefits will be based
on the setting in which the covered equipment or supplies are received.
Hearing Aid Benefit Maximum for Members under 18 years of age One hearing aid every 5 years
n- and Out-of-Network combined

Emergency Room Services
Emergency Room
Emergency Room Facility Charge

[$[200 to 250] Copayment] [per visit] [plus] [[0 to
50]% Coinsurance] [after Deductible]
[Copayment waived if admitted]
Emergency Room Doctor Charge [0 to 50]% Coinsurance after Deductible
Other Facility Charges (including diagnostic x-ray and lab
services, medical supplies)
[0 to 50]% Coinsurance after Deductible
Advanced Diagnostic maging (including MRs, CAT scans) [0 to 50]% Coinsurance after Deductible
For Emergency services from an Out-of-Network Provider you do not need to pay any more than you would have paid
for services from an n-Network Provider.

Home Care
Home Care Visits [$[20 to 60] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Home Dialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home nfusion Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Specialty Prescription Drugs [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Home Care Services / Supplies [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Care Benefit Maximum 28 hours of visits per week
7
Benefits In-Network Out-of-Network
n- and Out-of-Network combined
The limit does not apply to Home nfusion
Therapy or Home Dialysis.

Home Infusion Therapy See "Home Care.

Hospice Care
Home Care
Respite Hospital Stays

[No Copayment or
Coinsurance after
Deductible] [After
Deductible no
Coinsurance]
[10 to 50]%
Coinsurance after
Deductible

Human Organ and Tissue TranspIant (Bone Marrow / Stem CeII)
Services
Please see the separate summary later in this
section.

InfertiIity Services See "Maternity and Reproductive Health
Services.

Inpatient Services
Facility Room & Board Charge:
Hospital / Acute Care Facility

[$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility [$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility / Habilitation Services / Rehabilitation
Services (ncludes Services in an Outpatient Day Rehabilitation
Program) Benefit Maximum
160 days per Benefit Period n- and Out-of-
Network combined
Other Facility Services / Supplies (including diagnostic lab/x-ray,
medical supplies, therapies, anesthesia)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Addition if Copayment cost share: [HospitaI Transfers: f you are transferred between Facilities, only one
Copayment will apply. You will not have to pay separate Copayments per Facility.

HospitaI Readmissions: f you are readmitted to the Hospital within 72 hours of your discharge for the same medical
diagnosis, you will not have to pay an additional Copayment upon readmission.]
Doctor Services for:
General Medical Care / Evaluation and Management (E&M) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Surgery [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
8
Benefits In-Network Out-of-Network

ManipuIation Therapy See "Therapy Services.

Maternity and Reproductive HeaIth Services
Maternity Visits (Global fee for the ObGyn's prenatal, postnatal,
and delivery services)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
npatient Services (Delivery) See "npatient Services.
Newborn / Maternity Stays: f the newborn needs services other than routine nursery care or stays in the Hospital
after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission.
nfertility

Benefits are based on the setting in which
Covered Services are received.
nfertility Benefit Maximum Unlimited

Massage Therapy See "Therapy Services.

MentaI HeaIth, BioIogicaIIy Based MentaI IIIness, AIcohoI and
Substance Abuse Services

npatient Facility Services

[$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Residential Treatment Center Services [$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] after
Deductible]
[50-90]%
Coinsurance after
Deductible
npatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Outpatient Facility Services

[$250 Copayment per
visit] [plus][[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Outpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Partial Hospitalization Program / ntensive Outpatient Services [$250 to 500
Copayment per visit]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Office Visits [$[15 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Mental Health, Biologically Based Mental llness, Alcohol and Substance Abuse Services will be covered as required by
9
Benefits In-Network Out-of-Network
state and federal law. Please see "Mental Health Parity and Addiction Equity Act in the "Additional Federal Notices
section for details.

OccupationaI Therapy See "Therapy Services.

Office Visits


Primary Care Physician / Provider (PCP) [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]
Retail Health Clinic Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Online Care Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Counseling ncudes
Family Planning and
Nutritional Counseling
(Other than Eating
Disorders)
[$[10 to 60] Copayment
per visit] [[for the first 3
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Nutritional Counseling for
Eating Disorders
[$[10 to 60] Copayment
per visit] [[for the first [3]
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Allergy Testing [$[10 to 60] Copayment
per visit] [[0 to
50]%Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / njections (other than allergy serum) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
10
Benefits In-Network Out-of-Network
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests (non-preventive; including hearing and EKG) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic maging (including MRs, CAT scans) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy Services:
! Acupuncture/Nerve Pathway Therapy, Chiropractic
CareManipulation Therapy & Massage Therapy
[$[20 to 30] Copayment
per visit] [for the first 3
visits, then [0 to 50]%
Coinsurance] [after
Deductible]
Not Covered
! Physical, Speech, & Occupational Therapy [$[20 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Dialysis / Hemodialysis

[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Radiation / Chemotherapy / Non-Preventive nfusion &
njection
[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Cardiac Rehabilitation & Pulmonary Therapy [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
See "Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
11
Benefits In-Network Out-of-Network

{PIans with copay for first 3 visits: [Important Note on Office Visit Copayments: Several services listed above
have a Copayment for the first three visits. This Copayment applies to any combination of services for the first three
visits during the Benefit Period. Starting with the fourth visit, you pay Deductible and Coinsurance, instead of a
Copayment. The three Copayments will not apply to Preventive Care, Maternity Services, or Urgent Care visits. You
will not have to pay any Deductible or Coinsurance when you pay the Copayment.]

Orthotics See "Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Outpatient FaciIity Services
Facility Surgery Charge

[$125 to 250 Copayment
per visit] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges (including diagnostic x-ray and
lab services, medical supplies)
[$125 to 250 Copayment
per visit] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Doctor Surgery Charges [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Doctor Charges (including Anesthesiologist, Pathologist,
Radiologist, Surgical Assistant)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Facility Charges (for procedure rooms or other ancillary
services)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests: Hearing, EKG, etc. (Non-Preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
12
Benefits In-Network Out-of-Network
Advanced Diagnostic maging (including MRs, CAT scans) [$250 Copayment [per
service] [per visit] [plus]
[[0 to 50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy:
! Chiropractic CareManipulation Therapy

[0 to 50]% Coinsurance
after Deductible
Not Covered
! Physical, Speech, & Occupational Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Radiation / Chemotherapy / Non-Preventive nfusion &
njection
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Dialysis / Hemodialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Cardiac Rehabilitation & Pulmonary Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
See "Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in an Outpatient Facility [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Site-of-Service:
[Outpatient Freestanding FaciIity
Facility Surgery Charge / Ambulatory Surgery Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges/ Ambulatory Surgical Center
(including diagnostic x-ray and lab services, medical supplies)
[0 to 50]% Coinsurance [10 to 50]%
Coinsurance after
Deductible
Doctor Charges in Ambulatory Surgical Center / Freestanding
Radiology Center (including Anesthesiologist, Pathologist,
Radiologist, Surgery, Surgical Assistant)
No Copayment,
Deductible, or
Coinsurance

[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray / Freestanding Radiology Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic maging (including MRs, CAT scans)/
Freestanding Radiology Center
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible]]

PhysicaI Therapy See "Therapy Services.

Preventive Care


No Copayment,
Deductible, or
Coinsurance
[10 to 50]%
Coinsurance after
Deductible
Preventive care from an Out-of-Network Provider is not subject to the Maximum Allowed Amount.
13
Benefits In-Network Out-of-Network

Prosthetics See "Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

PuImonary Therapy See "Therapy Services.

Radiation Therapy See "Therapy Services.

RehabiIitation Services Benefits are based on the setting in which
Covered Services are received.

Respiratory Therapy See "Therapy Services.

SkiIIed Nursing FaciIity See "npatient Services.

Speech Therapy See "Therapy Services.

Surgery Benefits are based on the setting in which
Covered Services are received.

TeIemedicine
Primary Care Physician / Provider (PCP) $[20 to 60] Copayment
per visit [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) $[20 to 100] Copayment
per visit] [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]

TemporomandibuIar and CraniomandibuIar Joint Treatment Benefits are based on the setting in which
Covered Services are received.

14
Benefits In-Network Out-of-Network
Therapy Services Benefits are based on the setting in which
Covered Services are received.
Benefit Maximum(s): Benefit Maximum(s) are for n- and Out-of-
Network visits combined, for rehabilitative and
habilitative services combined, and for office
and outpatient visits combined.
Physical & Occupational Therapy 40 visits each per Benefit Period
Speech Therapy 40 visits per Benefit Period.
For cleft palate or cleft lip conditions, Medically
necessary speech therapy is not limited, but
those visits lower the number of speech therapy
visits available to treat other problems.
Acupuncture/Nerve Pathway Therapy, Chiropractic
CareManipulation Therapy & Massage Therapy
20 visits per Benefit
Period
Limit does not apply to
osteopathic caretherapy
Not covered
Cardiac Rehabilitation Unlimited
Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice
benefit.

Transgender Services Benefits are based on the setting in which
Covered Services are received.

TranspIant Services See "Human Organ and Tissue Transplant
(Bone Marrow / Stem Cell) Services.

Urgent Care Services (Office Visits)
Urgent Care Office Visit Charge [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Testing [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / njections (other than allergy serum) [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Charges (e.g., diagnostic x-ray and lab services, medical
supplies)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
15
Benefits In-Network Out-of-Network
Advanced Diagnostic maging (including MRs, CAT scans)

[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75]
Copayment per visit]
[then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]%
Coinsurance after
Deductible
[10 to 50]%
Coinsurance after
Deductible
f you get urgent care at a Hospital or other outpatient Facility, please refer to "Outpatient Facility Services for details
on what you will pay.

{Pediatric exam onIy: [Vision Services For Members Through Age 18

Note: To get the n-Network benefit, you must use an n-Network vision Provider. f you need help finding an n-
Network vision Provider, please call us at the number on the back of your D card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
DeductibleCover
ed up to $30]

{Pediatric vision:
[Vision Services For Members Through Age 18

Note: To get the n-Network benefit, you must use an n-Network vision Provider. f you need help finding an n-
Network vision Provider, please call us at the number on the back of your D card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

0% Coinsurance not
subject to
DeductibleCovered
up to $30
Standard Plastic Lenses
Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Progressive $20 Copayment Covered up to $40
Note: n-Network, lenses include factory scratch coating and UV coating at no additional cost. Polycarbonate and
photocromic lenses are also covered at no extra cost n Network
Frames $0 Copayment, Covered
up to $130
Covered up to $45
Limited to one set of frames from the Anthem formulary every other Benefit Period.
Contact Lenses
Limited to one set of contact lenses from the Anthem formulary every other Benefit Period. Available only if the
eyeglass lenses benefit is not used.
Elective Contact Lenses (Conventional or Disposable) $0 Copayment, Covered Covered up to $60
16
Benefits In-Network Out-of-Network
up to $80
Non-Elective Contact Lenses No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

{AduIt vision:
[Vision Services For Members Age 19 and OIder
Note: To get the n-Network benefit, you must use an n-Network vision Provider. f y Provider, please call us at the
number on the back of your D card. ou need help finding an n-Network vision
Routine Eye Exam

Limited to one exam per Benefit Period
$20 Copayment Covered up to $30
Standard Plastic Lenses

Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Photochromic $20 Copayment (in
addition to lens
Copayment)
Not covered
Note: n-Network, lenses include factory scratch coating at no additional cost.
Frames

Limited to one set of frames every other Benefit Period.
Covered up to $130 Covered up to $45
Contact Lenses

Limited to one set of contact lenses every other Benefit Period. Available only if the eyeglass lenses benefit is not
used.
Elective Contact Lenses (Conventional or Disposable) Covered up to $80 Covered up to $60
Non-Elective Contact Lenses


No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

Vision Services (AII Members / AII Ages)
(For medical and surgical treatment of injuries and/or diseases of
the eye)

Certain vision screenings required by Federal law are covered
under the "Preventive Care" benefit.
Benefits are based on the setting in which
Covered Services are received.


17
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services


PIease caII our TranspIant Department as soon you think you may need a transpIant to taIk about your benefit
options. You must do this !"#$%" you have an evaIuation and/or work-up for a transpIant. To get the most
benefits under your PIan, you must get certain human organ and tissue transpIant services from a Network
TranspIant Provider. Even if a Hospital is an n-Network Provider for other services, it may not be an n-Network
Transplant Provider for certain transplant services. Please call us to find out which Hospitals are n-Network Transplant
Providers. (When calling Customer Service, ask for the Transplant Case Manager for further details.)

The requirements described beIow do not appIy to the foIIowing:

Cornea and kidney transplants, which are covered as any other surgery; and
Any Covered Services related to a Covered Transplant Procedure, that you get before or after the Transplant
Benefit Period. Please note that the initial evaluation, any added tests to determine your eligibility as a candidate
for a transplant by your Provider, and the harvest and storage of bone marrow/stem cells is included in the Covered
Transplant Procedure benefit regardless of the date of service.

Benefits for Covered Services that are not part of the Human Organ and Tissue Transplant benefit will be based on the
setting in which Covered Services are received. Please see the "Benefits/Coverage (What is Covered) section for
additional details.

TranspIant Benefit Period In-Network TranspIant
Provider

Out-of-Network TranspIant
Provider
Starts one day before a
Covered Transplant
Procedure and lasts for the
applicable case rate / global
time period. The number of
days will vary depending on
the type of transplant
received and the n-Network
Transplant Provider
agreement. Call the Case
Manager for specific n-
Network Transplant
Provider information for
services received at or
coordinated by an n-
Network Transplant
Provider Facility.
Starts one day before a
Covered Transplant
Procedure and continues to
the date of discharge at an
Out-of- Network Transplant
Provider Facility.

Covered TranspIant Procedure during the
TranspIant Benefit Period
In-Network TranspIant
Provider FaciIity

Out-of-Network TranspIant
Provider FaciIity

Precertification required


During the Transplant
Benefit Period, [$500
Copayment per admission]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible].

Before and after the
Transplant Benefit Period,
Covered Services will be
covered as npatient
Services, Outpatient
Services, Home Visits, or
Office Visits depending
where the service is
During the Transplant Benefit
Period, [10 to 50]%
Coinsurance after Deductible.

During the Transplant Benefit
Period, Covered Transplant
Procedure charges at an Out-
of-Network Transplant
Provider Facility will NOT
apply to your Out-of-Pocket
Limit.

f the Provider is also an n-
Network Provider for this Plan
(for services other than
18
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services

performed. Covered Transplant
Procedures), then you will not
have to pay for Covered
Transplant Procedure charges
over the Maximum Allowed
Amount.

f the Provider is an Out-of-
Network Provider for this
Plan, you wiII have to pay for
Covered Transplant
Procedure charges over the
Maximum Allowed Amount.

Prior to and after the
Transplant Benefit Period,
Covered Services will be
covered as npatient Services,
Outpatient Services, Home
Visits, or Office Visits
depending where the service
is performed.

Covered TranspIant Procedure during the
TranspIant Benefit Period
In-Network TranspIant
Provider ProfessionaI and
AnciIIary (non-HospitaI)
Providers

Out-of-Network TranspIant
Provider ProfessionaI and
AnciIIary (non-HospitaI)
Providers
[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Transportation and Lodging

[0 to 50]% Coinsurance
after Deductible
[10 to 50]% Coinsurance after
Deductible

Transportation and Lodging Limit

Covered, as approved by us, up to $10,000 per transplant.
n- and Out-of-Network combined

UnreIated donor searches from an authorized,
Iicensed registry for bone marrow/stem ceII
transpIants for a Covered TranspIant Procedure

[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Donor Search Limit Covered, as approved by us, up to $30,000 per transplant.
n- and Out-of-Network combined

Live Donor HeaIth Services [0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

19
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services

Donor HeaIth Service Limit Donor benefits are limited to benefits not available to the
donor from any other source. Medically Necessary charges
for getting an organ from a live donor are covered up to our
Maximum Allowed Amount, including complications from the
donor procedure for up to six weeks from the date of
procurement.

Prescription Drug RetaiI Pharmacy and Home
DeIivery (MaiI Order) Benefits
In-Network Out-of-Network
Each Prescription Drug will be subject to a cost share (e.g., Copayment/Coinsurance) as described below. f your
Prescription Order includes more than one Prescription Drug, a separate cost share will apply to each covered Drug.
You will be required to pay the lesser of your scheduled cost share or the Maximum Allowed Amount.
{Prescription deductibIe:
[Prescription Drug DeductibIe
Does not apply to Tier 1
Per Member $[250 to 500] n- and Out-of-Network combined
Per Family $[500 to 1,000] n- and Out-of-Network combined
Note: The Prescription Drug Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan. You must pay the Deductible before you pay any Copayments / Coinsurance listed below. The
Prescription Drug Deductible is included in the Out-of-Pocket Limit.]
Day SuppIy Limitations - Prescription Drugs will be subject to various day supply and quantity limits. Certain
Prescription Drugs may have a lower day-supply limit than the amount shown below due to other Plan requirements
such as prior authorization, quantity limits, and/or age limits and utilization guidelines.
Retail Pharmacy (n-Network and Out-of-Network) 30 days
Home Delivery (Mail Order) Pharmacy 90 days
Specialty Pharmacy (n-Network and Out-of-
Network)
30 days*
*See additional information in the "Specialty Drug
Copayments / Coinsurance section below.
RetaiI Pharmacy Copayments / Coinsurance:

Tier 1 Prescription Drugs

[$15 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 2 Prescription Drugs [$35 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance][ after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 3 Prescription Drugs

[$70 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
[10 to 50]% Coinsurance
[after Deductible]
20
Prescription Drug RetaiI Pharmacy and Home
DeIivery (MaiI Order) Benefits
In-Network Out-of-Network
Home DeIivery Pharmacy Copayments /
Coinsurance:

Tier 1 Prescription Drugs

[$38 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered

Tier 2 Prescription Drugs [$88 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 3 Prescription Drugs [$175 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
Not covered
SpeciaIty Drug Copayments / Coinsurance:
Please note that certain Specialty Drugs are only available from a Specialty Pharmacy and you will not be able to get
them at a Retail Pharmacy or through the Home Delivery (Mail Order) Pharmacy. Please see "Specialty Pharmacy in
the section "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy for further details. When
you get Specialty Drugs from a Specialty Pharmacy, you will have to pay the same Copayments/Coinsurance you pay
for a 30-day supply at a Retail Pharmacy.

{Preferred Generic / Brand PenaIty:
[Note: Prescription Drugs will always be dispensed as ordered by your Doctor. You may ask for, or your Doctor may
order, the Brand Name Drug. However, if a Generic Drug is available, you will have to pay the difference in the cost
between the Generic and Brand Name Drug, as well as your Tier 1 Copayment. By law, Generic and Brand Name
Drugs must meet the same standards for safety, strength, and effectiveness. Using generics generally saves money,
yet gives the same quality. We reserve the right, in our sole discretion, to remove certain higher cost Generic Drugs
from this policy.]
{ReguIar PPO:
[Note: No Copayment, Deductible, or Coinsurance applies to certain diabetic and asthmatic supplies when you get
them from an n-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical Equipment
if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable Prescription
Drug Copayment / Coinsurance.]
{HSA pIans:
[Note: Certain diabetic and asthmatic supplies are covered subject to applicable Prescription Drug Copayments when
you get them from an n-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical
Equipment if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable
Prescription Drug Copayment / Coinsurance.]


21
FederaI Patient Protection and AffordabIe Care Act Notices
Choice of Primary Care Physician / Provider
We generally allow the designation of a Primary Care Physician / Provider (PCP). You have the right to designate any
PCP who participates in our network and who is available to accept you or your family members. For information on how
to select a PCP, and for a list of PCPs, contact the telephone number on the back of your dentification Card or refer to
our website, www.anthem.com. For children, you may designate a pediatrician as the PCP.
Access to ObstetricaI and GynecoIogicaI (ObGyn) Care
You do not need referral or authorization from us or from any other person (including a PCP) in order to obtain access to
obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or
gynecology. The health care professional, however, may be required to comply with certain procedures, including
obtaining prior authorization for certain services or following a pre-approved treatment plan. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of your
dentification Card or refer to our website, www.anthem.com.
22
AdditionaI FederaI Notices
Statement of Rights under the Newborns' and Mother's HeaIth Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the
mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). n any case, plans and issuers may not, under Federal law, require that
a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
Statement of Rights under the Women's Cancer Rights Act of 1998
f you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and
Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in
a manner determined in consultation with the attending Physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other medical and surgical
benefits provided under this Plan. (See the "Schedule of Benefits (Who Pays What) for details.) f you would like more
information on WHCRA benefits, call us at the number on the back of your dentification Card.
Coverage for a ChiId Due to a QuaIified MedicaI Support Order ("QMCSO")
f you or your spouse are required, due to a QMCSO, to provide coverage for your child(ren), you may ask the Group to
provide you, without charge, a written statement outlining the procedures for getting coverage for such child(ren).
MentaI HeaIth Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate treatment limitations
(day or visit limits) on mental health and substance abuse benefits with day or visit limits on medical and surgical benefits.
n general, group health plans offering mental health and substance abuse benefits cannot set day/visit limits on mental
health or substance abuse benefits that are lower than any such day or visit limits for medical and surgical benefits. A plan
that does not impose day or visit limits on medical and surgical benefits may not impose such day or visit limits on mental
health and substance abuse benefits offered under the plan. Also, the plan may not impose Deductibles, Copayment,
Coinsurance, and out of pocket expenses on mental health and substance abuse benefits that are more restrictive than
Deductibles, Copayment, Coinsurance and out of pocket expenses applicable to other medical and surgical benefits.
Medical Necessity criteria are available upon request.
SpeciaI EnroIIment Notice
f you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance
coverage, you may in the future be able to enroll yourself or your Dependents in this Plan if you or your Dependents lose
eligibility for that other coverage (or if the employer stops contributing towards your or your Dependents' other coverage).
However, you must request enrollment within 31 days after your or your Dependents' other coverage ends (or after the
employer stops contributing toward the other coverage.
n addition, if you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and Your Dependents. However, you must request enrollment within 31 days after the marriage,
birth, adoption, or placement for adoption.
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
23
The Subscriber's or Dependent's Medicaid or Children's Health nsurance Program (CHP) coverage is terminated as
a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program).
The Subscriber or Dependent must request Special Enrollment within 60 days of the loss of Medicaid/CHP or of the
eligibility determination.
To request special enrollment or obtain more information, call us at the Customer Service telephone number on your
dentification Card, or contact the Group.
Statement of ERISA Rights
Please note: This section applies to employer sponsored plans other than Church employer groups and government
groups. f you have questions about whether this Plan is governed by ERSA, please contact the Plan Administrator (the
Group).
The Employee Retirement ncome Security Act of 1974 (ERSA) entitles you, as a Member of the Group under this
Contract, to:
Examine, without charge, at the Plan Administrator's office and at other specified locations such as worksites and
union halls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed by this plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions;
Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for these copies; and
Receive a summary of the plan's annual financial report. The Plan Administrator is required by law to furnish each
participant with a copy of this summary financial report.
n addition to creating rights for you and other employees, ERSA imposes duties on the people responsible for the
operation of your employee benefit plan. The people who operate your plan are called plan fiduciaries. They must handle
your plan prudently and in the best interest of you and other plan participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you
from obtaining a welfare benefit or exercising your right under ERSA. f your claim for welfare benefits is denied, in whole
or in part, you must receive a written explanation of the reason for the denial. You have the right to have your claims
reviewed and reconsidered.
Under ERSA, there are steps you can take to enforce the above rights. For instance, if you request materials from the
Plan Administrator and do not receive them within 30 days, you may file suit in a federal court. n such case, the court
may require the Plan Administrator to provide you the materials and pay you up to $110 a day until you receive the
materials, unless the materials are not sent because of reasons beyond the control of the Plan Administrator. f your
claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. f plan fiduciaries
misuse the plan's money or if you are discriminated against for asserting your rights, you may seek assistance from the
U.S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal
fees. t may order you to pay these expenses, for example, if it finds your claim is frivolous. f you have any questions
about your plan, you should contact the Plan Administrator. f you have any questions about this statement or about your
rights under ERSA, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical Assistance and nquiries, Employee
Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
24
Notices Required by State Law
Cancer Screenings
At Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado, nc., we believe cancer screenings
provide important preventive care that supports our mission: to improve the lives of the people we serve and the health of
our communities. We cover cancer screenings as described below.
Pap Tests
All Plans provide coverage under the preventive care benefits for a routine annual Pap test and the related office visit.
Payment for the routine Pap test is based on the Plan's provisions for preventive care service. Payment for the related
office visit is based on the Plan's preventive care provisions.
Mammogram Screenings
All Plans provide coverage under the preventive care benefits for routine screening or diagnostic mammogram regardless
of age. Payment for the mammogram screening benefit is based on the Plan's provisions for preventive care.
Prostate Cancer Screenings
All Plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for
the prostate cancer screening is based on the Plan's provisions for preventive care.
CoIorectaI Cancer Screenings
Several types of colorectal cancer screening methods exist. All Plans provide coverage for routine colorectal cancer
screenings, such as fecal occult blood tests, barium enema, sigmoidoscopies and colonoscopies. Depending on the type
of colorectal cancer screening received, payment for the benefit is based on where the services are rendered and if
rendered as a screening or medical procedure. Colorectal cancer screenings are covered under preventive care as long
as the services provided are for a preventive screening. Payment for preventive colorectal cancer screenings based on
the Plan's provisions for preventive care.
The information above is only a summary of the benefits described. The rest of this Booklet includes important additional
information about limitations, exclusions and covered benefits. The "Schedule of Benefits (Who Pays What) section
includes additional information about Copayments, Deductibles and Coinsurance. f you have any questions, please call
Customer Service at the number on the back of your dentification Card.
{No aduIt dentaI:
[No-AduIt DentaI Services

This policy does not provide any dental benefits to individuals age nineteen (19) or older, except as specifically provided
in the benefit booklet. This policy is being offered so the purchaser will have pediatric dental coverage as required by the
Affordable Care Act. f you want adult dental benefits, you will need to buy a plan that has adult dental benefits. Except as
stated in the benefit booklet, this plan will not pay for any adult dental care, so you will have to pay the full price of any
care you receive.]




25
Notice of
Protection Provided by
Life and HeaIth Insurance Protection Association
This notice provides a brief summary of the Life and Health nsurance Protection Association ("the Association) and the
protection it provides for policyholders. This safety net was created under Colorado law, which determines who and what
is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or health insurance
company becomes financially unable to meet its obligations and is taken over by its nsurance Department. f this should
happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Colorado law, with
funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
Life nsurance
! $300,000 in death benefits
! $100,000 in cash surrender or withdrawal values
Health nsurance
! $500,000 in hospital, medical and surgical insurance benefits
! $300,000 in disability insurance benefits
! $300,000 in long-term care insurance benefits
! $100,000 in other types of health insurance benefits
Annuities
! $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000.
Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain poIicies and contracts may not be covered or fuIIy covered. For example, coverage does not extend to
any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the
account value of a variable life insurance policy or a variable annuity contract. There are also various residency
requirements and other limitations under Colorado law.
To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please
visit the Association's website http://colorado.lhiga.com, email jkelldorf@aol.com or contact:
Colorado Life and Health
Insurance Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 292-5022
Colorado Division of Insurance
1560 Broadway, Suite 850
Denver, CO 80202

(303) 894-7499
Insurance companies and agents are not aIIowed by CoIorado Iaw to use the existence of the Association or its
coverage to encourage you to purchase any form of insurance. When seIecting an insurance company, you
shouId not reIy on Association coverage. If there is any inconsistency between this notice and CoIorado Iaw,
then CoIorado Iaw wiII controI.
26
Section 2. TitIe Page (Cover Page)

Anthem Blue Cross and Blue Shield


[Anthem SiIver BIue Priority PPO 2500/20%/6000 PIus]
[Anthem GoId PPO 1000/20%/3500]
[Anthem GoId PPO 2000/40%/4000]
[Anthem SiIver PPO 2000/50%/6350]
[Anthem GoId PPO 750/20%/4500]
[Anthem GoId PPO 1500/20%/4000]
[Anthem GoId PPO 500/20%/4500]
[Anthem SiIver PPO 2000/30%/4500 PIus w/DentaI]
[Anthem SiIver PPO 2000/30%/4500 PIus]
[Anthem SiIver PPO 3000/30%/4000 PIus]
[Anthem Bronze PPO 5850/30%/6600 PIus]
[Anthem GoId PPO 500/20%/3000 PIus w/DentaI]
[Anthem GoId PPO 500/20%/3000 PIus]
[Anthem SiIver PPO 1500/30%/4250 PIus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem SiIver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 PIus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 PIus w/HSA]
[Anthem SiIver PPO 2500/20%/4500 w/HSA]
[Anthem GoId PPO 2000/20%/5000 PIus w/HRA]
[Anthem GoId PPO 4000/20%/5000 PIus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 PIus]




27

Section 3. Contact Us
WeIcome to Anthem!
We are pleased that you have become a Member of our health insurance Plan. We want to make sure
that our services are easy to use. We've designed this Booklet to give a clear description of your
benefits, as well as our rules and procedures.
The Booklet explains many of the rights and duties between you and us. t also describes how to get
health care, what services are covered, and what part of the costs you will need to pay. Many parts of
this Booklet are related. Therefore, reading just one or two sections may not give you a full understanding
of your coverage. You should read the whole Booklet to know the terms of your coverage.
This Booklet replaces any Booklet issued to you in the past. The coverage described is based upon the
terms of the Group Contract issued to your Group, and the Plan that your Group chose for you. This
Booklet, and any endorsements, amendments or riders attached, form the entire legal contract under
which Covered Services are available. n addition the Group has a Group Contract and Group
Application which includes terms that apply to this coverage.
Many words used in the Booklet have special meanings (e.g., Group, Covered Services, and Medical
Necessity). These words are capitalized and are defined in the "Definitions" section. See these
definitions for the best understanding of what is being stated. Throughout this Booklet you will also see
references to "we, "us, "our, "you, and "your. The words "we, "us, and "our mean Anthem Blue
Cross and Blue Shield. The words "you and "your mean the Member, Subscriber and each covered
Dependent.
f you have any questions about your Plan, please be sure to call Customer Service at the number on the
back of your dentification Card. You can also contact us at:
800-234-0111
Anthem Blue Cross and Blue Shield
700 Broadway
Denver, CO 80273
Also be sure to check our website, www.anthem.com for details on how to find a Provider, get answers to
questions, and access valuable health and wellness tips. Thank you again for enrolling in the Plan!
{HSA pIans:
[High-DeductibIe HeaIth PIan for Use with HeaIth Savings Accounts
This Plan is meant to be federally tax qualified and used with a qualified health savings account. Approval
by the Division of nsurance does not guarantee tax qualification and this Plan has not been submitted for
approval by the RS. Please seek the advice of a tax advisor.]
How to Get Language Assistance
Anthem is committed to communicating with our Members about their health Plan, no matter what their
language is. Anthem employs a language line interpretation service for use by all of our Customer Service
call centers. Simply call the Customer Service phone number on the back of your dentification Card and
a representative will be able to help you. Translation of written materials about your benefits can also
be asked for by contacting Customer Service. TTY/TDD services also are available by dialing 711. A
special operator will get in touch with us to help with your needs.


28


Mike Ramseier
President and General Manager
Anthem Blue Cross and Blue Shield
29

Your Rights and ResponsibiIities as an Anthem BIue Cross and BIue
ShieId Member
As a Member you have certain rights and responsibilities when receiving your health care. You also have
a responsibility to take an active role in your care. As your health care partner, we're committed to making
sure your rights are respected while providing your health benefits. That also means giving you access to
our n-Network Providers and the information you need to make the best decisions for your health and
welfare.

You have the right to:
Speak freely and privately with your Doctors and other health Providers about all health care
options and treatment needed for your condition. This is no matter what the cost or whether it's
covered under your Plan.
Work with your Doctors in making choices about your health care.
Be treated with respect and dignity.
Expect us to keep your personal health information private. This is as long as it follows state and
Federal laws and our privacy policies.
Get the information you need to help make sure you get the most from your health Plan, and share
your feedback. This includes information on:
! Our company and services.
! Our network of Doctors and other health care Providers.
! Your rights and responsibilities.
! The rules of your health care Plan.
! The way your health Plan works.
Make a complaint or file an appeal about:
! Your Plan.
! Any care you get.
! Any Covered Service or benefit ruling that your Plan makes.
Say no to any care, for any condition, sickness or disease, without it affecting any care you may get in
the future. This includes the right to have your Doctor tell you how that may affect your health now
and in the future.
Get all of the most up-to-date information from a Doctor or other health care professional Provider
about the cause of your illness, your treatment and what may result from it. f you don't understand
certain information, you can choose a person to be with you to help you understand.

You have the responsibiIity to:
Read and understand, to the best of your ability, all information about your health benefits or ask for
help if you need it.
Follow all Plan rules and policies.
Choose an n-Network Primary Care Physician (Doctor) / Provider, also called a PCP, if your health
care Plan requires it.
Treat all Doctors, health care Providers and staff with courtesy and respect.
Keep all scheduled appointments with your health care Providers. Call their office if you may be late
or need to cancel.
Understand your health problems as well as you can and work with your Doctors or other health care
Providers to make a treatment plan that you all agree on.
Tell your Doctors or other health care Providers if you don't understand any type of care you're
getting or what they want you to do as part of your care plan.

30
Follow the care plan that you have agreed on with your Doctors or health care Providers.
Give us, your Doctors and other health care professionals the information needed to help you get the
best possible care and all the benefits you are entitled to. This may include information about other
health and insurance benefits you have in addition to your coverage with us.
Let our customer service department know if you have any changes to your name, address or family
members covered under your Plan.

We are committed to providing quality benefits and customer service to our Members. Benefits and
coverage for services provided under the benefit program are governed by the Booklet and not by this
Member Rights and Responsibilities statement.
We value your feedback regarding the benefits and service provided under Our policies and your overall
thoughts and concerns regarding Our operations. f you have any concerns regarding how your benefits
were applied or any concerns about services you requested which were not covered under this Booklet,
you are free to file a complaint or appeal as explained in this Booklet. f you have any concerns regarding
a participating Provider or facility, you can file a grievance as explained in this Booklet. And if you have
any concerns or suggestions on how we can improve Our overall operations and service, We encourage
you to contact customer service.
f you need more information or would like to contact us, please go to anthem.com and select Customer
Support > Contact Us. Or call the Member Services number on your D card.




31

Section 4. TabIe of Contents
Section 1. ScheduIe of Benefits (Who Pays What) .................................................................................. 1
Section 2. TitIe Page (Cover Page) .......................................................................................................... 26
Section 3. Contact Us ............................................................................................................................... 27
Welcome to Anthem! ............................................................................................................................... 27
[High-Deductible Health Plan for Use with Health Savings Accounts ..................................................... 27
How to Get Language Assistance ........................................................................................................... 27
Your Rights and Responsibilities as an Anthem Blue Cross and Blue Shield Member ...................... 2928
Section 4. TabIe of Contents ................................................................................................................ 3130
Section 5. EIigibiIity .............................................................................................................................. 3635
Who is Eligible for Coverage ............................................................................................................... 3635
The Subscriber ................................................................................................................................. 3635
Dependents ...................................................................................................................................... 3635
Types of Coverage ........................................................................................................................... 3736
When You Can Enroll .......................................................................................................................... 3736
nitial Enrollment .............................................................................................................................. 3736
Open Enrollment .............................................................................................................................. 3837
Special Enrollment Periods .............................................................................................................. 3837
Special Rules if Your Group Health Plan is Offered Through an Exchange ................................... 3837
Medicaid and Children's Health nsurance Program Special Enrollment ........................................ 3938
Late Enrollees .................................................................................................................................. 3938
Members Covered Under the Group's Prior Plan ............................................................................ 3938
Enrolling Dependent Children ............................................................................................................. 3938
Newborn Children ............................................................................................................................ 3938
Adopted Children ............................................................................................................................. 3938
Adding a Child due to Award of Legal Custody or Guardianship .................................................... 4039
Qualified Medical Child Support Order ............................................................................................ 4039
Updating Coverage and/or Removing Dependents ............................................................................ 4039
Nondiscrimination ................................................................................................................................ 4039
Statements and Forms ........................................................................................................................ 4039
Section 6. How to Access Your Services and Obtain ApprovaI of Benefits (AppIicabIe to managed
care pIans) ............................................................................................................................................. 4140
ntroduction .......................................................................................................................................... 4140
n-Network Services ............................................................................................................................ 4140
Out-of-Network Services ..................................................................................................................... 4241
How to Find a Provider in the Network ................................................................................................ 4241
[Designated Participating Provider Program ....................................................................................... 4241
Continuity of Care ................................................................................................................................ 4342
Crediting Prior Plan Coverage ............................................................................................................. 4342
The BlueCard Program ........................................................................................................................ 4342
dentification Card ................................................................................................................................ 4443
Obtain Approval of Benefits ................................................................................................................. 4544
Types of Requests ............................................................................................................................... 4544
Request Categories ............................................................................................................................. 4645
Decision and Notice Requirements ..................................................................................................... 4746
Health Plan ndividual Case Management .......................................................................................... 4847
Section 7. Benefits/Coverage (What is Covered) ............................................................................... 4948
Acupuncture/Nerve Pathway ............................................................................................................... 4948
Allergy Services ................................................................................................................................... 4948
Ambulance Services ............................................................................................................................ 4948

32
Autism Services ................................................................................................................................... 5049
Behavioral Health Services ................................................................................................................. 5150
Cardiac Rehabilitation ......................................................................................................................... 5150
Chemotherapy ..................................................................................................................................... 5150
Chiropractor Services .......................................................................................................................... 5150
Clinical Trials ....................................................................................................................................... 5150
Dental Services ................................................................................................................................... 5251
Your Dental Benefits ........................................................................................................................ 5251
Pretreatment Estimate ..................................................................................................................... 5352
[Pediatric Dental for Members through Age 18 ............................................................................... 5352
[Dental Services .................................................................................................................................. 5655
Dental Services for Members through Age 18 ................................................................................. 5655
Diagnostic and Preventive Services ................................................................................................ 5655
Basic Restorative Services .............................................................................................................. 5655
Major Restorative Services .............................................................................................................. 5756
Oral Surgery ..................................................................................................................................... 5756
Orthodontic Care .............................................................................................................................. 5756
Dental Services for Members Age 19 and Older ............................................................................. 5857
Diagnostic and Preventive Services ................................................................................................ 5857
Basic Restorative Services .............................................................................................................. 5958
Endodontic Services ........................................................................................................................ 5958
Periodontal Services ........................................................................................................................ 5958
Oral Surgery Services ...................................................................................................................... 6059
Major Restorative Services .............................................................................................................. 6160
Prosthodontic Services .................................................................................................................... 6160
Dental Services (All Members / All Ages) ............................................................................................ 6361
Preparing the Mouth for Medical Treatments .................................................................................. 6361
Accident-Related Dental Services ................................................................................................... 6362
Cleft Palate and Cleft Lip Conditions ............................................................................................... 6362
Dental Anesthesia for Children ........................................................................................................ 6362
Diabetes Equipment, Education, and Supplies ................................................................................... 6362
Diagnostic Services ............................................................................................................................. 6462
Diagnostic Laboratory and Pathology Services ............................................................................... 6463
Diagnostic maging Services and Electronic Diagnostic Tests ........................................................ 6463
Advanced maging Services ............................................................................................................ 6463
Dialysis ................................................................................................................................................ 6463
Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies ............................................................................................................................................... 6463
Durable Medical Equipment and Medical Devices .......................................................................... 6463
Hearing Aid Services ....................................................................................................................... 6564
Orthotics ........................................................................................................................................... 6564
Prosthetics ....................................................................................................................................... 6564
Medical and Surgical Supplies ......................................................................................................... 6665
Blood and Blood Products ............................................................................................................... 6665
Emergency Care Services ................................................................................................................... 6665
Emergency Services ........................................................................................................................ 6665
Home Care Services ........................................................................................................................... 6766
Home nfusion Therapy ....................................................................................................................... 6766
Hospice Care ....................................................................................................................................... 6766
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services ....................................... 6867
Prior Approval and Precertification .................................................................................................. 6968
nfertility Services ................................................................................................................................ 7069
npatient Services ................................................................................................................................ 7069
npatient Hospital Care .................................................................................................................... 7069
npatient Professional Services ....................................................................................................... 7170
Maternity and Reproductive Health Services ...................................................................................... 7170

33
Maternity Services ........................................................................................................................... 7170
Contraceptive Benefits ..................................................................................................................... 7271
Sterilization Services ........................................................................................................................ 7271
Abortion Services ............................................................................................................................. 7271
nfertility Services ............................................................................................................................. 7271
Mental Health, Alcohol and Substance Abuse Services ..................................................................... 7271
Occupational Therapy ......................................................................................................................... 7472
Office Visits and Doctor Services ........................................................................................................ 7472
Orthotics .............................................................................................................................................. 7472
Outpatient Facility Services ................................................................................................................. 7473
Physical Therapy ................................................................................................................................. 7573
Preventive Care ................................................................................................................................... 7573
Prosthetics ........................................................................................................................................... 7674
Pulmonary Therapy ............................................................................................................................. 7674
Radiation Therapy ............................................................................................................................... 7674
Rehabilitation Services ........................................................................................................................ 7674
Habilitative Services ......................................................................................................................... 7674
Respiratory Therapy ............................................................................................................................ 7674
Skilled Nursing Facility ........................................................................................................................ 7675
Smoking Cessation .............................................................................................................................. 7775
Speech Therapy .................................................................................................................................. 7775
Surgery ................................................................................................................................................ 7775
Oral Surgery ..................................................................................................................................... 7775
Reconstructive Surgery.................................................................................................................... 7775
Transgender Surgery ....................................................................................................................... 7876
Telemedicine ....................................................................................................................................... 7876
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services ............................................. 7877
Therapy Services ................................................................................................................................. 7977
Physical Medicine Therapy Services ............................................................................................... 7977
Early ntervention Services .............................................................................................................. 7977
Other Therapy Services ................................................................................................................... 8078
Transplant Services ............................................................................................................................. 8078
Urgent Care Services .......................................................................................................................... 8078
Routine Eye Exam ........................................................................................................................... 8179
Eyeglass Lenses .............................................................................................................................. 8179
Frames ............................................................................................................................................. 8179
Contact Lenses ................................................................................................................................ 8179
[Vision Services for Members Age 19 and Older ................................................................................ 8280
Routine Eye Exam ........................................................................................................................... 8280
Eyeglass Lenses .............................................................................................................................. 8280
Frames ............................................................................................................................................. 8280
Contact Lenses ................................................................................................................................ 8280
Vision Services (All Members / All Ages) ............................................................................................ 8381
Prescription Drugs Administered by a Medical Provider ..................................................................... 8482
mportant Details About Prescription Drug Coverage ...................................................................... 8482
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy ................................. 8583
Prescription Drug Benefits ............................................................................................................... 8583
Section 8. Limitations/ExcIusions (What is Not Covered and Pre-Existing Conditions) .............. 8987
What's Not Covered Under Your Prescription Drug Retail or Home Delivery (Mail Order) Pharmacy
Benefit.................................................................................................................................................. 9492
Pre-existing Conditions ........................................................................................................................ 9694
Section 9. Member Payment ResponsibiIity ....................................................................................... 9795
Your Cost-Shares ................................................................................................................................ 9795
Maximum Allowed Amount .................................................................................................................. 9795
Claims Review ................................................................................................................................... 10098

34
Section 10. CIaims Procedure (How to FiIe a CIaim) ....................................................................... 10199
Notice of Claim & Proof of Loss ........................................................................................................ 10199
Claim Forms ...................................................................................................................................... 10199
Member's Cooperation ...................................................................................................................... 10199
Payment of Benefits .......................................................................................................................... 10199
nter-Plan Programs ........................................................................................................................ 102100
Out-of-Area Services ....................................................................................................................... 102100
BlueCard

Program ..................................................................................................................... 102100

Non-Participating Healthcare Providers Outside Our Service Area ............................................ 103101
Section 11. GeneraI PoIicy Provisions ............................................................................................ 104102
Assignment ...................................................................................................................................... 104102
Automobile nsurance Provisions .................................................................................................... 104102
Clerical Error .................................................................................................................................... 104102
Confidentiality and Release of nformation...................................................................................... 105103
Conformity with Law ........................................................................................................................ 105103
Contract with Anthem ...................................................................................................................... 105103
Entire Contract ................................................................................................................................. 105103
Form or Content of Booklet ............................................................................................................. 106104
Government Programs .................................................................................................................... 106104
Medical Policy and Technology Assessment .................................................................................. 106104
Medicare .......................................................................................................................................... 106104
Modifications .................................................................................................................................... 106104
Network Access Plan ....................................................................................................................... 107105
Not Liable for Provider Acts or Omissions ....................................................................................... 107105
Policies and Procedures .................................................................................................................. 107105
Relationship of Parties (Group-Member-Anthem) ........................................................................... 107105
Relationship of Parties (Anthem and n-Network Providers) ........................................................... 107105
Reservation of Discretionary Authority ............................................................................................ 108106
Right of Recovery ............................................................................................................................ 108106
Unauthorized Use of dentification Card .......................................................................................... 109107
Value-Added Programs ................................................................................................................... 109107
Value of Covered Services .............................................................................................................. 109107
Voluntary Clinical Quality Programs ................................................................................................ 109107
Voluntary Wellness ncentive Programs .......................................................................................... 109107
Waiver.............................................................................................................................................. 110108
Workers' Compensation .................................................................................................................. 110108
Subrogation and Reimbursement .................................................................................................... 110108
Subrogation .................................................................................................................................. 110108
Reimbursement ............................................................................................................................ 110108
The Member's Duties ................................................................................................................... 111109
Coordination of Benefits When Members Are nsured Under More Than One Plan ...................... 111109
Section 12. Termination/NonrenewaI/Continuation ....................................................................... 116114
Termination ...................................................................................................................................... 116114
Removal of Members ...................................................................................................................... 116114
Special Rules if Your Group Health Plan is Offered Through an Exchange ................................... 117115
Continuation of Coverage Under Federal Law (COBRA) ................................................................ 117115
Qualifying events for Continuation Coverage under Federal Law (COBRA) ............................... 117115
f Your Group Offers Retirement Coverage ................................................................................. 118116
Second qualifying event ............................................................................................................... 118116
Notification Requirements ............................................................................................................ 119117
Disability extension of 18-month period of continuation coverage .............................................. 119117
Trade Adjustment Act Eligible ndividual ..................................................................................... 119117
When COBRA Coverage Ends .................................................................................................... 120118
f You Have Questions ................................................................................................................. 120118
Continuation of Coverage Under State Law .................................................................................... 120118

35
Continuation of Coverage Due To Military Service ......................................................................... 121119
Maximum Period of Coverage During a Military Leave ............................................................... 122120
Reinstatement of Coverage Following a Military Leave .............................................................. 122120
Family and Medical Leave Act of 1993 ........................................................................................... 122120
Benefits After Termination Of Coverage ......................................................................................... 123121
Section 13. AppeaIs and CompIaints .............................................................................................. 124122
Complaints ....................................................................................................................................... 124122
Appeals ............................................................................................................................................ 125123
Grievances ...................................................................................................................................... 127125
Division of nsurance nquiries ..................................................................................................... 127125
Binding Arbitration ........................................................................................................................ 127125
Legal Action ................................................................................................................................. 127125
Section 14. Information on PoIicy and Rate Changes ................................................................... 129127
nsurance Premiums ........................................................................................................................ 129127
Section 15. Definitions ...................................................................................................................... 130128

36
Section 5. EIigibiIity
n this section you will find information on who is eligible for coverage under this Plan and when Members
can be added to your coverage. Eligibility requirements are described in general terms below. For more
specific information, please see your Human Resources or Benefits Department.
Who is EIigibIe for Coverage
The Subscriber
To be eligible to enroll as a Subscriber, the individual must:
Be an employee of the Group, and;
Be entitled to participate in the benefit Plan arranged by the Group, and;
Have satisfied any probationary or waiting period established by the Group and perform the duties of
your principal occupation for the Group.
Dependents
To be eligible to enroll as a Dependent, you must be listed on the enrollment form completed by the
Subscriber, meet all Dependent eligibility criteria established by the Group, and be one of the following:
The Subscriber's spouse, including the partner to a civil union as recognized by Colorado law. For
information on spousal eligibility please contact the Group.
Common-law spouse. A Common-Law Marriage Affidavit is needed to enroll a common-law spouse.
You can get the affidavit from your employer or you can call us. All references to spouse in this
Booklet include a common-law spouse.
A common law spouse is an eligible Dependent who has a valid common-law marriage in Colorado.
This is the same as any other marriage and can only end by death or divorce.
Designated beneficiary. Your Group may have decided to offer benefits under this plan to designated
beneficiaries. Check with your Group to learn more. f they are recognized by the Group, all
references to spouse in this Booklet include a designated beneficiary. A Recorded Designated
Beneficiary Agreement will need to be provided. A designated beneficiary is not eligible for COBRA
under this Booklet.
A designated beneficiary is an agreement entered into by two people for the purpose of making each
a beneficiary of the other and which has been recorded with the county clerk and recorder in the
county in which one of the person lives. The agreement is based on the Colorado Designated
Beneficiary Act.
Same-sex domestic partner. Domestic Partner, or Domestic Partnership means a person of the same
sex who has signed the Domestic Partner Affidavit certifying that he or she is the Subscriber's sole
Domestic Partner; he or she is mentally competent; he or she is not related to the Subscriber by
blood closer than permitted by state law for marriage; he or she is not married to anyone else; and he
or she is financially interdependent with the Subscriber.
For purposes of this Plan, a Domestic Partner or partner to a recognized civil union shall be treated
the same as a spouse, and that partner's child, adopted child, or child for whom he or she has legal
guardianship shall be treated the same as any other child. The coverage of a Domestic Partner, civil
union partner, or the child of any such partner ends on the date of dissolution of the Domestic
Partnership or civil union.
While this Booklet will recognize and provide benefits for a Member who is a spouse or child in
connection with a Domestic Partner or recognized civil union relationship, not every federal or state

37
law that applies to a Member who is a spouse or child under this Plan will also apply to a Domestic
Partner or a partner under a civil union. This includes but is not limited to, COBRA and FMLA.
We reserve the right to make the ultimate decision in determining eligibility of the Domestic Partner.
The children of the Subscriber or the Subscriber's spouse, including natural children, stepchildren,
newborn and legally adopted children and children who the Group has determined are covered under
a Qualified Medical Child Support Order as defined by ERSA or any applicable state law.
Children, including grandchildren, for whom the Subscriber or the Subscriber's spouse is a permanent
legal guardian or as otherwise required by law.
All enrolled eligible children will continue to be covered until the age limit listed in the "Schedule of
Benefits (Who Pays What). Coverage may be continued past the age limit in the following circumstances:
For unmarried Dependents who cannot work to support themselves due to mental retardation or
physical handicapchildren of any age who are medically certified as disabled and dependent upon the
parent. The Dependent's disability must start before the end of the period they would become
ineligible for coverage. We must be informed of the Dependent's eligibility for continuation of
coverage within 31 days after the Dependent would normally become ineligible. You must then give
proof as often as we require. This will not be more often than once a year after the two-year period
following the child reaching the limiting age. You must give the proof at no cost to us. You must
notify us if the Dependent's marital status changes and they are no longer eligible for continued
coverage.
We may require you to give proof of continued eligibility for any enrolled child. Your failure to give this
information could result in termination of a child's coverage.
To obtain coverage for children, we may require you to give us a copy of any legal documents awarding
permanent guardianship of such child(ren) to you.

Your group may have limited or excluded the eligibility of certain Dependent types and so not all
Dependents listed in this Plan may be entitled to enroll. For more specific information, please see your
Human Resources or Benefits Department.
Types of Coverage
Your Group offers some or all of the enrollment options listed below. After reviewing the available options,
you may choose the option that best meets your needs. The options may include:
Subscriber only (also referred to as single coverage);
Subscriber and spouse; or Domestic Partner;
Subscriber and child(ren);
Subscriber and family.
When You Can EnroII
InitiaI EnroIIment
The Group will offer an initial enrollment period to new Subscribers and their Dependents when the
Subscriber is first eligible for coverage. Coverage will be effective based on the waiting period chosen by
the Group, and will not exceed 90 days.
f you did not enroll yourself and/or your Dependents during the initial enrollment period you will only be
able to enroll during an Open Enrollment period or during a Special Enrollment period, as described
below.

38
Open EnroIIment
Open Enrollment refers to a period of time, usually 60 days, during which eligible Subscribers and
Dependents can apply for or change coverage. Open Enrollment occurs only once per year. The Group
will notify you when Open Enrollment is available.
SpeciaI EnroIIment Periods
f a Subscriber or Dependent does not apply for coverage when they were first eligible, they may be able
to join the Plan prior to Open Enrollment if they qualify for Special Enrollment. Except as noted otherwise
below, the Subscriber or Dependent must request Special Enrollment within 31 days of a qualifying event.
Special Enrollment is available for eligible individuals who:
Lost eligibility under a prior health plan for reasons other than non-payment of premium or due to
fraud or intentional misrepresentation of a material fact;
Lost coverage due to death of a covered employee; the termination or reduction in number of hours of
the covered employee's employment (regardless of eligibility for COBRA or state continuation
coverage); involuntary termination of coverage; lost eligibility under the Colorado Medical Assistance
Act or the Children's Basic Health Plan; or the covered employee becoming eligible for benefits under
Title XV of the Federal Social Security Act, as amended;
Lost coverage under a health benefit plan due to the divorce or legal separation of the covered
employee from the covered employee's spouse or partner in civil union, or due to the termination of a
recognized domestic partnership;
s now eligible for coverage due to marriage (including a civil union where recognized in the state
where the Subscriber resides), birth, adoption, placement for adoption, by entering into a Designated
Beneficiary Agreement, or pursuant to a QMCSO or other court or administrative order mandating
that the individual be covered;
Exhausted COBRA or state continuation benefits or stopped receiving group contributions toward the
cost of the prior health plan; or
Lost employer contributions towards the cost of the other coverage.

Important Notes about SpeciaI EnroIIment:
Members who enroll during Special Enrollment are not considered Late Enrollees.
ndividuals must request coverage within 31 days of a qualifying event (i.e., marriage, exhaustion of
COBRA, etc.).
f the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
SpeciaI RuIes if Your Group HeaIth PIan is Offered Through an Exchange
f your Plan is offered through a public exchange operated by the state or federal government as part of
the Patient Protection and Affordable Care Act ("Exchange), all enrollment changes must be made
through the Exchange by you or your Group. Each Exchange will have rules on how to do this. For plans
offered on the Exchange there are additional opportunities for Special Enrollment. They include:
Your enrollment or non-enrollment in another qualified health plan was unintentional, inadvertent or
erroneous and was a result of an error, misrepresentation, or inaction by an employee or
representative of the Exchange;
You adequately demonstrate to the Exchange that the health plan under which you are enrolled has
substantially violated a material provision of its contract with you;
You move and become eligible for new qualified health plans;

39
You are a Native American ndian, as defined by section 4 of the ndian Health Care mprovement
Act, and allowed to change from one qualified health plan to another as often as once per month; or
The Exchange determines, under federal law, that you meet other exceptional circumstances that
warrant a Special Enrollment.
You must give the Exchange notice within 30 days of the above events if you wish to enroll.
Medicaid and ChiIdren's HeaIth Insurance Program SpeciaI EnroIIment
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
The Subscriber's or Dependent's Medicaid or Children's Health nsurance Program (CHP) coverage
is terminated as a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program)
The Subscriber or Dependent must request Special Enrollment within 60 days of the above events.
Late EnroIIees
f the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Members Covered Under the Group's Prior PIan
Members who were previously enrolled under another plan offered by the Group that is being replaced by
this Plan are eligible for coverage on the Effective Date of this coverage.
EnroIIing Dependent ChiIdren
Newborn ChiIdren
Newborn children are covered automatically from the moment of birth. Following the birth of a child, you
should submit an application / change form to the Group within 31, but no more than 60, days to add the
newborn to your Plan. During the first 31 days after birth, a newborn child will be covered for Medically
Necessary care. This includes well child care and treatment of medically diagnosed congenital defects
and birth abnormalities. This is regardless of the limitations and exclusions applicable to other conditions
or procedures of this Booklet.
Even if no additional Premium is required, you should still submit an application / change form to the
Group to add the newborn to your Plan, to make sure we have accurate records and are able to cover
your claims.
Adopted ChiIdren
A child will be considered adopted from the earlier of: (1) the moment of placement in your home; or (2)
the date of an entry of an order granting custody of the child to you. The placement begins when you
assume or retain a legal obligation to partially or totally support a child in anticipation of the child's
adoption. A placement terminates at the time such legal obligation terminates. The child will continue to
be considered adopted unless the child is removed from your home prior to issuance of a legal decree of
adoption.
Your Dependent's Effective Date will be the date of the adoption or placement for adoption if you send us
the completed application / change form within 31 days of the event.

40
Adding a ChiId due to Award of LegaI Custody or Guardianship
f you or your spouse is awarded permanent legal custody or permanent guardianship for a child, an
application must be submitted within 31 days of the date legal custody or guardianship is awarded by the
court. Coverage will be effective on the date the court granted legal custody or guardianship.
QuaIified MedicaI ChiId Support Order
f you are required by a qualified medical child support order or court order, as defined by ERSA and/or
applicable state or federal law, to enroll your child in this Plan, we will permit the child to enroll at any time
without regard to any Open Enrollment limits and will provide the benefits of this Plan according to the
applicable requirements of such order. However, a child's coverage will not extend beyond any
Dependent Age Limit listed in the "Schedule of Benefits (Who Pays What).
Updating Coverage and/or Removing Dependents
You are required to notify the Group of any changes that affect your eligibility or the eligibility of your
Dependents for this Plan. When any of the following occurs, contact the Group and complete the
appropriate forms:
Changes in address;
Marriage or divorce or entering into or terminating a recognized civil union or domestic partnership;
Death of an enrolled family member (a different type of coverage may be necessary);
Enrollment in another health plan or in Medicare;
Eligibility for Medicare;
Dependent child reaching the Dependent Age Limit (see "Termination/Nonrenewal/Continuation);
Enrolled Dependent child either becomes totally or permanently disabled, or is no longer disabled.
Failure to notify us of individuals no longer eligible for services will not obligate us to cover such services,
even if Premium is received for those individuals. All notifications must be in writing and on approved
forms.
Nondiscrimination
No person who is eligible to enroll will be refused enrollment based on health status, health care needs,
genetic information, previous medical information, disability, sexual orientation or identity, gender or age.
Statements and Forms
All Members must complete and submit applications or other forms or statements that we may reasonably
request.
Any rights to benefits under this Plan are subject to the condition that all such information is true, correct,
and complete. Any intentional material misrepresentation by you may result in termination of coverage as
provided in the "Termination/Nonrenewal/Continuation" section. We will not use a statement made by you
to void or reduce your coverage after that coverage has been in effect for two years, unless such
statement is contained in a written instrument signed by you making such statement and a copy of that
instrument is or has been given to you or your beneficiary.


41
Section 6. How to Access Your Services and Obtain ApprovaI
of Benefits (AppIicabIe to managed care pIans)
Introduction
Your Plan is a PPO plan. The Plan has two sets of benefits: n-Network and Out-of-Network. f you
choose an n-Network Provider, you will pay less in out-of-pocket costs, such as Copayments,
Deductibles, and Coinsurance. f you use an Out-of-Network Provider, you will have to pay more out-of-
pocket costs.
In-Network Services
When you use an n-Network Provider or get care as part of an Authorized Service, Covered Services will
be covered at the n-Network level. Regardless of Medical Necessity, benefits will be denied for care that
is not a Covered Service. We have final authority to decide the Medical Necessity of the service.
In-Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for you. Referrals are never needed to visit an n-Network Specialist, including behavioral
health Providers.
To see a Doctor, call their office:
Tell them you are an Anthem Member,
Have your Member dentification Card handy. The Doctor's office may ask you for your group or
Member D number.
Tell them the reason for your visit.
When you go to the office, be sure to bring your Member dentification Card with you.
For services from n-Network Providers:
1. You will not need to file claims. n-Network Providers will file claims for Covered Services for you.
(You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be
billed by your n-Network Provider(s) for any non-Covered Services you get or when you have not
followed the terms of this Booklet.
2. Precertification will be done by the n-Network Provider. (See this section for further details.)
We do not guarantee that an n-Network Provider is available for all services and supplies covered under
your PPO plan. For some services and supplies We may not have arrangements with n-Network
Providers. For example, some Hospital-based labs are not part of our Reference Lab Network. Please
read the "Member Payment Responsibility section for additional information on Authorized Services.
After Hours Care
f you need care after normal business hours, your Doctor may have several options for you. You should
call your Doctor's office for instructions if you need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. f you have an Emergency, call 911 or go to the nearest
Emergency Room.

42
Out-of-Network Services
When you do not use an n-Network Provider or get care as part of an Authorized Service, Covered
Services are covered at the Out-of-Network level, unless otherwise indicated in this Booklet.
For services from an Out-of-Network Provider:
1. n addition to any Deductible and/or Coinsurance/Copayments, the Out-of-Network Provider can
charge you the difference between their bill and the Plan's Maximum Allowed Amount;
2. You may have higher cost sharing amounts (i.e., Deductibles, Coinsurance, and/or Copayments);
3. You will have to pay for services that are not Medically Necessary;
4. You will have to pay for non-Covered Services;
5. You may have to file claims; and
6. You must make sure any necessary Precertification is done. (Please see this section for more
details.)
We will not deny or restrict Covered Services just because you get treatment from an Out-of-Network
Provider; however, you may have to pay more.
We pay the benefits of this Booklet directly to Out-of-Network Providers, if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of you.
We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services.
How to Find a Provider in the Network
There are three ways you can find out if a Provider or Facility is in the network for this Plan. You can also
find out where they are located and details about their license or training.
See your Plan's directory of n-Network Providers at www.anthem.com, which lists the Doctors,
Providers, and Facilities that participate in this Plan's network.
Call Customer Service to ask for a list of Doctors and Providers that participate in this Plan's network,
based on specialty and geographic area.
Check with your Doctor or Provider.
f you need help choosing a Doctor who is right for you, call the Customer Service number on the back of
your Member dentification Card. TTY/TDD services also are available by dialing 711. A special operator
will get in touch with us to help with your needs.
{Narrow network:
[Please note that we have several networks, and that a Provider that is n-Network for one plan may not
be n-Network for another. Be sure to check your dentification Card or call Customer Service to find out
which network this Plan uses.]

{Tiered pIan:
[Designated Participating Provider Program
Certain Providers are part of our Designated Participating Provider Program, a program aimed at
improving the quality of our Members' health care. Providers in this program agree to coordinate much of
your care and will prepare care plans for Members who have multiple, complex health conditions.]

43
Continuity of Care
f you are getting ongoing care for a medical condition when you first enroll in this coverage, We may be
able to help ease the transition. Examples of ongoing care are prenatal/obstetrical care, Home Care or
Hospice Care. We try to avoid disruption of a new Member's care through Our transition of care policy. f
interested, you or your Provider must review the reference sheet, complete a "Transition of Care Form
and submit them to Us for review. You or your Provider can get these materials by calling Our Customer
Service.
Crediting Prior PIan Coverage
f you were covered by the Group's prior carrier / plan immediately before the Group signs up with us, with
no break in coverage, then you will get credit for any accrued Deductible and, if applicable and approved
by us, Out of Pocket amounts under that other plan. This does not apply to people who were not covered
by the prior carrier or plan on the day before the Group's coverage with us began, or to people who join
the Group later.
f your Group moves from one of our plans to another, (for example, changes its coverage from HMO to
PPO), and you were covered by the other product immediately before enrolling in this product with no
break in coverage, then you may get credit for any accrued Deductible and Out of Pocket amounts, if
applicable and approved by us. Any maximums, when applicable, will be carried over and charged
against the maximums under this Plan.
f your Group offers more than one of our products, and you change from one product to another with no
break in coverage, you will get credit for any accrued Deductible and, if applicable, Out of Pocket
amounts and any maximums will be carried over and charged against maximums under this Plan.
f your Group offers coverage through other products or carriers in addition to ours, and you change
products or carriers to enroll in this product with no break in coverage, you will get credit for any accrued
Deductible, Out of Pocket, and any maximums under this Plan.
This Section Does Not AppIy To You If:
Your Group moves to this Plan at the beginning of a Benefit Period.
You change from one of our individual policies to a group plan;
You change employers; or
You are a new Member of the Group who joins the Group after the Group's initial enrollment with us.
The BIueCard Program
Like all Blue Cross & Blue Shield plans throughout the country, we participate in a program called
"BlueCard." This program lets you get Covered Services at the n-Network cost-share when you are
traveling out of state and need health care, as long as you use a BlueCard Provider. All you have to do is
show your dentification Card to a participating Blue Cross & Blue Shield Provider, and they will send your
claims to us.
f you are out of state and an Emergency or urgent situation arises, you should get care right away.
n a non-Emergency situation, you can find the nearest contracted Provider by visiting the BlueCard
Doctor and Hospital Finder website (www.BCBS.com) or call the number on the back of your dentification
Card.
You can also access Doctors and Hospitals outside of the U.S. The BlueCard program is recognized in
more than 200 countries throughout the world.

44
Care Outside the United States - BIueCard

WorIdwide
Before you travel outside the United States, check with your Group or call Customer Service at the
number on your dentification Card to find out if your plan has BlueCard Worldwide benefits. Your
coverage outside the United States may be different and we suggest:
Before you leave home, call the Customer Service number on your dentification Card for coverage
details.
Always carry your up to date Anthem dentification Card.
n an Emergency, go straight to the nearest Hospital.
The BlueCard Worldwide Service Center is on hand 24 hours a day, seven days a week toll-free at
(800) 810-BLUE (2583) or by calling collect at (804) 673-1177. An assistance coordinator, along with
a health care professional, will arrange a Doctor visit or Hospital stay, if needed.
CaII the Service Center in these non-emergency situations:
You need to find a Doctor or Hospital or need health care. An assistance coordinator, along with a
medical professional, will arrange a Doctor visit or Hospital stay, if needed.
You need npatient care. After calling the Service Center, you must also call us to get approval for
benefits at the phone number on your dentification Card. Note: this number is different than the
phone numbers listed above for BlueCard Worldwide.
Payment DetaiIs
Participating BIueCard WorIdwide HospitaIs. n most cases, when you make arrangements for a
Hospital stay through BlueCard Worldwide, you should not need to pay upfront for npatient care at
participating BlueCard Worldwide hospitals except for the out-of-pocket costs (non-Covered Services,
Deductible, Copayments and Coinsurance) you normally pay. The Hospital should send in your claim
for you.
Doctors and/or non-participating HospitaIs. You will need to pay upfront for outpatient services,
care received from a Doctor, and npatient care not arranged through the BlueCard Worldwide
Service Center. Then you can fill out a BlueCard Worldwide claim form and send it with the original
bill(s) to the BlueCard Worldwide Service Center (the address is on the form).
CIaim FiIing
The Hospital will file your claim if the BlueCard Worldwide Service Center arranged your Hospital
stay. You will need to pay the Hospital for the out-of-pocket costs you normally pay.
You must file the claim for outpatient and Doctor care, or npatient care not arranged through the
BlueCard Worldwide Service Center. You will need to pay the Provider and subsequently send an
international claim form with the original bills to us.
CIaim Forms
You can get international claim forms from us, the BlueCard Worldwide Service Center, or online at
www.bcbs.com/bluecardworldwide. The address for sending in claims is on the form.
Identification Card
We will give an dentification Card to each Member enrolled in the Plan. When you get care, you must
show your dentification Card. Only a Member who has paid the Premiums for this Plan has the right to
services or benefits under this Booklet. f anyone gets services or benefits to which they are not entitled to
under the terms of this Booklet, he/she must pay for the actual cost of the services.

45
Obtain ApprovaI of Benefits
Your Plan includes the processes of Precertification, Predetermination and Post Service Clinical Claims
Review to decide when services should be covered by your Plan. Their purpose is to aid the delivery of
cost-effective health care by reviewing the use of treatments and, when proper, the setting or place of
service that they are performed. Covered Services must be Medically Necessary for benefits to be
covered. When setting or place of service is part of the review, services that can be safely given to you in
a lower cost setting will not be Medically Necessary if they are given in a higher cost setting.
Prior Authorization: n-Network Providers must obtain prior authorization in order for you to get benefits
for certain services. Prior authorization criteria will be based on many sources including medical policy,
clinical guidelines, and pharmacy and therapeutics guidelines. Anthem may decide that a service that was
first prescribed or asked for is not Medically Necessary if you have not tried other treatments which are
more cost effective.
f you have any questions about the information in this section, you may call the Customer Service phone
number on the back of your dentification Card.
Types of Requests
Precertification - A required review of a service, treatment or admission for a benefit coverage
determination which must be done before the service, treatment or admission start date. For
Emergency admissions, you, your authorized representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a reasonable period of time. For labor / childbirth
admissions, Precertification is not needed unless there is a problem and/or the mother and baby are
not sent home at the same time.
Predetermination - An optional, voluntary Prospective or Continued Stay Review request for a
benefit coverage determination for a service or treatment. We will check your Booklet to find out if
there is an Exclusion for the service or treatment. f there is a related clinical coverage guideline, the
benefit coverage review will include a review to decide whether the service meets the definition of
Medical Necessity under this Booklet or is Experimental / nvestigational as that term is defined in this
Booklet.
Post Service CIinicaI CIaims Review - A Retrospective review for a benefit coverage determination
to decide the Medical Necessity or Experimental / nvestigational nature of a service, treatment or
admission that did not need Precertification and did not have a Predetermination review performed.
Medical reviews are done for a service, treatment or admission in which we have a related clinical
coverage guideline and are typically initiated by us.
Typically, n-Network Providers know which services need Precertification and will get any Precertification
or ask for a Predetermination when needed. Your Primary Care Physician / Provider and other n-
Network Providers have been given detailed information about these procedures and are responsible for
meeting these requirements. Generally, the ordering Provider, Facility or attending Doctor will get in touch
with us to ask for a Precertification or Predetermination review ("requesting Provider). We will work with
the requesting Provider for the Precertification request. However, you may choose an authorized
representative to act on your behalf for a specific request. The authorized representative can be anyone
who is 18 years of age or older.

46
Who is responsibIe for Precertification
Services given by an In-
Network Provider
Services given by a BIueCard/Out-of-Network/Non-
Participating Provider
Provider
Member must get Precertification.
f Member fails to get Precertification, Member may be
financially responsible for service and/or setting in
whole or in part.
For Emergency admissions, you, your authorized
representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a
reasonable period of time.

We use our clinical coverage guidelines, such as medical policy, clinical guidelines, preventative care
clinical coverage guidelines and other applicable policies and procedures to help make our Medical
Necessity decisions, including decisions about Prescription and Specialty Drug services. Medical policies
and clinical guidelines reflect the standards of practice and medical interventions identified as proper
medical practice. We reserve the right to review and update these clinical coverage guidelines from time
to time. Your Booklet and Group Contract take precedence over these guidelines.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning your
request. To ask for this information, call the Precertification phone number on the back of your
dentification Card.
Anthem may, from time to time, waive, enhance, change or end certain medical management processes
(including utilization management, case management, and disease management) if in our discretion,
such change furthers the provision of cost effective, value based and/or quality services.
We may also select certain qualifying Providers to take part in a program that exempts them from certain
procedural or medical management processes that would otherwise apply. We may also exempt your
claim from medical review if certain conditions apply.
Just because Anthem exempts a process, Provider or Claim from the standards which otherwise would
apply, it does not mean that Anthem will do so in the future, or will do so in the future for any other
Provider, claim or Member. Anthem may stop or change any such exemption with or without advance
notice.
You may find out whether a Provider is taking part in certain programs by checking your on-line Provider
Directory or contacting the Customer Service number on the back of your D card.

We also may identify certain Providers to review for potential fraud, waste, abuse or other inappropriate
activity if the claims data suggests there may be inappropriate billing practices. f a Provider is selected
under this program, then we may use one or more clinical utilization management guidelines in the review
of claims submitted by this Provider, even if those guidelines are not used for all Providers delivering
services to this Plan's Members.
Request Categories
Expedited - A request for Precertification or Predetermination that, in the view of the treating
Provider or any Doctor with knowledge of your medical condition, could; without such care or
treatment, seriously threaten your life or health or your ability to regain maximum function; or subject
you to severe pain that cannot be adequately managed without such care or treatment; or if you have

47
a physical or mental disability, create an imminent and substantial limitation on your existing ability to
live independently.
Prospective - A request for Precertification or Predetermination that is conducted before the service,
treatment or admission.
Continued Stay Review - A request for Precertification or Predetermination that is conducted during
the course of outpatient treatment or during an npatient admission.
Retrospective - A request for Precertification that is conducted after the service, treatment or
admission has happened. Post Service Clinical Claims Reviews are also retrospective.
Retrospective review does not include a review that is limited to an evaluation of reimbursement
levels, veracity of documentation, accuracy of coding or adjudication of payment.
Decision and Notice Requirements
We will review requests for benefits according to the timeframes listed below. The timeframes and
requirements listed are based on state and federal laws. Where state laws are stricter than federal laws,
we will follow state laws. f you live in and/or get services in a state other than the state where your
Contract was issued other state-specific requirements may apply. You may call the phone number on the
back of your dentification Card for more details.
Request Category Timeframe Requirement for Decision and
Notification
Prospective Expedited 72 hours from the receipt of request
Prospective Non-Expedited 15 calendar days from the receipt of the request
Continued Stay Review when hospitalized
at the time of the request
72 hours from the receipt of the request and prior to
expiration of current certification.
Continued Stay Review Expedited when
request is received more than 24 hours
before the end of the previous authorization
24 hours from the receipt of the request
Continued Stay Review Expedited when
request is received less than 24 hours
before the end of the previous authorization
or no previous authorization exists
72 hours from the receipt of the request
Continued Stay Review Non-Expedited 15 calendar days from the receipt of the request
Retrospective 30 calendar days from the receipt of the request
f more information is needed to make our decision, we will tell the requesting Provider and send written
notice to you or your authorized representative of the specific information needed to finish the review. f
we do not get the specific information we need or if the information is not complete by the timeframe
identified in the written notice, we will make a decision based upon the information we have.
We will give notice of our decision as required by state and federal law. Notice may be given by the
following methods:
VerbaI: Oral notice given to the requesting Provider by phone or by electronic means if agreed to by
the Provider.
Written: Mailed letter or electronic means including email and fax given to, at a minimum, the
requesting Provider and you or your authorized representative
For benefits to be covered, Precertification wiII consider the foIIowing:
1. You must be eligible for benefits;

48
2. Premium must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under your Plan;
4. The service cannot be subject to an Exclusion under your Plan;
5. You must not have exceeded any applicable limits under your Plan; and
6. You did not perform an act, practice, or omission that constitutes fraud or abuse when requesting the
Precertification.
HeaIth PIan IndividuaI Case Management
Our health plan case management programs (Case Management) help coordinate services for Members
with health care needs due to serious, complex, and/or chronic health conditions. Our programs
coordinate benefits and educate Members who agree to take part in the Case Management program to
help meet their health-related needs.
Our Case Management programs are confidential and voluntary and are made available at no extra cost
to you. These programs are provided by, or on behalf of and at the request of, your health plan case
management staff. These Case Management programs are separate from any Covered Services you are
receiving.
f you meet program criteria and agree to take part, we will help you meet your identified health care
needs. This is reached through contact and team work with you and/or your chosen authorized
representative, treating Doctor(s), and other Providers.
n addition, we may assist in coordinating care with existing community-based programs and services to
meet your needs. This may include giving you information about external agencies and community-
based programs and services.
n certain cases of severe or chronic illness or injury, we may provide benefits for alternate care that is not
listed as a Covered Service through our Case Management program. We may also extend Covered
Services beyond the Benefit Maximums of this Plan. We will make our decision case-by-case, if in our
discretion the alternate or extended benefit is in the best interest of the Member and Anthem. A decision
to provide extended benefits or approve alternate care in one case does not obligate us to provide the
same benefits again to you or to any other Member. We reserve the right, at any time, to alter or stop
providing extended benefits or approving alternate care. n such case, we will notify you or your
authorized representative in writing.


49
Section 7. Benefits/Coverage (What is Covered)
This section describes the Covered Services available under your Plan. Covered Services are subject to
all the terms and conditions listed in this Booklet, including, but not limited to, Benefit Maximums,
Deductibles, Copayments, Coinsurance, Exclusions and Medical Necessity requirements. Please read
the "Schedule of Benefits (Who Pays What)" for details on the amounts you must pay for Covered
Services and for details on any Benefit Maximums. Also be sure to read "How to Access Your Services
and Obtain Approval of Benefits (Applicable to managed care plans)" for more information on your Plan's
rules. Read the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for
important details on Excluded Services.
Your benefits are described below. Benefits are listed alphabetically to make them easy to find. Please
note that several sections may apply to your claims. For example, if you have inpatient surgery, benefits
for your Hospital stay will be described under "npatient Hospital Care "and benefits for your Doctor's
services will be described under "npatient Professional Services. As a result, you should read all
sections that might apply to your claims.
You should also know that many of Covered Services can be received in several settings, including a
Doctor's office, an Urgent Care Facility, an Outpatient Facility, or an npatient Facility. Benefits will often
vary depending on where you choose to get Covered Services, and this can result in a change in the
amount you need to pay. Please see the "Schedule of Benefits (Who Pays What) for more details on
how benefits vary in each setting.
Acupuncture/Nerve Pathway Therapy
Please see "Therapy Service later in this section.
AIIergy Services
Your Plan includes benefits for Medically Necessary allergy testing and treatment, including allergy serum
and allergy shots.
AmbuIance Services
Medically Necessary ambulance services are a Covered Service when one or more of the following
criteria are met:
You are transported by a state licensed vehicle that is designed, equipped, and used only to transport
the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other
certified medical professionals. This includes ground, water, fixed wing, and rotary wing air
transportation.
For ground ambulance, you are taken:
! From your home, the scene of an accident or medical Emergency to a Hospital;
! Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an n-Network Hospital
! Between a Hospital and a Skilled Nursing Facility or other approved Facility.
For air or water ambulance, you are taken:
! From the scene of an accident or medical Emergency to a Hospital;
! Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an n-Network Hospital
! Between a Hospital and an approved Facility.

50
Emergency ambulance services do not require prior authorization and are allowed regardless of whether
the Provider is an n-Network or Out-of-Network Provider. However non-Emergency Aambulance services
are subject to Medical Necessity reviews by us. When using an air ambulance for non-Emergency
services, we reserve the right to select the air ambulance Provider. For non-Emergency ambulance
services if you do not use the air ambulance Provider we select, the Out-of-Network Provider may bill you
for any charges that exceed the Plan's Maximum Allowed Amount.
You must be taken to the nearest Facility that can give care for your condition. n certain cases we may
approve benefits for transportation to a Facility that is not the nearest Facility.
Benefits also include Medically Necessary treatment of a sickness or injury by medical professionals from
an ambulance service, even if you are not taken to a Facility.
Ambulance services are not covered when another type of transportation can be used without
endangering your health. Ambulance services for your convenience or the convenience of your family or
Doctor are not a Covered Service.
Other non-covered ambulance services, include but are not limited to, trips to:
A Doctor's office or clinic;
A morgue or funeral home.
Important Notes on Air AmbuIance Benefits
Benefits are only available for air ambulance when it is not appropriate to use a ground or water
ambulance. For example, if using a ground ambulance would endanger your health and your medical
condition requires a more rapid transport to a Facility than the ground ambulance can provide, the Plan
will cover the air ambulance. Air ambulance will also be covered if you are in an area that a ground or
water ambulance cannot reach.
Air ambulance will not be covered if you are taken to a Hospital that is not an acute care Hospital (such
as a Skilled Nursing Facility), or if you are taken to a Physician's office or your home.
HospitaI to HospitaI Transport
f you are moving from one Hospital to another, air ambulance will only be covered if using a ground
ambulance would endanger your health and if the Hospital that first treats cannot give you the medical
services you need. Certain specialized services are not available at all Hospitals. For example, burn
care, cardiac care, trauma care, and critical care are only available at certain Hospitals. To be covered,
you must be taken to the closest Hospital that can treat you. Coverage is not avaiIabIe for air
ambuIance transfers simpIy because you, your famiIy, or your Provider prefers a specific HospitaI
or Physician.
Autism Services
Covered Services are provided for the assessment, diagnosis, and treatment of Autism Spectrum
Disorders (ASD) for a covered child. The following treatments will not be considered Experimental or
nvestigational and will be considered appropriate, effective, or efficient for the treatment of Autism
Spectrum Disorders where We determine such services are Medically Necessary:
Evaluation and assessment services;
Behavior training and behavior management and Applied Behavior Analysis, including but not limited
to consultations, direct care, supervision, or treatment, or any combination thereof, for Autism
Spectrum Disorders provided by Autism Services Providers;

51
Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy,
or speech therapy, or any combination of those therapies;
Prescription Drugs;
Psychiatric care;
Psychological care, including family counseling; and
Therapeutic care.
Treatment for Autism Spectrum Disorders must be prescribed or ordered by a Doctor or psychologist, and
services must be provided by a Provider covered under this Plan and approved to provide those services.
However, behavior training, behavior management, or Applied Behavior Analysis services (whether
provided directly or as part of Therapeutic Care), must be provided by an Autism Services Provider.
Coverage of Autism Spectrum Disorders in this section is in addition to coverage provided for early
intervention and Congenital Defects and Birth Abnormality. Autism services and the Autism Treatment
Plan are subject to review under the "How to Access Your Services and Obtain Approval of Benefits
(Applicable to managed care plans) section.
BehavioraI HeaIth Services
See "Mental Health, Alcohol and Substance Abuse Services later in this section.
Cardiac RehabiIitation
Please see "Therapy Services later in this section.
Chemotherapy
Please see "Therapy Services later in this section.
Chiropractor Services
Please see "Therapy Services later in this section.
CIinicaI TriaIs
Benefits include coverage for services given to you as a participant in an approved clinical trial if the
services are Covered Services under this Plan. An "approved clinical trial means a phase , phase ,
phase , or phase V clinical trial that studies the prevention, detection, or treatment of cancer or other
life-threatening conditions. The term life-threatening condition means any disease or condition from which
death is likely unless the disease or condition is treated.
Benefits are limited to the following trials:
1. Federally funded trials approved or funded by one of the following:
a. The National nstitutes of Health.
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.

52
e. Cooperative group or center of any of the entities described in (a) through (d) or the Department
of Defense or the Department of Veterans Affairs.
f. A qualified non-governmental research entity identified in the guidelines issued by the National
nstitutes of Health for center support grants.
g. Any of the following in i-iii below if the study or investigation has been reviewed and approved
through a system of peer review that the Secretary determines 1) to be comparable to the system
of peer review of studies and investigations used by the National nstitutes of Health, and 2)
assures unbiased review of the highest scientific standards by qualified individuals who have no
interest in the outcome of the review.
i. The Department of Veterans Affairs.
ii. The Department of Defense.
iii. The Department of Energy.
2. Studies or investigations done as part of an investigational new drug application reviewed by the
Food and Drug Administration;
3. Studies or investigations done for drug trials which are exempt from the investigational new drug
application.
Your Plan may require you to use an n-Network Provider to maximize your benefits.
When a requested service is part of an approved clinical trial, it is a Covered Service even though it might
otherwise be nvestigational as defined by this Plan. All other requests for clinical trials services that are
not part of approved clinical trials will be reviewed according to our Clinical Coverage Guidelines, related
policies and procedures.
Your Plan is not required to provide benefits for the following services. We reserve our right to exclude
any of the following services:
i. The nvestigational item, device, or service, itself; or
ii. tems and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
DentaI Services
Your DentaI Benefits
Anthem does not determine whether dental services listed in this section are medically necessary to treat
your specific condition or restore your dentition. There is a preset schedule of dental services that are
covered under this Plan. We evaluate the procedures submitted to us on your claim to determine if they
are a covered service under this Plan.

Exception: Claims for orthodontic care will be reviewed to determine if it was Dentally Necessary
Orthodontic Care. See the section "Orthodontic Care for more information.
Your dentist may recommend or prescribe other dental care services that are not covered, are cosmetic in
nature, or exceed the benefit frequencies of this Plan. While these services may be necessary for your
dental condition, they may not be covered by us. There may be an alternative dental care service
available to you that is covered under your Plan. These alternative services are called optional
treatments. f an allowance for an optional treatment is available, you may apply this allowance to the

53
initial dental service prescribed by your dentist. You are responsible for any costs that exceed the
allowance, in addition to any coinsurance or deductible you may have.
The decision as to what dental care treatment is best for you is solely between you and your dentist.
Pretreatment Estimate
A pretreatment estimate is a valuable tool for you and your dentist. t provides you and the dentist with an
idea of what your out of pocket costs will be for the dental care treatment. This will allow the dentist and
you to make any necessary financial arrangements before treatment begins. t is a good idea to get a
pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or
orthodontic care
The pretreatment estimate is recommended, but not required for you to receive benefits for covered
dental care services.
A pretreatment estimate does not authorize treatment or determine its medical necessity (except for
orthodontics), and does not guarantee benefits. The estimate will be based on your current eligibility and
the Plan benefits in effect at the time the estimate is submitted to us. This is an estimate only. Our final
payment will be based on the claim that is submitted at the time of the completed dental care service(s).
Submission in other claims, changes to your eligibility or changes to the Plan may affect our final
payment.
You can ask your dentist to submit a pretreatment estimate for you, or you can send it to us yourself.
Please include the procedure codes for the services to be performed (your dentist can tell you what
procedure codes). Pretreatment estimate requests can be sent to the address on your dental D card.
{Pediatric dentaI:
[Pediatric DentaI for Members through Age 18

This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.

Diagnostic and Preventive Services

OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive

Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s)
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.

DentaI CIeaning (ProphyIaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.


54
FIuoride Treatment (TopicaI appIication) or fIuoride varnish) Covered 2 times per 12-month period.

SeaIants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.

Space Maintainers and Recementation of Space Maintainer - Covered only for premature loss of
primary posterior (back) teeth.

Emergency (PaIIiative) Treatment (for pain relief).

Basic Restorative Services

AmaIgam (siIver) Restoration Treatment to restore decayed or fractured permanent or primary
posterior (back) teeth. Covered once in a 24 month period per tooth surface.

Composite (white) Resin Restorations Covered once in a 24 month period for the same amalgam
restoration.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.

Major Restorative Services

Recement Crown.

Prefabricated StainIess SteeI or Resin Crown - Covered once per tooth in a 24 month period.

Sedative FiIIing.

Pin Retention per tooth in addition to restoration.

OraI Surgery

Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

CompIex SurgicaI Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth

Note: Surgical removal of 3rd molars are covered only if the removal is associated with symptoms of oral
pathology.

Endodontic Services

Therapeutic PuIpotomy - Covered for primary teeth only.

Root CanaI Therapy - Covered for permanent teeth only .


55
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

DentaIIy Necessary Orthodontic Care
To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:
a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth when
you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores at a
level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem that
interferes with the biting function.

Orthodontic treatment may include the following:
Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
nterceptive Treatment - A limited (phase ) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments
Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive ongoing
payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate of
Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued. A
new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve as
the claim form to be submitted 6 months from the date of appliance placement.]


56
{Pediatric/AduIt dentaI:
[DentaI Services
DentaI Services for Members through Age 18
This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.
Diagnostic and Preventive Services
OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive
Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s) 4 single x-rays per 12-month period.
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.
DentaI CIeaning (ProphyIaxis) -Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.
FIuoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.
SeaIants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.
Space Maintainers and Recementation of Space Maintainer. Covered only for premature loss of
primary posterior (back) teeth.
Emergency (PaIIiative) Treatment (for pain reIief).
Basic Restorative Services
AmaIgam (siIver) Restoration Treatment to restore decayed or fractured permanent or primary teeth
posterior (back) teeth. Covered once in a 24 month period per tooth surface.
Composite (white) Resin Restorations Covered once in a 24 month period per tooth surface.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be

57
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.
Major Restorative Services
Recement Crown.
Prefabricated StainIess SteeI or Resin Crown. Covered once per tooth in a 24 month period.
Sedative FiIIing.
Pin Retention - per tooth in addition to restoration.
OraI Surgery
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

CompIex SurgicaI Extractions

Surgical removal of impacted tooth

Note: Surgical removal of 3
rd
molars are covered only if the removal is associated with symptoms
of oral pathology.

Endodontic Services

Therapeutic PuIpotomy. Covered only for primary teeth.

Root CanaI Therapy. Covered for permanent teeth only.
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

DentaIIy Necessary Orthodontic Care

To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:

a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth
when you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores
at a level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem
that interferes with the biting function.


58
Orthodontic treatment may incIude the foIIowing:

Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
nterceptive Treatment - A limited (phase ) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments

Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive
ongoing payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate
of Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued.
A new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve
as the claim form to be submitted 6 months from the date of appliance placement.]
DentaI Services for Members Age 19 and OIder
This Plan covers the dental services below for Members age 19 and older when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive treatment.
Diagnostic and Preventive Services
OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Radiographs (X-rays)
Bitewings - 1 series per 24-month period.
Full Mouth (Complete Series) or Panoramic - Once per 60-month period.
Periapical(s) - 4 single x-rays per 12-month period.
Occlusal - 2 series per 24-month period.

59
DentaI CIeaning (ProphyIaxis) Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain
from teeth. Any combination of this procedure and periodontal maintenance (See "Periodontal Services
below) are covered 2 times per calendar year.
Basic Restorative Services
Emergency Treatment Emergency (palliative) treatment for the temporary relief of pain or infection.
AmaIgam (siIver) Restorations Treatment to restore decayed or fractured permanent or primary teeth.
Composite (white) Resin Restorations
Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anterior
(front) teeth.
Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posterior
(back) teeth.
Benefits will be limited to the same surfaces and allowances for amalgam (silver filling). You must pay
the difference in cost between the Maximum Allowed Amount for the Covered Service and the optional
treatment plus any Deductible and/or Coinsurance.
Benefits for amalgam or composite restorations will be limited to one service per tooth surface per 24-
month period.
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root
Brush Biopsy - Covered once per 36-month period for Members age 20 to 39. Covered once per 12-
month period for Members age 40 and older.
Endodontic Services
Endodontic Therapy on Primary Teeth
Pulpal Therapy
Therapeutic Pulpotomy
Endodontic Therapy on Permanent Teeth
Root Canal Therapy
Root Canal Retreatment
All of the above endodontic services are limited to once per tooth per lifetime.
PeriodontaI Services
PeriodontaI Maintenance A procedure that includes removal of bacteria from the gum pocket areas,
scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patients who
have completed periodontal treatment.

60
Benefits for any combination of this procedure and dental cleanings (see "Diagnostic and Preventive
Services section) are limited to 2 times per calendar year.
Basic Non-SurgicaI PeriodontaI Care Treatment of diseases of the gingival (gums) and bone
supporting the teeth.
Periodontal scaling & root planning is covered once per 36 months if the tooth has a pocket depth of
4 millimeters or greater.
Full mouth debridement is covered once per lifetime.
CompIex SurgicaI PeriodontaI Care Surgical treatment of diseases of the gingival (gums) and bone
supporting the teeth. The following services are considered complex surgical periodontal services:
Gingivectomy/gingivoplasty;
Gingival flap;
Apically positioned flap;
Osseous surgery;
Bone replacement graft;
Pedicle soft tissue graft;
Free soft tissue graft;
Subepithelial connective tissue graft;
Soft tissue allograft;
Combined connective tissue and double pedicle graft;
Distal/proximal wedge - Covered on natural teeth only
Complex surgical periodontal services are limited as follows:
Only one complex surgical periodontal service is covered per 36-month period per single tooth; or
Only one complex surgical periodontal service is covered per 36-month period for multiple teeth in the
same quadrant if the pocket depth of the tooth is 5 millimeters or greater.
OraI Surgery Services
CompIex SurgicaI Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth
Surgical removal of residual tooth roots
Surgical removals of third molars are only covered if the removal is associated with symptoms of oral
pathology.
Other CompIex SurgicaI Procedures Covered only when required to prepare for dentures and limited to
once in a 60-month period:
Alveoloplasty
Vestibuloplasty
Removal of exostosis-per site
Surgical reduction of osseous tuberosity
SurgicaI Reduction of Fibrous Tuberosity Covered once every 6 months.

61
Adjunctive GeneraI Services
ntravenous Conscious Sedation, V Sedation, and General Anesthesia Covered only when given
with covered complex surgical services. Benefits are not available when given with non-surgical
dental care.
Major Restorative Services
GoId foiI restorations The Plan will cover an amalgam (silver filling) benefit equal to the same number of
surfaces and allowances.
You must pay the difference in cost between the Maximum Allowed Amount for the Covered Services and
optional treatment plus any Deductible and/or Coinsurance that applies. Covered once per 24-month
period.
InIays Benefit will equal an amalgam (silver) restoration for the same number of surfaces.
f an inlay is performed to restore a posterior (back) tooth with a metal, porcelain, or any composite
(white) based resin material, the patient must pay the difference in cost between the Maximum Allowed
Amount for the Covered Service and inlay, plus any Deductible and/or Coinsurance that applies.
OnIays and/or Permanent Crowns Covered once every 7 years if the tooth has extensive loss of natural
tooth structure due to decay or tooth fracture such that a restoration cannot be used to restore the tooth.
We will pay up to the Maximum Allowed Amount for a porcelain to noble metal crown. You must pay the
difference in cost between the porcelain to noble metal crown and the optional treatment, plus any
Deductible and/or Coinsurance that applies.
ImpIant Crowns See "Prosthodontic Services.
Recement InIay, OnIay, and Crowns Covered 6 months after initial placement.
Crown/InIay/OnIay Repair Covered once per 12-month period per tooth when the submitted narrative
from the treating dentist supports the procedure.
Restorative cast post and core buiId-up, incIuding 1 post per tooth and 1 pin per surface Covered
once every 7 years when necessary to retain an indirectly fabricated restoration due to extensive loss of
actual tooth structure due to caries or fracture.
Prosthodontic Services
Tissue Conditioning Covered once per 24-month period.
ReIine and Rebase Covered once per 24-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge).
Repairs, RepIacement of Broken ArtificiaI Teeth, RepIacement of Broken CIasp(s) Covered once per
6-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance;

62
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge); and
When the submitted narrative from the treating dentist supports the procedure.
Denture Adjustments Covered 2 times per 12-month period when:
The denture is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the denture.
PartiaI and Bridge Adjustments Covered 2 times per 24-month period when:
The partial or bridge is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the partial or bridge.
RemovabIe Prosthetic Services (Dentures and PartiaIs) Covered once per 7 year period:
For the replacement of extracted (removed) permanent teeth;
f 7 years have passed since the last covered removable prosthetic appliance (denture or partial) and
the existing denture or partial cannot be repaired or adjusted.
Fixed Prosthetic Services (Bridge) Covered once every 7 years:
For the replacement of extracted (removed) permanent teeth;
f no more than 3 teeth are missing in the same arch;
A natural, healthy, sound tooth is present to serve as the anterior and posterior retainer;
No other missing teeth in the same arch that have not been replaced with a removable partial
denture;
f none of the individual units of the bridge has been covered previously as a crown or cast restoration
in the last 7 years;
f 7 years have passed since the last covered removable prosthetic appliance (bridge) and the
existing bridge cannot be repaired or adjusted.
f there are multiple missing teeth, benefits may only be paid for a removable partial denture if it would be
the least costly, commonly performed course of treatment. Any optional benefits are subject to all
contract limits on the Covered Service.
Recement Fixed Prosthetic Covered once per 12 months.
SingIe Tooth ImpIant Body, Abutment and Crown Covered once per 7 year period. Coverage includes
only the single surgical placement of the implant body, implant abutment and implant/abutment supported
crown.
Some adjunctive impIant services may not be covered. We recommend that you get a
pretreatment estimate to estimate the amount of payment before you begin treatment.

Orthodontic Services
Orthodontic services for members age 19 and older is not covered, except as provided under the Dental
Services (All Members / All Ages) section below.]

63
DentaI Services (AII Members / AII Ages)
Preparing the Mouth for MedicaI Treatments
Your Plan includes coverage for dental services to prepare the mouth for medical services and treatments
such as radiation therapy to treat cancer and prepare for transplants. Covered Services include:
Evaluation
Dental x-rays
Extractions, including surgical extractions
Anesthesia
Accident-ReIated DentaI Services
Benefits are also available for dental work needed to treat injuries to the jaw, sound natural teeth, mouth
or face as a result of an accident. An injury that results from chewing or biting is not considered an
Accidental njury under this Plan, unless the chewing or biting results from a medical or mental condition.
Treatment must begin within 90 days of the injury to be a Covered Service under this Plan.
CIeft PaIate and CIeft Lip Conditions
Benefits are available for inpatient care and outpatient care, including:
Orofacial surgery
Surgical care and follow-up care by plastic surgeons and oral surgeons
Orthodontics and prosthodontic treatment
Prosthetic treatment such as obturators, speech appliances, and prosthodontic
Prosthodontic and surgical reconstruction for the treatment of cleft palate and/or cleft lip
f you have a dental plan, the dental plan would be the main plan and must fully cover orthodontics and
dental care for cleft palate and cleft lip conditions.
DentaI Anesthesia for ChiIdren
Benefits are available for general anesthesia from a Hospital, outpatient surgical Facility or other Facility,
and for the Hospital or Facility charges needed for dental care for a covered Dependent child who:
Has a physical, mental or medically compromising condition
Has dental needs for which local anesthesia is not effective because of acute infection, anatomic
variation or allergy
s extremely uncooperative, unmanageable, uncommunicative or anxious and whose dental needs
are deemed sufficiently important that dental care cannot be deferred
Has sustained extensive orofacial and dental trauma.
Diabetes Equipment, Education, and SuppIies
Your Plan covers diabetes training and medical nutrition therapy if you have diabetes (whether or not it is
insulin dependent), or if you have raised blood glucose levels caused by pregnancy. Other medical
conditions may also qualify. But the services need to be ordered by a Doctor and given by a Provider
who is certified, registered or with training in diabetes. Diabetes training sessions must be provided by a
Provider in an outpatient Facility or in a Doctor's office.

64
Screenings for gestational diabetes are covered under "Preventive Care later in this section.
Diagnostic Services
Your Plan includes benefits for tests or procedures to find or check a condition when specific symptoms
exist. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or
Hospital admission. Benefits include the following services:
Diagnostic Laboratory and PathoIogy Services
Diagnostic Imaging Services and EIectronic Diagnostic Tests
X-rays / regular imaging services
Ultrasound
Electrocardiograms (EKG)
Electroencephalography (EEG)
Echocardiograms
Hearing and vision tests for a medical condition or injury (not for screenings or preventive care)
Tests ordered before a surgery or admission.
Advanced Imaging Services
Benefits are also available for advanced imaging services, which include but are not limited to:
CT scan
CTA scan
Magnetic Resonance maging (MR)
Magnetic Resonance Angiography (MRA)
Magnetic resonance spectroscopy (MRS)
Nuclear Cardiology
PET scans
PET/CT Fusion scans
QTC Bone Densitometry
Diagnostic CT Colonography
The list of advanced imaging services may change as medical technologies change.
DiaIysis
See "Therapy Services later in this section.
DurabIe MedicaI Equipment and MedicaI Devices, Orthotics,
Prosthetics, and MedicaI and SurgicaI SuppIies
DurabIe MedicaI Equipment and MedicaI Devices
Your Plan includes benefits for durable medical equipment and medical devices when the equipment
meets the following criteria:
s meant for repeated use and is not disposable.
s used for a medical purpose and is of no further use when medical need ends.
s meant for use outside a medical Facility.

65
s only for the use of the patient.
s made to serve a medical use.
s ordered by a Provider.
Benefits include purchase-only equipment and devices (e.g., crutches and customized equipment),
purchase or rent-to-purchase equipment and devices (e.g., Hospital beds and wheelchairs), and
continuous rental equipment and devices (e.g., oxygen concentrator, ventilator, and negative pressure
wound therapy devices). Continuous rental equipment must be approved by us. We may limit the
amount of coverage for ongoing rental of equipment. We may not cover more in rental costs than the cost
of simply purchasing the equipment.
Benefits include repair and replacement costs as well as supplies and equipment needed for the use of
the equipment or device, for example, a battery for a powered wheelchair.
Oxygen and equipment for its administration are also Covered Services. Benefits are also available for
cochlear implants.
Hearing Aid Services
For children under 18, subject to the terms of the Booklet, your Plan covers the following hearing aids and
the services that go with them when provided by or purchased as a result of a written recommendation
from an otolaryngologist or a state-certified audiologist:
Audiological testing to measure the level of hearing loss and to choose the proper make and model of
a hearing aid. These evaluations will be provided under the prior "Diagnostic Services of this
section;
Hearing aids (monaural or binaural) including ear mold(s), the hearing aid instrument, batteries, cords
and other ancillary equipment. The Plan covers auditory training when it is offered using approved
professional standards. nitial and replacement hearing aids will be supplied every 5 years, a new
hearing aid may be a covered service when alterations to your existing hearing aid cannot adequately
meet your needs or be repaired; and
Visits for fitting, counseling, adjustments and repairs after receiving the covered hearing aid.
Orthotics
Benefits are available for certain types of orthotics (braces, boots, splints). Covered Services include the
initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support,
align, prevent, or correct deformities or to improve the function of movable parts of the body, or which
limits or stops motion of a weak or diseased body part.
Prosthetics
Your Plan also includes benefits for prosthetics, which are artificial substitutes for body parts for functional
or therapeutic purposes, when they are required to adequately meet your needs.
Benefits include the purchase, fitting, adjustments, repairs and replacements. Covered Services may
include, but are not limited to:
1) Artificial limbs and accessories. For prosthetic arms and legs we cover up to the benefits amounts
provide by federal laws for Medicare or where needed to meet state insurance laws;
2) One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes);
3) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women's
Health and Cancer Rights Act;

66
4) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to
ostomy care;
5) Restoration prosthesis (composite facial prosthesis);
MedicaI and SurgicaI SuppIies
Your Plan includes coverage for medical and surgical supplies that serve only a medical purpose, are
used once, and are purchased (not rented). Covered supplies include syringes, needles, surgical
dressings, splints, diabetic supplies, and other similar items that serve only a medical purpose. Covered
Services do not include items often stocked in the home for general use like Band-Aids, thermometers,
and petroleum jelly.
BIood and BIood Products
Your Plan also includes coverage for the administration of blood products unless they are received from a
community source, such as blood donated through a blood bank.
Emergency Care Services
Emergency Services
Benefits are available in a Hospital Emergency Room for services and supplies to treat the onset of
symptoms, screen and stabilize an Emergency, which is defined below:
Emergency (Emergency MedicaI Condition)
"Emergency or "Emergency Medical Condition means health care services provided in connection with
any event that a prudent layperson having average knowledge of health services and medicine and acting
reasonably would believe threatens his or her life or limb in such a manner that a need for immediate
medical care is created to prevent death or serious impairment of health.
Emergency Care
"Emergency Care means a medical exam done in the Emergency Department of a Hospital, and
includes services routinely available in the Emergency Department to evaluate an Emergency Condition.
t includes any further medical exams and treatment required to stabilize the patient.
f you are experiencing an Emergency please call 911 or visit the nearest Hospital for treatment.
Medically Necessary services will be covered whether you get care from an n-Network or Out-of-Network
Provider. Emergency Care you get from an Out-of-Network Provider will be covered as an n-Network
service, you will not need to pay more than what you would have if you had seen an n-Network Provider.
f you are admitted to the Hospital from the Emergency Room, be sure that you or your Doctor calls us as
soon as possible. We will review your care to decide if a Hospital stay is needed and how many days you
should stay. See "How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) for more details. f you or your Doctor do not call us, you may have to pay for services that
are determined to be not Medically Necessary.
With respect to an Emergency, stabilize means to provide such medical treatment of the condition as may
be necessary to assure, within reasonable medical probability, that no material deterioration of the
condition is likely to result from or occur during the transfer of the Member from a facility. With respect to
a pregnant woman who is having contractions, the term "stabilize also means to deliver (including the

67
placenta), if there is inadequate time to effect a safe transfer to another Hospital before delivery or
transfer may pose a threat to the health or safety of the woman or the unborn child. Treatment you get
after your condition has stabilized is not Emergency Care. f you continue to get care from an Out-of-
Network Provider, Covered Services will be covered at the Out-of-Network level unless we agree to cover
it as an Authorized Service.
Home Care Services
Benefits are available for Covered Services performed by a Home Health Care Agency or other Provider
in your home. To be eligible forHome care benefits, you must essentially be confined to the home, as are
an alternative to a Hospital stay, and you must be physically unable to get needed medical services on an
outpatient basis. Services must be prescribed by a Doctor and the services must be so inherently
complex that they can be safely and effectively performed only by qualified, technical, or professional
health staff.
Covered Services include but are not limited to:
ntermittent skilled nursing services by an R.N. or L.P.N.
Medical / social services
Diagnostic services
Nutritional guidance
Training of the patient and/or family/caregiver
Home health aide services. You must be receiving skilled nursing or therapy. Services must be given
by appropriately trained staff working for the Home Health Care Provider. Other organizations may
give services only when approved by us, and their duties must be assigned and supervised by a
professional nurse on the staff of the Home Health Care Provider.
Therapy Services of physical, occupational, speech and language, respiratory and inhalation (except
for Manipulation Therapy which will not be covered when given in the home)
Medical supplies
Durable medical equipment, prosthetics and orthopedic appliances
Private duty nursing in the home
Home Infusion Therapy
See "Therapy Services later in this section.
Hospice Care
The services and supplies listed below are Covered Services when given by a Hospice for the palliative
care of pain and other symptoms that are part of a terminal disease. Palliative care means care that
controls pain and relieves symptoms, but is not meant to cure a terminal illness. Hospice care includes
routine home care, constant home care, inpatient Hospice and inpatient respite. Covered Services
include:
Care from an interdisciplinary team with the development and maintenance of an appropriate plan of
care.
Short-term npatient Hospital care when needed in periods of crisis or as respite care.
Skilled nursing services, home health aide services, and homemaker services given by or under the
supervision of a registered nurse.
Doctor services and diagnostic testing.
Social services and counseling services from a licensed social worker.
Nutritional support such as intravenous feeding and feeding tubes and nutritional counseling.

68
Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed
therapist.
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition,
including oxygen and related respiratory therapy supplies.
Prosthetics and orthopedic appliances.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Member's death.
Bereavement services are available to the patient/family consisting of those individuals who are
closely linked to the patient, including the immediate family, the primary or designated care giver and
individuals with significant personal ties.
Transportation.
Your Doctor and Hospice medical director must certify that you are terminally ill and likely have less than
six months to live. Your Doctor must agree to care by the Hospice and must be consulted in the
development of the care plan. The Hospice must keep a written care plan on file and give it to us upon
request.
Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy
given as palliative care, are available to a Member in Hospice. These additional Covered Services will be
covered under other parts of this Plan. Any care you get that has to do with an unrelated illness or
medical condition will be subject to the provisions of this plan that deals with that illness.
Human Organ and Tissue TranspIant (Bone Marrow / Stem CeII)
Services
Your Plan includes coverage for Medically Necessary human organ and tissue transplants. Certain
transplants (e.g., cornea and kidney) are covered like any other surgery, under the regular inpatient and
outpatient benefits described elsewhere in this Booklet.
This section describes benefits for certain Covered Transplant Procedures that you get during the
Transplant Benefit Period. Any Covered Services related to a Covered Transplant Procedure, received
before or after the Transplant Benefit Period, are covered under the regular npatient and outpatient
benefits described elsewhere in this Booklet.
n this section you will see some key terms, which are defined below:
Covered TranspIant Procedure
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage.
t also includes Medically Necessary myeloablative or reduced intensity preparative chemotherapy,
radiation therapy, or a combination of these therapies.
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and transfusions including necessary acquisition procedures, harvest and storage, and
including Medically Necessary preparatory myeloablative therapy.
In-Network TranspIant Provider
A Provider that we have chosen as a Center of Excellence and/or a Provider selected to take part as an
n-Network Transplant Provider by a designee. The Provider has entered into a Transplant Provider
Agreement to give Covered Transplant Procedures to you and take care of certain administrative duties
for the transplant network. A Provider may be an n-Network Transplant Provider for:

69
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
Out-of-Network TranspIant Provider
Any Provider that has NOT been chosen as a Center of Excellence by us or has not been selected to
take part as an n-Network Transplant Provider by a designee.
TranspIant Benefit Period
At an n-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts for the applicable case rate / global time period. The number of
days will vary depending on the type of transplant received and the n-Network Transplant Provider
agreement. Call the Case Manager for specific n-Network Transplant Provider details for services
received at or coordinated by an n-Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
Prior ApprovaI and Precertification
To maximize your benefits, you shouId caII our TranspIant Department as soon as you think you
may need a transpIant to taIk about your benefit options. You must do this before you have an
evaIuation and/or work-up for a transpIant. We will help you maximize your benefits by giving you
coverage information, including details on what is covered and if any clinical coverage guidelines, medical
policies, n-Network Transplant Provider rules, or Exclusions apply. Call the Customer Service phone
number on the back of your dentification Card and ask for the transplant coordinator. Even if we give a
prior approval for the Covered Transplant Procedure, you or your Provider must call our Transplant
Department for Precertification prior to the transplant whether this is performed in an npatient or
Outpatient setting.
Precertification is required before we will cover benefits for a transplant. Your Doctor must certify, and we
must agree, that the transplant is Medically Necessary. Your Doctor should send a written request for
Precertification to us as soon as possible to start this process. Not getting Precertification will result in a
denial of benefits.
Please note that there are cases where your Provider asks for approval for HLA testing, donor searches
and/or a harvest and storage of stem cells prior to the final decision as to what transplant procedure will
be needed. n these cases, the HLA testing and donor search charges will be covered as routine
diagnostic tests. The harvest and storage request will be reviewed for Medical Necessity and may be
approved. However, such an approval for HLA testing, donor search and/or harvest and storage is NOT
an approval for the later transplant. A separate Medical Necessity decision will be needed for the
transplant.
Donor Benefits
Benefits for an organ donor are as follows:
When both the person donating the organ and the person getting the organ are our covered
Members, each will get benefits under their Plan.
When the person getting the organ is our covered Member, but the person donating the organ is not,
benefits under this Plan are limited to benefits not available to the donor from any other source. This
includes, but is not limited to, other insurance, grants, foundations, and government programs.

70
f our covered Member is donating the organ to someone who is not a covered Member, benefits are
not available under this Plan.
Transportation and Lodging
We will cover the cost of reasonable and necessary travel costs when you get prior approval and need to
travel more than 75 miles from your permanent home to reach the Facility where the Covered Transplant
Procedure will be performed. Our help with travel costs includes transportation to and from the Facility,
and lodging for the patient and one companion. f the Member receiving care is a minor, then reasonable
and necessary costs for transportation and lodging may be allowed for two companions. You must send
itemized receipts for transportation and lodging costs in a form satisfactory to us when claims are filed.
Call us for complete information.
For lodging and ground transportation benefits, we will cover costs up to the current limits set forth in the
nternal Revenue Code.
Non-Covered Services for transportation and lodging include, but are not limited to:
Child care,
Mileage within the medical transplant Facility city,
Rental cars, buses, taxis, or shuttle service, except as specifically approved by us,
Frequent Flyer miles,
Coupons, Vouchers, or Travel tickets,
Prepayments or deposits,
Services for a condition that is not directly related, or a direct result, of the transplant,
Phone calls,
Laundry,
Postage,
Entertainment,
Travel costs for donor companion/caregiver,
Return visits for the donor for a treatment of an illness found during the evaluation,
Meals.
InfertiIity Services
Please see "Maternity and Reproductive Health Services later in this section.
Inpatient Services
Inpatient HospitaI Care
Covered Services include acute care in a Hospital setting.
Benefits for room, board, and nursing services include:
A room with two or more beds.
A private room. The most the Plan will cover for private rooms is the Hospital's average semi-private
room rate unless it is Medically Necessary that you use a private room for isolation and no isolation
facilities are available.

71
A room in a special care unit approved by us. The unit must have facilities, equipment, and supportive
services for intensive care or critically ill patients.
Routine nursery care for newborns during the mother's normal Hospital stay.
Newborn care for during and after the mother's maternity Hospital stay for treatment of injury and
sickness and medically diagnosed Congenital Defects and Birth Abnormalities.
Meals, special diets.
General nursing services.
Benefits for ancillary services include:
Operating, childbirth, and treatment rooms and equipment.
Prescribed Drugs.
Anesthesia, anesthesia supplies and services given by the Hospital or other Provider.
Medical and surgical dressings and supplies, casts, and splints.
Diagnostic services.
Therapy services.
Inpatient ProfessionaI Services
Covered Services include:
Medical care visits.
ntensive medical care when your condition requires it.
Treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for
surgery. Benefits include treatment by two or more Doctors during one Hospital stay when the nature
or severity of your health problem calls for the skill of separate Doctors.
A personal bedside exam by another Doctor when asked for by your Doctor. Benefits are not
available for staff consultations required by the Hospital, consultations asked for by the patient,
routine consultations, phone consultations, or EKG transmittals by phone.
Surgery and general anesthesia.
Newborn exam. A Doctor other than the one who delivered the child must do the exam.
Professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology.
ManipuIation Therapy
Please see "Therapy Services later in this section.
Maternity and Reproductive HeaIth Services
Maternity Services
Covered Services include services needed during a normal or complicated pregnancy, Complications of
Pregnancy, and for services needed for a miscarriage. Covered maternity services include:
Professional and Facility services for childbirth in a Facility or the home including the services of an
appropriately licensed nurse midwife;
Routine nursery care for the newborn during the mother's normal Hospital stay, including circumcision
of a covered male Dependent;
Prenatal and postnatal services; and
Fetal screenings, which are genetic or chromosomal tests of the fetus, as allowed by us.
f you are pregnant on your Effective Date and in the first trimester of the pregnancy, you must change to
an n-Network Provider to have Covered Services covered at the n-Network level. f you are pregnant on

72
your Effective Date and in your second or third trimester of pregnancy (13 weeks or later) as of the
Effective Date, benefits for obstetrical care will be available at the n-Network level even if an Out-of-
Network Provider is used if you fill out a Continuation of Care Request Form and send it to us. Covered
Services will include the obstetrical care given by that Provider through the end of the pregnancy and the
immediate post-partum period.
Important Note About Maternity Admissions: Under federal law, we may not limit benefits for any
Hospital length of stay for childbirth for the mother or newborn to less than 48 hours after vaginal birth, or
less than 96 hours after a cesarean section (C-section). f the baby is born between 8:00 p.m. and 8:00
a.m., coverage will continue until 8:00 a.m. on the morning after the 48 or 96 hours timeframe. However,
federal law as a rule does not stop the mother's or newborn's attending Provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours, or 96 hours, as applicable. n
any case, as provided by federal law, we may not require a Provider to get authorization from us before
prescribing a length of stay which is not more than 48 hours for a vaginal birth or 96 hours after a C-
section.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (UDs), and implants. Certain
contraceptives are covered under the "Preventive Care benefit. Please see that section for further
details.
SteriIization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the "Preventive Care benefit.
Abortion Services
Benefits include services for therapeutic or elective abortion regardless if Medically Necessary, unless
applicable law or regulation prohibits the Group from providing such coverage (in which case, Covered
Services are provided only to the extent necessary to prevent the death of the mother or unborn baby).
InfertiIity Services
Important Note: Although this Plan offers limited coverage of certain infertility services, it does not cover
all forms of infertility treatment. Benefits do not include assisted reproductive technologies (ART) or the
diagnostic tests and Drugs to support it. Examples of ART include artificial insemination, in-vitro
fertilization, zygote intrafallopian transfer (ZFT), or gamete intrafallopian transfer (GFT).
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy,
endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical
conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
Fertility treatments such as artificial insemination and in-vitro fertilization are not a Covered Service.
MedicaI Foods
Covered Services include Medically Necessary medical foods for home use for metabolic disorders which
may be taken by mouth or enterally. A Provider must have prescribed the medical foods that are
designed and manufactured for the treatment of inherited enzymatic disorders caused by single gene
defects involved in the metabolism of amino, organic, and fatty acids. Such disorders include:

73
Phenylketonuria, if you are 21 or younger (35 or younger for women of child-bearing age);
Maternal phenylketonuria;
Maple syrup urine disease;
Tyrosinemia;
Homocystinuria;
Histidinemia;
Urea cycle disorders;
Hyperlysinemia;
Glutaric acidemias;
Methylmalonic academia; and
Propionic acidemia.
Covered Services do not include enteral nutrition therapy or medical foods for Members with cystic
fibrosis or lactose- or soy- intolerance. Also all covered medical foods must be obtained through a
Pharmacy and are subject to the pharmacy payment requirements. Please see "Prescription Drug Benefit
at a Retail or Home Delivery (Mail Order) Pharmacy later in this section.
MentaI HeaIth, BioIogicaIIy Based MentaI IIIness, AIcohoI and
Substance Abuse Services
Covered Services include the following:

Inpatient Services in a Hospital or any facility that we must cover per state law. npatient benefits
include psychotherapy, psychological testing, electroconvulsive therapy, and detoxification.

Outpatient Services including office visits and treatment in an outpatient department of a Hospital or
outpatient Facility, such as partial hospitalization programs and intensive outpatient programs.

ResidentiaI Treatment which is specialized 24-hour treatment in a licensed residential treatment
center. t offers individualized and intensive treatment and includes:

Observation and assessment by a psychiatrist weekly or more often,
Rehabilitation, therapy, and education.

You can get Covered Services under this section from the following Providers:

Psychiatrist,
Psychologist,
Neuropsychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
Licensed professional counselor (L.P.C) or
Any agency licensed by the state to give these services, when we have to cover them by law!

74
OccupationaI Therapy
Please see "Therapy Services later in this section.
Office Visits and Doctor Services
Covered Services include:
Office Visits for medical care (including second surgical opinions) to examine, diagnose, and treat an
illness or injury.
Home Visits for medical care to examine, diagnose, and treat an illness or injury. Please note that
Doctor visits in the home are different than the "Home Care Services benefit described earlier in this
Booklet.
RetaiI HeaIth CIinic Care for limited basic health care services to Members on a "walk-in basis. These
clinics are normally found in major pharmacies or retail stores. Health care services are typically given by
Physician's Assistants or Nurse Practitioners. Services are limited to routine care and treatment of
common illnesses for adults and children.
WaIk-In Doctor's Office for services limited to routine care and treatment of common illnesses for adults
and children. You do not have to be an existing patient or have an appointment to use a walk-in Doctor's
office.
Urgent Care as described in "Urgent Care Services later in this section.
OnIine Care Visits when available in your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online care visits do not include reporting normal lab or
other test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Hearing Exams and tests to determine the need for hearing correction. For additional information on
hearing aid services, please see "Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies earlier in this section.
Prescription Drugs Administered in the Office
Orthotics
See "Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies earlier in this section.
Outpatient FaciIity Services
Your Plan includes Covered Services in an:
Outpatient Hospital,
Ambulatory Surgical Facility,
Mental Health / Substance Abuse Facility, or
Other Facilities approved by us.
Benefits include Facility and related (ancillary) charges, when proper, such as:

75
Surgical rooms and equipment,
Prescription Drugs, including Specialty Drugs,
Anesthesia and anesthesia supplies and services given by the Hospital or other Facility,
Medical and surgical dressings and supplies, casts, and splints,
Diagnostic services,
Therapy services.
PhysicaI Therapy
Please see "Therapy Services later in this section.
Preventive Care
Preventive care includes screenings and other services for adults and children with no current symptoms
or history of a health problem.
Members who have current symptoms or a diagnosed health problem will get benefits under the
"Diagnostic Services benefit, not this benefit.
Preventive care services will meet the requirements of federal and state law. Many preventive care
services are covered with no Deductible, Copayments or Coinsurance when you use an n-Network
Provider. That means we cover 100% of the Maximum Allowed Amount. Covered Services fall under
four broad groups:
1. Services with an "A or "B rating from the United States Preventive Services Task Force. Examples
include screenings for:
a. Breast cancer,
b. Cervical cancer,
c. Colorectal cancer,
d. High blood pressure,
e. Type 2 Diabetes Mellitus,
f. Cholesterol,
g. Child and adult obesity.
Tobacco use screening and tobaccoSmoking cessation counseling and intervention is also covered.
2. mmunizations for children, adolescents, and adults, including cervical cancer vaccinations for
females, where recommended by the Advisory Committee on mmunization Practices of the Centers
for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as listed in the guidelines
supported by the Health Resources and Services Administration; and
4. Preventive care and screening for women as listed in the guidelines supported by the Health
Resources and Services Administration, including:
a. Women's contraceptives, sterilization treatments, and counseling. This includes Generic and
single-source Brand Drugs as well as injectable contraceptives and patches. Contraceptive
devices such as diaphragms, intra uterine devices (UDs), and implants are also covered. Multi-
source Brand Drugs will be covered under the "Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy.
b. Breastfeeding support, supplies, and counseling. Benefits for breast pumps are limited to one
pump per pregnancy.

76
c. Gestational diabetes screening.
You may call Customer Service at the number on your dentification Card for more details about these
services or view the federal government's web sites,https://www.healthcare.gov/what-are-my-preventive-
care-benefits, http://www.ahrq.gov, and http://www.cdc.gov/vaccines/acip/index.html.
Prosthetics
See "Durable Medical Equipment and Medical Devices, Orthotics, and Medical and Surgical Supplies
earlier in this section.
PuImonary Therapy
Please see "Therapy Services later in this section.
Radiation Therapy
Please see "Therapy Services later in this section.
RehabiIitation Services
Benefits include services in a Hospital, free-standing Facility, Skilled Nursing Facility, or in an outpatient
day rehabilitation program.
Covered Services involve a coordinated team approach and several types of treatment, including skilled
nursing care, physical, occupational, and speech therapy, and services of a social worker or psychologist.
To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period
of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing
toward those goals.
HabiIitative Services
Benefits also include Habilitative Services that help you keep, learn or improve skills and functioning for
daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These
services may include physical and occupational therapy, speech-language pathology and other services
for people with disabilities in a variety of inpatient and/or outpatient settings.
Respiratory Therapy
Please see "Therapy Services later in this section.
SkiIIed Nursing FaciIity
When you require npatient skilled nursing and related services for convalescent and rehabilitative or
habilitative care, Covered Services are available if the Facility is licensed or certified under state law as a
Skilled Nursing Facility, or is otherwise licensed to provide the services. Custodial Care is not a Covered
Service.

77
Smoking Cessation
Please see "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy later in this
Booklet.
Speech Therapy
Please see "Therapy Services later in this section.
Surgery
Your Plan covers surgical services on an npatient or outpatient basis, including office surgeries.
Covered Services include:
Accepted operative and cutting procedures;
Other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain
or spine;
Endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Treatment of fractures and dislocations;
Anesthesia and surgical support when Medically Necessary;
Medically Necessary pre-operative and post-operative care.
OraI Surgery
Important Note: Although this Plan covers certain oral surgeries, many oral surgeries (e.g. removal of
wisdom teeth) are not covered, except as listed in this Booklet.
Benefits are limited to certain oral surgeries including:
Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;
Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or
lower jaw and is Medically Necessary to attain functional capacity of the affected part.
Oral / surgical correction of accidental injuries as indicated in the "Dental Services (All Members/All
Ages) section.
Treatment of non-dental lesions, such as removal of tumors and biopsies.
ncision and drainage of infection of soft tissue not including odontogenic cysts or abscesses
Your Plan also covers certain oral surgeries for children. Please refer to "Pediatric Dental Services for
Members through Age 18 for details.
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or
developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal
appearance. Benefits include surgery performed to restore symmetry after a mastectomy. Reconstructive
services needed as a result of an earlier treatment are covered only if the first treatment would have been
a Covered Service under this Plan.
Note: This section does not apply to orthognathic surgery. See the "Oral Surgery section above for that
benefit.

78
Mastectomy Notice
A Member who is getting benefits for a mastectomy or for follow-up care for a mastectomy and who
chooses breast reconstruction, will also get coverage for:
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to give a symmetrical appearance; and
Prostheses and treatment of physical problems of all stages of mastectomy, including lymphedemas.
When due to breast cancer, reconstructive and surgical coverage will be provided in a manner
determined in consultation with the attending Physician and the Member. Members will have to pay the
same Deductible, Coinsurance, and/or Copayments that normally apply to surgeries in this Plan.
Transgender Surgery
This Plan provides benefits for many of the charges for transgender surgery (also known as sex
reassignment surgery). Benefits must be approved by us for the type of transgender surgery requested
and must be authorized prior to being performed. Changes for services that are not authorized for the
transgender surgery requested wiII not be considered Covered Services. Some conditions appIy,
and aII services must be authorized by us as outIined in the "How to Access Your Services and
Obtain ApprovaI of Benefits" section.
TeIemedicine
When you cant travel to a Providers office, telemedicine benefits might be available when provided by
covered Providers. Telemedicine is the real-time transfer of health data and help. Services include the
use of interactive audio, video, or other electronic media to discuss and treat your health problem.
Typically, you communicate through an interactive means that is enough to start a link to the Provider
who is working at a different location from you. These services are covered if they would be Covered
Services when given in a face-to-face meeting with the Provider.
There are limits. Telemedicine does not include the use of phones or fax machines. t also is not
covered if you can go into the office of an n-Network Provider in the area where you live. Telemedicine
benefits may also be limited to only certain areas in Colorado. Please check with Customer Services to
see if your area is eligible.
Non-covered services are:
Reporting normal lab or other test results;
Office appointment requests;
Billing, insurance coverage or payment questions;
Requests for referrals to doctors outside the online care panel;
Benefit Preauthorization; Doctor talking to another Doctor.
TemporomandibuIar Joint (TMJ) and CraniomandibuIar Joint Services
Benefits are available to treat temporomandibular and craniomandibular disorders. The
temporomandibular joint connects the lower jaw to the temporal bone at the side of the head and the
craniomandibular joint involves the head and neck muscles.
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care,
and diagnostic services. Covered Services do not include fixed or removable appliances that involve
movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).

79
Therapy Services
PhysicaI Medicine Therapy Services
Your Plan includes coverage for the therapy services described below. To be a Covered Service, the
therapy must improve your level of function within a reasonable period of time.
For children under age 6, your Plan covers at least 20 visits, each, of physical, speech and occupational
therapy. Benefits include the treatment of Congenital Defects and Birth Abnormalities, even if it is a long
term condition. t also doesnt matter if the reason for the therapy is to maintain (not improve) the childs
skills.
Covered Services include:
PhysicaI therapy The treatment by physical means to ease pain, restore health, and to avoid
disability after an illness, injury, or loss of an arm or a leg. t includes hydrotherapy, heat, physical
agents, bio-mechanical and neuro-physiological principles and devices.
Speech therapy and speech-Ianguage pathoIogy (SLP) services Services to identify, assess,
and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or
treat communication or swallowing skills to correct a speech impairment.
OccupationaI therapy Treatment to restore a physically disabled person's ability to do activities of
daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a
bed, and bathing. t also includes therapy for tasks needed for the person's job. Occupational therapy
does not include recreational or vocational therapies, such as hobbies, arts and crafts.
Chiropractic / Osteopathic / ManipuIation tTherapy ncludes therapy to treat problems of the
bones, joints, and the back. The two therapies are similar, but chiropractic Manipulation tTherapy
focuses on the joints of the spine and the nervous system, while osteopathic therapy also focuses on
the joints and surrounding muscles, tendons and ligaments.
Massage therapy - njury or illness for which massage has a therapeutic result. Coverage is provided
for up to a 60 minute session per visit. Some Covered Services include acupressure and deep tissue
massage, or other approved services.
Acupuncture/Nerve Pathway therapy - Treatment ofs limited to the treatment of
neuromusculoskeletal pain, by an acupuncturist who acts within the scope of their license. Treatment
involves using through the use of needles inserted along specific nerve pathways to ease pain.
EarIy Intervention Services
From the Member's birth until the Member's third (3rd) birthday, this Plan covers Early ntervention
Services (as defined in this Booklet and by Colorado law in accordance with part C), that are authorized
through an eligible child's individualized family service plan (FSP) and delivered by a Qualified Early
ntervention Service Provider to an eligible child, to the extent required by applicable law. The services
stated in an FSP will be considered Medically Necessary. Coverage for early intervention services does
not include: nonemergency medical transportation; respite care; service coordination, as defined in
federal law; or assistive technology (unless covered under the applicable insurance policy as durable
medical equipment). Coverage is limited to up to 45 visits, in 15 minute increments, per Benefit Period.
A 45 minute visit counts as 3 billing increments.
This visit limit does not apply to rehabilitation or therapeutic services that are necessary as the result of
an acute medical condition or post-surgical rehabilitation or services provided to a child who is not
participating in part C. The coverage for Early ntervention Services is in addition to any other coverage
provided under this Booklet for congenital defects or birth abnormalities.

80
Other Therapy Services
Benefits are also available for:
Cardiac RehabiIitation - Medical evaluation, training, supervised exercise, and psychosocial
support to care for you after a cardiac event (heart problem). Benefits do not include home programs,
on-going conditioning, or maintenance care.
Chemotherapy Treatment of an illness by chemical or biological antineoplastic agents. See the
section "Prescription Drugs Administered by a Medical Provider for more details.
DiaIysis - Services for acute renal failure and chronic (end-stage) renal disease, including
hemodialysis, home intermittent peritoneal dialysis (PD), home continuous cycling peritoneal dialysis
(CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Covered Services include
dialysis treatments in an outpatient dialysis Facility. Covered Services also include home dialysis and
training for you and the person who will help you with home self-dialysis.
Infusion Therapy Nursing, durable medical equipment and Drug services that are delivered and
administered to you through an .V. in your home. Also includes Total Parenteral Nutrition (TPN),
Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections
(intra-muscular, subcutaneous, continuous subcutaneous). See the section "Prescription Drugs
Administered by a Medical Provider for more details.
PuImonary RehabiIitation ncludes outpatient short-term respiratory care to restore your health
after an illness or injury.
Radiation Therapy Treatment of an illness by x-ray, radium, or radioactive isotopes. Covered
Services include treatment (teletherapy, brachytherapy and intraoperative radiation, photon or high
energy particle sources), materials and supplies needed, and treatment planning.
Respiratory Therapy ncludes the use of dry or moist gases in the lungs, nonpressurized
inhalation treatment; intermittent positive pressure breathing treatment, air or oxygen, with or without
nebulized medication, continuous positive pressure ventilation (CPAP); continuous negative pressure
ventilation (CNP); chest percussion; therapeutic use of medical gases or Drugs in the form of
aerosols, and equipment such as resuscitators, oxygen tents, and incentive spirometers; broncho-
pulmonary drainage and breathing exercises.
TranspIant Services
See "Human Organ and Tissue Transplant earlier in this section.
Urgent Care Services
Often an urgent rather than an Emergency health problem exists. An urgent health problem is an
unexpected illness or injury that calls for care that cannot wait until a regularly scheduled office visit.
Urgent health problems are not life threatening and do not call for the use of an Emergency Room.
Urgent health problems include earache, sore throat, and fever (not above 104 degrees).
Benefits for urgent care include:
X-ray services;
Care for broken bones;
Tests such as flu, urinalysis, pregnancy test, rapid strep;
Lab services;
Stitches for simple cuts; and
Draining an abscess.


81
{Pediatric vision exam onIy:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.]

{Pediatric vision fuII coverage:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
EyegIass Lenses
This Plan also covers a choice of eyeglass lenses. Benefits include polycarbonate, photochromic and
factory scratch coating when n-Network.

Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:

Single vision
Bifocal
Trifocal (FT 25-28)
Progressive
Frames
A selection of frames is covered under this Plan. Members must choose a frame from the Anthem
formulary.
Contact Lenses
The Plan offers the following benefits for contact lenses:

Elective Contact Lenses Contacts chosen for comfort or appearance;

Non-Elective Contact Lenses Only for the following medical conditions:

Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.

SpeciaI Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASK.

82

This Plan only covers a choice of contact lenses or eyeglasses, but not both. f you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglasses until the next Benefit Period. f
you choose eyeglasses during a Benefit Period, no benefits will be available for contact lenses until the
next Benefit Period.]

{AduIt vision:
[Vision Services for Members Age 19 and OIder
The vision benefits described in this section only apply to Members age 19 or older.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
EyegIass Lenses
This Plan also covers a choice of eyeglass lenses. Lens benefits include factory scratch coating when n-
Network. Photochromic lenses are also available.
Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:
Single vision
Bifocal
Trifocal (FT 25-28)
Frames
A selection of frames is covered under this Plan. Members will get a benefit allowance toward the
purchase of any frame. f the frame you choose costs more than the Plan's allowance, you will have to
pay the amount over the Plan's allowance.
Contact Lenses
The Plan offers the following benefits for contact lenses:
Elective Contact Lenses Contacts chosen for comfort or appearance;
Non-Elective Contact Lenses Only for the following medical conditions:
Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.
SpeciaI Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASK.
This Plan only covers a choice of contact lenses or eyeglass lenses, but not both. f you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglass lenses until the next Benefit
Period. f you choose eyeglass lenses during a Benefit Period, no benefits will be available for contact
lenses until the next Benefit Period.]

83
Vision Services (AII Members / AII Ages)
Benefits include medical and surgical treatment of injuries and illnesses of the eye. Certain vision
screenings required by Federal law are covered under the "Preventive Care benefit.
Benefits do not include glasses or contact lenses except as listed in the "Prosthetics benefit.

84
Prescription Drugs Administered by a MedicaI Provider
Your Plan covers Prescription Drugs when they are administered to you as part of a doctor's visit, home
care visit, or at an outpatient Facility. This includes Drugs for infusion therapy, chemotherapy, Specialty
Drugs, blood products, and office-based injectables that must be administered by a Provider. This
section applies when your Provider orders the Drug and administers it to you. Benefits for Drugs that you
can inject or get at a Pharmacy (i.e., self-administered injectable Drugs) are not covered under this
section. Benefits for those Drugs are described in the "Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy section.
Note: When Prescription Drugs are covered under this benefit, they will not also be covered under the
"Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit. Also, if
Prescription Drugs are covered under the "Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, they will not be covered under this benefit.
Important DetaiIs About Prescription Drug Coverage
Your Plan includes certain features to determine when Prescription Drugs should be covered, which are
described below. As part of these features, your prescribing Doctor may be asked to give more details
before we can decide if the Drug is Medically Necessary. We may also set quantity and/or age limits for
specific Prescription Drugs or use recommendations made as part of our Medical Policy and Technology
Assessment Committee and/or Pharmacy and Therapeutics Process.
Prior Authorization
Prior authorization may be needed for certain Prescription Drugs to make sure proper use and guidelines
for Prescription Drug coverage are followed. We will contact your Provider to get the details we need to
decide if prior authorization should be given. We will give the results of our decision to both you and your
Provider.
f prior authorization is denied you have the right to file a Grievance as outlined in the "Appeals and
Complaints section of this Booklet.
For a list of Drugs that need prior authorization, please call the phone number on the back of your
dentification Card. The list will be reviewed and updated from time to time. ncluding a Drug or related
item on the list does not promise coverage under your Plan. Your Provider may check with us to verify
Drug coverage, to find out whether any quantity (amount) and/or age limits apply, and to find out which
brand or generic Drugs are covered under the Plan.
Step Therapy
Step therapy is a process in which you may need to use one type of Drug before we will cover another.
We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These
guidelines help you get high quality and cost effective Prescription Drugs. f a Doctor decides that a
certain Drug is needed, the prior authorization will apply.
Therapeutic Substitution
Therapeutic substitution is an optional program that tells you and your Doctors about alternatives to
certain prescribed Drugs. We may contact you and your Doctor to make you aware of these choices.
Only you and your Doctor can determine if the therapeutic substitute is right for you. We have a
therapeutic Drug substitutes list, which we review and update from time to time. For questions or issues
about therapeutic Drug substitutes, call Customer Service at the phone number on the back of your
dentification Card.

85
Prescription Drug Benefit at a RetaiI or Home DeIivery (MaiI Order)
Pharmacy
Your Plan also includes benefits for Prescription Drugs you get at a Retail or Mail Order Pharmacy. We
use a Pharmacy Benefits Manager (PBM) to manage these benefits. The PBM has a network of Retail
Pharmacies, a Home Delivery (Mail Order) Pharmacy, and a Specialty Pharmacy. The PBM works to
make sure Drugs are used properly. This includes checking that Prescriptions are based on recognized
and appropriate doses and checking for Drug interactions or pregnancy concerns.
PIease note: Benefits for Prescription Drugs, including Specialty Drugs, which are administered to you in
a medical setting (e.g., doctor's office, home care visit, or outpatient Facility) are covered under the
"Prescription Drugs Administered by a Medical Provider benefit. Please read that section for important
details.
Prescription Drug Benefits
As described in the "Prescription Drugs Administered by a Medical Provider section, Prescription Drug
benefits may depend on reviews to decide when Drugs should be covered. These reviews may include
prior authorization, step therapy, use of a Prescription Drug List, Therapeutic Substitution, day / supply
limits, and other utilization reviews. Your n-Network Pharmacist will be told of any rules when you fill a
Prescription, and will be also told about any details we need to decide benefits.
Covered Prescription Drugs
To be a Covered Service, Prescription Drugs must be approved by the Food and Drug Administration
(FDA) and, under federal law, require a Prescription. Prescription Drugs must be prescribed by a
licensed Provider and you must get them from a licensed Pharmacy.
Benefits are available for the following:
Prescription Legend Drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy;
Specialty Drugs;
Self-administered injectable Drugs. These are Drugs that do not need administration or monitoring by
a Provider in an office or Facility. Office-based injectables and infused Drugs that need Provider
administration and/or supervision are covered under the "Prescription Drugs Administered by a
Medical Provider benefit;
Self-injectable insulin and supplies and equipment used to administer insulin;
Self-administered contraceptives, including oral contraceptive Drugs, self-injectable contraceptive
Drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the
"Preventive Care benefit. Please see that section for more details;
Special food products or supplements, including metabolic formulas, when prescribed by a Doctor if
we agree they are Medically Necessary,
Flu Shots (including administration). These will be covered under the "Preventive Care benefit;
Prescription Drugs that help you stop smoking or reduce your dependence on tobacco products.
These Drugs will be covered under the "Preventive Care benefit;
FDA-approved smoking cessation products, including over the counter nicotine replacement
products, when obtained with a Prescription for a Member age 18 or older. These products will be
covered under the "Preventive Care benefit.
Certain Legend Drugs, including orally administered anticancer medication, may also be used for
treatment of cancer even though it has not been approved by the Food and Drug Administration (FDA) for
treatment of a specific type of cancer, if the following conditions are met:

86
the off-label use of the FDA approved drug is supported for the treatment of cancer by the
authoritative reference compendia identified by the Department of Health and Human Services; and
the condition being treated is covered under this Booklet.
Where You Can Get Prescription Drugs
In-Network Pharmacy
You can visit one of the local Retail Pharmacies in our network. Give the Pharmacy the prescription from
your Doctor and your dentification Card and they will file your claim for you. You will need to pay any
Copayment, Coinsurance, and/or Deductible that applies when you get the Drug. f you do not have your
dentification Card, the Pharmacy will charge you the full retail price of the Prescription and will not be
able to file the claim for you. You will need to ask the Pharmacy for a detailed receipt and send it to us
with a written request for payment.
SpeciaIty Pharmacy
f you need a Specialty Drug, you or your Doctor should order it from the PBM's Specialty Pharmacy. We
keep a list of Specialty Drugs that may be covered based upon clinical findings from the Pharmacy and
Therapeutics (P&T) Process, and where appropriate, certain clinical economic reasons. This list will
change from time to time.
The PBM's Specialty Pharmacy has dedicated patient care coordinators to help you take charge of your
health problem and offers toll-free twenty-four hour access to nurses and pharmacists to answer your
questions about Specialty Drugs.
When you use the PBM's Specialty Pharmacy a patient care coordinator will work with you and your
Doctor to get prior authorization and to ship your Specialty Drugs to you or your Doctor's office. Your
patient care coordinator will also tell you when it is time to refill your prescription.
You can get the list of covered Specialty Drugs by calling Customer Service at the phone number on the
back of your dentification Card or check our website at www.anthem.com.
Home DeIivery Pharmacy
The PBM also has a Home Delivery Pharmacy which lets you get certain Drugs by mail if you take them
on a regular basis. You will need to contact the PBM to sign up when you first use the service. You can
mail written prescriptions from your Doctor or have your Doctor send the prescription to the Home
Delivery Pharmacy. Your Doctor may also call the Home Delivery Pharmacy. You will need to send in
any Copayments, Deductible, or Coinsurance amounts that apply when you ask for a prescription or refill.
Out-of-Network Pharmacy
You may also use a Pharmacy that is not in our network. You will be charged the full retail price of the
Drug and you will have to send your claim for the Drug to us. (Out-of-Network Pharmacies won't file the
claim for you.) You can get a claims form from us or the PBM. You must fill in the top section of the form
and ask the Out-of-Network Pharmacy to fill in the bottom section. f the bottom section of this form
cannot be filled out by the pharmacist, you must attach a detailed receipt to the claim form. The receipt
must show:
Name and address of the Out-of-Network Pharmacy;
Patient's name;
Prescription number;
Date the prescription was filled;
Name of the Drug;

87
Cost of the Drug;
Quantity (amount) of each covered Drug or refill dispensed.
You must pay the amount shown in the "Schedule of Benefits (Who Pays What). This is based on the
Maximum Allowed Amount as determined by our normal or average contracted rate with network
pharmacies on or near the date of service.
What You Pay for Prescription Drugs
Tiers
Your share of the cost for Prescription Drugs may vary based on the tier the Drug is in.
Tier 1 Drugs have the lowest Coinsurance or Copayment. This tier contains low cost and preferred
Drugs that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.
Tier 2 Drugs have a higher Coinsurance or Copayment than those in Tier 1. This tier contains
preferred Drugs that may be Generic, single source, or multi-source Brand Drugs.
Tier 3 Drugs have a higher Coinsurance or Copayment than those in Tier 2. This tier contains non-
preferred and high cost Drugs. This includes Drugs considered Generic, single source brands, and
multi-source brands.
Tier 4 Drugs have a higher Coinsurance or Copayment than those in Tier 3.
We assign drugs to tiers based on clinical findings from the Pharmacy and Therapeutics (P&T) Process.
We retain the right, at our discretion, to decide coverage for doses and administration (i.e., by mouth,
shots, topical, or inhaled). We may cover one form of administration instead of another, or put other forms
of administration in a different tier.
Prescription Drug List
We also have an Anthem Prescription Drug List, (a formulary), which is a list of FDA-approved Drugs that
have been reviewed and recommended for use based on their quality and cost effectiveness. Benefits
may not be covered for certain Drugs if they are not on the Prescription Drug List.
The Drug List is developed by us based upon clinical findings, and where proper, the cost of the Drug
relative to other Drugs in its therapeutic class or used to treat the same or similar condition. t is also
based on the availability of over the counter medicines, Generic Drugs, the use of one Drug over another
by our Members, and where proper, certain clinical economic reasons.
We retain the right, at our discretion, to decide coverage for doses and administration methods (i.e., by
mouth, shots, topical, or inhaled) and may cover one form of administration instead of another as
Medically Necessary.
AdditionaI Features of Your Prescription Drug Pharmacy Benefit
Day SuppIy and RefiII Limits
Certain day supply limits apply to Prescription Drugs as listed in the "Schedule of Benefits (Who Pays
What). n most cases, you must use a certain amount of your prescription before it can be refilled. n
some cases we may let you get an early refill. For example, we may let you refill your prescription early if
it is decided that you need a larger dose. We will work with the Pharmacy to decide when this should
happen.

88
f you are going on vacation and you need more than the day supply allowed, you should ask your
pharmacist to call our PBM and ask for an override for one early refill. f you need more than one early
refill, please call Customer Service at the number on the back of your dentification Card.
HaIf-TabIet Program
The Half-Tablet Program lets you pay a reduced Copayment on selected "once daily dosage Drugs on
our approved list. The program lets you get a 30-day supply (15 tablets) of the higher strength Drug
when the Doctor tells you to take a " tablet daily. The Half-Tablet Program is strictly voluntary and you
should talk to your Doctor about the choice when it is available. To get a list of the Drugs in the program
call the number on the back of your dentification Card.
SpeciaI Programs
From time to time we may offer programs to support the use of more cost-effective or clinically effective
Prescription Drugs including Generic Drugs, Home Delivery Drugs, over the counter Drugs or preferred
products. Such programs may reduce or waive Copayments or Coinsurance for a limited time. We may
discontinue a program at any time. f you are participating in a program that We discontinue, We will
provide you at least a 30 day advance written notice of the discontinuance.

89
Section 8. Limitations/ExcIusions (What is Not Covered and
Pre-Existing Conditions)
n this section you will find a review of items that are not covered by your Plan. Excluded items will not be
covered even if the service, supply, or equipment is Medically Necessary. This section is only meant to be
an aid to point out certain items that may be misunderstood as Covered Services. This section is not
meant to be a complete list of all the items that are excluded by your Plan.

We will have the right to make the final decision about whether services or supplies are Medically
Necessary and if they will be covered by your Plan.
1) Acts of War, Disasters, or NucIear Accidents n the event of a major disaster, epidemic, war, or
other event beyond our control, we will make a good faith effort to give you Covered Services. We will
not be responsible for any delay or failure to give services due to lack of available Facilities or staff.
Benefits will not be given for any illness or injury that is a result of war, service in the armed forces, a
nuclear explosion, nuclear accident, release of nuclear energy, a riot, or civil disobedience.
2) Administrative Charges
a) Charges to complete claim forms,
b) Charges to get medical records or reports,
c) Membership, administrative, or access fees charged by Doctors or other Providers. Examples
include, but are not limited to, fees for educational brochures or calling you to give you test
results.
3) AIternative / CompIementary Medicine Services or supplies for alternative or complementary
medicine, regardless of the Provider rendering such services or supplies. This includes, but is not
limited to:
a. Holistic medicine,
b. Homeopathic medicine,
c. Hypnosis,
d. Aroma therapy,
e. Reiki therapy,
f. Herbal, vitamin or dietary products or therapies,
g. Naturopathy,
h. Thermography,
i. Orthomolecular therapy,
j. Contact reflex analysis,
k. Bioenergial synchronization technique (BEST),
l. ridology-study of the iris,
m. Auditory integration therapy (AT),
n. Colonic irrigation,
o. Magnetic innervation therapy,
p. Electromagnetic therapy,
q. Neurofeedback / Biofeedback.
4) Before Effective Date or After Termination Date Charges for care you get before your Effective
Date or after your coverage ends, except as written in this Plan.

90
5) Certain Providers Services you get from Providers that are not licensed by law to provide Covered
Services as defined in this Booklet. .
6) Charges Over the Maximum AIIowed Amount Charges over the Maximum Allowed Amount for
Covered Services, except as written in this Plan.
7) Charges Not Supported by MedicaI Records Charges for services not described in your medical
records.
8) CompIications of Non-Covered Services Care for problems directly related to a service that is not
covered by this Plan. Directly related means that the care took place as a direct result of the non-
Covered Service and would not have taken place without the non-Covered Service.
9) Cosmetic Services Treatments, services, Prescription Drugs, equipment, or supplies given for
cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or
are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or
treatments to change the texture or look of your skin or to change the size, shape or look of facial or
body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).
10) Court Ordered Testing Court ordered testing or care unless the testing or care is Medically
Necessary and otherwise a Covered Service under this Booklet.
11) Crime Treatment of an injury or illness that results from a crime you committed, or tried to commit.
This Exclusion does not apply if your involvement in the crime was solely the result of a medical or
mental condition, or where you were the victim of a crime, including domestic violence.
12) CustodiaI Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to
Hospice services.
13) [DentaI Services
a) {Pediatric dentaI: [Dental services for Members age 19 or older, unless listed as covered in this
Booklet]
b) Dental services not listed as covered in this Booklet.
c) New, experimental or investigational dental techniques or services may be denied until there is, to
our satisfaction, an established scientific basis for recommendation.
d) Dental services completed prior to the date the member became eligible for coverage.
e) Services of anesthesiologists.
f) Analgesia, analgesia agents, anxiolysis, nitrous oxide, medicines, or drugs for non-surgical or
dental care
g) ntravenous conscious sedation, V sedation and general anesthesia are not covered when given
with non-surgical dental care. EXCEPTON: General anesthesia for dental services for members
under age 19 years of age when rendered in a hospital, outpatient surgical facility or other facility
licensed pursuant to Section 25-3-101 of the Colorado Revised Statutes if the child, in the opinion
of the treating Dentist, satisfies one or more of the following criteria: (a) the child has a physical,
mental, or medically compromising condition; (b) the child has dental needs for which local
anesthesia is ineffective because of acute infection, anatomic variations, or allergy; (c) the child is
an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent
with dental needs deemed sufficiently important that dental care cannot be deferred; or (d) the
child has sustained extensive orofacial and dental trauma.
h) Dental services performed other than by a licensed dentist, licensed physician, his or her
employees, or a licensed Provider acting within the scope of the Provider's license.
i) Dental services, appliances or restorations that are necessary to alter, restore or maintain
occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth
structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

91
j) Services or supplies that have the primary purpose of improving the appearance of your teeth.
This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of
the teeth.
k) Restorations placed for preventative or cosmetic purposes.
l) Occlusal or athletic mouth guards
m) Prosthodontic services, such as dentures or bridges {AduIt dentaI: [for members through age
18].
n) Periodontal services {AduIt dentaI: [for members through age 18].
o) Retreatment or additional treatment necessary to correct or relieve the results of treatment
previously covered under the Plan.
p) Separate services billed when they are an inherent component of another covered service.
q) Temporomandibular Joint Disorder (TMJ) except as covered under your medical coverage.
r) Oral hygiene instructions.
s) Surgical exposure of impacted or unerupted teeth for orthodontic reasons, except as listed in this
Booklet.
t) Surgical repositioning of teeth, except as listed in this Booklet.
u) Case presentations, office visits and consultations.
v) mplant services, except as listed in this Booklet.
w) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or non-resorbable filling
material(s) and the procedures used to prepare and place material(s) in the canals (root).
x) Root canal obstruction, internal root repair of perforation defects, incomplete endodontic
treatment and bleaching of discolored teeth.
y) ncomplete root canals.
z) Procedures designed to enable prosthetic or restorative services to be performed such as a
crown lengthening.
aa) Services or supplies that are medical in nature, including dental oral surgery services performed
in a hospital, except as covered under your medical coverage.
bb) Adjunctive diagnostic tests.]
14) EducationaI Services Services or supplies for teaching, vocational, or self-training purposes, except
as listed in this Booklet.
15) ExperimentaI or InvestigationaI Services Services or supplies that we find are Experimental /
nvestigational. This also applies to services related to Experimental / nvestigational services,
whether you get them before, during, or after you get the Experimental / nvestigational service or
supply.
The fact that a service or supply is the only available treatment will not make it Covered Service if we
conclude it is Experimental / nvestigational.
16) EyegIasses and Contact Lenses Eyeglasses and contact lenses to correct your eyesight unless
listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye
surgery.
17) Eye Exercises Orthoptics and vision therapy.
18) Eye Surgery Eye surgery to fix errors of refraction, such as near-sightedness. This includes, but is
not limited to, LASK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

92
19) FamiIy Members Services prescribed, ordered, referred by or given by a member of your immediate
family, including your spouse, child, brother, sister, parent, in-law, or self.
20) Foot Care Routine foot care unless Medically Necessary. This Exclusion applies to cutting or
removing corns and calluses; trimming nails; cleaning and preventive foot care, including but not
limited to:
a) Cleaning and soaking the feet.
b) Applying skin creams to care for skin tone.
c) Other services that are given when there is not an illness, injury or symptom involving the foot.
21) Foot Orthotics Foot orthotics, orthopedic shoes or footwear or support items unless used for an
illness affecting the lower limbs, such as severe diabetes.
22) Foot Surgery Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet;
tarsalgia; metatarsalgia; hyperkeratoses.
23) Free Care Services you would not have to pay for if you didn't have this Plan. This includes, but is not
limited to government programs, services during a jail or prison sentence, services you get from
Workers Compensation, and services from free clinics.
f Workers' Compensation benefits are not available to you, this Exclusion does not apply. This
Exclusion will apply if you get the benefits in whole or in part.
24) Hearing Aids Hearing aids or exams to prescribe or fit hearing aids, unless listed as covered in this
Booklet. This Exclusion does not apply to cochlear implants.
25) HeaIth CIub Memberships and Fitness Services Health club memberships, workout equipment,
charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or
facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health
spas.
26) IntractabIe Pain and/or Chronic Pain Charges for a pain state in which the cause of the pain cannot
be removed and which in the course of medical practice no relief or cure of the cause of the pain is
possible, or none has been found after reasonable efforts. t is pain that lasts more than 6 months, is
not life threatening, and may continue for a lifetime, and has not responded to current treatment.
27) Maintenance Therapy Treatment given when no further gains are clear or likely to occur.
Maintenance therapy includes care that helps you keep your current level of function and prevents
loss of that function, but does not result in any change for the better.
28) MedicaI Equipment and SuppIies
a) Replacement or repair of purchased or rental equipment because of misuse, or loss.
b) Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury.
c) Non-Medically Necessary enhancements to standard equipment and devices.
29) Medicare For which benefits are payable under Medicare Parts A, B, and/or D, or would have been
payable if you had applied for Parts A and/or B, except as listed in this Booklet or as required by
federal law, as described in the section titled "Medicare" in General Provisions. f you do not enroll in
Medicare Part B, We will calculate benefits as if you had enrolled. You should sign up for Medicare
Part B as soon as possible to avoid large out of pocket costs.
30) Missed or CanceIIed Appointments Charges for missed or cancelled appointments.
31) Non-MedicaIIy Necessary Services Services we conclude are not Medically Necessary. This
includes services that do not meet our medical policy, clinical coverage, or benefit policy guidelines.
32) NutritionaI or Dietary SuppIements Nutritional and/or dietary supplements, except as described in
this Booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional

93
formulas and dietary supplements that you can buy over the counter and those you can get without a
written Prescription or from a licensed pharmacist.
33) OraI Surgery Extraction of teeth, surgery for impacted teeth, jaw augmentation or reduction
(orthognathic Surgery), and other oral surgeries to treat the teeth, jaw or bones and gums directly
supporting the teeth, except as listed in this Booklet.
34) Orthodontic Care, unIess for MedicaIIy Necessary care for cIeft paIate and cIeft conditions as
provided by this BookIet
a) Monthly treatment visits that are inclusive of treatment cost,
b) Repair or replacement of lost/broken/stolen appliances,
c) Orthodontic retention/retainer as a separate service,
d) Retreatment and/or services for any treatment due to relapse,
e) npatient or outpatient hospital expenses (please refer to your medical coverage to determine if
this is a covered medical service),
f) Provisional splinting, temporary procedures or interim stabilization of teeth,
g) Dental services or health care services not specifically covered under this Booklet (including any
hospital charges, prescription drug charges and dental services or supplies that are medical in
nature).
35) PersonaI Care and Convenience
a) tems for personal comfort, convenience, protection, cleanliness such as air conditioners,
humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs,
b) First aid supplies and other items kept in the home for general use (bandages, cotton-tipped
applicators, thermometers, petroleum jelly, tape, non-sterile gloves, heating pads),
c) Home workout or therapy equipment, including treadmills and home gyms,
d) Pools, whirlpools, spas, or hydrotherapy equipment.
e) Hypo-allergenic pillows, mattresses, or waterbeds,
f) Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs,
escalators, elevators, stair glides, emergency alert equipment, handrails).
36) Private Duty Nursing Private Duty Nursing Services, except as specifically stated in this Booklet.
37) Prosthetics Prosthetics for sports or cosmetic purposes. This includes wigs and scalp hair
prosthetics.
38) SexuaI Dysfunction Services or supplies for male or female sexual problems.
39) Smoking Cessation Programs Programs to help you stop smoking if the program is not affiliated
with Anthem.
40) Stand-By Charges Stand-by charges of a Doctor or other Provider.
41) SteriIization Services to reverse an elective sterilization.
42) Surrogate Mother Services Services or supplies for a person not covered under this Plan for a
surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an
infertile couple).
43) TemporomandibuIar Joint Treatment Fixed or removable appliances which move or reposition the
teeth, fillings, or prosthetics (crowns, bridges, dentures).
44) TraveI Costs Mileage, lodging, meals, and other Member-related travel costs except as described in
this Plan.

94
45) Vein Treatment Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any
method (including sclerotherapy or other surgeries) for cosmetic purposes.
46) {Pediatric vision exam onIy: [Vision Services
Vision services for Members age 19 or older, unless listed as covered in this Booklet
Eyeglass lenses, frames, or contact lenses.
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.]
{Pediatric/aduIt vision: [Vision Services
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.
Safety glasses and accompanying frames.
For two pairs of glasses in lieu of bifocals.
Plano lenses (lenses that have no refractive power)
Lost or broken lenses or frames if the Member has already received benefits during a Benefit
Period.
Vision services not listed as covered in this Booklet.
Cosmetic lenses or options.
Blended lenses.
Oversize lenses.
Sunglasses and accompanying frames.
For Members through age 18, no benefits are available for frames not on the Anthem
formulary.
Certain frames in which the manufacturer imposes a no discount policy.]
47) Weight Loss Programs Programs, whether or not under medical supervision, unless listed as
covered in this Booklet.
This Exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
48) Weight Loss Surgery Bariatric surgery. This includes but is not limited to Roux-en-Y (RNY),
Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgeries lower stomach
capacity and divert partly digested food from the duodenum to the jejunum, the section of the small
intestine extending from the duodenum), or Gastroplasty, (surgeries that reduce stomach size), or
gastric banding procedures.
What's Not Covered Under Your Prescription Drug RetaiI or Home
DeIivery (MaiI Order) Pharmacy Benefit
n addition to the above Exclusions, certain items are not covered under the Prescription Drug Retail or
Home Delivery (Mail Order) Pharmacy benefit:
1. Administration Charges Charges for the administration of any Drug except for covered
immunizations as approved by us or the PBM.

95
2. CIinicaIIy-EquivaIent AIternatives Certain Prescription Drugs may not be covered if you could use a
clinically equivalent Drug, unless required by law. "Clinically equivalent means Drugs that for most
Members, will give you similar results for a disease or condition. f you have questions about whether
a certain Drug is covered and which Drugs fall into this group, please call the number on the back of
your dentification Card, or visit our website at www.anthem.com.
3. Compound Drugs Compound Drugs unless its primary ingredient (the highest cost ingredient) is
FDA approved and requires a prescription to dispense, and the Compound Drug is not essentially the
same as an FDA-approved product from a drug manufacturer.
4. Contrary to Approved MedicaI and ProfessionaI Standards Drugs given to you or prescribed in a
way that is against approved medical and professional standards of practice.
5. DeIivery Charges Charges for delivery of Prescription Drugs.
6. Drugs Given at the Provider's Office / FaciIity Drugs you take at the time and place where you are
given them or where the Prescription Order is issued. This includes samples given by a Doctor. This
Exclusion does not apply to Drugs used with a diagnostic service, Drugs given during chemotherapy
in the office as described in the "Prescription Drugs Administered by a Medical Provider section, or
Drugs covered under the "Medical and Surgical Supplies benefit they are Covered Services.
7. Drugs Not on the Anthem Prescription Drug List (a formuIary) You can get a copy of the list by
calling us or visiting our website at www.anthem.com.
8. Drugs That Do Not Need a Prescription Drugs that do not need a prescription by federal law
(including Drugs that need a prescription by state law, but not by federal law), except for injectable
insulin or where applicable law requires coverage of the drug.
9. Drugs Over Quantity or Age Limits Drugs in quantities which are over the limits set by the Plan, or
which are over any age limits set by us.
10. Drugs Over the Quantity Prescribed or RefiIIs After One Year Drugs in amounts over the quantity
prescribed, or for any refill given more than one year after the date of the original Prescription Order.
11. FIuoride Treatments Topical and oral fluoride treatments. While these services are not covered
under the "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit,
they may be covered under the "Pediatric Dental Services for Members through Age 18 benefit.
Please see that section for further details.
12. InfertiIity Drugs Drugs used in assisted reproductive technology procedures to achieve conception
(e.g., VF, ZFT, GFT).
13. Items Covered as DurabIe MedicaI Equipment (DME) Therapeutic DME, devices and supplies
except peak flow meters, spacers, and blood glucose monitors. tems not covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit may be covered
under the "Durable Medical Equipment and Medical Devices benefit. Please see that section for
details.
14. Items Covered as MedicaI SuppIies Oral immunizations and biologicals, even if they are federal
legend Drugs, are covered as medical supplies based on where you get the service or item. Over the
counter Drugs, devices or products, are not Covered Services unless we must cover them under
federal law.
15. Items Covered Under the "AIIergy Services" Benefit Allergy desensitization products or allergy
serum. While not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, these items may be covered under the "Allergy Services benefit. Please
see that section for details.
16. Lost or StoIen Drugs Refills of lost or stolen Drugs.
17. MaiI Order Providers other than the PBM's Home DeIivery MaiI Order Provider Prescription
Drugs dispensed by any Mail Order Provider other than the PBM's Home Delivery Mail Order
Provider, unless we must cover them by law.

96
18. Non-approved Drugs Drugs not approved by the FDA.
19. Off IabeI use Off label use, unless we must cover the use by law or if we, or the PBM, approve it.
20. Onychomycosis Drugs Drugs for Onchomycosis (toenail fungus) except when we allow it to treat
Members who are immuno-compromised or diabetic.
21. Over-the-Counter Items Drugs, devices and products, or Prescription Legend Drugs with over the
counter equivalents and any Drugs, devices or products that are therapeutically comparable to an
over the counter Drug, device, or product. This includes Prescription Legend Drugs when any version
or strength becomes available over the counter.
This Exclusion does not apply to over-the-counter products that we must cover under federal law with
a Prescription.
22. Sex Change Drugs Drugs for sex change surgery, unless we must cover such drugs under
applicable law.
23. SexuaI Dysfunction Drugs Drugs to treat sexual or erectile problems.
24. Syringes Hypodermic syringes except when given for use with insulin and other covered self-
injectable Drugs and medicine.
25. Weight Loss Drugs Any Drug mainly used for weight loss.
Pre-existing Conditions
Not applicable, plan does not impose limitation period for pre-existing conditions.

97
Section 9. Member Payment ResponsibiIity
Your Cost-Shares
Your Plan may involve Copayments, Deductibles, and/or Coinsurance, which are charges that you must
pay when receiving Covered Services. Your Plan may also have an Out-of-Pocket Limit, which limits the
cost-shares you must pay. Please read the "Schedule of Benefits (Who Pays What) for details on your
cost-shares. Also read the "Definitions section for a better understanding of each type of cost share.
Maximum AIIowed Amount
GeneraI
This section describes how we determine the amount of reimbursement for Covered Services.
Reimbursement for services rendered by n-Network and Out-of-Network Providers is based on this
Booklet's Maximum Allowed Amount for the Covered Service that you receive. Please see the "Claims
Procedure (How to File a Claim) section for additional information.
The Maximum Allowed Amount for this Booklet is the maximum amount of reimbursement we will allow
for services and supplies:
That meet our definition of Covered Services, to the extent such services and supplies are covered
under your Booklet and are not excluded;
That are Medically Necessary; and
That are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in your Booklet.
You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met
your Deductible or have a Copayment or Coinsurance. n addition, when you receive Covered Services
from an Out-of-Network Provider, you may be responsible for paying any difference between the
Maximum Allowed Amount and the Provider's actual charges. This amount can be significant.
When you receive Covered Services from a Provider, we will, to the extent applicable, apply claim
processing rules to the claim submitted for those Covered Services. These rules evaluate the claim
information and, among other things, determine the accuracy and appropriateness of the procedure and
diagnosis codes included in the claim. Applying these rules may affect our determination of the Maximum
Allowed Amount. Our application of these rules does not mean that the Covered Services you received
were not Medically Necessary. t means we have determined that the claim was submitted inconsistent
with procedure coding rules and/or reimbursement policies. For example, your Provider may have
submitted the claim using several procedure codes when there is a single procedure code that includes
all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be
based on the single procedure code rather than a separate Maximum Allowed Amount for each billed
code.
Likewise, when multiple procedures are performed on the same day by the same Doctor or other
healthcare professional, we may reduce the Maximum Allowed Amounts for those secondary and
subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those
procedures would represent duplicative payment for components of the primary procedure that may be
considered incidental or inclusive.

98
Provider Network Status
The Maximum Allowed Amount may vary depending upon whether the Provider is an n-Network Provider
or an Out-of-Network Provider.
An n-Network Provider is a Provider who is in the managed network for this specific product or in a
special Center of Excellence/or other closely managed specialty network, or who has a participation
contract with us. For Covered Services performed by an n-Network Provider, the Maximum Allowed
Amount for this Booklet is the rate the Provider has agreed with us to accept as reimbursement for the
Covered Services. Because n-Network Providers have agreed to accept the Maximum Allowed Amount
as payment in full for those Covered Services, they should not send you a bill or collect for amounts
above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion
of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or
Coinsurance. Please call Customer Service for help in finding an n-Network Provider or visit
www.anthem.com.
Providers who have not signed any contract with us and are not in any of our networks are Out-of-
Network Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain
ancillary providers.
For Covered Services you receive from an Out-of-Network Provider, the Maximum Allowed Amount for
this Booklet will be one of the following as determined by us:
1. An amount based on Anthem's non-participating Provider fee schedule/rate, which is established at
Anthem's discretion, and which Anthem may modify from time to time, after considering one or more
of the following: reimbursement amounts accepted by like/similar Providers contracted with Anthem,
reimbursement amounts paid by the Centers for Medicare and Medicaid Services (CMS) for the same
services or supplies, and other industry cost, reimbursement and utilization data; or
2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid
Services ("CMS). When basing the Maximum Allowed amount upon the level or method of
reimbursement used by CMS, Anthem will update such information, which is unadjusted for
geographic locality, no less than annually; or
3. An amount based on information provided by a third party vendor, which may reflect one or more of
the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience
required for the treatment; or (3) comparable Providers' fees and costs to deliver care, or
4. An amount negotiated by us or a third party vendor which has been agreed to by the Provider. This
may include rates for services coordinated through case management, or
5. An amount based on or derived from the total charges billed by the Out-of-Network Provider.
Unlike n-Network Providers, Out-of-Network Providers may send you a bill and collect for the amount of
the Provider's charge that exceeds our Maximum Allowed Amount. You are responsible for paying the
difference between the Maximum Allowed Amount and the amount the Provider charges. This amount
can be significant. Choosing an n-Network Provider will likely result in lower out of pocket costs to you.
Please call Customer Service for help in finding an n-Network Provider or visit our website at
www.anthem.com.
Customer Service is also available to assist you in determining this Booklet's Maximum Allowed Amount
for a particular service from an Out-of-Network Provider. n order for us to assist you, you will need to
obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the
Provider will render. You will also need to know the Provider's charges to calculate your out of pocket
responsibility. Although Customer Service can assist you with this pre-service information, the final
Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider.

99
For Prescription Drugs, the Maximum Allowed Amount is the amount determined by us using Prescription
Drug cost information provided by the Pharmacy Benefits Manager.
Member Cost Share
For certain Covered Services and depending on your Plan design, you may be required to pay a part of
the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or
Coinsurance).
Your cost share amount and Out-of-Pocket Limits may vary depending on whether you received services
from an n-Network or Out-of-Network Provider. Specifically, you may be required to pay higher cost
sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see
the "Schedule of Benefits (Who Pays What) in this Booklet for your cost share responsibilities and
limitations, or call Customer Service to learn how this Booklet's benefits or cost share amounts may vary
by the type of Provider you use.
We will not provide any reimbursement for non-Covered Services. You may be responsible for the total
amount billed by your Provider for non-Covered Services, regardless of whether such services are
performed by an n-Network or Out-of-Network Provider. Non-covered services include services
specifically excluded from coverage by the terms of your Plan and received after benefits have been
exhausted Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits.
n some instances you may only be asked to pay the lower n-Network cost sharing amount when you use
an Out-of-Network Provider. For example, if you go to an n-Network Hospital or Provider Facility and
receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or
pathologist who is employed by or contracted with an n-Network Hospital or Facility, you will pay the n-
Network cost share amounts for those Covered Services. You will not have to pay more for the Covered
Services than you would have had to pay if it had been received from an n-Network Provider.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklet's cost share amounts; see your 'Schedule of Benefits (Who Pays What)" for
your applicable amounts.
Example: Your Plan has a Coinsurance cost share of 20% for In-Network services, and 30% for Out-of-
Network services after the In-Network or Out-of-Network Deductible has been met.
You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-
Network anesthesiologist to perform the anesthesiology services for the surgery. You have no control
over the anesthesiologist used.
The Out-of-Network anesthesiologist's charge for the service is $1200, your coinsurance responsibility
is 20% of $1200, or $240.
You choose an In-Network surgeon. The charge was $2500. The Maximum Allowed Amount for the
surgery is $1500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of
$1500, or $300. We allow 80% of $1500, or $1200. The In-Network surgeon accepts the total of
$1500 as reimbursement for the surgery regardless of the charges. Your total out of pocket
responsibility would be $300.
Authorized Services
n some circumstances, such as where there is no n-Network Provider available, or if we don't have an
n-Network Provider within a reasonable number of miles from your home, for the Covered Service, we
may authorize the n-Network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply
to a claim for a Covered Service you receive from an Out-of-Network Provider. n such circumstances,
you must contact us in advance of obtaining the Covered Service. f approved, we will pay the Out-of-

100
Network Provider at the n-Network level of benefits and you won't need to pay more for the services than
if the services had been received from an n-Network Provider. A precertification or preauthorization is not
the same thing as an Authorized Service; we must specifically authorize the service from an Out-of-
Network Provider at the n-Network cost share amounts.
Sometimes you may need to travel a reasonable distance to get care from an n-Network Provider. This
does not apply if care is for an Emergency.
f you do not receive a preauthorized network exception to obtain Covered Services from an Out-of-
Network Provider at the n-Network cost share amounts, the claim will be processed using your Out-of-
Network cost shares.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklet's cost share amounts; see your 'Schedule of Benefits (Who Pays What)" for
your applicable amounts.
Example:
You require the services of a specialty Provider; but there is no In-Network Provider for that specialty in
your state of residence. You contact us in advance of receiving any Covered Services, and we authorize
you to go to an available Out-of-Network Provider for that Covered Service and we agree that the In-
Network cost share will apply.
Your Plan has a $45 Copayment for Out-of-Network Providers and a $25 Copayment for In-Network
Providers for the Covered Service. The Out-of-Network Provider's charge for this service is $500. The
Maximum Allowed Amount is $200.
Because we have authorized the In-Network cost share amount to apply in this situation, you will be
responsible for the In-Network Copayment of $25 and we will be responsible for the remaining $475.
CIaims Review
Anthem has processes to review claims before and after payment to detect fraud, waste, abuse and other
inappropriate activity. Members seeking services from Out-of Network Providers could be balance billed
by the Out-of-Network Provider for those services that are determined to be not payable as a result of
these review processes. A claim may also be determined to be not payable due to a Provider's failure to
submit medical records with the claims that are under review in these processes.


101
Section 10. CIaims Procedure (How to FiIe a CIaim)
This section describes how we reimburse claims and what information is needed when you submit a
claim. When you receive care from an n-Network Provider, you do not need to file a claim because the
n-Network Provider will do this for you. f you receive care from an Out-of-Network Provider, you will
need to make sure a claim is filed. Many Out-of-Network Hospitals, Doctors and other Providers will file
your claim for you, although they are not required to do so. f you file the claim, use a claim form as
described later in this section.
Notice of CIaim & Proof of Loss
After you get Covered Services, we must receive written notice of your claim within 365 days in order for
benefits to be paid. The claim must have the information we need to determine benefits. f the claim
does not include enough information, we will ask for more details and it must be sent to us within the time
listed below or no benefits will be covered, unless required by law.
n certain cases, you may have some extra time to file a claim. f we did not get your claim within 365
days, but it is sent in as soon as reasonably possible and within one year after the 365-day period ends
(i.e., within 24 months), you may still be able to get benefits. However, any cIaims, or additionaI
information on cIaims, sent in more than 24 months after you get Covered Services wiII be denied.
CIaim Forms
Claim forms will usually be available from most Providers. f forms are not available, either send a written
request for a claims form to us, or contact Customer Service and ask for a claims form to be sent to you.
f you do not receive the claims form within 15 days of notifying us, written notice of services rendered
may be submitted to us without the claim form. The same information that would be given on the claim
form must be included in the written notice of claim. This includes:
Name of patient.
Patient's relationship with the Subscriber.
dentification number.
Date, type, and place of service.
Your signature and the Provider's signature.
Member's Cooperation
You will be expected to complete and submit to us all such authorizations, consents, releases,
assignments and other documents that may be needed in order to obtain or assure reimbursement under
Medicare, Workers' Compensation or any other governmental program. f you fail to cooperate (including
if you fail to enroll under Part B of the Medicare program where Medicare is the responsible payor), you
will be responsible for any charge for services.
Payment of Benefits
We will make benefit payments directly to Network Providers for Covered Services. f you use an Out-of-
Network Provider, however, we may make benefit payments to you unless if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of
you. We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services. Payments may also be made to, and notice regarding the receipt
and/or adjudication of claims sent to, an Alternate Recipient (any child of a Subscriber who is recognized,
under a Qualified Medical Child Support Order (QMSCO), as having a right to enrollment under the
Group's Contract), or that person's custodial parent or designated representative. Any benefit payments

102
made by us will discharge our obligation for Covered Services. You cannot assign your right to benefits
to anyone else, except as required by a "Qualified Medical Child Support Order as defined by ERSA or
any applicable state law.
Once a Provider performs a Covered Service, we will not honor a request for us to withhold payment of
the claims submitted.
Inter-PIan Programs
Out-of-Area Services
Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to
generally as "nter-Plan Programs. Whenever you obtain healthcare services outside of Anthem's
Service Area, the claims for these services may be processed through one of these nter-Plan Programs,
which include the BlueCard Program and may include negotiated National Account arrangements
available between Anthem and other Blue Cross and Blue Shield Licensees.
Typically, when accessing care outside Anthem's Service Area, you will obtain care from healthcare
Providers that have a contractual agreement (i.e., are "participating Providers) with the local Blue Cross
and/or Blue Shield Licensee in that other geographic area ("Host Blue). n some instances, you may
obtain care from nonparticipating healthcare Providers. Anthem's payment practices in both instances are
described below.
BIueCard

Program
Under the BlueCard

Program, when you access covered healthcare services within the geographic area
served by a Host Blue, Anthem will remain responsible for fulfilling Anthem's contractual obligations.
However, the Host Blue is responsible for contracting with and generally handling all interactions with its
participating healthcare Providers.
Whenever you access covered healthcare services outside Anthem's Service Area and the claim is
processed through the BlueCard Program, the amount you pay for covered healthcare services is
calculated based on the lower of:
The billed covered charges for your Covered Services; or
The negotiated price that the Host Blue makes available to Anthem.
Often, this "negotiated price will be a simple discount that reflects an actual price that the Host Blue pays
to your healthcare Provider. Sometimes, it is an estimated price that takes into account special
arrangements with your healthcare Provider or Provider group that may include types of settlements,
incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on
a discount that results in expected average savings for similar types of healthcare Providers after taking
into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for
over- or underestimation of modifications of past pricing for the types of transaction modifications noted
above. However, such adjustments will not affect the price Anthem uses for your claim because they will
not be applied retroactively to claims already paid.
Federal law or the law in a small number of states may require the Host Blue to add a surcharge to your
calculation. f federal law or any state laws mandate other liability calculation methods, including a
surcharge, we would then calculate your liability for any covered healthcare services according to
applicable law.

103
Non-Participating HeaIthcare Providers Outside Our Service Area
Member LiabiIity CaIcuIation
When covered healthcare services are provided outside of our Service Area by non-participating
healthcare providers, the amount you pay for such services will generally be based on either the Host
Blue's nonparticipating healthcare provider local payment or the pricing arrangements required by
applicable state law. n these situations, you may be liable for the difference between the amount that the
non-participating healthcare provider bills and the payment we will make for the Covered Services as set
forth in this paragraph.
Exceptions
n certain situations, we may use other payment bases, such as billed covered charges, the payment we
would make if the healthcare services had been obtained within our Service Area, or a special negotiated
payment, as permitted under nter-Plan Programs Policies, to determine the amount we will pay for
services rendered by nonparticipating healthcare providers. n these situations, you may be liable for the
difference between the amount that the non-participating healthcare provider bills and the payment we
will make for the Covered Services as set forth in this paragraph.
f you obtain services in a state with more than one Blue Plan network, an exclusive network arrangement
may be in place. f you see a Provider who is not part of an exclusive network arrangement, that
Provider's service(s) will be considered Non-Network care, and you may be billed the difference between
the charge and the Maximum Allowable Amount. You may call the Customer Service number on your D
card for more information about such arrangements.


104
Section 11. GeneraI PoIicy Provisions
Assignment
The Group cannot legally transfer this Booklet, without obtaining written permission from us. Members
cannot legally transfer the coverage. Benefits available under this Booklet are not assignable by any
Member without obtaining written permission from us, unless in a way described in the "How to Access
Your Services and Obtain Approval of Benefits (Applicable to Managed Care Plans) and in "Claims
Procedure (How to File a Claim) sections.
AutomobiIe Insurance Provisions
We will coordinate the benefits of this Booklet with the benefits of a complying auto insurance policy.
A complying automobile insurance policy is an auto policy approved by the Colorado Division of
nsurance that provides at least the minimum coverage required by law, and one which is subject to the
Colorado Auto Accident Reparations Act or Colorado Revised Statutes 10-4-601 et seq. Any state or
federal law requiring similar benefits through legislation or regulation is also considered a complying auto
policy.
How We Coordinate Benefits with Auto PoIicies - Your benefits under this Booklet may be coordinated
with the coverage's afforded by an auto policy. After any primary coverage's offered by the auto policy
are exhausted, including without limitation any no-fault, personal injury protection, or medical payment
coverages, We will pay benefits subject to the terms and conditions of this Booklet. f there is more than
one auto policy that offers primary coverage, each will pay its maximum coverage before We are liable for
any further payments.
You, your representative, agents and heirs must fully cooperate with Us to make sure that the auto policy
has paid all required benefits. We may require you to take a physical examination in disputed cases. f
there is an auto policy in effect, and you waive or fail to assert your rights to such benefits, this plan will
not pay those benefits that could be available under an auto policy.
We may require proof that the auto policy has paid all primary benefits before making any payments
under this Booklet. On the other hand, we may but are not required to pay benefits under this Booklet,
and later coordinate with or seek reimbursement under the auto policy. n all cases, upon payment, we
are entitled to exercise Our rights under this Booklet and under applicable law against any and all
potentially responsible parties or insurers. n that event, we may exercise the rights found in this section.
What Happens If You Do Not Have Another PoIicy - We will pay benefits if you are injured while you
are riding in or driving a motor vehicle that you own if it is not covered by an auto policy.
Similarly if not covered by an auto policy, we will also pay benefits for your injuries if as a non-owner or
driver, passenger or when walking you were in a motor vehicle accident. n that event, we may exercise
the rights found in this section.
CIericaI Error
A clerical error will never disturb or affect your coverage, as long as your coverage is valid under the rules
of the Plan. This rule applies to any clerical error, regardless of whether it was the fault of the Group or
us.

105
ConfidentiaIity and ReIease of Information
We will use reasonable efforts, and take the same care to preserve the confidentiality of your medical
information. We may use data collected in the course of providing services hereunder for statistical
evaluation and research. f such data is ever released to a third party, it shall be released only in
aggregate statistical form without identifying you. Medical information may be released only with your
written consent or as required by law. t must be signed, dated and must specify the nature of the
information and to which persons and organizations it may be disclosed. You may access your own
medical records.
We may release your medical information to professional peer review organizations and to the Group for
purposes of reporting claims experience or conducting an audit of our operations, provided the
information disclosed is reasonably necessary for the Group to conduct the review or audit.
A statement describing our policies and procedures for preserving the confidentiality of medical records is
available and will be furnished to you upon request.
Conformity with Law
Any term of the Plan which is in conflict with the laws of the state in which the Group Contract is issued,
or with federal law, will hereby be automatically amended to conform with the minimum requirements of
such laws.
Contract with Anthem
The Group, on behalf of itself and its participants, hereby expressly acknowledges its understanding that
this Plan constitutes a Contract solely between the Group and us, Anthem Blue Cross and Blue Shield
(Anthem), and that we are an independent corporation licensed to use the Blue Cross and Blue Shield
names and marks in the state of Colorado. The Blue Cross Blue Shield marks are registered by the Blue
Cross and Blue Shield Association, an association of independently licensed Blue Cross and Blue Shield
plans, with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries. Further, we
are not contracting as the agent of the Blue Cross and Blue Shield Association or any other Blue Cross
and/or Blue Shield plan or licensee. The Group, on behalf of itself and its participants, further
acknowledges and agrees that it has not entered into this Contract based upon representations by any
person other than Anthem Blue Cross and Blue Shield (Anthem) and that no person, entity, or
organization other than Anthem Blue Cross and Blue Shield (Anthem) shall be held accountable or liable
to the Group for any of Anthem Blue Cross and Blue Shield (Anthem)'s obligations to the Group created
under the Contract. This paragraph shall not create any additional obligations whatsoever on our part
other than those obligations created under other terms of this agreement.
Entire Contract
Note: The laws of the state in which the Group Contract is issued will apply unless otherwise stated
herein.
This Booklet, any riders, endorsements or attachments, and the individual applications of the Subscriber
and Dependents constitute the entire Contract between the Group and us and as of the Effective Date,
supersede all other agreements. n addition the Group has a Group Contract and Group application
which includes terms that apply to this coverage. Any and all statements made to us by the Group and
any and all statements made to the Group by us are representations and not warranties. No such
statement, unless it is contained in a written application for coverage under this Booklet, shall be used in
defense to a claim under this Booklet.

106
Form or Content of BookIet
No agent or employee of ours is authorized to change the form or content of this Booklet. Changes can
only be made through a written authorization, signed by an officer of Anthem. Changes are further noted
in "Modifications below this section.
Government Programs
The benefits under this Plan shall not duplicate any benefits that you are entitled to, or eligible for, under
any other governmental program. This does not apply if any particular laws require us to be the primary
payor. f we have duplicated such benefits, all money paid by such programs to you for services you
have or are receiving, shall be returned by or on your behalf to us.
MedicaI PoIicy and TechnoIogy Assessment
Anthem reviews and evaluates new technology according to its technology evaluation criteria developed
by its medical directors. Technology assessment criteria are used to determine the Experimental /
nvestigational status or Medical Necessity of new technology. Guidance and external validation of
Anthem's medical policy is provided by the Medical Policy and Technology Assessment Committee
(MPTAC) which consists of approximately 20 Doctors from various medical specialties including Anthem's
medical directors, Doctors in academic medicine and Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Medicare
Any benefits covered under both this Plan and Medicare will be covered according to Medicare
Secondary Payor legislation, regulations, and Centers for Medicare & Medicaid Services guidelines,
subject to federal court decisions. Federal law controls whenever there is a conflict among state law,
Booklet terms, and federal law.
Except when federal law requires us to be the primary payor, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Part B. Where Medicare is the responsible payor, all
sums payable by Medicare for services provided to you shall be reimbursed by or on your behalf to us, to
the extent we have made payment for such services. For the purposes of the calculation of benefits, if
you have not enrolled in Medicare Parts B and/or D, we will calculate benefits as if you had enrolled. You
shouId enroII in Medicare Part B as soon as possibIe to avoid potentiaI IiabiIity. For Medicare Part
D we will calculate benefits as if you had enrolled in the Standard Basic Plan.
Modifications
This Booklet allows the Group to make Plan coverage available to eligible Members. However, this
Booklet shall be subject to amendment, modification, and termination in accordance with any of its terms,
the Group Contract, or by mutual agreement between the Group and us without the permission or
involvement of any Member. Changes will not be effective until the date specified in the written notice we
give to the Group about the change. By electing medical and Hospital coverage under the Plan or
accepting Plan benefits, all Members who are legally capable of entering into a contract, and the legal
representatives of all Members that are incapable of entering into a contract, agree to all terms and
conditions in this Booklet.

107
For employer groups of one to 50, if we amend this Booklet to change benefits, notice of the amendment
will be given to the employer no less than 90 days before to the Effective Date of such change and the
amendment(s) will be effective for each group on the renewal or anniversary date of the Group Contract.
For all other changes, such as changes due to state or federal law or regulation, we may amend this
Booklet when authorized by one of our officers and, to the extent required by law, will provide the Group
60 days' notice of such changes. We will then provide the Group with any amendments within 60 days
following the effective date of the amendment. f the Group requests a change that reduces or eliminates
coverage, such change must be requested in writing or signed by the Group. The Group will notify you of
such change(s) to coverage. We or the Group will later send or make available to you an amendment to
this Booklet or a new Booklet.
Network Access PIan
We strive to provide Provider networks in Colorado that addresses your health care needs. The Network
Access Plan describes our Provider network standards for network sufficiency in service, access and
availability, as well as assessment procedures we follow in our effort to maintain adequate and accessible
networks. To request a copy of this document, call customer service. This document is also available on
our website or for in-person review at 700 Broadway in Denver, Colorado.
Not LiabIe for Provider Acts or Omissions
We are not responsible for the actual care you receive from any person. This Booklet does not give
anyone any claim, right, or cause of action against Anthem based on the actions of a Provider of health
care, services, or supplies.
PoIicies and Procedures
We are able to introduce new policies, procedures, rules and interpretations, as long as they are
reasonable. Such changes are introduced to make the Plan more orderly and efficient. Members must
follow and accept any new policies, procedures, rules, and interpretations.
Under the terms of the Group Contract, we have the authority, in our sole discretion, to introduce or
terminate from time to time, pilot or test programs for disease management or wellness initiatives which
may result in the payment of benefits not otherwise specified in this Booklet. We reserve the right to
discontinue a pilot or test program at any time. We will give thirty (30) days advance written notice to the
Group of the introduction or termination of any such program.
ReIationship of Parties (Group-Member-Anthem)
The Group is responsible for passing information to you. For example, if we give notice to the Group, it is
the Group's responsibility to pass that information to you. The Group is also responsible for passing
eligibility data to us in a timely manner. f the Group does not give us with timely enrollment and
termination information, we are not responsible for the payment of Covered Services for Members.
ReIationship of Parties (Anthem and In-Network Providers)
The relationship between Anthem and n-Network Providers is an independent contractor relationship. n-
Network Providers are not agents or employees of ours, nor is Anthem, or any employee of Anthem, an
employee or agent of n-Network Providers.
Your health care Provider is solely responsible for all decisions regarding your care and treatment,
regardless of whether such care and treatment is a Covered Service under this Plan. We shall not be

108
responsible for any claim or demand on account of damages arising out of, or in any manner connected
with, any injuries suffered by you while receiving care from any n-Network Provider or in any n-Network
Provider's Facilities.
Your n-Network Provider's agreement for providing Covered Services may include financial incentives or
risk sharing relationships related to the provision of services or referrals to other Providers, including n-
Network Providers, Out-of-Network Providers, and disease management programs. f you have
questions regarding such incentives or risk sharing relationships, please contact your Provider or us.
Reservation of Discretionary Authority
This section only applies when the interpretation of this Booklet is governed by the Employee Retirement
ncome Security Act (ERSA), 29 U.S.C. 1001 et seq.
We, or anyone acting on our behalf, shall determine the administration of benefits and eligibility for
participation in such a manner that has a rational relationship to the terms set forth herein. However, we,
or anyone acting on our behalf, have complete discretion to determine the administration of your benefits.
Our determination shall be final and conclusive and may include, without limitation, determination of
whether the services, care, treatment, or supplies are Medically Necessary, Experimental /
nvestigational, whether surgery is cosmetic, and whether charges are consistent with the Maximum
Allowable Amount. However, a Member may utilize all applicable complaint and appeals procedures, and
where required by applicable law, Our determination may be reviewed de novo (as if for the first time) in a
later appeal or legal action.
We, or anyone acting on our behalf, shall have all the powers necessary or appropriate to enable us to
carry out the duties in connection with the operation and administration of the Plan. This includes, without
limitation, the power to construe the Contract, to determine all questions arising under the Booklet and to
make, establish and amend the rules, regulations, and procedures with regard to the interpretation and
administration of the provisions of this Plan. However, these powers shall be exercised in such a manner
that has reasonable relationship to the provisions of the Contract, the Booklet, Provider agreements, and
applicable state or federal laws. A specific limitation or exclusion will override more general benefit
language.
Right of Recovery
Whenever payment has been made in error, we will have the right to recover such payment from you or, if
applicable, the Provider. n the event we recover a payment made in error from the Provider, except in
cases of fraud, we will only recover such payment from the Provider during the 24 months after the date
we made the payment on a claim submitted by the Provider, unless the law permits a different timeframe
in which to recover. We reserve the right to deduct or offset any amounts paid in error from any pending
or future claim. The cost share amount shown in your Explanation of Benefits is the final determination
and you will not receive notice of an adjusted cost share amount as a result of such Recovery activity.
We have oversight responsibility for compliance with Provider and vendor contracts. We may enter into a
settlement or compromise regarding enforcement of these contracts and may retain any recoveries made
from a Provider or vendor resulting from these audits if the return of the overpayment is not feasible. We
have established Recovery policies to determine which recoveries are to be pursued, when to incur costs
and expenses and settle or compromise Recovery amounts. We will not pursue recoveries for
overpayments if the cost of collection exceeds the overpayment amount. We may not give you notice of
overpayments made by us or you if the Recovery method makes providing such notice administratively
burdensome.

109
Unauthorized Use of Identification Card
f you permit your dentification Card to be used by someone else or if you use the card before coverage
is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting
from the unauthorized use. Fraudulent misuse could also result in termination of the coverage.
VaIue-Added Programs
We may offer health or fitness related programs to our Members, through which you may access
discounted rates from certain vendors for products and services available to the general public. Products
and services available under this program are not Covered Services under your Plan but are in addition to
Plan benefits. As such, program features are not guaranteed under your health Plan Contract and could
be discontinued at any time. We do not endorse any vendor, product or service associated with this
program. Program vendors are solely responsible for the products and services you receive.
VaIue of Covered Services
For purposes of subrogation, reimbursement of excess benefits, or reimbursement under any Workers'
Compensation or Employer Liability Law, the value of Covered Services shall be the amount we paid for
the Covered Services.
VoIuntary CIinicaI QuaIity Programs
We may offer additional opportunities to assist you in obtaining certain covered preventive or other care
(e.g., well child check-ups or certain laboratory screening tests) that you have not received in the
recommended timeframe. These opportunities are called voluntary clinical quality programs. They are
designed to encourage you to get certain care when you need it and are separate from Covered Services
under your Plan. These programs are not guaranteed and could be discontinued at any time. We will
give you the choice and if you choose to participate in one of these programs, and obtain the
recommended care within the program's timeframe, you may receive incentives such as gift cards. Under
other clinical quality programs, you may receive a home test kit that allows you to collect the specimen for
certain covered laboratory tests at home and mail it to the laboratory for processing. You may need to
pay any cost shares that normally apply to such covered laboratory tests (e.g., those applicable to the
laboratory processing fee) but will not need to pay for the home test kit. (f you receive a gift card and use
it for purposes other than for qualified medical expenses, this may result in taxable income to you. For
additional guidance, please consult your tax advisor.)
VoIuntary WeIIness Incentive Programs
We may offer health or fitness related program options for purchase by your Group to help you achieve
your best health. These programs are not Covered Services under your Plan, but are separate
components, which are not guaranteed under this Plan and could be discontinued at any time. f your
Group has selected one of these options to make available to all employees, you may receive incentives
such as gift cards by participating in or completing such voluntary wellness promotion programs as health
assessments, weight management or tobacco cessation coaching. Under other options a Group may
select, you may receive such incentives by achieving specified standards based on health factors under
wellness programs that comply with applicable law. f you think you might be unable to meet the
standard, you might qualify for an opportunity to earn the same reward by different means. You may
contact us at the customer service number on your D card and we will work with you (and, if you wish,
your Doctor) to find a wellness program with the same reward that is right for you in light of your health
status. (f you receive a gift card as a wellness reward and use it for purposes other than for qualified
medical expenses, this may result in taxable income to you. For additional guidance, please consult your
tax advisor.)

110
Waiver
No agent or other person, except an authorized officer of Anthem, is able to disregard any conditions or
restrictions contained in this Booklet, to extend the amount of time for making a payment to us, or to bind
us by making any promise or representation or by giving or receiving any information.
Workers' Compensation
The benefits under this Plan are not designed to duplicate benefits that you are eligible for under
Workers' Compensation Law. All money paid or owed by Workers' Compensation for services provided
to you shall be paid back by you, or on your behalf, to us if we have made or make payment for the
services received. t is understood that coverage under this Plan does not replace or affect any Workers'
Compensation coverage requirements.
Subrogation and Reimbursement
This section applies when we pay benefits as a result of injuries or illness and another party or party(ies)
agrees or is ordered to pay money because of these injuries or when the Member received or is entitled
to receive a Recovery because of these injuries or illnesses. Reimbursement or subrogation under this
Booklet may only be permitted if you have been fully compensated, and, the amount recoverable by us
may be reduced by a proportionate share of your attorney fees and costs, if state law so requires.
Subrogation
We have the right to recover payments we make on your behalf. The following apply:
f you have been fully compensated, we have a lien against all or a portion of the benefits that have
been paid to you from the following parties, including, but not limited to, the party or parties who
caused the injuries or illness, the insurer or other indemnifier of the party or parties who caused the
injuries or illness, a guarantor of the party or parties who caused the injuries or illness, your own
insurer (for example, uninsured, underinsured, medical payments or no-fault coverage, or a worker's
compensation insurer), or any other person, entity, policy or plan that may be liable or legally
responsible in relation to the injuries or illness. However, our Recovery cannot exceed the amount
actually paid by us under this Booklet as it relates to the injuries or illness that are the subject of the
subrogation action; and
You and your legal representative must do whatever is necessary to enable us to exercise our rights
and do nothing to prejudice them. f you have not pursued a claim against a third party allegedly at
fault for your injuries by the date that is sixty (60) days before to the date on which the applicable
statute of limitations expires, we have a right to bring legal action against the at-fault party.
Reimbursement
f you, a person who represents your legal interest, or beneficiary have been fully compensated and We
have not been repaid for the health insurance benefits we paid on the Member's behalf, we shall have a
right to be repaid from the Recovery in the amount of the health insurance benefits we paid on your
behalf and the following apply:
You must reimburse us to the extent of the health insurance benefits we paid on the Member's behalf
from any Recovery, including, but not limited to, the party or parties who caused the injuries or illness,
the insurer or other indemnifier of the party or parties who caused the injuries or illness, a guarantor
of the party or parties who caused the injuries or illness, your own insurer (for example, underinsured,
medical payments, or a worker's compensation insurer), or any other person, entity, policy or plan
that may be liable or legally responsible in relation to the injuries or illness;

111
Notwithstanding any allocation made in a settlement agreement or court order, we shall have a right
of reimbursement; and
You, a person who represents your legal interest, or beneficiary must hold in trust for us right away
the amount recovered in gross that is to be paid to us. The amount recovered in gross is the total
amount of your Recovery reduced by your lawyer fees and costs.
The Member's Duties
You, a person who represents your legal interest, or beneficiary must tell us right away the how, when
and where an accident or event that resulted in your injury or illness. We must find out what
happened and get all the details about the parties involved;
You, a person who represents your legal interest, or beneficiary must work with us in investigating,
settling and protecting rights;
You, a person who represents your legal interest, or beneficiary must send us copies of all police
reports, notices or other papers received in connection with the accident or incident resulting in
personal injury or illness;
You, a person who represents your legal interest, or beneficiary must promptly notify us if you retain
an attorney or if a lawsuit is filed;
f you, a person who represents your legal interest, or beneficiary gets a Recovery that is less than
the sum of all your damages incurred by you, you are required to tell us within 60 days of your receipt
of the Recovery. The notice to us must include:
! Total amount and source of the Recovery;
! Coverage limits applicable to any available insurance policy, contract or benefit plan; and
! The amount of any costs charged to you.
f we receive your notice that you have not been fully paid, we have the right to dispute that
determination;
f we dispute whether your Recovery is less than the sum of all your damages, such dispute must be
resolved through arbitration; and
f you, a person who represents your legal interest, or beneficiary resides in a state where automobile
personal injury protection or medical payment coverage is mandatory, that coverage is primary and
the Booklet takes secondary status. The Booklet will reduce benefits for an amount equal to, but not
less than, that state's mandatory minimum personal injury protection or medical payment
requirement.
Coordination of Benefits When Members Are Insured Under More
Than One PIan
We may coordinate benefits when you have coverage with more than one health coverage.
DupIicate Coverage
Duplicate coverage is the term used to describe when you are covered by this Booklet and also covered
by another:
Group or group-type health insurance;
Health benefits coverage; or

112
Blanket coverage.
The total benefits received by you, or on your behalf, from all coverage's combined for any claim for
Covered Services will not exceed 100 percent of the total covered charges.
Order of Benefit Determination RuIes - The foIIowing ruIes are used in the order as Iisted:
How We Determine Which Coverage is Primary and Which is Secondary
We will determine the primary coverage and secondary coverage according to the following rule: A plan
that does not have order of benefit determination rules or if it has rules will always be primary unless the
provisions of both plans state that the plan is primary.
Non-Dependent or Dependent
The plan that covers the person other than as a dependent, for example as an employee, member,
subscriber or retiree, is primary and the plan that covers the person, as a dependent, is secondary. f the
person is a Medicare beneficiary, please refer to the section below of "Determining Primacy Between
Medicare and Us for primary and secondary payer rules.
Active EmpIoyee, Retired or Laid-Off EmpIoyee
a. The plan that covers a person as an active employee, who is not laid off or retired, or a dependent of
an active employee, is the primary plan.
b. f the secondary, or other plan, does not have this rule, and as result the plans do not agree on the
order of benefits, this rule is ignored.
c. This rule does not apply if the section above of "Non-Dependent or Dependent can determine the
order of benefits.
COBRA or State Continuation Coverage
a. f a person whose coverage is provided in accordance with COBRA, or under a right of continuation
according to state or federal law is covered under another plan, the plan covering the person as an
employee, member, subscriber or retiree or covering the person as a dependent of an employee,
member, subscriber, or retiree, is the primary plan and the plan covering that same person in
accordance with COBRA, or under a right of continuation in accordance with state or other federal
law, is the secondary plan.
b. f the other plan does not have this rule, and if, as a result, the plans do not agree on the order of
benefits, this rule is ignored.
c. This rule does not apply if the section above of "Non-Dependent or Dependent can determine the
order of benefits.
Longer or Shorter Length of Coverage
a. f the rules above do not determine the order of benefits, the plan that covered the person for the
longer period of time is primary plan and the plan that covered the person for the shorter period of
time is the secondary plan.
b. To determine the length of time a person has been covered under a plan, two (2) successive plans
will be treated as one if the covered person was eligible under the second within twenty-four (24)
hours after the first ended.
c. The start of a new plan does not include:
(1) A change in the amount or scope of a plan's benefits;

113
(2) A change in the entity that pays, provides or administers the plan's benefits; or
(3) A change from one type of plan to another (such as, from a single employer plan to that of a
multiple employer plan).
d. The person's length of time covered under a plan is measured from the person's first date of
coverage under that plan. f that date is not readily available for a group plan, the date the person first
became a member of the group will be used as the date from which to determine the length of time
the person's coverage under the present plan has been in force.
f none of the rules above determine the primary plan, the allowable expenses will be shared equally
between the plans.
Dependent ChiId Covered Under More Than One PIan
Unless there is a court decree stating otherwise, plans covering a dependent child will determine the
order of benefits as follows:
a. For a dependent child whose parents are married or are living together, whether or not they have
been married:
(1) The plan of the parent whose birthday falls earlier in the calendar year, by month and day, is the
primary plan; or
(2) f both parents have the same birthday, the plan that has covered the parent the longest is the
primary plan.
b. For a dependent child whose parents are divorced or separated or are not living together, whether or
not they have ever been married:
(1) f the court decree states that one of the parents is responsible for the dependent child's health
care expenses or health care coverage, and the plan of that parent has actual knowledge of
those terms, that plan is primary. f the parent with financial responsibility has no health care
coverage for the dependent child's health care, but that parent's spouse does, the spouse's plan
is primary. This item will not apply with respect to a plan year during which benefits are paid or
provided before the entity has actual knowledge of the court decree provision;
(2) f the court decree states that both parents are responsible for the dependent child's health care
expenses or health care coverage, paragraph a above will determine the order of benefits;
(3) f the divorce decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the depend child,
paragraph a above will determine the order of benefits; or
(4) f there is no court decree allocating responsibility for the child's health care expenses of health
care coverage, the order of benefits for the child are as follows:
(a) The plan of the custodial parent;
(b) The plan of the spouse of the custodial parent;
(c) The plan of the noncustodial parent; and then
(d) The plan of the spouse of the noncustodial parent.
c. For a dependent child covered under more than one plan of individuals who are not parents of the
child, the order of benefits will be determined, as applicable, according to paragraph a. or b. above as
if those individuals were the parents of the child.
d. For a dependent child who has coverage under either or both parents' plans and also has his or her
own coverage as a dependent under a spouse's plan, the rule in the section above for "Longer or
Shorter Length of Coverage applies.

114
n the event the dependent child's coverage under the spouse's plan began on the same date as the
dependent child's coverage under either or both parents' plans, the order of benefits will be determined by
applying the birthday rule to the dependent child's parent(s) and the dependent's spouse.
RuIes for Coordination of Benefits
When a person is covered by two (2) or more plans, the rules for determining the order of benefit
payments are as follows:
1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.
2. f the primary plan is a Closed Panel Plan, and the secondary plan is not a Closed Panel Plan, the
secondary plan will pay or provide benefits as if it were the primary plan when a covered person uses
a non-panel provider, except for emergency services or authorized referrals that are paid or provided
by the primary provider.
3. When multiple contracts providing coordinated coverage are treated as a single plan, this section only
applies to the plan as a whole, and coordination among the component contracts is governed by the
terms of the contracts.
4. f a person is covered by more than one secondary plan, each secondary plan will take into
consideration the benefits of the primary plan, or plans, and the benefits of any other plan, which, has
its benefits determined before those of that secondary plan.
5. Under the terms of a Closed Panel Plan, benefits are not payable if the covered person does not use
the services of a closed panel provider, with the exceptions of medical emergencies and if there are
allowable benefits available. n most instances, Coordination of Benefits does not occur if a covered
person is enrolled in two (2) or more Closed Panel Plans and obtains services from a provider in one
of the Closed Panel Plans because the other Closed Panel Plan (the one whose providers were not
used) has no liability. However, Coordination of Benefits may occur during the claim determination
period when the covered person receives emergency services that would have been covered by both
plans.
Determining Primacy Between Medicare and Us
We will be the primary payer for persons with Medicare age 65 and older if the policyholder is actively
working for an employer who is providing the policy holder's health insurance and the employer has 20 or
more employees. Medicare will be the primary payer for persons with Medicare age 65 and older if the
policyholder is not actively working and the Member is enrolled in Medicare. Medicare will be the primary
payer for persons with Medicare age 65 and older if the employer has less than 20 employees and the
Member is enrolled in Medicare.
We will be the primary payer for persons enrolled with Medicare under age 65 when Medicare coverage
is due to disability if the policyholder is actively working for an employer who is providing the
policyholder's health insurance and the employer has 100 or more employees. Medicare will be the
primary payer for persons enrolled in Medicare due to disability if the policyholder is not actively working
or the employer has less than 100 employees.
We will be the primary payer for persons with Medicare under age 65 when Medicare coverage is due to
End Stage Renal Disease (ESRD), for the first 30 months from the entitIement to or eIigibiIity for
Medicare (whether or not Medicare is taken at that time). After 30 months, Medicare will become the
primary payer if Medicare is in effect (30-month coordination period).
When a Member becomes eligible for Medicare due to a second entitlement, such as age, We remain
primary. But this will only apply if the group health coverage was primary at the point when the second
entitlement took effect, for the duration of 30 months after becoming Medicare entitled or eligible due to
ESRD. f Medicare was primary at the point of the second entitlement, then Medicare remains primary.
There will be no 30-month coordination period for ESRD.

115
Members with Medicare and Two Group Insurance PoIicies
Based on the primacy rules, if Medicare is secondary to a group coverage (see Medicare primacy rules),
the primary coverage covering the Member will pay first. Medicare will then pay second, and the
coverage covering the Member as a retiree or inactive employee or Dependent will pay third. The order
of primacy is not based on the policyholder of the group health insurance.
f Medicare is the primary payer due to Medicare primacy rules, then the rules of primacy for employees
and their spouses will be used to determine the coverage that will pay second and third.
Your ObIigations
You have an obligation to provide us with current and accurate information regarding the existence of
other coverage.
Benefits payable under another coverage include benefits that would be paid by that coverage, whether
or not a claim is made. t also includes benefits that would have been paid but were refused. This is due
to the claim not being sent to the Provider of other coverage on a timely basis.
Your benefits under this Booklet will be reduced by the amount that such benefits would duplicate
benefits payable under the primary coverage.
Our Rights to Receive and ReIease Necessary Information
We may release to, or obtain, from any insurance company or other organization or person any
information which we may need to carry out the terms of this Booklet. Members will furnish to us such
information as may be necessary to carry out the terms of this Booklet.
Payment of Benefits to Others
When payments that should have been made under this Booklet were made under any other coverage, we will
have the right to pay to the other coverage any amount we determine to be warranted to satisfy the intent of
this provision. Any amount so paid will be considered to be benefits paid under this Booklet, and with that
payment we will fully satisfy our liability under this provision.
DupIicate Coverage and Coordination of Benefits Overpayment Recovery
f we have overpaid for Covered Services under this section, we will have the right, by offset or otherwise, to
recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were
made.

116
Section 12. Termination/NonrenewaI/Continuation
Termination
Except as otherwise provided, your coverage may terminate in the following situations:
When the Contract between the Group and us terminates. f your coverage is through an association,
your coverage will terminate when the Contract between the association and us terminates, or when
your Group leaves the association. t will be the Group's responsibility to notify you of the termination
of coverage.
f you choose to terminate your coverage.
f you or your Dependents cease to meet the eligibility requirements of the Plan, subject to any
applicable continuation requirements. f you cease to be eligible, the Group and/or you must notify us
immediately. The Group and/or you shall be responsible for payment for any services incurred by you
after you cease to meet eligibility requirements.
f you elect coverage under another carrier's health benefit plan, which is offered by the Group as an
option instead of this Plan, subject to the consent of the Group. The Group agrees to immediately
notify us that you have elected coverage elsewhere.
f you perform an act, practice, or omission that constitutes fraud or make an intentional
misrepresentation of material fact, as prohibited by the terms of your Plan, your coverage and the
coverage of your Dependents can be retroactively terminated or rescinded. A rescission of coverage
means that the coverage may be legally voided back to the start of your coverage under the Plan, just
as if you never had coverage under the Plan. You will be provided with a 30 calendar day advance
notice with appeal rights before your coverage is retroactively terminated or rescinded. You are
responsible for paying us for the cost of previously received services based on the Maximum Allowable
Amount for such services, less any Copayments made or Premium paid for such services.
f you fail to pay or fail to make satisfactory arrangements to pay your portion of the Premium, we may
terminate your coverage and may also terminate the coverage of your Dependents.
f you permit the fraudulent use of your or any other Member's Plan dentification Card by any other
person; use another person's dentification Card; or use an invalid dentification Card to obtain
services, your coverage will terminate immediately upon our written notice to the Group. Anyone
involved in the misuse of a Plan dentification Card will be liable to and must reimburse us for the
Maximum Allowed Amount for services received through such misuse.
f you are a partner to a civil union, recognized domestic partnership, or other relationship recognized
as a spousal relationship in the state where the subscriber resides, on the date such union or
relationship is revoked or terminated. Also, if there is coverage for designated beneficiaries, on the date
a Recorded Designated Beneficiary Agreement is revoked or terminated. Where permitted by law,
such a Dependent may be able to seek COBRA or state continuation coverage, subject to the terms of
this Booklet.
You will be notified in writing of the date your coverage ends by either us or the Group.
RemovaI of Members
Upon written request through the Group, you may cancel your coverage and/or your Dependent's
coverage from the Plan. f this happens, no benefits will be provided for Covered Services after the
termination date even if we have preauthorized the service, unless the Provider confirmed eligibility within
two business days before the service is received.

117
SpeciaI RuIes if Your Group HeaIth PIan is Offered Through an
Exchange
f your Plan is offered through an Exchange, either you or your Group may cancel your coverage and/or
your Dependent's coverage through the Exchange. Each Exchange will have rules on how to do this.
You may cancel coverage by sending a written notice to either the Exchange or us. The date that
coverage will end will be either:
The date that you ask for coverage to end, if you provide written notice within 14 days of that date; or
14 days after you ask for coverage to end, if you ask for a termination date more than 14 days before
you gave written notice. We may agree in certain circumstances to allow an earlier termination date
that you request.
Continuation of Coverage Under FederaI Law (COBRA)
The following applies if you are covered by a Group that is subject to the requirements of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended.
COBRA continuation coverage can become available to you when you would otherwise lose coverage
under your Group's health Plan. t can also become available to other Members of your family, who are
covered under the Group's health Plan, when they would otherwise lose their health coverage. For
additional information about your rights and duties under federal law, you should contact the Group.
QuaIifying events for Continuation Coverage under FederaI Law (COBRA)
COBRA continuation coverage is available when your coverage would otherwise end because of certain
"qualifying events. After a qualifying event, COBRA continuation coverage must be offered to each
person who is a "qualified beneficiary. You, your spouse and your Dependent children could become
qualified beneficiaries if you were covered on the day before the qualifying event and your coverage
would be lost because of the qualifying event. Qualified beneficiaries who elect COBRA must pay for this
COBRA continuation coverage.
This benefit entitles each Member of your family who is enrolled in the Plan to elect continuation
independently. Each qualified beneficiary has the right to make independent benefit elections at the time
of annual enrollment. Covered Subscribers may elect COBRA continuation coverage on behalf of their
spouses, and parents or legal guardians may elect COBRA continuation coverage on behalf of their
children. A child born to, or placed for adoption with, a covered Subscriber during the period of
continuation coverage is also eligible for election of continuation coverage.


118
InitiaI QuaIifying Event Length of AvaiIabiIity of Coverage

For Subscribers:

Voluntary or nvoluntary Termination (other than
gross misconduct) or Reduction n Hours Worked





18 months


For Dependents:

A Covered Subscriber's Voluntary or nvoluntary
Termination (other than gross misconduct) or
Reduction n Hours Worked

Covered Subscriber's Entitlement to Medicare

Divorce or Legal Separation

Death of a Covered Subscriber






18 months

36 months

36 months

36 months

For Dependent ChiIdren:

Loss of Dependent Child Status



36 months


COBRA coverage will end before the end of the maximum continuation period listed above if you become
entitled to Medicare benefits. n that case a qualified beneficiary other than the Medicare beneficiary
is entitled to continuation coverage for no more than a total of 36 months. (For example, if you become
entitled to Medicare prior to termination of employment or reduction in hours, COBRA continuation
coverage for your spouse and children can last up to 36 months after the date of Medicare entitlement.)
If Your Group Offers Retirement Coverage
f you are a retiree under this Plan, filing a proceeding in bankruptcy under Title 11 of the United States
Code can be a qualifying event. f a proceeding in bankruptcy is filed with respect to your Group, and that
bankruptcy results in the loss of coverage, you will become a qualified beneficiary with respect to the
bankruptcy. Your Dependents will also become qualified beneficiaries if bankruptcy results in the loss of
their coverage under this Plan. f COBRA coverage becomes available to a retiree and his or her covered
family members as a result of a bankruptcy filing, the retiree may continue coverage for life and his or her
Dependents may also continue coverage for a maximum of up to 36 months following the date of the
retiree's death.
Second quaIifying event
f your family has another qualifying event (such as a legal separation, divorce, etc.) during the initial 18
months of COBRA continuation coverage, your Dependents can receive up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months from the original qualifying event. Such
additional coverage is only available if the second qualifying event would have caused your Dependents
to lose coverage under the Plan had the first qualifying event not occurred.

119
Notification Requirements
The Group will offer COBRA continuation coverage to qualified beneficiaries only after the Group has
been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the Subscriber, commencement of a proceeding in
bankruptcy with respect to the employer, or the Subscriber's becoming entitled to Medicare benefits
(under Part A, Part B, or both), the Group will notify the COBRA Administrator (e.g., Human Resources or
their external vendor) of the qualifying event.
You Must Give Notice of Some QuaIifying Events
For other qualifying events (e.g., divorce or legal separation of the Subscriber and spouse or a
Dependent child's losing eligibility for coverage as a Dependent child), you must notify the Group within
60 days after the qualifying event occurs.
EIecting COBRA Continuation Coverage
To continue your coverage, you or an eligible family Member must make an election within 60 days of the
date your coverage would otherwise end, or the date the company's benefit Plan Administrator notifies
you or your family Member of this right, whichever is later. You must pay the total Premium appropriate
for the type of benefit coverage you choose to continue. f the Premium rate changes for active
associates, your monthly Premium will also change. The Premium you must pay cannot be more than
102% of the Premium charged for Employees with similar coverage, and it must be paid to the company's
benefit plan administrator within 30 days of the date due, except that the initial Premium payment must be
made before 45 days after the initial election for continuation coverage, or your continuation rights will be
forfeited.
DisabiIity extension of 18-month period of continuation coverage
For Subscribers who are determined, at the time of the qualifying event, to be disabled under Title
(OASD) or Title XV (SS) of the Social Security Act, and Subscribers who become disabled during the
first 60 days of COBRA continuation coverage, coverage may continue from 18 to 29 months. These
Subscribers' Dependents are also eligible for the 18- to 29-month disability extension. (This also applies
if any covered family Member is found to be disabled.) This would only apply if the qualified beneficiary
gives notice of disability status within 60 days of the disabling determination. n these cases, the
Employer can charge 150% of Premium for months 19 through 29. This would allow health coverage to
be provided in the period between the end of 18 months and the time that Medicare begins coverage for
the disabled at 29 months. (f a qualified beneficiary is determined by the Social Security Administration to
no longer be disabled, such qualified beneficiary must notify the Plan Administrator of that fact in writing
within 30 days after the Social Security Administration's determination.)
Trade Adjustment Act EIigibIe IndividuaI
f you don't initially elect COBRA coverage and later become eligible for trade adjustment assistance
under the U.S. Trade Act of 1974 due to the same event which caused you to be eligible initially for
COBRA coverage under this Plan, you will be entitled to another 60-day period in which to elect COBRA
coverage. This second 60-day period will commence on the first day of the month on which you become
eligible for trade adjustment assistance. COBRA coverage elected during this second election period will
be effective on the first day of the election period. You may also be eligible to receive a tax credit equal
to 65% of the cost for health coverage for you and your Dependents charged by the Plan. This tax credit
also may be paid in advance directly to the health coverage Provider, reducing the amount you have to
pay out of pocket.

120
When COBRA Coverage Ends
COBRA benefits are available without proof of insurability and coverage will end on the earliest of the
following:
A covered individual reaches the end of the maximum coverage period;
A covered individual fails to pay a required Premium on time;
A covered individual becomes covered under any other group health plan after electing COBRA. f
the other group health plan contains any exclusion or limitation on a pre-existing condition that
applies to you, you may continue COBRA coverage only until these limitations cease;
A covered individual becomes entitled to Medicare after electing COBRA; or
The Group terminates all of its group welfare benefit plans.
If You Have Questions
Questions concerning your Group's health Plan and your COBRA continuation coverage rights should be
addressed to the Group. For more information about your rights under ERSA, including COBRA, the
Health nsurance Portability and Accountability Act (HPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits
Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses
and phone numbers of Regional and District EBSA Offices are available through EBSA's website.)
Continuation of Coverage Under State Law
Groups with less than 20 employees who provide health care coverage for their employees are subject to
state law for continuation of coverage. The state continuation coverage period will not exceed 18 months
for you and/or any Dependents. State continuation coverage for you and your Dependents will start on
the date of the earliest of the following qualifying events:
Your termination of employment. To qualify, you must have been covered by the Group health
coverage for at least (6) six straight months;
Your reduction in working hours which results in loss of coverage. Reduction in working hours would
include circumstances resulting from economic conditions, injury, disability, or chronic health
conditions;
Your death; or
Divorce or legal separation of you and the spouse.
State Continuation Coverage Notification
Unless termination or reduction in working hours is the qualifying event, a Subscriber, spouse or
Dependent child must tell the Group of their choice to keep coverage within 30 days after being eligible.
The Group is responsible for telling the Subscriber, spouse and/or Dependent child of how to choose
state continuation. Once the Group has given notice to the Subscriber, spouse and/or Dependent child,
we must get timely notice from the Group that you want state continuation. We must also get timely
payment of Premiums from the Group when paid by the Subscriber.
We should get the notice from the Group and your first no later than 30 days after the qualifying event. f
the group fails to give timely notice to you of your rights, this deadline may extend to 60 days after the
qualifying event. For more, contact your Group.

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When State Continuation Coverage Ends
Your state continuation coverage ends upon the earlier of the following:
A covered individual reaches the end of the maximum coverage period;
The Group Master Contract between Us and your employer ends. f the employer gets other group
coverage, continuation coverage will continue under the new plan;
A covered individual fails to pay Premium timely;
You are eligible for another group health plan unless the other plan does not cover something that is
covered by the continuation coverage. n that case, the state continuation coverage lasts until the
continuation period ends or the other plan covers the excluded condition;
f you are covered as a Designated Beneficiary, on the date the Recorded Designated Beneficiary
Agreement is revoked or terminated;
The date the spouse remarries and becomes eligible for coverage under the new spouse's group
health plan;
You get Medicare or Medicaid; or
You tell us in writing to cancel.
Continuation of Coverage Due To MiIitary Service
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the
Subscriber or his / her Dependents may have a right to continue health care coverage under the Plan if
the Subscriber must take a leave of absence from work due to military leave.
Employers must give a cumulative total of five years and in certain instances more than five years, of
military leave.
"Military service means performance of duty on a voluntary or involuntary basis and includes active duty,
active duty for training, initial active duty for training, inactive duty training, and full-time National Guard
duty.
During a military leave covered by USERRA, the law requires employers to continue to give coverage
under this Plan to its Members. The coverage provided must be identical to the coverage provided to
similarly situated, active employees and Dependents. This means that if the coverage for similarly
situated, active employees and Dependents is modified, coverage for you (the individual on military leave)
will be modified.
You may elect to continue to cover yourself and your eligible Dependents by notifying your employer in
advance and submitting payment of any required contribution for health coverage. This may include the
amount the employer normally pays on your behalf. f your military service is for a period of time less
than 31 days, you may not be required to pay more than the active Member contribution, if any, for
continuation of health coverage. For military leaves of 31 days or more, you may be required to pay up to
102% of the full cost of coverage, i.e., the employee and employer share.
The amount of time you continue coverage due to USERRA will reduce the amount of time you will be
eligible to continue coverage under COBRA.

122
Maximum Period of Coverage During a MiIitary Leave
Continued coverage under USERRA will end on the earlier of the following events:
1. The date you fail to return to work with the Group following completion of your military leave.
Subscribers must return to work within:
a) The first full business day after completing military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service.
b) 14 days after completing military service for leaves of 31 to 180 days,
c) 90 days after completing military service for leaves of more than 180 days; or
2. 24 months from the date your leave began.
Reinstatement of Coverage FoIIowing a MiIitary Leave
Regardless of whether you continue coverage during your military leave, if you return to work your health
coverage and that of your eligible Dependents will be reinstated under this Plan if you return within:
1. The first full business day of completing your military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service;
2. 14 days of completing your military service for leaves of 31 to 180 days; or
3. 90 days of completing your military service for leaves of more than 180 days.
f, due to an illness or injury caused or aggravated by your military service, you cannot return to work
within the time frames stated above, you may take up to:
1. Two years; or
2. As soon as reasonably possible if, for reasons beyond your control you cannot return within two years
because you are recovering from such illness or injury.
f your coverage under the Plan is reinstated, all terms and conditions of the Plan will apply to the extent
that they would have applied if you had not taken military leave and your coverage had been continuous.
Any waiting/probationary periods will apply only to the extent that they applied before.
Please note that, regardless of the continuation and/or reinstatement provisions listed above, this Plan
will not cover services for any illness or injury caused or aggravated by your military service, as indicated
in the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions)" section.
FamiIy and MedicaI Leave Act of 1993
A Subscriber who takes a leave of absence under the Family and Medical Leave Act of 1993 (the Act) will
still be eligible for this Plan during their leave. We will not consider the Subscriber and his or her
Dependents ineligible because the Subscriber is not at work.
f the Subscriber ends their coverage during the leave, the Subscriber and any Dependents who were
covered immediately before the leave may be added back to the Plan when the Subscriber returns to
work without medical underwriting. To be added back to the Plan, the Group may have to give us
evidence that the Family and Medical Leave Act applied to the Subscriber. We may require a copy of the
health care Provider statement allowed by the Act.

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Benefits After Termination Of Coverage
Except as stated below, we will not pay for any services given to you after your coverage ends even if we
preauthorized the service, unless the Provider confirmed your eligibility within two business days before
each service received. Benefits cease on the date your coverage ends as described above. You may be
responsible for benefit payments made by us on your behalf for services provided after your coverage
has ended.
When your coverage ends for any reason other than for nonpayment of Premium, fraud or abuse, We will
continue coverage if you are being treated at an inpatient facility, until you are discharged or transferred
to another level of care. This is subject to the terms of this Booklet. The discharge date is seen as the
first date on which you are discharged from the facility or transferred to another level of care. We will not
cover the services you get after your discharge date.
Unless a law requires, we do not cover services after your date of termination even if:
We approved the services; or
The services were made necessary by an accident, illness or other event that occurred while coverage
was in effect.

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Section 13. AppeaIs and CompIaints
We want your experience with us to be as positive as possible. There may be times, however, when you
have a complaint, problem, or question about your Plan or a service you have received. n those cases,
please contact Customer Service by calling the number on the back of your D card. We will try to resolve
your complaint informally by talking to your Provider or reviewing your claim. f you are not satisfied with
the resolution of your complaint, you have the right to file a Grievance / Appeal, which is defined as
follows:
We may have turned down your claim for benefits. We may have also denied your request to
preauthorize or receive a service or a supply. f you disagree with Our decision you can:
1. File a complaint
2. File an appeal; or
3. File a grievance.

CompIaints
f you want to file a complaint about our customer service or how we processed your claim, please call
customer services. A trained staff member will try to clear up any confusion about the matter. They will
also try to resolve your complaint. f you prefer, you can send a written complaint to this address:
For services that are not dentaI or vision send to:
Anthem
Customer Services Department
P.O. Box 17549
Denver, CO 80217-0549
For dentaI benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:
Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
f your complaint isn't solved either by writing or calling, or if you don't want to file a complaint, you can file
an appeal. We'll tell you how to do that next, in the Appeals section below.
Note: More details on the complaints and appeals process and time periods can be found in the Appeals
Guide. You may get a copy of the Appeals Guide by visiting www.anthem.com or you can call customer
service.



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AppeaIs
f we have denied a claim that you feel should have been covered, or handled in a different way, or had
your coverage cancelled retroactively for a reason that it not because of your failure to pay premiums, you
can file an appeal. You can appeal a denial that was made by us before the service is received. You can
also appeal a denial on a service after it is received. You may also appeal an eligibility determination
made by us.
While we encourage you to file an appeal within 60 days of the unfavorable benefit determination, the
written or oral appeal must be received by us within 180 days of the unfavorable benefit determination.
We will assign an employee to help you in the appeal process. An appeal can be filed verbally by calling
customer service.
An appeaI can be fiIed by writing to this address for services that are not a dentaI or vision
service:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway
Denver, CO 80273
For dentaI benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
You don't have to file a complaint before you file an appeal. n your appeal, please state as plainly as
possible why you think we shouldn't have denied your claim for benefits. nclude any documents you
didn't submit with the original claim or service/supply request. Also send any other documents that
support your appeal. You don't have to file the appeal yourself. Someone else, like your Doctor or
another representative, can file an appeal for you. Just let us know in writing who will be filing the appeal
for you.
The appeals process allows you to request an internal appeal, and in certain cases, an independent
external appeal.
InternaI AppeaIs
We have an internal process that We follow when reviewing your appeal. Members of our staff, who were
not involved when your claim was first denied, will review the appeal. They may also talk with co-workers
to assist in the review.
f your first internal appeal is denied, you can ask for a second level appeal. But you don't have to file a
second level appeal with Us before requesting an independent external review appeal or pursuing legal
action.
Expedited internaI appeaI - f you have an urgent case, you may request that your internal appeal be
reviewed in a shorter time period. This is called an expedited internal appeal. You or your representative

126
can ask for an expedited appeal if you had Emergency services but haven't been discharged from the
Facility. Also, you can ask for an expedited appeal if the regular appeal schedule would:
Seriously jeopardize your life or health;
Jeopardize your ability to regain maximum function;
Create an immediate and substantial limitation on your ability to live independently, if you're disabled;
or
n the opinion of a Doctor with knowledge of your condition, would subject you to severe pain that can't
be adequately managed without the service in question.
Independent ExternaI AppeaIs
For claims based on Utilization Review, or a rescission or retroactive cancellation of coverage for reasons
other than nonpayment of premium, you can request an independent external appeal. Utilization Review
includes claims we denied as Experimental or nvestigational or not Medically Necessary. t also includes
claims where we reviewed your medical circumstances to decide if an exclusion applied. For these
appeals, your case is reviewed by an external review entity, selected by the Colorado Division of
nsurance.
Your request for independent external review must be made within 4 months of our appeal decision.
Generally, you have to have completed at least the first level internal appeal. But if we fail to handle the
appeal according to applicable Colorado insurance law and regulations, you will be eligible to request
independent external review.
Expedited externaI appeaI You or your representative can request an expedited independent external
review, but only in certain cases:
You had Emergency services but haven't been discharged from the Facility.
A Doctor certifies to us that you have a medical condition where following the normal external review
appeal process would seriously jeopardize your life or health, would jeopardize your ability to regain
maximum function or, if you're disabled, would create an imminent and substantial limitation of your
ability to live independently; or
We denied coverage for a requested medical service as being Experimental or nvestigational, your
treating physician certifies in writing that the requested service would be significantly less effective if
not promptly initiated and certifies that either:
! Standard health care services or treatments have not been effective in improving your condition
or are not medically appropriate for you; or
! The Doctor is a licensed, board-certified or board-eligible physician qualified to practice in the
area of medicine appropriate to treat your condition, there is no available standard health care
service or treatment covered by this Booklet that is more beneficial than the requested service,
and scientifically valid studies using accepted protocols demonstrate that the requested service is
likely to be more beneficial to you than any available standard services.
f it meets these conditions, your request for expedited external appeal can be filed at the same time as
your request for an expedited internal appeal.
For more information on where and how to request an internal or external appeal, please consult the
Appeals Guide available at www.anthem.com, or call customer service.

127
Grievances
f you have an issue or concern about the quality or services you receive from an n-Network Provider or
Facility, you can file a grievance. The quality management department strives to resolve grievances fairly
and quickly.
You may caII customer service or send a written grievance for services that are not a, dentaI or
vision service to:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway

Denver, CO 80273-0001
For dentaI benefit issues send to:

Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122

For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
Our quality management department will acknowledge that we've received your grievance. They'll also
investigate it. We treat every grievance confidentially.
Division of Insurance Inquiries
For inquiries about health care coverage in Colorado, you may call the Division of nsurance between
8:00 a.m. and 5:00 p.m., Monday through Friday, at (303) 894-7490, or write to the Division of nsurance
to the attention of the CARE Section, 1560 Broadway, Suite 850, Denver, Colorado 80202.
Binding Arbitration
The binding arbitration provision under this Booklet is applicable to claims arising under all individual
plans, governmental plans, church plans, plans or claims to which ERSA preemption does not apply, and
plans maintained outside the United States. Any such arbitration will be governed by the procedures and
rules established by the American Arbitration Association. You may obtain a copy of the Rules of
Arbitration by calling our customer services. The law of the state in which the policy was issued and
delivered to you shall govern the dispute. The arbitration decision is binding on both you and us.
Judgment on the award made in arbitration may be enforced in any court with proper jurisdiction. f any
person subject to this arbitration clause initiates legal action of any kind, the other party may apply for a
court of competent jurisdiction to enjoin, stay or dismiss any such action and direct the parties to arbitrate
in accordance with this section.
LegaI Action
Before you take legal action on a claim decision, you must first follow the process found in this section.
You must meet all the requirements of this Booklet.

128
No action in law or in equity shall be brought to recover on this Booklet before the expiration of 60
calendar days after a claim has been filed according to the requirements of this Booklet. f you have
exhausted all mandatory levels of review in your appeal, you may be entitled to have the claim decision
reviewed de novo (as if for the first time) in any court with jurisdiction and to a trial by jury.
No such action shall be brought at all unless brought within three years after claim has been filed as
required by the Booklet.

129
Section 14. Information on PoIicy and Rate Changes
Insurance Premiums
How Premiums are EstabIished and Changed - Premiums are the monthly charges you and/or the
Group must pay us to get coverage. We figure out and set the required Premiums.
The Group is responsible for paying the employee's Premium to us according to the terms of the Group
Contract. Groups may have you contribute to the Premium cost through payroll deduction. Some Groups
may choose to have your Premium determined by the age of the Subscriber, with Premium set by age
brackets. We may change membership Premiums on the annual date on which the Group renews its
coverage, which we may assess when a Subscriber changes to a new five-year increment age bracket,
e.g., age 25 through age 29. f the age of the Subscriber is misstated at enrollment, all amounts payable
for the correct age will be adjusted and billed to the Group.
Grace Period - f a Group fails to submit Premium payments to us in a timely manner, the Group is
entitled to a grace period of 31 days for the payment of such Premium. During the grace period, our
contract with the Group shall continue in force unless the Group gives us written notice of termination of
the contract. f the Group has obtained replacement coverage during the grace period, the contract with
us will be terminated as of the last day for which we have received Premium, and any and aII cIaims paid
during the grace period wiII be retroactiveIy adjusted to deny. These claims that we retroactively
deny should be submitted to the replacement carrier. f the Group has not obtained replacement
coverage during the grace period, or fails to inform Us that the employer has not obtained replacement
coverage, we will process any and all claims with dates of service during the grace period in accordance
with the terms of this Booklet.

130
Section 15. Definitions
f a word or phrase in this Booklet has a special meaning, such as Medical Necessity or Experimental /
nvestigational, it will start with a capital letter, and be defined below. f you have questions on any of
these definitions, please call Customer Service at the number on the back of your dentification Card.
AccidentaI Injury
An unexpected njury for which you need Covered Services while enrolled in this Plan. t does not include
injuries that you get benefits for under any Workers' Compensation, Employer's liability or similar law.
AmbuIatory SurgicaI FaciIity
A freestanding Facility, with a staff of Doctors, that:
1. s licensed as required;
2. Has permanent facilities and equipment to perform surgical procedures on an Outpatient basis;
3. Gives treatment by or under the supervision of Doctors, and nursing services when the patient is in
the Facility;
4. Does not have npatient accommodations; and
5. s not, other than incidentally, used as an office or clinic for the private practice of a Doctor or other
professional Provider.
AppIied BehavioraI AnaIysis
The use of behavior analytic methods and research findings to change socially important behaviors in
meaningful ways.
Authorized Service(s)
A Covered Service you get from an Out-of-Network Provider that we have agreed to cover at the n-
Network level. You will not have to pay any more than the n-Network Deductible, Coinsurance, and/or
Copayment(s) that apply. Please see "Claims Procedure (How to File a Claim) for more details.
Autism Services Provider
A person who provides services to a Member with Autism Spectrum Disorders. The Provider must be
licensed, certified, or registered by the applicable state licensing board or by a nationally recognized
organization, and who meets the requirements as defined by state law:
Autism Spectrum Disorders or ASD
ncludes the following neurobiological disorders: autistic disorder, Asperger's disorder, and atypical
autism as a diagnosis within pervasive developmental disorder not otherwise specified, as defined in the
most recent edition of the diagnostic and statistical manual of mental disorders, at the time of the
diagnosis.
Autism Treatment PIan
A plan for a Member by an Autism Services Provider and prescribed by a Doctor or psychologist in line
with evaluating or again reviewing a Member's diagnosis; proposed treatment by type, frequency, and
expected treatment; the expected outcomes stated as goals; and the rate by which the treatment plan will
be updated. The treatment plan is in line with the patient-centered medical home as defined in state law.

131
Benefit Period
The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit
Period starts on January 1
st
and ends on December 31
st
. For Plan Year plans, the Benefit Period starts
on your Group's effective or renewal date and lasts for 12 months. (See your Group for details.) The
"Schedule of Benefits (Who Pays What) shows if your Plan's Benefit Period is a Calendar Year or a Plan
Year. f your coverage ends before the end of the year, then your Benefit Period also ends.
Benefit Period Maximum
The most we will cover for a Covered Service during a Benefit Period.
BookIet
This document (also called the certificate), which describes the terms of your benefits. t is part of the
Group Contract with your Employer, and is also subject to the terms of the Group Contract.
Brand Name Drug
Prescription Drugs that the PBM has classified as Brand Name Drugs through use of an independent
proprietary industry database.
Centers of ExceIIence (COE) Network
A network of health care facilities, which have been selected to give specific services to our Members
based on their experience, outcomes, efficiency, and effectiveness. An n-Network Provider under this
Plan is not necessarily a COE. To be a COE, the Provider must have signed a Center of Excellence
Agreement with us.
CIosed PaneI PIan
A health maintenance organization (HMO), preferred provider organization (PPO) or other plan that
provides health benefits to covered persons primarily in the form of services through a panel of providers
that have contracted with either directly, indirectly, or are employed by the plan, and that limits or
excludes benefits for services provided by other providers, except in cases of emergency or referral by a
panel provider.
Coinsurance
Your share of the cost for Covered Services, which is a percent of the Maximum Allowed Amount. You
normally pay Coinsurance after you meet your Deductible. For example, if your Plan lists 20%
Coinsurance on office visits, and the Maximum Allowed Amount is $100, your Coinsurance would be $20
after you meet the Deductible. The Plan would then cover the rest of the Maximum Allowed Amount.
See the "Schedule of Benefits (Who Pays What) for details. Your Coinsurance will not be reduced by
any refunds, rebates, or any other form of negotiated post-payment adjustments.
CompIications of Pregnancy
Complications of Pregnancy means:

Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but
are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis,
cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable
severity. This does not include false labor, occasional spotting, physician-prescribed rest during the
period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar

132
conditions associated with the management of a difficult pregnancy not constituting a nosologically
distinct complication of pregnancy;

Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination
of pregnancy, which occurs during a period of gestation in which a viable birth is not possible.

CongenitaI Defect
A defect or anomaly existing before birth, such as cleft lip or club foot. Disorders of growth and
development over time are not considered congenital.
Copayment
A fixed amount you pay toward a Covered Service. You normally have to pay the Copayment when you
get health care. The amount can vary by the type of Covered Service you get. For example, you may
have to pay a $15 Copayment for an office visit, but a $150 Copayment for Emergency Room Services.
See the "Schedule of Benefits (Who Pays What) for details. Your Copayment will be the lesser of the
amount shown in the "Schedule of Benefits (Who Pays What)" or the amount the Provider charges.
Covered Services
Health care services, supplies, or treatment described in this Booklet that are given to you by a Provider.
To be a Covered Service the service, supply or treatment must be:
Medically Necessary or specifically included as a benefit under this Booklet.
Within the scope of the Provider's license.
Given while you are covered under the Plan.
Not Experimental / nvestigational, excluded, or limited by this Booklet, or by any amendment or rider
to this Booklet.
Approved by us before you get the service if prior authorization is needed.
A charge for a Covered Service will apply on the date the service, supply, or treatment was given to you.
Covered Services do not include services or supplies not described in the Provider records.
Covered TranspIant Procedure
Please see the "Benefits/Coverage (What is Covered) section for details.
CustodiaI Care
Any type of care, including room and board, that (a) does not require the skills of professional or technical
workers; (b) is not given to you or supervised by such workers or does not meet the rules for post-
Hospital Skilled Nursing Facility care; (c) is given when you have already reached the greatest level of
physical or mental health and are not likely to improve further.
Custodial Care includes any type of care meant to help you with activities of daily living that does not
require the skill of trained medical or paramedical workers. Examples of Custodial Care include:
Help in walking, getting in and out of bed, bathing, dressing, eating, or using the toilet,
Changing dressings of non-infected wounds, after surgery or chronic conditions,
Preparing meals and/or special diets,
Feeding by utensil, tube, or gastrostomy,

133
Common skin and nail care,
Supervising medicine that you can take yourself,
Catheter care, general colostomy or ileostomy care,
Routine services which we decide can be safely done by you or a non-medical person without the
help of trained medical and paramedical workers,
Residential care and adult day care,
Protective and supportive care, including education,
Rest and convalescent care.
Care can be Custodial even if it is recommended by a professional or performed in a Facility, such as a
Hospital or Skilled Nursing Facility, or at home.
DeductibIe
The amount you must pay for Covered Services before benefits begin under this Plan. For example, if
your Deductible is $1,000, your Plan won't cover anything until you meet the $1,000 Deductible. The
Deductible may not apply to all Covered Services. Please see the "Schedule of Benefits (Who Pays
What) for details.
Dependent
A member of the Subscriber's family who meets the rules listed in the "Eligibility section and who has
enrolled in the Plan.
{Tiered network:
[Designated Participating Provider
A Physician, advanced nurse practitioner, nurse practitioner, clinical nurse specialist, physician assistant,
or any other Provider licensed by law and allowed under the Plan, who gives, directs, or helps you get a
range of health care services.]
Doctor
See the definition of "Physician.
EarIy Intervention Services
Services, as defined by Colorado law in accordance with part C, that are authorized through an Eligible
Child's FSP but that exclude: nonemergency medical transportation; respite care; service coordination,
as defined in federal law; and assistive technology (unless covered under this Booklet as durable medical
equipment).
Eligible Child - means an infant or toddler, from birth through two years of age, who is an eligible
Dependent and who, as defined by Colorado law, has significant delays in development or has a
diagnosed physical or mental condition that has a high probability of resulting in significant delays in
development or who is eligible for services pursuant to Colorado law.
ndividualized family service plan or FSP - means a written plan developed pursuant to federal law
that authorizes early intervention services to an Eligible Child and the child's family. An FSP shall
serve as the individualized plan for an Eligible Child from birth through two years of age.
Effective Date
The date your coverage begins under this Plan.

134
Emergency (Emergency MedicaI Condition)
Please see the "Benefits/Coverage (What is Covered)" section.
Emergency Care
Please see the "Benefits/Coverage (What is Covered)" section.
EnroIIment Date
The first day you are covered under the Plan or, if the Group imposes a waiting period, the first day of
your waiting period.
ExcIuded Services (ExcIusion)
Health care services your Plan doesn't cover.
ExperimentaI or InvestigationaI (ExperimentaI / InvestigationaI)
(a) Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other
health condition which we determine in our sole discretion to be Experimental or nvestigational.
We will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or
supply to be Experimental or nvestigational if we determine that one or more of the following criteria
apply when the service is rendered with respect to the use for which benefits are sought.
The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA) or any other state or federal regulatory agency, and such final approval has not
been granted;
Has been determined by the FDA to be contraindicated for the specific use;
s provided as part of a clinical research protocol or clinical trial (except as noted in the Clinical Trials
section under Covered Services in this Booklet as required by state law), or is provided in any other
manner that is intended to evaluate the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply; or is subject to review and
approval of an nstitutional Review Board (RB) or other body serving a similar function; or
s provided pursuant to informed consent documents that describe the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply as Experimental or
nvestigational, or otherwise indicate that the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation.
(b) Any service not deemed Experimental or nvestigational based on the criteria in subsection (a) may
still be deemed to be Experimental or nvestigational by us. n determining whether a service is
Experimental or nvestigational, we will consider the information described in subsection (c) and assess
all of the following:
Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes;
Whether the evidence demonstrates that the service improves the net health outcomes of the total
population for whom the service might be proposed as any established alternatives; or

135
Whether the evidence demonstrates the service has been shown to improve the net health outcomes
of the total population for whom the service might be proposed under the usual conditions of medical
practice outside clinical investigatory settings.
(c) The information we consider or evaluate to determine whether a drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply is Experimental or nvestigational under
subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:
Randomized, controlled, clinical trials published in authoritative, peer-reviewed United States medical
or scientific journal;
Evaluations of national medical associations, consensus panels and other technology evaluation
bodies;
Documents issued by and/or filed with the FDA or other federal, state or local agency with the
authority to approve, regulate or investigate the use of the drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply;
Documents of an RB or other similar body performing substantially the same function;
Consent documentation(s) used by the treating Physicians, other medical professionals or facilities,
or by other treating Physicians, other medical professionals or facilities studying substantially the
same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
The written protocol(s) used by the treating Physicians, other medical professionals or facilities or by
other treating Physicians, other medical professionals or facilities studying substantially the same
drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
Medical records; or
The opinions of consulting Providers and other experts in the field.
(d) We have the sole authority and discretion to identify and weigh all information and determine all
questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is Experimental or nvestigational.
FaciIity
A facility including but not limited to, a Hospital, Ambulatory Surgical Facility, Chemical Dependency
Treatment Facility, Skilled Nursing Facility, Home Health Care Agency or mental health facility, as defined
in this Booklet. The Facility must be licensed, registered or approved by the Joint Commission on
Accreditation of Hospitals or meet specific rules set by us.
Generic Drugs
Prescription Drugs that the PBM has classified as Generic Drugs through use of an independent
proprietary industry database. Generic Drugs have the same active ingredients, must meet the same
FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as
the Brand Name Drug.
Group
The employer or other organization (e.g., association), which has a Group Contract with us, Anthem for
this Plan.

136
Group Contract (or Contract)
The Contract between us, Anthem, and the Group (also known as the Group Master Contract). t
includes this Booklet, your application, any application or change form, your dentification Card, any
endorsements, riders or amendments, and any legal terms added by us to the original Contract.
The Group Master Contract is kept on file by the Group. f a conflict occurs between the Group Master
Contract and this Booklet, the Group Master Contract controls.
HabiIitative Services
Habilitative Services help you keep, learn or improve skills and functioning for daily living. Examples
include therapy for a child who isn't walking or talking at the expected age.
Home HeaIth Care Agency
A Facility, licensed in the state in which it is located, that:
1. Gives skilled nursing and other services on a visiting basis in your home; and
2. Supervises the delivery of services under a plan prescribed and approved in writing by the attending
Doctor.
Hospice
A Provider that gives care to terminally ill patients and their families, either directly or on a consulting
basis with the patient's Doctor. t must be licensed by the appropriate agency.
HospitaI
A Provider licensed and operated as required by law, which has:
1. Room, board, and nursing care;
2. A staff with one or more Doctors on hand at all times;
3. 24 hour nursing service;
4. All the facilities on site are needed to diagnose, care, and treat an illness or injury; and
5. s fully accredited by the Joint Commission on Accreditation of Health Care Organizations.
The term Hospital does not include a Provider, or that part of a Provider, used mainly for:
1. Nursing care
2. Rest care
3. Convalescent care
4. Care of the aged
5. Custodial Care
6. Educational care
7. Subacute care
8. Treatment of alcohol abuse
9. Treatment of drug abuse
Identification Card
The card we give you that shows your Member identification, Group numbers, and the plan you have.

137
In-Network Provider
A Provider that has a contract, either directly or indirectly, with us, or another organization, to give
Covered Services to Members through negotiated payment arrangements.
In-Network TranspIant Provider
Please see the "Benefits/Coverage (What is Covered) section for details.
Inpatient
A Member who is treated as a registered bed patient in a Hospital and for whom a room and board
charge is made.
Late EnroIIees
Subscribers or Dependents who enroll in the Plan after the initial enrollment period. A person will not be
considered a Late Enrollee if he or she enrolls during a Special Enrollment period. Please see the
"Eligibility section for further details.

Maintenance Medications
Please see the "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section for
details.
ManipuIation Therapy
A system of therapy that includes the therapeutic application of manual manipulation treatment, analysis
and adjustments of the spine and other body structures, and muscle stimulation by any means, including
therapeutic use of heat, cold, and exercise.

Maximum AIIowed Amount
The maximum payment that we will allow for Covered Services. For more information, see the "Member
Payment Responsibility section.
MedicaI Necessity (MedicaIIy Necessary)
The diagnosis, evaluation and treatment of a condition, illness, disease or injury that we solely decide to be:
Medically appropriate for and consistent with your symptoms and proper diagnosis or treatment of
your condition, illness, disease or injury;
Obtained from a Doctor or Provider;
Provided in line with medical or professional standards;
Known to be effective, as proven by scientific evidence, in improving health;
The most appropriate supply, setting or level of service that can safely be provided to you and which
cannot be omitted. t will need to be consistent with recognized professional standards of care. n
the case of a Hospital stay, also means that safe and adequate care could not be obtained as an
outpatient;
Cost-effective compared to alternative interventions, including no intervention. Cost effective does not
always mean lowest cost" t does mean that as to the diagnosis or treatment of your illness, injury or

138
disease, the service is: (1) not more costly than an alternative service or sequence of services that is
medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate;
Not Experimental or nvestigational;
Not primarily for you, your families, or your Provider's convenience; and
Not otherwise an exclusion under this Booklet.
The fact that a Doctor or Provider may prescribe, order, recommend or approve care, treatment, services or
supplies does not, of itself, make such care, treatment, services or supplies Medically Necessary.
Member
People, including the Subscriber and his or her Dependents, who have met the eligibility rules, applied for
coverage, and enrolled in the Plan. Members are called "you and "your in this Booklet.
MentaI HeaIth, BioIogicaIIy Based MentaI IIIness and Substance Abuse
A condition that is listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) as a mental health or substance abuse condition. Coverage is also provided for Biologically Based
Mental llness for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive
disorder, specific obsessive-compulsive disorder, and panic disorder. t does not include Autism
Spectrum Disorder, which under state law is considered a medical condition.
Open EnroIIment
A period of time in which eligible people or their dependents can enroll without penalty after the initial
enrollment. See the "Eligibility section for more details.
Out-of-Network Provider
A Provider that does not have an agreement or contract with us, or our subcontractor(s) to give services
to our Members.
You will often get a lower level of benefits when you use Out-of-Network Providers.
Out-of-Network TranspIant Provider
Please see the "Benefits/Coverage (What is Covered) section for details.
Out-of-Pocket Limit
The most you pay in Copayments, Deductibles, and Coinsurance during a Benefit Period for Covered
Services. The Out-of-Pocket limit does !"# include your Premium, amounts over the Maximum Allowed
Amount, or charges for health care that your Plan doesn't cover. Please see the "Schedule of Benefits
(Who Pays What) for details.
Pharmacy
A place licensed by state law where you can get Prescription Drugs and other medicines from a licensed
pharmacist when you have a prescription from your Doctor.

139
Pharmacy and Therapeutics (P&T) Process
A process to make clinically based recommendations that will help you access quality, low cost medicines
within your Plan. The process includes health care professionals such as nurses, pharmacists, and
Doctors. The committees of the WellPoint National Pharmacy and Therapeutics Process meet regularly
to talk about and find the clinical and financial value of medicines for our Members. This process first
evaluates the clinical evidence of each product under review. The clinical review is then combined with
an in-depth review of the market dynamics, Member impact and financial value to make choices for the
formulary. Our programs may include, but are not limited to, Drug utilization programs, prior authorization
criteria, therapeutic conversion programs, cross-branded initiatives, and Drug profiling initiatives.
Physician (Doctor)
ncludes the following when licensed by law:
Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery,
Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O.,
Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor;
Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and
Doctor of Dental Medicine (D.D.M.), Doctor of Dental Surgery (D.D.S.), legally entitled to provide
dental services.
Optometrists, Clinical Psychologists (PhD), and surgical chiropodists are also Providers when legally
licensed and giving Covered Services within the scope of their licenses.
PIan
The benefit plan your Group has purchased, which is described in this Booklet.
Precertification
Please see the section "How to Access Your Services and Obtain Approval of Benefits for details.
Predetermination
Please see the section "How to Access Your Services and Obtain Approval of Benefits for details.
Premium
The amount that you and/or the Group must pay to be covered by this Plan. This may be based on your
age and will depend on the Group's Contract with us.
Prescription Drug (Drug)
A medicine that is made to treat illness or injury. Under the Federal Food, Drug & Cosmetic Act, such
substances must bear a message on its original packing label that says, "Caution: Federal law prohibits
dispensing without a prescription. This includes the following:
1. Compounded (combination) medications, when the primary ingredient (the highest cost ingredient) is
FDA-approved and requires a prescription to dispense, and is not essentially the same as an FDA-
approved product from a drug manufacturer.
2. nsulin, diabetic supplies, and syringes.

140
Primary Care Physician / Provider ("PCP")
A Provider who gives or directs health care services for you. The Provider may work in family practice,
general practice, internal medicine, pediatrics or any other practice allowed by the Plan. A PCP
supervises, directs and gives initial care and basic medical services to you and is in charge of your
ongoing care.
Provider
A professional or Facility licensed by law that gives health care services within the scope of that license
and is approved by us. This includes any Provider that state law says we must cover when they give you
services that state law says we must cover. Providers that deliver Covered Services are described
throughout this Booklet. f you have a question about a Provider not described in this Booklet please call
the number on the back of your dentification Card.
QuaIified EarIy Intervention Service Provider
Means a person or agency, as defined by Colorado law in accordance with part C, who provides Early
ntervention Services and is listed on the registry of early intervention service providers.
Recovery
Recovery is money the Member, the Member's legal representative, or beneficiary receives whether by
settlement, verdict, judgment, order or by some other monetary award or determination, from another,
their insurer, or from any uninsured motorist, underinsured motorist, medical payments, personal injury
protection, or any other insurance coverage, to compensate the Member as a result of bodily injury or
illness to the Member. Regardless of how the Member, the Member's legal representative, or beneficiary
or any agreement may characterize the money received, it shall be subject to the Subrogation and
Reimbursement under the "General Policy Provisions section of this Booklet.
ReferraI
Please see the "How to Access Services and Obtain Approval of Benefits section for details.
RetaiI HeaIth CIinic
A Facility that gives limited basic health care services to Members on a "walk-in basis. These clinics are
often found in major pharmacies or retail stores. Medical services are typically given by Physician
Assistants and Nurse Practitioners.
Service Area
The geographical area where you can get Covered Services from an n-Network Provider.
SkiIIed Nursing FaciIity
A Facility operated alone or with a Hospital that cares for you after a Hospital stay when you have a
condition that needs more care than you can get at home. t must be licensed by the appropriate agency
and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or otherwise approved by us. A Skilled Nursing
Facility gives the following:
1. npatient care and treatment for people who are recovering from an illness or injury;
2. Care supervised by a Doctor;

141
3. 24 hour per day nursing care supervised by a full-time registered nurse.
A Skilled Nursing Facility is not a place mainly for care of the aged, Custodial Care or domiciliary care,
treatment of alcohol or drug dependency; or a place for rest, educational, or similar services.
SpeciaI EnroIIment
A period of time in which eligible people or their dependents can enroll after the initial enrollment, typically
due to an event such as marriage, birth, adoption, etc. See the "Eligibility section for more details.
SpeciaIist (SpeciaIty Care Physician \ Provider or SCP)
A Specialist is a Doctor who focuses on a specific area of medicine or group of patients to diagnose,
manage, prevent, or treat certain types of symptoms and conditions. A non-Physician Specialist is a
Provider who has added training in a specific area of health care.
SpeciaIty Drugs
Drugs that typically need close supervision and checking of their effect on the patient by a medical
professional. These drugs often need special handling, such as temperature-controlled packaging and
overnight delivery, and are often not available at retail pharmacies. They may be administered in many
forms including, but not limited to, injectable, infused, oral and inhaled.
Subscriber
An employee or member of the Group who is eligible for and has enrolled in the Plan.
TranspIant Benefit Period
Please see the "Benefits/Coverage (What is Covered) section for details.
Urgent Care Center
A licensed health care Facility that is separate from a Hospital and whose main purpose is giving
immediate, short-term medical care, without an appointment, for urgent care.
UtiIization Review
A set of formal techniques to monitor or evaluate the clinical necessity, appropriateness, efficacy or
efficiency of, health care services, procedures or settings. Techniques include ambulatory review,
prospective review, second opinion, certification, concurrent review, Care Management, discharge
planning and/or retrospective review. Utilization Review also includes reviewing whether or not a
procedure or treatment is considered Experimental or nvestigational, and reviewing your medical
circumstances when such a review is needed to determine if an exclusion applies.



End of BookIet
[Repository D/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HOS D]_20150101]


Certificate
(Referred to as "Booklet in the following pages)

Anthem
[Anthem SiIver BIue Priority PPO 2500/20%/6000 PIus]
[Anthem GoId PPO 1000/20%/3500]
[Anthem GoId PPO 2000/40%/4000]
[Anthem SiIver PPO 2000/50%/6350]
[Anthem GoId PPO 750/20%/4500]
[Anthem GoId PPO 1500/20%/4000]
[Anthem GoId PPO 500/20%/4500]
[Anthem SiIver PPO 2000/30%/4500 PIus w/DentaI]
[Anthem SiIver PPO 2000/30%/4500 PIus]
[Anthem SiIver PPO 3000/30%/4000 PIus]
[Anthem Bronze PPO 5850/30%/6600 PIus]
[Anthem GoId PPO 500/20%/3000 PIus w/DentaI]
[Anthem GoId PPO 500/20%/3000 PIus]
[Anthem SiIver PPO 1500/30%/4250 PIus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem SiIver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 PIus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 PIus w/HSA]
[Anthem SiIver PPO 2500/20%/4500 w/HSA]
[Anthem GoId PPO 2000/20%/5000 PIus w/HRA]
[Anthem GoId PPO 4000/20%/5000 PIus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 PIus]

January 1, 2015

[Repository D/Contract Code]
COSGPPO (1/15) [EOC_ENG_Anthem [HOS D]_20150101]






Si necesita ayuda en espaoI para entender este documento, puede soIicitarIa sin costo adicionaI,
IIamando aI nmero de servicio aI cIiente.

f you need Spanish-language assistance to understand this document, you may request it at no
additional cost by calling Customer Service at the number on the back of your dentification Card.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, nc. HMO products are
underwritten by HMO Colorado, nc. Life and disability products underwritten by Anthem Life nsurance Company. ndependent
licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem nsurance Companies,
nc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association
1
Section 1. ScheduIe of Benefits (Who Pays What)

n this section you will find an outline of the benefits included in your Plan and a summary of any Deductibles,
Coinsurance, and Copayments that you must pay. Also listed are any Benefit Period Maximums or limits that apply.
Please read the "Benefits/Coverage (What is Covered)"section for more details on the Plan's Covered Services. Read
the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for details on Excluded Services.

All Covered Services are subject to the conditions, Exclusions, limitations, and terms of this Booklet including any
endorsements, amendments, or riders.

To get the highest benefits at the Iowest out-of-pocket cost, you must get Covered Services from an In-Network
Provider. Benefits for Covered Services are based on the Maximum Allowed Amount, which is the most the Plan will
allow for a Covered Service. When you use an Out-of-Network Provider you may have to pay the difference between the
Out-of-Network Provider's billed charge and the Maximum Allowed Amount in addition to any Coinsurance, Copayments,
Deductibles, and non-covered charges. This amount can be substantial. Please read the "Claims Procedure (How to File
a Claim) section for more details.

Deductibles, Coinsurance, and Benefit Period Maximums are calculated based upon the Maximum Allowed Amount, not
the Provider's billed charges.

EssentiaI HeaIth Benefits provided within this BookIet are not subject to Iifetime or annuaI doIIar maximums.
Certain non-essentiaI heaIth benefits, however, are subject to either a Iifetime and/or doIIar maximum.

EssentiaI HeaIth Benefits are defined by federaI Iaw and refer to benefits in at Ieast the foIIowing categories:

AmbuIatory patient services,
Emergency services,
HospitaIization,
Maternity and newborn care,
MentaI heaIth and substance use disorder services, incIuding behavioraI heaIth treatment,
Prescription drugs,
RehabiIitative and HabiIitative Services and devices,
Laboratory services,
Preventive and weIIness services, and
Chronic disease management and pediatric services, incIuding oraI and vision care.

Such benefits shaII be consistent with those set forth under the Patient Protection and AffordabIe Care Act of
2010 and any reguIations issued pursuant thereto.

Benefit Period [Calendar][Plan] Year

Dependent Age Limit To the end of the month in which the child attains age 26.

Please see the "Eligibility section for further details.

DeductibIe In-Network Out-of-Network
Per Member [$500 to 5,900] [$1,250 to 14,750]
Per Family
{Aggregate: [(All other Members combined)]
[$1,500 to 11,800] [$2,500 to 29,500]
The n-Network and Out-of-Network Deductibles are separate and cannot be combined.

{Option for Non-Embedded pIans of HSA/HRA: [f you, the Subscriber, are the only person covered by this Plan,
only the "per Member amounts applies to you. f you also cover Dependents (other family members) under this Plan,
only the "per Family amount applies.)]


2
DeductibIe In-Network Out-of-Network
When the Deductible applies, you must pay it before benefits begin. See the sections below to find out when the
Deductible applies.

{DeductibIe First for HRA pIans: [Note: To meet the n-Network Deductible, your Plan will work as follows:

Step 1 - Upfront In-Network DeductibIe Members must pay a certain part of the n-Network Deductible
listed above, $[1,000 to 2,000] per Member / $[2,000 to 4,000] per Family, before using their HRA account.
HRA funds cannot be used for this part of the Deductible (known as the "upfront Deductible). Amounts paid
toward the upfront Deductible will apply toward the annual n-Network Deductible.

Step 2 - HeaIth Reimbursement Account After meeting the upfront Deductible, Members can use money in
their HRA to help meet the rest of the annual n-Network Deductible.

Step 3 - TraditionaI HeaIth Coverage - Once the Annual n-Network Deductible has been met, coverage
under this Plan begins.]

Copayments and Coinsurance are separate from and do not apply to the Deductible.

{DeductibIe First for HRA pIans: [HRA funds cannot be used for services listed under "Dental Services for Members
age 19 and Older or for services listed under "Vision Services for Members age 19 and Older.]


Coinsurance In-Network Out-of-Network
Plan Pays [50 to 100%] [50 to 90]%
Member Pays [0 to 50%] [10 to 50]%
Reminder: Your Coinsurance will be based on the Maximum Allowed Amount. f you use an Out-of-Network Provider,
you may have to pay Coinsurance plus the difference between the Out-of-Network Provider's billed charge and the
Maximum Allowed Amount.

Note: The Coinsurance listed above may not apply to all benefits, and some benefits may have a different Coinsurance.
Please see the rest of this Schedule for details.


Out-of-Pocket Limit In-Network Out-of-Network
Per Member $[3,000 to 6,600]

$[6,000 to 19,800]
Per Family
{Aggregate: [(All other Members combined)]
$[6,000 to 13,200] $[18,000 to 39,600]
{Option for Non-Embedded pIans of HSA/HRA: [f you, the Subscriber, are the only person covered by this Plan,
only the "per Member amount applies to you. f you also cover Dependents (other family members) under this Plan,
only the "per Family amount applies.)]

The Out-of-Pocket Limit includes all Deductibles, [[and] Coinsurance], [and Copayments] you pay during a Benefit
Period unless otherwise indicated below. t does not include charges over the Maximum Allowed Amount or amounts
you pay for non-Covered Services.

The Out-of-Pocket Limit does not include amounts you pay for the following benefits:

{Option for embedded aduIt dentaI benefit: [Services listed under "Dental Services for Members Age 19 and
Older
{Option for embedded aduIt vision benefit: [Services listed under "Vision Services for Members Age 19 and
3
Out-of-Pocket Limit In-Network Out-of-Network
Older]
Out-of-Network Human Organ and Tissue Transplant services.

Once the Out-of- Pocket Limit is satisfied, you will not have to pay additional Deductibles, [[or] Coinsurance], or
Copayments] for the rest of the Benefit Period, except for the services listed above.

The n-Network and Out-of-Network Out-of-Pocket Limits are separate and do not apply toward each other.

Important Notice about Your Cost Shares

n certain cases, if we pay a Provider amounts that are your responsibility, such as Deductibles, Copayments or
Coinsurance, we may collect such amounts directly from you. You agree that we have the right to collect such amounts
from you.

The tables below outline the Plan's Covered Services and the cost share(s) you must pay. n many spots you will see the
statement, "Benefits are based on the setting in which Covered Services are received. n these cases you should
determine where you will receive the service (i.e., in a doctor's office, at an outpatient hospital facility, etc.) and look up
that location to find out which cost share will apply. For example, you might get physical therapy in a doctor's office, an
outpatient hospital facility, or during an inpatient hospital stay. For services in the office, look up "Office Visits. For
services in the outpatient department of a hospital, look up "Outpatient Facility Services. For services during an inpatient
stay, look up "npatient Services.

Benefits In-Network Out-of-Network
Acupuncture See "Therapy Services.

AIIergy Services Benefits are based on the setting in which
Covered Services are received.

AmbuIance Services (Air and Water) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an n-Network Provider.

Important Note: Air ambulance services for non-Emergency Hospital to Hospital transfers must be approved through
precertification. Please see "How to Access Your Services and Obtain Approval of Benefits for details.


AmbuIance Services (Ground) [0 to 50]% Coinsurance after Deductible
For Emergency ambulance services from an Out-of-Network Provider you do not need to pay any more than would
have paid for services from an n-Network Provider.

Important Note: All scheduled ground ambulance services for non-Emergency transfers, except transfers from one
acute Facility to another, must be approved through precertification. Please see "How to Access Your Services and
Obtain Approval of Benefits for details.

Autism Services


Applied Behavioral Analysis Services Benefit Maximum
Benefits are based on the setting in which
Covered Services are received.

The following annual Benefit Period maximums
are effective for Applied Behavior Analysis
services for n- and Out-of-Network services
4
Benefits In-Network Out-of-Network
combined:
From birth to age eight (up to Member's ninth
birthday): 550 sessions of 25 minutes for
each session, however we may exceed this
limit if required by state law
Age nine to age eighteen (up to Member's
nineteenth birthday): 185 sessions of 25
minutes for each session, however we may
exceed this limit if required by state law
The limits for physical, occupational, and speech therapy will not apply to children between age 3 and 6 with Autism
Spectrum Disorders, if part of a Member's Autism Treatment Plan, and determined Medically Necessary by Us.

When you get physical, occupational or speech therapy which also is considered by Us as Applied Behavioral Analysis
for the treatment of autism, the Applied Behavioral Analysis visit limit will apply instead of the Therapy Services limits
listed below.

BehavioraI HeaIth Services See "Mental Health, Alcohol and Substance
Abuse Services.

Cardiac RehabiIitation See "Therapy Services.

Chemotherapy See "Therapy Services.

Chiropractor Services See "Therapy Services.

CIinicaI TriaIs Benefits are based on the setting in which
Covered Services are received.

DentaI Services For Members Through Age 18

Note: To get the n-Network benefit, you must use a participating dental Provider. f you need help finding a
participating dental Provider, please call us at the number on the back of your D card.
{Embedded Pediatric/AduIt DentaI pIan: [Each Member must pay a Deductible of $50 per Benefit Period for the
dental services below. This Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan.]
Diagnostic and Preventive Services {Embedded Pediatric
DentaI: [Deductible
waived, subject to]
10% Coinsurance
30% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Basic Restorative Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Endodontic Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible}
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Periodontal Services Not Covered Not Covered
5
Benefits In-Network Out-of-Network
Oral Surgery Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Major Restorative Services 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]
Prosthodontic Services Not Covered Not Covered
Dentally Necessary Orthodontic Care 50% Coinsurance
{Embedded Pediatric
DentaI: [after
Deductible]
50% Coinsurance
{Embedded
Pediatric DentaI:
[after Deductible]

{Embedded AduIt DentaI:
[DentaI Services For Members Age 19 and OIder

Note: To get the n-Network benefit, you must use a participating dental Provider. f you need help finding a
participating dental Provider, please call us at the number on the back of your D card.
Each Member must pay a Deductible of $50 per Benefit Period for the dental services below. This Deductible is
separate and does not apply toward any other Deductible for Covered Services in this Plan.
Diagnostic and Preventive Services No Copayment,
Deductible, or
Coinsurance
50% Coinsurance
Basic Restorative Services 20% Coinsurance 60% Coinsurance
Endodontic Services 50% Coinsurance 75% Coinsurance
Periodontal Services 50% Coinsurance 75% Coinsurance
Oral Surgery Services 50% Coinsurance 75% Coinsurance
Major Restorative Services 50% Coinsurance 75% Coinsurance
Prosthodontic Services 50% Coinsurance 75% Coinsurance
Orthodontic Care Not covered Not covered
Dental Services for Members Age 19 and Older Benefit Maximum $1,000 per Benefit Period
n- and Out-of-Network combined]

DentaI Services (AII Members / AII Ages) Benefits are based on the setting in which
Covered Services are received.

Diabetes Equipment, Education, and SuppIies Benefits are based on the setting in which
Covered Services are received.
Screenings for gestational diabetes are covered
under "Preventive Care.

6
Benefits In-Network Out-of-Network
Diagnostic Services

Benefits are based on the setting in which
Covered Services are received.

DiaIysis See "Therapy Services.

DurabIe MedicaI Equipment (DME) and MedicaI Devices,
Orthotics, Prosthetics, MedicaI and SurgicaI SuppIies (Received
from a Supplier)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible

The cost-shares listed above only apply when you get the equipment or supplies from a third-party supplier. f you
receive the equipment or supplies as part of an office or outpatient visit, or during a Hospital stay, benefits will be based
on the setting in which the covered equipment or supplies are received.
Hearing Aid Benefit Maximum for Members under 18 years of age One hearing aid every 5 years
n- and Out-of-Network combined

Emergency Room Services
Emergency Room
Emergency Room Facility Charge

[$[200 to 250] Copayment] [per visit] [plus] [[0 to
50]% Coinsurance] [after Deductible]
[Copayment waived if admitted]
Emergency Room Doctor Charge [0 to 50]% Coinsurance after Deductible
Other Facility Charges (including diagnostic x-ray and lab
services, medical supplies)
[0 to 50]% Coinsurance after Deductible
Advanced Diagnostic maging (including MRs, CAT scans) [0 to 50]% Coinsurance after Deductible
For Emergency services from an Out-of-Network Provider you do not need to pay any more than you would have paid
for services from an n-Network Provider.

Home Care
Home Care Visits [$[20 to 60] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Home Dialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home nfusion Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Specialty Prescription Drugs [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Home Care Services / Supplies [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Home Care Benefit Maximum 28 hours of visits per week
7
Benefits In-Network Out-of-Network
n- and Out-of-Network combined
The limit does not apply to Home nfusion
Therapy or Home Dialysis.

Home Infusion Therapy See "Home Care.

Hospice Care
Home Care
Respite Hospital Stays

[No Copayment or
Coinsurance after
Deductible] [After
Deductible no
Coinsurance]
[10 to 50]%
Coinsurance after
Deductible

Human Organ and Tissue TranspIant (Bone Marrow / Stem CeII)
Services
Please see the separate summary later in this
section.

InfertiIity Services See "Maternity and Reproductive Health
Services.

Inpatient Services
Facility Room & Board Charge:
Hospital / Acute Care Facility

[$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility [$500 Copayment per
admission] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Skilled Nursing Facility / Habilitation Services / Rehabilitation
Services (ncludes Services in an Outpatient Day Rehabilitation
Program) Benefit Maximum
160 days per Benefit Period n- and Out-of-
Network combined
Other Facility Services / Supplies (including diagnostic lab/x-ray,
medical supplies, therapies, anesthesia)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Addition if Copayment cost share: [HospitaI Transfers: f you are transferred between Facilities, only one
Copayment will apply. You will not have to pay separate Copayments per Facility.

HospitaI Readmissions: f you are readmitted to the Hospital within 72 hours of your discharge for the same medical
diagnosis, you will not have to pay an additional Copayment upon readmission.]
Doctor Services for:
General Medical Care / Evaluation and Management (E&M) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Surgery [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
8
Benefits In-Network Out-of-Network

Maternity and Reproductive HeaIth Services
Maternity Visits (Global fee for the ObGyn's prenatal, postnatal,
and delivery services)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
npatient Services (Delivery) See "npatient Services.
Newborn / Maternity Stays: f the newborn needs services other than routine nursery care or stays in the Hospital
after the mother is discharged (sent home), benefits for the newborn will be treated as a separate admission.
nfertility

Benefits are based on the setting in which
Covered Services are received.
nfertility Benefit Maximum Unlimited

Massage Therapy See "Therapy Services.

MentaI HeaIth, AIcohoI and Substance Abuse Services
npatient Facility Services

[$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Residential Treatment Center Services [$500 Copayment per
admission] [plus] [[0 to
50% Coinsurance] after
Deductible]
[50-90]%
Coinsurance after
Deductible
npatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Outpatient Facility Services

[$250 Copayment per
visit] [plus][[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Outpatient Doctor Services [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Partial Hospitalization Program / ntensive Outpatient Services [$250 to 500
Copayment per visit]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Office Visits [$[15 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Mental Health, Alcohol and Substance Abuse Services will be covered as required by state and federal law. Please
see "Mental Health Parity and Addiction Equity Act in the "Additional Federal Notices section for details.

9
Benefits In-Network Out-of-Network
OccupationaI Therapy See "Therapy Services.

Office Visits


Primary Care Physician / Provider (PCP) [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]
Retail Health Clinic Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Online Care Visit [$[10 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Counseling ncudes
Family Planning and
Nutritional Counseling
(Other than Eating
Disorders)
[$[10 to 60] Copayment
per visit] [[for the first 3
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Nutritional Counseling for
Eating Disorders
[$[10 to 60] Copayment
per visit] [[for the first [3]
visits, then] [0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Allergy Testing [$[10 to 60] Copayment
per visit] [[0 to
50]%Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / njections (other than allergy serum) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
10
Benefits In-Network Out-of-Network
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray (non-preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests (non-preventive; including hearing and EKG) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic maging (including MRs, CAT scans) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75] Copayment
per visit] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy Services:
! Acupuncture, Chiropractic Care & Massage Therapy [$[20 to 30] Copayment
per visit] [for the first 3
visits, then [0 to 50]%
Coinsurance] [after
Deductible]
Not Covered
! Physical, Speech, & Occupational Therapy [$[20 to 60] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Dialysis / Hemodialysis

[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Radiation / Chemotherapy / Non-Preventive nfusion &
njection
[$[10 to 100] Copayment
per visit] [for the first [3]
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
! Cardiac Rehabilitation & Pulmonary Therapy [$[20 to 100] Copayment
per visit] [for the first 3
visits, then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
See "Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
11
Benefits In-Network Out-of-Network

{PIans with copay for first 3 visits: [Important Note on Office Visit Copayments: Several services listed above
have a Copayment for the first three visits. This Copayment applies to any combination of services for the first three
visits during the Benefit Period. Starting with the fourth visit, you pay Deductible and Coinsurance, instead of a
Copayment. The three Copayments will not apply to Preventive Care, Maternity Services, or Urgent Care visits. You
will not have to pay any Deductible or Coinsurance when you pay the Copayment.]

Orthotics See "Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

Outpatient FaciIity Services
Facility Surgery Charge

[$125 to 250 Copayment
per visit] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges (including diagnostic x-ray and
lab services, medical supplies)
[$125 to 250 Copayment
per visit] [plus] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Doctor Surgery Charges [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Doctor Charges (including Anesthesiologist, Pathologist,
Radiologist, Surgical Assistant)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Other Facility Charges (for procedure rooms or other ancillary
services)
[$250 Copayment per
visit] [plus] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Lab [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Diagnostic Tests: Hearing, EKG, etc. (Non-Preventive) [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
12
Benefits In-Network Out-of-Network
Advanced Diagnostic maging (including MRs, CAT scans) [$250 Copayment [per
service] [per visit] [plus]
[[0 to 50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Therapy:
! Chiropractic Care

[0 to 50]% Coinsurance
after Deductible
Not Covered
! Physical, Speech, & Occupational Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Radiation / Chemotherapy / Non-Preventive nfusion &
njection
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Dialysis / Hemodialysis [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
! Cardiac Rehabilitation & Pulmonary Therapy [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
See "Therapy Services for details on Benefit Maximums.
Prescription Drugs Administered in an Outpatient Facility [0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
{Site-of-Service:
[Outpatient Freestanding FaciIity
Facility Surgery Charge / Ambulatory Surgery Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Other Facility Surgery Charges/ Ambulatory Surgical Center
(including diagnostic x-ray and lab services, medical supplies)
[0 to 50]% Coinsurance [10 to 50]%
Coinsurance after
Deductible
Doctor Charges in Ambulatory Surgical Center / Freestanding
Radiology Center (including Anesthesiologist, Pathologist,
Radiologist, Surgery, Surgical Assistant)
No Copayment,
Deductible, or
Coinsurance

[10 to 50]%
Coinsurance after
Deductible
Diagnostic X-ray / Freestanding Radiology Center $[125 to 150]
Copayment per visit
[10 to 50]%
Coinsurance after
Deductible
Advanced Diagnostic maging (including MRs, CAT scans)/
Freestanding Radiology Center
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible]]

PhysicaI Therapy See "Therapy Services.

Preventive Care


No Copayment,
Deductible, or
Coinsurance
[10 to 50]%
Coinsurance after
Deductible
Preventive care from an Out-of-Network Provider is not subject to the Maximum Allowed Amount.
13
Benefits In-Network Out-of-Network

Prosthetics See "Durable Medical Equipment (DME) and
Medical Devices, Orthotics, Prosthetics, Medical
and Surgical Supplies.

PuImonary Therapy See "Therapy Services.

Radiation Therapy See "Therapy Services.

RehabiIitation Services Benefits are based on the setting in which
Covered Services are received.

Respiratory Therapy See "Therapy Services.

SkiIIed Nursing FaciIity See "npatient Services.

Speech Therapy See "Therapy Services.

Surgery Benefits are based on the setting in which
Covered Services are received.

TeIemedicine
Primary Care Physician / Provider (PCP) $[20 to 60] Copayment
per visit [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your PCP is a Designated Participating Provider you will pay a $[15 to 30] Copayment per visit.]
Specialty Care Physician / Provider (SCP) $[20 to 100] Copayment
per visit] [for the first 3
visits, then [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
{Tiered network:
[Note: f your Specialty Care Physician/Provider (SCP) is a Designated Participating Provider you will pay a $[30 to 60]
Copayment per visit.]

TemporomandibuIar and CraniomandibuIar Joint Treatment Benefits are based on the setting in which
Covered Services are received.

14
Benefits In-Network Out-of-Network
Therapy Services Benefits are based on the setting in which
Covered Services are received.
Benefit Maximum(s): Benefit Maximum(s) are for n- and Out-of-
Network visits combined, for rehabilitative and
habilitative services combined, and for office
and outpatient visits combined.
Physical & Occupational Therapy 40 visits each per Benefit Period
Speech Therapy 40 visits per Benefit Period.
For cleft palate or cleft lip conditions, Medically
necessary speech therapy is not limited, but
those visits lower the number of speech therapy
visits available to treat other problems.
Acupuncture, Chiropractic Care & Massage Therapy 20 visits per Benefit
Period
Limit does not apply to
osteopathic care
Not covered
Cardiac Rehabilitation Unlimited
Note: The limits for physical, occupational, and speech therapy will not apply if you get that care as part of the Hospice
benefit.

Transgender Services Benefits are based on the setting in which
Covered Services are received.

TranspIant Services See "Human Organ and Tissue Transplant
(Bone Marrow / Stem Cell) Services.

Urgent Care Services (Office Visits)
Urgent Care Office Visit Charge [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Testing [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Allergy Shots / njections (other than allergy serum) [$[35 to 75] Copayment
per visit] [then] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Preferred Diagnostic Labs (i.e., reference labs) [No Copayment,
Deductible, or
Coinsurance] [[0 to
50]% Coinsurance]
[after Deductible]
[10 to 50]%
Coinsurance after
Deductible
Other Charges (e.g., diagnostic x-ray and lab services, medical
supplies)
[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
15
Benefits In-Network Out-of-Network
Advanced Diagnostic maging (including MRs, CAT scans)

[0 to 50]% Coinsurance
after Deductible
[10 to 50]%
Coinsurance after
Deductible
Office Surgery [$[40 to 75]
Copayment per visit]
[then] [[0 to 50]%
Coinsurance] [after
Deductible]
[10 to 50]%
Coinsurance after
Deductible
Prescription Drugs Administered in the Office (includes allergy
serum)
[0 to 50]%
Coinsurance after
Deductible
[10 to 50]%
Coinsurance after
Deductible
f you get urgent care at a Hospital or other outpatient Facility, please refer to "Outpatient Facility Services for details
on what you will pay.

{Pediatric exam onIy: [Vision Services For Members Through Age 18

Note: To get the n-Network benefit, you must use an n-Network vision Provider. f you need help finding an n-
Network vision Provider, please call us at the number on the back of your D card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

Covered up to $30]

{Pediatric vision:
[Vision Services For Members Through Age 18

Note: To get the n-Network benefit, you must use an n-Network vision Provider. f you need help finding an n-
Network vision Provider, please call us at the number on the back of your D card.
Routine Eye Exam

Limited to one exam per Benefit Period
$0 Copayment

Covered up to $30
Standard Plastic Lenses
Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Progressive $20 Copayment Covered up to $40
Note: n-Network, lenses include factory scratch coating and UV coating at no additional cost. Polycarbonate and
photocromic lenses are also covered at no extra cost n Network
Frames $0 Copayment, Covered
up to $130
Covered up to $45
Limited to one set of frames from the Anthem formulary every other Benefit Period.
Contact Lenses
Limited to one set of contact lenses from the Anthem formulary every other Benefit Period. Available only if the
eyeglass lenses benefit is not used.
Elective Contact Lenses (Conventional or Disposable) $0 Copayment, Covered
up to $80
Covered up to $60
16
Benefits In-Network Out-of-Network
Non-Elective Contact Lenses No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

{AduIt vision:
[Vision Services For Members Age 19 and OIder
Note: To get the n-Network benefit, you must use an n-Network vision Provider. f y Provider, please call us at the
number on the back of your D card. ou need help finding an n-Network vision
Routine Eye Exam

Limited to one exam per Benefit Period
$20 Copayment Covered up to $30
Standard Plastic Lenses

Limited to one set of lenses every other Benefit Period. Available only if the contact lenses benefit is not used.
Single Vision $20 Copayment Covered up to $25
Bifocal $20 Copayment Covered up to $40
Trifocal $20 Copayment Covered up to $55
Photochromic $20 Copayment (in
addition to lens
Copayment)
Not covered
Note: n-Network, lenses include factory scratch coating at no additional cost.
Frames

Limited to one set of frames every other Benefit Period.
Covered up to $130 Covered up to $45
Contact Lenses

Limited to one set of contact lenses every other Benefit Period. Available only if the eyeglass lenses benefit is not
used.
Elective Contact Lenses (Conventional or Disposable) Covered up to $80 Covered up to $60
Non-Elective Contact Lenses


No Copayment,
Deductible, or
Coinsurance
Covered up to $210]

Vision Services (AII Members / AII Ages)
(For medical and surgical treatment of injuries and/or diseases of
the eye)

Certain vision screenings required by Federal law are covered
under the "Preventive Care" benefit.
Benefits are based on the setting in which
Covered Services are received.


17
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services


PIease caII our TranspIant Department as soon you think you may need a transpIant to taIk about your benefit
options. You must do this !"#$%" you have an evaIuation and/or work-up for a transpIant. To get the most
benefits under your PIan, you must get certain human organ and tissue transpIant services from a Network
TranspIant Provider. Even if a Hospital is an n-Network Provider for other services, it may not be an n-Network
Transplant Provider for certain transplant services. Please call us to find out which Hospitals are n-Network Transplant
Providers. (When calling Customer Service, ask for the Transplant Case Manager for further details.)

The requirements described beIow do not appIy to the foIIowing:

Cornea and kidney transplants, which are covered as any other surgery; and
Any Covered Services related to a Covered Transplant Procedure, that you get before or after the Transplant
Benefit Period. Please note that the initial evaluation, any added tests to determine your eligibility as a candidate
for a transplant by your Provider, and the harvest and storage of bone marrow/stem cells is included in the Covered
Transplant Procedure benefit regardless of the date of service.

Benefits for Covered Services that are not part of the Human Organ and Tissue Transplant benefit will be based on the
setting in which Covered Services are received. Please see the "Benefits/Coverage (What is Covered) section for
additional details.

TranspIant Benefit Period In-Network TranspIant
Provider

Out-of-Network TranspIant
Provider
Starts one day before a
Covered Transplant
Procedure and lasts for the
applicable case rate / global
time period. The number of
days will vary depending on
the type of transplant
received and the n-Network
Transplant Provider
agreement. Call the Case
Manager for specific n-
Network Transplant
Provider information for
services received at or
coordinated by an n-
Network Transplant
Provider Facility.
Starts one day before a
Covered Transplant
Procedure and continues to
the date of discharge at an
Out-of- Network Transplant
Provider Facility.

Covered TranspIant Procedure during the
TranspIant Benefit Period
In-Network TranspIant
Provider FaciIity

Out-of-Network TranspIant
Provider FaciIity

Precertification required


During the Transplant
Benefit Period, [$500
Copayment per admission]
[plus] [[0 to 50]%
Coinsurance] [after
Deductible].

Before and after the
Transplant Benefit Period,
Covered Services will be
covered as npatient
Services, Outpatient
Services, Home Visits, or
Office Visits depending
where the service is
During the Transplant Benefit
Period, [10 to 50]%
Coinsurance after Deductible.

During the Transplant Benefit
Period, Covered Transplant
Procedure charges at an Out-
of-Network Transplant
Provider Facility will NOT
apply to your Out-of-Pocket
Limit.

f the Provider is also an n-
Network Provider for this Plan
(for services other than
18
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services

performed. Covered Transplant
Procedures), then you will not
have to pay for Covered
Transplant Procedure charges
over the Maximum Allowed
Amount.

f the Provider is an Out-of-
Network Provider for this
Plan, you wiII have to pay for
Covered Transplant
Procedure charges over the
Maximum Allowed Amount.

Prior to and after the
Transplant Benefit Period,
Covered Services will be
covered as npatient Services,
Outpatient Services, Home
Visits, or Office Visits
depending where the service
is performed.

Covered TranspIant Procedure during the
TranspIant Benefit Period
In-Network TranspIant
Provider ProfessionaI and
AnciIIary (non-HospitaI)
Providers

Out-of-Network TranspIant
Provider ProfessionaI and
AnciIIary (non-HospitaI)
Providers
[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Transportation and Lodging

[0 to 50]% Coinsurance
after Deductible
[10 to 50]% Coinsurance after
Deductible

Transportation and Lodging Limit

Covered, as approved by us, up to $10,000 per transplant.
n- and Out-of-Network combined

UnreIated donor searches from an authorized,
Iicensed registry for bone marrow/stem ceII
transpIants for a Covered TranspIant Procedure

[0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

Donor Search Limit Covered, as approved by us, up to $30,000 per transplant.
n- and Out-of-Network combined

Live Donor HeaIth Services [0 to 50]% Coinsurance
after Deductible

[10 to 50]% Coinsurance after
Deductible

These charges will NOT apply
to your Out-of-Pocket Limit.

19
Human Organ and Tissue TranspIant (Bone Marrow
/ Stem CeII) Services

Donor HeaIth Service Limit Donor benefits are limited to benefits not available to the
donor from any other source. Medically Necessary charges
for getting an organ from a live donor are covered up to our
Maximum Allowed Amount, including complications from the
donor procedure for up to six weeks from the date of
procurement.

Prescription Drug RetaiI Pharmacy and Home
DeIivery (MaiI Order) Benefits
In-Network Out-of-Network
Each Prescription Drug will be subject to a cost share (e.g., Copayment/Coinsurance) as described below. f your
Prescription Order includes more than one Prescription Drug, a separate cost share will apply to each covered Drug.
You will be required to pay the lesser of your scheduled cost share or the Maximum Allowed Amount.
{Prescription deductibIe:
[Prescription Drug DeductibIe
Does not apply to Tier 1
Per Member $[250 to 500] n- and Out-of-Network combined
Per Family $[500 to 1,000] n- and Out-of-Network combined
Note: The Prescription Drug Deductible is separate and does not apply toward any other Deductible for Covered
Services in this Plan. You must pay the Deductible before you pay any Copayments / Coinsurance listed below.]
Day SuppIy Limitations - Prescription Drugs will be subject to various day supply and quantity limits. Certain
Prescription Drugs may have a lower day-supply limit than the amount shown below due to other Plan requirements
such as prior authorization, quantity limits, and/or age limits and utilization guidelines.
Retail Pharmacy (n-Network and Out-of-Network) 30 days
Home Delivery (Mail Order) Pharmacy 90 days
Specialty Pharmacy (n-Network and Out-of-
Network)
30 days*
*See additional information in the "Specialty Drug
Copayments / Coinsurance section below.
RetaiI Pharmacy Copayments / Coinsurance:

Tier 1 Prescription Drugs

[$15 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 2 Prescription Drugs [$35 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance][ after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 3 Prescription Drugs

[$70 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance after
Deductible]
[10 to 50]% Coinsurance
[after Deductible]
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
[10 to 50]% Coinsurance
[after Deductible]
20
Prescription Drug RetaiI Pharmacy and Home
DeIivery (MaiI Order) Benefits
In-Network Out-of-Network
Home DeIivery Pharmacy Copayments /
Coinsurance:

Tier 1 Prescription Drugs

[$38 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered

Tier 2 Prescription Drugs [$88 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 3 Prescription Drugs [$175 Copayment per
Prescription Drug] [[0 to
50]% Coinsurance] [after
Deductible]
Not covered
Tier 4 Prescription Drugs [[0 to 50]% Coinsurance] [to
a maximum of $[250 to 500]]
[after Deductible] [per
Prescription Drug]
Not covered
SpeciaIty Drug Copayments / Coinsurance:
Please note that certain Specialty Drugs are only available from a Specialty Pharmacy and you will not be able to get
them at a Retail Pharmacy or through the Home Delivery (Mail Order) Pharmacy. Please see "Specialty Pharmacy in
the section "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy for further details. When
you get Specialty Drugs from a Specialty Pharmacy, you will have to pay the same Copayments/Coinsurance you pay
for a 30-day supply at a Retail Pharmacy.

{Preferred Generic / Brand PenaIty:
[Note: Prescription Drugs will always be dispensed as ordered by your Doctor. You may ask for, or your Doctor may
order, the Brand Name Drug. However, if a Generic Drug is available, you will have to pay the difference in the cost
between the Generic and Brand Name Drug, as well as your Tier 1 Copayment. By law, Generic and Brand Name
Drugs must meet the same standards for safety, strength, and effectiveness. Using generics generally saves money,
yet gives the same quality. We reserve the right, in our sole discretion, to remove certain higher cost Generic Drugs
from this policy.]
{ReguIar PPO:
[Note: No Copayment, Deductible, or Coinsurance applies to certain diabetic and asthmatic supplies when you get
them from an n-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical Equipment
if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable Prescription
Drug Copayment / Coinsurance.]
{HSA pIans:
[Note: Certain diabetic and asthmatic supplies are covered subject to applicable Prescription Drug Copayments when
you get them from an n-Network Pharmacy. These supplies are covered as Medical Supplies and Durable Medical
Equipment if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable
Prescription Drug Copayment / Coinsurance.]


21
FederaI Patient Protection and AffordabIe Care Act Notices
Choice of Primary Care Physician / Provider
We generally allow the designation of a Primary Care Physician / Provider (PCP). You have the right to designate any
PCP who participates in our network and who is available to accept you or your family members. For information on how
to select a PCP, and for a list of PCPs, contact the telephone number on the back of your dentification Card or refer to
our website, www.anthem.com. For children, you may designate a pediatrician as the PCP.
Access to ObstetricaI and GynecoIogicaI (ObGyn) Care
You do not need referral or authorization from us or from any other person (including a PCP) in order to obtain access to
obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or
gynecology. The health care professional, however, may be required to comply with certain procedures, including
obtaining prior authorization for certain services or following a pre-approved treatment plan. For a list of participating
health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of your
dentification Card or refer to our website, www.anthem.com.
22
AdditionaI FederaI Notices
Statement of Rights under the Newborns' and Mother's HeaIth Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the
mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn
earlier than 48 hours (or 96 hours as applicable). n any case, plans and issuers may not, under Federal law, require that
a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
Statement of Rights under the Women's Cancer Rights Act of 1998
f you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and
Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in
a manner determined in consultation with the attending Physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other medical and surgical
benefits provided under this Plan. (See the "Schedule of Benefits (Who Pays What) for details.) f you would like more
information on WHCRA benefits, call us at the number on the back of your dentification Card.
Coverage for a ChiId Due to a QuaIified MedicaI Support Order ("QMCSO")
f you or your spouse are required, due to a QMCSO, to provide coverage for your child(ren), you may ask the Group to
provide you, without charge, a written statement outlining the procedures for getting coverage for such child(ren).
MentaI HeaIth Parity and Addiction Equity Act
The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate treatment limitations
(day or visit limits) on mental health and substance abuse benefits with day or visit limits on medical and surgical benefits.
n general, group health plans offering mental health and substance abuse benefits cannot set day/visit limits on mental
health or substance abuse benefits that are lower than any such day or visit limits for medical and surgical benefits. A plan
that does not impose day or visit limits on medical and surgical benefits may not impose such day or visit limits on mental
health and substance abuse benefits offered under the plan. Also, the plan may not impose Deductibles, Copayment,
Coinsurance, and out of pocket expenses on mental health and substance abuse benefits that are more restrictive than
Deductibles, Copayment, Coinsurance and out of pocket expenses applicable to other medical and surgical benefits.
Medical Necessity criteria are available upon request.
SpeciaI EnroIIment Notice
f you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance
coverage, you may in the future be able to enroll yourself or your Dependents in this Plan if you or your Dependents lose
eligibility for that other coverage (or if the employer stops contributing towards your or your Dependents' other coverage).
However, you must request enrollment within 31 days after your or your Dependents' other coverage ends (or after the
employer stops contributing toward the other coverage.
n addition, if you have a new Dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and Your Dependents. However, you must request enrollment within 31 days after the marriage,
birth, adoption, or placement for adoption.
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
23
The Subscriber's or Dependent's Medicaid or Children's Health nsurance Program (CHP) coverage is terminated as
a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program).
The Subscriber or Dependent must request Special Enrollment within 60 days of the loss of Medicaid/CHP or of the
eligibility determination.
To request special enrollment or obtain more information, call us at the Customer Service telephone number on your
dentification Card, or contact the Group.
Statement of ERISA Rights
Please note: This section applies to employer sponsored plans other than Church employer groups and government
groups. f you have questions about whether this Plan is governed by ERSA, please contact the Plan Administrator (the
Group).
The Employee Retirement ncome Security Act of 1974 (ERSA) entitles you, as a Member of the Group under this
Contract, to:
Examine, without charge, at the Plan Administrator's office and at other specified locations such as worksites and
union halls, all plan documents, including insurance contracts, collective bargaining agreements and copies of all
documents filed by this plan with the U.S. Department of Labor, such as detailed annual reports and plan descriptions;
Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The
Plan Administrator may make a reasonable charge for these copies; and
Receive a summary of the plan's annual financial report. The Plan Administrator is required by law to furnish each
participant with a copy of this summary financial report.
n addition to creating rights for you and other employees, ERSA imposes duties on the people responsible for the
operation of your employee benefit plan. The people who operate your plan are called plan fiduciaries. They must handle
your plan prudently and in the best interest of you and other plan participants and beneficiaries. No one, including your
employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you
from obtaining a welfare benefit or exercising your right under ERSA. f your claim for welfare benefits is denied, in whole
or in part, you must receive a written explanation of the reason for the denial. You have the right to have your claims
reviewed and reconsidered.
Under ERSA, there are steps you can take to enforce the above rights. For instance, if you request materials from the
Plan Administrator and do not receive them within 30 days, you may file suit in a federal court. n such case, the court
may require the Plan Administrator to provide you the materials and pay you up to $110 a day until you receive the
materials, unless the materials are not sent because of reasons beyond the control of the Plan Administrator. f your
claim for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. f plan fiduciaries
misuse the plan's money or if you are discriminated against for asserting your rights, you may seek assistance from the
U.S. Department of Labor, or may file suit in a federal court. The court will decide who should pay court costs and legal
fees. t may order you to pay these expenses, for example, if it finds your claim is frivolous. f you have any questions
about your plan, you should contact the Plan Administrator. f you have any questions about this statement or about your
rights under ERSA, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical Assistance and nquiries, Employee
Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
24
Notices Required by State Law
Cancer Screenings
At Anthem Blue Cross and Blue Shield and our subsidiary company, HMO Colorado, nc., we believe cancer screenings
provide important preventive care that supports our mission: to improve the lives of the people we serve and the health of
our communities. We cover cancer screenings as described below.
Pap Tests
All Plans provide coverage under the preventive care benefits for a routine annual Pap test and the related office visit.
Payment for the routine Pap test is based on the Plan's provisions for preventive care service. Payment for the related
office visit is based on the Plan's preventive care provisions.
Mammogram Screenings
All Plans provide coverage under the preventive care benefits for routine screening or diagnostic mammogram regardless
of age. Payment for the mammogram screening benefit is based on the Plan's provisions for preventive care.
Prostate Cancer Screenings
All Plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for
the prostate cancer screening is based on the Plan's provisions for preventive care.
CoIorectaI Cancer Screenings
Several types of colorectal cancer screening methods exist. All Plans provide coverage for routine colorectal cancer
screenings, such as fecal occult blood tests, barium enema, sigmoidoscopies and colonoscopies. Depending on the type
of colorectal cancer screening received, payment for the benefit is based on where the services are rendered and if
rendered as a screening or medical procedure. Colorectal cancer screenings are covered under preventive care as long
as the services provided are for a preventive screening. Payment for preventive colorectal cancer screenings based on
the Plan's provisions for preventive care.
The information above is only a summary of the benefits described. The rest of this Booklet includes important additional
information about limitations, exclusions and covered benefits. The "Schedule of Benefits (Who Pays What) section
includes additional information about Copayments, Deductibles and Coinsurance. f you have any questions, please call
Customer Service at the number on the back of your dentification Card.
{No aduIt dentaI:
[No-AduIt DentaI Services

This policy does not provide any dental benefits to individuals age nineteen (19) or older, except as specifically provided
in the benefit booklet. This policy is being offered so the purchaser will have pediatric dental coverage as required by the
Affordable Care Act. f you want adult dental benefits, you will need to buy a plan that has adult dental benefits. Except as
stated in the benefit booklet, this plan will not pay for any adult dental care, so you will have to pay the full price of any
care you receive.]




25
Notice of
Protection Provided by
Life and HeaIth Insurance Protection Association
This notice provides a brief summary of the Life and Health nsurance Protection Association ("the Association) and the
protection it provides for policyholders. This safety net was created under Colorado law, which determines who and what
is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, annuity or health insurance
company becomes financially unable to meet its obligations and is taken over by its nsurance Department. f this should
happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Colorado law, with
funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
Life nsurance
! $300,000 in death benefits
! $100,000 in cash surrender or withdrawal values
Health nsurance
! $500,000 in hospital, medical and surgical insurance benefits
! $300,000 in disability insurance benefits
! $300,000 in long-term care insurance benefits
! $100,000 in other types of health insurance benefits
Annuities
! $250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $300,000.
Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain poIicies and contracts may not be covered or fuIIy covered. For example, coverage does not extend to
any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the
account value of a variable life insurance policy or a variable annuity contract. There are also various residency
requirements and other limitations under Colorado law.
To learn more about the above protections, as well as protections relating to group contracts or retirement plans, please
visit the Association's website http://colorado.lhiga.com, email jkelldorf@aol.com or contact:
Colorado Life and Health
Insurance Protection Association
P.O. Box 36009
Denver, CO 80236
(303) 292-5022
Colorado Division of Insurance
1560 Broadway, Suite 850
Denver, CO 80202

(303) 894-7499
Insurance companies and agents are not aIIowed by CoIorado Iaw to use the existence of the Association or its
coverage to encourage you to purchase any form of insurance. When seIecting an insurance company, you
shouId not reIy on Association coverage. If there is any inconsistency between this notice and CoIorado Iaw,
then CoIorado Iaw wiII controI.
26
Section 2. TitIe Page (Cover Page)

Anthem Blue Cross and Blue Shield


[Anthem SiIver BIue Priority PPO 2500/20%/6000 PIus]
[Anthem GoId PPO 1000/20%/3500]
[Anthem GoId PPO 2000/40%/4000]
[Anthem SiIver PPO 2000/50%/6350]
[Anthem GoId PPO 750/20%/4500]
[Anthem GoId PPO 1500/20%/4000]
[Anthem GoId PPO 500/20%/4500]
[Anthem SiIver PPO 2000/30%/4500 PIus w/DentaI]
[Anthem SiIver PPO 2000/30%/4500 PIus]
[Anthem SiIver PPO 3000/30%/4000 PIus]
[Anthem Bronze PPO 5850/30%/6600 PIus]
[Anthem GoId PPO 500/20%/3000 PIus w/DentaI]
[Anthem GoId PPO 500/20%/3000 PIus]
[Anthem SiIver PPO 1500/30%/4250 PIus]
[Anthem Bronze PPO 5500/0%/5500 w/HSA]
[Anthem SiIver PPO 3500/0%/3500 w/HSA]
[Anthem Bronze PPO 2500/50%/6350 PIus w/HSA]
[Anthem Bronze PPO 4500/30%/6350 PIus w/HSA]
[Anthem SiIver PPO 2500/20%/4500 w/HSA]
[Anthem GoId PPO 2000/20%/5000 PIus w/HRA]
[Anthem GoId PPO 4000/20%/5000 PIus w/HRA]
[Anthem Bronze PPO 5900/0%/6600 PIus]




27

Section 3. Contact Us
WeIcome to Anthem!
We are pleased that you have become a Member of our health insurance Plan. We want to make sure
that our services are easy to use. We've designed this Booklet to give a clear description of your
benefits, as well as our rules and procedures.
The Booklet explains many of the rights and duties between you and us. t also describes how to get
health care, what services are covered, and what part of the costs you will need to pay. Many parts of
this Booklet are related. Therefore, reading just one or two sections may not give you a full understanding
of your coverage. You should read the whole Booklet to know the terms of your coverage.
This Booklet replaces any Booklet issued to you in the past. The coverage described is based upon the
terms of the Group Contract issued to your Group, and the Plan that your Group chose for you. This
Booklet, and any endorsements, amendments or riders attached, form the entire legal contract under
which Covered Services are available. n addition the Group has a Group Contract and Group
Application which includes terms that apply to this coverage.
Many words used in the Booklet have special meanings (e.g., Group, Covered Services, and Medical
Necessity). These words are capitalized and are defined in the "Definitions" section. See these
definitions for the best understanding of what is being stated. Throughout this Booklet you will also see
references to "we, "us, "our, "you, and "your. The words "we, "us, and "our mean Anthem Blue
Cross and Blue Shield. The words "you and "your mean the Member, Subscriber and each covered
Dependent.
f you have any questions about your Plan, please be sure to call Customer Service at the number on the
back of your dentification Card. Also be sure to check our website, www.anthem.com for details on how
to find a Provider, get answers to questions, and access valuable health and wellness tips. Thank you
again for enrolling in the Plan!
{HSA pIans:
[High-DeductibIe HeaIth PIan for Use with HeaIth Savings Accounts
This Plan is meant to be federally tax qualified and used with a qualified health savings account. Approval
by the Division of nsurance does not guarantee tax qualification and this Plan has not been submitted for
approval by the RS. Please seek the advice of a tax advisor.]
How to Get Language Assistance
Anthem is committed to communicating with our Members about their health Plan, no matter what their
language is. Anthem employs a language line interpretation service for use by all of our Customer Service
call centers. Simply call the Customer Service phone number on the back of your dentification Card and
a representative will be able to help you. Translation of written materials about your benefits can also
be asked for by contacting Customer Service. TTY/TDD services also are available by dialing 711. A
special operator will get in touch with us to help with your needs.



Mike Ramseier
President and General Manager
Anthem Blue Cross and Blue Shield
28

Your Rights and ResponsibiIities as an Anthem BIue Cross and BIue
ShieId Member
As a Member you have certain rights and responsibilities when receiving your health care. You also have
a responsibility to take an active role in your care. As your health care partner, we're committed to making
sure your rights are respected while providing your health benefits. That also means giving you access to
our n-Network Providers and the information you need to make the best decisions for your health and
welfare.

You have the right to:
Speak freely and privately with your Doctors and other health Providers about all health care
options and treatment needed for your condition. This is no matter what the cost or whether it's
covered under your Plan.
Work with your Doctors in making choices about your health care.
Be treated with respect and dignity.
Expect us to keep your personal health information private. This is as long as it follows state and
Federal laws and our privacy policies.
Get the information you need to help make sure you get the most from your health Plan, and share
your feedback. This includes information on:
! Our company and services.
! Our network of Doctors and other health care Providers.
! Your rights and responsibilities.
! The rules of your health care Plan.
! The way your health Plan works.
Make a complaint or file an appeal about:
! Your Plan.
! Any care you get.
! Any Covered Service or benefit ruling that your Plan makes.
Say no to any care, for any condition, sickness or disease, without it affecting any care you may get in
the future. This includes the right to have your Doctor tell you how that may affect your health now
and in the future.
Get all of the most up-to-date information from a Doctor or other health care professional Provider
about the cause of your illness, your treatment and what may result from it. f you don't understand
certain information, you can choose a person to be with you to help you understand.

You have the responsibiIity to:
Read and understand, to the best of your ability, all information about your health benefits or ask for
help if you need it.
Follow all Plan rules and policies.
Choose an n-Network Primary Care Physician (Doctor) / Provider, also called a PCP, if your health
care Plan requires it.
Treat all Doctors, health care Providers and staff with courtesy and respect.
Keep all scheduled appointments with your health care Providers. Call their office if you may be late
or need to cancel.
Understand your health problems as well as you can and work with your Doctors or other health care
Providers to make a treatment plan that you all agree on.
Tell your Doctors or other health care Providers if you don't understand any type of care you're
getting or what they want you to do as part of your care plan.

29
Follow the care plan that you have agreed on with your Doctors or health care Providers.
Give us, your Doctors and other health care professionals the information needed to help you get the
best possible care and all the benefits you are entitled to. This may include information about other
health and insurance benefits you have in addition to your coverage with us.
Let our customer service department know if you have any changes to your name, address or family
members covered under your Plan.

We are committed to providing quality benefits and customer service to our Members. Benefits and
coverage for services provided under the benefit program are governed by the Booklet and not by this
Member Rights and Responsibilities statement.
We value your feedback regarding the benefits and service provided under Our policies and your overall
thoughts and concerns regarding Our operations. f you have any concerns regarding how your benefits
were applied or any concerns about services you requested which were not covered under this Booklet,
you are free to file a complaint or appeal as explained in this Booklet. f you have any concerns regarding
a participating Provider or facility, you can file a grievance as explained in this Booklet. And if you have
any concerns or suggestions on how we can improve Our overall operations and service, We encourage
you to contact customer service.
f you need more information or would like to contact us, please go to anthem.com and select Customer
Support > Contact Us. Or call the Member Services number on your D card.




30

Section 4. TabIe of Contents
Section 1. ScheduIe of Benefits (Who Pays What) .................................................................................. 1
Section 2. TitIe Page (Cover Page) .......................................................................................................... 26
Section 3. Contact Us ............................................................................................................................... 27
Welcome to Anthem! ............................................................................................................................... 27
[High-Deductible Health Plan for Use with Health Savings Accounts ..................................................... 27
How to Get Language Assistance ........................................................................................................... 27
Your Rights and Responsibilities as an Anthem Blue Cross and Blue Shield Member .......................... 28
Section 4. TabIe of Contents .................................................................................................................... 30
Section 5. EIigibiIity .................................................................................................................................. 35
Who is Eligible for Coverage ................................................................................................................... 35
The Subscriber ..................................................................................................................................... 35
Dependents .......................................................................................................................................... 35
Types of Coverage ............................................................................................................................... 36
When You Can Enroll .............................................................................................................................. 36
nitial Enrollment .................................................................................................................................. 36
Open Enrollment .................................................................................................................................. 37
Special Enrollment Periods .................................................................................................................. 37
Special Rules if Your Group Health Plan is Offered Through an Exchange ....................................... 37
Medicaid and Children's Health nsurance Program Special Enrollment ............................................ 38
Late Enrollees ...................................................................................................................................... 38
Members Covered Under the Group's Prior Plan ................................................................................ 38
Enrolling Dependent Children ................................................................................................................. 38
Newborn Children ................................................................................................................................ 38
Adopted Children ................................................................................................................................. 38
Adding a Child due to Award of Legal Custody or Guardianship ........................................................ 39
Qualified Medical Child Support Order ................................................................................................ 39
Updating Coverage and/or Removing Dependents ................................................................................ 39
Nondiscrimination .................................................................................................................................... 39
Statements and Forms ............................................................................................................................ 39
Section 6. How to Access Your Services and Obtain ApprovaI of Benefits (AppIicabIe to managed
care pIans) ................................................................................................................................................. 40
ntroduction .............................................................................................................................................. 40
n-Network Services ................................................................................................................................ 40
Out-of-Network Services ......................................................................................................................... 41
How to Find a Provider in the Network .................................................................................................... 41
[Designated Participating Provider Program ........................................................................................... 41
Continuity of Care .................................................................................................................................... 42
Crediting Prior Plan Coverage ................................................................................................................. 42
The BlueCard Program ............................................................................................................................ 42
dentification Card .................................................................................................................................... 43
Obtain Approval of Benefits ..................................................................................................................... 44
Types of Requests ................................................................................................................................... 44
Request Categories ................................................................................................................................. 45
Decision and Notice Requirements ......................................................................................................... 46
Health Plan ndividual Case Management .............................................................................................. 47
Section 7. Benefits/Coverage (What is Covered) ................................................................................... 48
Acupuncture ............................................................................................................................................ 48
Allergy Services ....................................................................................................................................... 48
Ambulance Services ................................................................................................................................ 48

31
Autism Services ....................................................................................................................................... 49
Behavioral Health Services ..................................................................................................................... 50
Cardiac Rehabilitation ............................................................................................................................. 50
Chemotherapy ......................................................................................................................................... 50
Chiropractor Services .............................................................................................................................. 50
Clinical Trials ........................................................................................................................................... 50
Dental Services ....................................................................................................................................... 51
Your Dental Benefits ............................................................................................................................ 51
Pretreatment Estimate ......................................................................................................................... 52
[Pediatric Dental for Members through Age 18 ................................................................................... 52
[Dental Services ...................................................................................................................................... 55
Dental Services for Members through Age 18 ..................................................................................... 55
Diagnostic and Preventive Services .................................................................................................... 55
Basic Restorative Services .................................................................................................................. 55
Major Restorative Services .................................................................................................................. 56
Oral Surgery ......................................................................................................................................... 56
Orthodontic Care .................................................................................................................................. 56
Dental Services for Members Age 19 and Older ................................................................................. 57
Diagnostic and Preventive Services .................................................................................................... 57
Basic Restorative Services .................................................................................................................. 58
Endodontic Services ............................................................................................................................ 58
Periodontal Services ............................................................................................................................ 58
Oral Surgery Services .......................................................................................................................... 59
Major Restorative Services .................................................................................................................. 60
Prosthodontic Services ........................................................................................................................ 60
Dental Services (All Members / All Ages) ................................................................................................ 61
Preparing the Mouth for Medical Treatments ...................................................................................... 61
Accident-Related Dental Services ....................................................................................................... 62
Cleft Palate and Cleft Lip Conditions ................................................................................................... 62
Dental Anesthesia for Children ............................................................................................................ 62
Diabetes Equipment, Education, and Supplies ....................................................................................... 62
Diagnostic Services ................................................................................................................................. 62
Diagnostic Laboratory and Pathology Services ................................................................................... 63
Diagnostic maging Services and Electronic Diagnostic Tests ............................................................ 63
Advanced maging Services ................................................................................................................ 63
Dialysis .................................................................................................................................................... 63
Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies ................................................................................................................................................... 63
Durable Medical Equipment and Medical Devices .............................................................................. 63
Hearing Aid Services ........................................................................................................................... 64
Orthotics ............................................................................................................................................... 64
Prosthetics ........................................................................................................................................... 64
Medical and Surgical Supplies ............................................................................................................. 65
Blood and Blood Products ................................................................................................................... 65
Emergency Care Services ....................................................................................................................... 65
Emergency Services ............................................................................................................................ 65
Home Care Services ............................................................................................................................... 66
Home nfusion Therapy ........................................................................................................................... 66
Hospice Care ........................................................................................................................................... 66
Human Organ and Tissue Transplant (Bone Marrow / Stem Cell) Services ........................................... 67
Prior Approval and Precertification ...................................................................................................... 68
nfertility Services .................................................................................................................................... 69
npatient Services .................................................................................................................................... 69
npatient Hospital Care ........................................................................................................................ 69
npatient Professional Services ........................................................................................................... 70
Maternity and Reproductive Health Services .......................................................................................... 70

32
Maternity Services ............................................................................................................................... 70
Contraceptive Benefits ......................................................................................................................... 71
Sterilization Services ............................................................................................................................ 71
Abortion Services ................................................................................................................................. 71
nfertility Services ................................................................................................................................. 71
Mental Health, Alcohol and Substance Abuse Services ......................................................................... 71
Occupational Therapy ............................................................................................................................. 72
Office Visits and Doctor Services ............................................................................................................ 72
Orthotics .................................................................................................................................................. 72
Outpatient Facility Services ..................................................................................................................... 73
Physical Therapy ..................................................................................................................................... 73
Preventive Care ....................................................................................................................................... 73
Prosthetics ............................................................................................................................................... 74
Pulmonary Therapy ................................................................................................................................. 74
Radiation Therapy ................................................................................................................................... 74
Rehabilitation Services ............................................................................................................................ 74
Habilitative Services ............................................................................................................................. 74
Respiratory Therapy ................................................................................................................................ 74
Skilled Nursing Facility ............................................................................................................................ 75
Smoking Cessation .................................................................................................................................. 75
Speech Therapy ...................................................................................................................................... 75
Surgery .................................................................................................................................................... 75
Oral Surgery ......................................................................................................................................... 75
Reconstructive Surgery........................................................................................................................ 75
Transgender Surgery ........................................................................................................................... 76
Telemedicine ........................................................................................................................................... 76
Temporomandibular Joint (TMJ) and Craniomandibular Joint Services ................................................. 77
Therapy Services ..................................................................................................................................... 77
Physical Medicine Therapy Services ................................................................................................... 77
Early ntervention Services .................................................................................................................. 77
Other Therapy Services ....................................................................................................................... 78
Transplant Services ................................................................................................................................. 78
Urgent Care Services .............................................................................................................................. 78
Routine Eye Exam ............................................................................................................................... 79
Eyeglass Lenses .................................................................................................................................. 79
Frames ................................................................................................................................................. 79
Contact Lenses .................................................................................................................................... 79
[Vision Services for Members Age 19 and Older .................................................................................... 80
Routine Eye Exam ............................................................................................................................... 80
Eyeglass Lenses .................................................................................................................................. 80
Frames ................................................................................................................................................. 80
Contact Lenses .................................................................................................................................... 80
Vision Services (All Members / All Ages) ................................................................................................ 81
Prescription Drugs Administered by a Medical Provider ......................................................................... 82
mportant Details About Prescription Drug Coverage .......................................................................... 82
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy ..................................... 83
Prescription Drug Benefits ................................................................................................................... 83
Section 8. Limitations/ExcIusions (What is Not Covered and Pre-Existing Conditions) .................. 87
What's Not Covered Under Your Prescription Drug Retail or Home Delivery (Mail Order) Pharmacy
Benefit...................................................................................................................................................... 92
Pre-existing Conditions ............................................................................................................................ 94
Section 9. Member Payment ResponsibiIity ........................................................................................... 95
Your Cost-Shares .................................................................................................................................... 95
Maximum Allowed Amount ...................................................................................................................... 95
Claims Review ......................................................................................................................................... 98

33
Section 10. CIaims Procedure (How to FiIe a CIaim) ............................................................................. 99
Notice of Claim & Proof of Loss .............................................................................................................. 99
Claim Forms ............................................................................................................................................ 99
Member's Cooperation ............................................................................................................................ 99
Payment of Benefits ................................................................................................................................ 99
nter-Plan Programs .............................................................................................................................. 100
Out-of-Area Services ............................................................................................................................. 100
BlueCard

Program ........................................................................................................................... 100

Non-Participating Healthcare Providers Outside Our Service Area .................................................. 101
Section 11. GeneraI PoIicy Provisions .................................................................................................. 102
Assignment ............................................................................................................................................ 102
Automobile nsurance Provisions .......................................................................................................... 102
Clerical Error .......................................................................................................................................... 102
Confidentiality and Release of nformation............................................................................................ 103
Conformity with Law .............................................................................................................................. 103
Contract with Anthem ............................................................................................................................ 103
Entire Contract ....................................................................................................................................... 103
Form or Content of Booklet ................................................................................................................... 104
Government Programs .......................................................................................................................... 104
Medical Policy and Technology Assessment ........................................................................................ 104
Medicare ................................................................................................................................................ 104
Modifications .......................................................................................................................................... 104
Network Access Plan ............................................................................................................................. 105
Not Liable for Provider Acts or Omissions ............................................................................................. 105
Policies and Procedures ........................................................................................................................ 105
Relationship of Parties (Group-Member-Anthem) ................................................................................. 105
Relationship of Parties (Anthem and n-Network Providers) ................................................................. 105
Reservation of Discretionary Authority .................................................................................................. 106
Right of Recovery .................................................................................................................................. 106
Unauthorized Use of dentification Card ................................................................................................ 107
Value-Added Programs ......................................................................................................................... 107
Value of Covered Services .................................................................................................................... 107
Voluntary Clinical Quality Programs ...................................................................................................... 107
Voluntary Wellness ncentive Programs ................................................................................................ 107
Waiver.................................................................................................................................................... 108
Workers' Compensation ........................................................................................................................ 108
Subrogation and Reimbursement .......................................................................................................... 108
Subrogation ........................................................................................................................................ 108
Reimbursement .................................................................................................................................. 108
The Member's Duties ......................................................................................................................... 109
Coordination of Benefits When Members Are nsured Under More Than One Plan ............................ 109
Section 12. Termination/NonrenewaI/Continuation ............................................................................. 114
Termination ............................................................................................................................................ 114
Removal of Members ............................................................................................................................ 114
Special Rules if Your Group Health Plan is Offered Through an Exchange ......................................... 115
Continuation of Coverage Under Federal Law (COBRA) ...................................................................... 115
Qualifying events for Continuation Coverage under Federal Law (COBRA) ..................................... 115
f Your Group Offers Retirement Coverage ....................................................................................... 116
Second qualifying event ..................................................................................................................... 116
Notification Requirements .................................................................................................................. 117
Disability extension of 18-month period of continuation coverage .................................................... 117
Trade Adjustment Act Eligible ndividual ........................................................................................... 117
When COBRA Coverage Ends .......................................................................................................... 118
f You Have Questions ....................................................................................................................... 118
Continuation of Coverage Under State Law .......................................................................................... 118

34
Continuation of Coverage Due To Military Service ............................................................................... 119
Maximum Period of Coverage During a Military Leave ..................................................................... 120
Reinstatement of Coverage Following a Military Leave .................................................................... 120
Family and Medical Leave Act of 1993 ................................................................................................. 120
Benefits After Termination Of Coverage ............................................................................................... 121
Section 13. AppeaIs and CompIaints .................................................................................................... 122
Complaints ............................................................................................................................................. 122
Appeals .................................................................................................................................................. 123
Grievances ............................................................................................................................................ 125
Division of nsurance nquiries ........................................................................................................... 125
Binding Arbitration .............................................................................................................................. 125
Legal Action ....................................................................................................................................... 125
Section 14. Information on PoIicy and Rate Changes ......................................................................... 127
nsurance Premiums .............................................................................................................................. 127
Section 15. Definitions ............................................................................................................................ 128

35
Section 5. EIigibiIity
n this section you will find information on who is eligible for coverage under this Plan and when Members
can be added to your coverage. Eligibility requirements are described in general terms below. For more
specific information, please see your Human Resources or Benefits Department.
Who is EIigibIe for Coverage
The Subscriber
To be eligible to enroll as a Subscriber, the individual must:
Be an employee of the Group, and;
Be entitled to participate in the benefit Plan arranged by the Group, and;
Have satisfied any probationary or waiting period established by the Group and perform the duties of
your principal occupation for the Group.
Dependents
To be eligible to enroll as a Dependent, you must be listed on the enrollment form completed by the
Subscriber, meet all Dependent eligibility criteria established by the Group, and be one of the following:
The Subscriber's spouse, including the partner to a civil union as recognized by Colorado law. For
information on spousal eligibility please contact the Group.
Common-law spouse. A Common-Law Marriage Affidavit is needed to enroll a common-law spouse.
You can get the affidavit from your employer or you can call us. All references to spouse in this
Booklet include a common-law spouse.
A common law spouse is an eligible Dependent who has a valid common-law marriage in Colorado.
This is the same as any other marriage and can only end by death or divorce.
Designated beneficiary. Your Group may have decided to offer benefits under this plan to designated
beneficiaries. Check with your Group to learn more. f they are recognized by the Group, all
references to spouse in this Booklet include a designated beneficiary. A Recorded Designated
Beneficiary Agreement will need to be provided. A designated beneficiary is not eligible for COBRA
under this Booklet.
A designated beneficiary is an agreement entered into by two people for the purpose of making each
a beneficiary of the other and which has been recorded with the county clerk and recorder in the
county in which one of the person lives. The agreement is based on the Colorado Designated
Beneficiary Act.
Same-sex domestic partner. Domestic Partner, or Domestic Partnership means a person of the same
sex who has signed the Domestic Partner Affidavit certifying that he or she is the Subscriber's sole
Domestic Partner; he or she is mentally competent; he or she is not related to the Subscriber by
blood closer than permitted by state law for marriage; he or she is not married to anyone else; and he
or she is financially interdependent with the Subscriber.
For purposes of this Plan, a Domestic Partner or partner to a recognized civil union shall be treated
the same as a spouse, and that partner's child, adopted child, or child for whom he or she has legal
guardianship shall be treated the same as any other child. The coverage of a Domestic Partner, civil
union partner, or the child of any such partner ends on the date of dissolution of the Domestic
Partnership or civil union.
While this Booklet will recognize and provide benefits for a Member who is a spouse or child in
connection with a Domestic Partner or recognized civil union relationship, not every federal or state

36
law that applies to a Member who is a spouse or child under this Plan will also apply to a Domestic
Partner or a partner under a civil union. This includes but is not limited to, COBRA and FMLA.
We reserve the right to make the ultimate decision in determining eligibility of the Domestic Partner.
The children of the Subscriber or the Subscriber's spouse, including natural children, stepchildren,
newborn and legally adopted children and children who the Group has determined are covered under
a Qualified Medical Child Support Order as defined by ERSA or any applicable state law.
Children, including grandchildren, for whom the Subscriber or the Subscriber's spouse is a permanent
legal guardian or as otherwise required by law.
All enrolled eligible children will continue to be covered until the age limit listed in the "Schedule of
Benefits (Who Pays What). Coverage may be continued past the age limit in the following circumstances:
For unmarried Dependents who cannot work to support themselves due to mental retardation or
physical handicap. The Dependent's disability must start before the end of the period they would
become ineligible for coverage. We must be informed of the Dependent's eligibility for continuation of
coverage within 31 days after the Dependent would normally become ineligible. You must then give
proof as often as we require. This will not be more often than once a year after the two-year period
following the child reaching the limiting age. You must give the proof at no cost to us. You must
notify us if the Dependent's marital status changes and they are no longer eligible for continued
coverage.
We may require you to give proof of continued eligibility for any enrolled child. Your failure to give this
information could result in termination of a child's coverage.
To obtain coverage for children, we may require you to give us a copy of any legal documents awarding
permanent guardianship of such child(ren) to you.

Your group may have limited or excluded the eligibility of certain Dependent types and so not all
Dependents listed in this Plan may be entitled to enroll. For more specific information, please see your
Human Resources or Benefits Department.
Types of Coverage
Your Group offers some or all of the enrollment options listed below. After reviewing the available options,
you may choose the option that best meets your needs. The options may include:
Subscriber only (also referred to as single coverage);
Subscriber and spouse; or Domestic Partner;
Subscriber and child(ren);
Subscriber and family.
When You Can EnroII
InitiaI EnroIIment
The Group will offer an initial enrollment period to new Subscribers and their Dependents when the
Subscriber is first eligible for coverage. Coverage will be effective based on the waiting period chosen by
the Group, and will not exceed 90 days.
f you did not enroll yourself and/or your Dependents during the initial enrollment period you will only be
able to enroll during an Open Enrollment period or during a Special Enrollment period, as described
below.

37
Open EnroIIment
Open Enrollment refers to a period of time, usually 60 days, during which eligible Subscribers and
Dependents can apply for or change coverage. Open Enrollment occurs only once per year. The Group
will notify you when Open Enrollment is available.
SpeciaI EnroIIment Periods
f a Subscriber or Dependent does not apply for coverage when they were first eligible, they may be able
to join the Plan prior to Open Enrollment if they qualify for Special Enrollment. Except as noted otherwise
below, the Subscriber or Dependent must request Special Enrollment within 31 days of a qualifying event.
Special Enrollment is available for eligible individuals who:
Lost eligibility under a prior health plan for reasons other than non-payment of premium or due to
fraud or intentional misrepresentation of a material fact;
Lost coverage due to death of a covered employee; the termination or reduction in number of hours of
the covered employee's employment (regardless of eligibility for COBRA or state continuation
coverage); involuntary termination of coverage; lost eligibility under the Colorado Medical Assistance
Act or the Children's Basic Health Plan; or the covered employee becoming eligible for benefits under
Title XV of the Federal Social Security Act, as amended;
Lost coverage under a health benefit plan due to the divorce or legal separation of the covered
employee from the covered employee's spouse or partner in civil union, or due to the termination of a
recognized domestic partnership;
s now eligible for coverage due to marriage (including a civil union where recognized in the state
where the Subscriber resides), birth, adoption, placement for adoption, by entering into a Designated
Beneficiary Agreement, or pursuant to a QMCSO or other court or administrative order mandating
that the individual be covered;
Exhausted COBRA or state continuation benefits or stopped receiving group contributions toward the
cost of the prior health plan; or
Lost employer contributions towards the cost of the other coverage.

Important Notes about SpeciaI EnroIIment:
Members who enroll during Special Enrollment are not considered Late Enrollees.
ndividuals must request coverage within 31 days of a qualifying event (i.e., marriage, exhaustion of
COBRA, etc.).
f the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
SpeciaI RuIes if Your Group HeaIth PIan is Offered Through an Exchange
f your Plan is offered through a public exchange operated by the state or federal government as part of
the Patient Protection and Affordable Care Act ("Exchange), all enrollment changes must be made
through the Exchange by you or your Group. Each Exchange will have rules on how to do this. For plans
offered on the Exchange there are additional opportunities for Special Enrollment. They include:
Your enrollment or non-enrollment in another qualified health plan was unintentional, inadvertent or
erroneous and was a result of an error, misrepresentation, or inaction by an employee or
representative of the Exchange;
You adequately demonstrate to the Exchange that the health plan under which you are enrolled has
substantially violated a material provision of its contract with you;
You move and become eligible for new qualified health plans;

38
You are a Native American ndian, as defined by section 4 of the ndian Health Care mprovement
Act, and allowed to change from one qualified health plan to another as often as once per month; or
The Exchange determines, under federal law, that you meet other exceptional circumstances that
warrant a Special Enrollment.
You must give the Exchange notice within 30 days of the above events if you wish to enroll.
Medicaid and ChiIdren's HeaIth Insurance Program SpeciaI EnroIIment
Eligible Subscribers and Dependents may also enroll under two additional circumstances:
The Subscriber's or Dependent's Medicaid or Children's Health nsurance Program (CHP) coverage
is terminated as a result of loss of eligibility; or
The Subscriber or Dependent becomes eligible for a subsidy (state premium assistance program)
The Subscriber or Dependent must request Special Enrollment within 60 days of the above events.
Late EnroIIees
f the Subscriber does not enroll themselves and/or their Dependents when first eligible or during a
Special Enrollment period, they will not be eligible to enroll until the next Open Enrollment Period.
Members Covered Under the Group's Prior PIan
Members who were previously enrolled under another plan offered by the Group that is being replaced by
this Plan are eligible for coverage on the Effective Date of this coverage.
EnroIIing Dependent ChiIdren
Newborn ChiIdren
Newborn children are covered automatically from the moment of birth. Following the birth of a child, you
should submit an application / change form to the Group within 31 days to add the newborn to your Plan.
During the first 31 days after birth, a newborn child will be covered for Medically Necessary care. This
includes well child care and treatment of medically diagnosed congenital defects and birth abnormalities.
This is regardless of the limitations and exclusions applicable to other conditions or procedures of this
Booklet.
Even if no additional Premium is required, you should still submit an application / change form to the
Group to add the newborn to your Plan, to make sure we have accurate records and are able to cover
your claims.
Adopted ChiIdren
A child will be considered adopted from the earlier of: (1) the moment of placement in your home; or (2)
the date of an entry of an order granting custody of the child to you. The placement begins when you
assume or retain a legal obligation to partially or totally support a child in anticipation of the child's
adoption. A placement terminates at the time such legal obligation terminates. The child will continue to
be considered adopted unless the child is removed from your home prior to issuance of a legal decree of
adoption.
Your Dependent's Effective Date will be the date of the adoption or placement for adoption if you send us
the completed application / change form within 31 days of the event.

39
Adding a ChiId due to Award of LegaI Custody or Guardianship
f you or your spouse is awarded permanent legal custody or permanent guardianship for a child, an
application must be submitted within 31 days of the date legal custody or guardianship is awarded by the
court. Coverage will be effective on the date the court granted legal custody or guardianship.
QuaIified MedicaI ChiId Support Order
f you are required by a qualified medical child support order or court order, as defined by ERSA and/or
applicable state or federal law, to enroll your child in this Plan, we will permit the child to enroll at any time
without regard to any Open Enrollment limits and will provide the benefits of this Plan according to the
applicable requirements of such order. However, a child's coverage will not extend beyond any
Dependent Age Limit listed in the "Schedule of Benefits (Who Pays What).
Updating Coverage and/or Removing Dependents
You are required to notify the Group of any changes that affect your eligibility or the eligibility of your
Dependents for this Plan. When any of the following occurs, contact the Group and complete the
appropriate forms:
Changes in address;
Marriage or divorce or entering into or terminating a recognized civil union or domestic partnership;
Death of an enrolled family member (a different type of coverage may be necessary);
Enrollment in another health plan or in Medicare;
Eligibility for Medicare;
Dependent child reaching the Dependent Age Limit (see "Termination/Nonrenewal/Continuation);
Enrolled Dependent child either becomes totally or permanently disabled, or is no longer disabled.
Failure to notify us of individuals no longer eligible for services will not obligate us to cover such services,
even if Premium is received for those individuals. All notifications must be in writing and on approved
forms.
Nondiscrimination
No person who is eligible to enroll will be refused enrollment based on health status, health care needs,
genetic information, previous medical information, disability, sexual orientation or identity, gender or age.
Statements and Forms
All Members must complete and submit applications or other forms or statements that we may reasonably
request.
Any rights to benefits under this Plan are subject to the condition that all such information is true, correct,
and complete. Any intentional material misrepresentation by you may result in termination of coverage as
provided in the "Termination/Nonrenewal/Continuation" section. We will not use a statement made by you
to void or reduce your coverage after that coverage has been in effect for two years, unless such
statement is contained in a written instrument signed by you making such statement and a copy of that
instrument is or has been given to you or your beneficiary.


40
Section 6. How to Access Your Services and Obtain ApprovaI
of Benefits (AppIicabIe to managed care pIans)
Introduction
Your Plan is a PPO plan. The Plan has two sets of benefits: n-Network and Out-of-Network. f you
choose an n-Network Provider, you will pay less in out-of-pocket costs, such as Copayments,
Deductibles, and Coinsurance. f you use an Out-of-Network Provider, you will have to pay more out-of-
pocket costs.
In-Network Services
When you use an n-Network Provider or get care as part of an Authorized Service, Covered Services will
be covered at the n-Network level. Regardless of Medical Necessity, benefits will be denied for care that
is not a Covered Service. We have final authority to decide the Medical Necessity of the service.
In-Network Providers include Primary Care Physicians / Providers (PCPs), Specialists (Specialty Care
Physicians / Providers - SCPs), other professional Providers, Hospitals, and other Facilities who contract
with us to care for you. Referrals are never needed to visit an n-Network Specialist, including behavioral
health Providers.
To see a Doctor, call their office:
Tell them you are an Anthem Member,
Have your Member dentification Card handy. The Doctor's office may ask you for your group or
Member D number.
Tell them the reason for your visit.
When you go to the office, be sure to bring your Member dentification Card with you.
For services from n-Network Providers:
1. You will not need to file claims. n-Network Providers will file claims for Covered Services for you.
(You will still need to pay any Coinsurance, Copayments, and/or Deductibles that apply.) You may be
billed by your n-Network Provider(s) for any non-Covered Services you get or when you have not
followed the terms of this Booklet.
2. Precertification will be done by the n-Network Provider. (See this section for further details.)
We do not guarantee that an n-Network Provider is available for all services and supplies covered under
your PPO plan. For some services and supplies We may not have arrangements with n-Network
Providers. For example, some Hospital-based labs are not part of our Reference Lab Network. Please
read the "Member Payment Responsibility section for additional information on Authorized Services.
After Hours Care
f you need care after normal business hours, your Doctor may have several options for you. You should
call your Doctor's office for instructions if you need care in the evenings, on weekends, or during the
holidays and cannot wait until the office reopens. f you have an Emergency, call 911 or go to the nearest
Emergency Room.

41
Out-of-Network Services
When you do not use an n-Network Provider or get care as part of an Authorized Service, Covered
Services are covered at the Out-of-Network level, unless otherwise indicated in this Booklet.
For services from an Out-of-Network Provider:
1. n addition to any Deductible and/or Coinsurance/Copayments, the Out-of-Network Provider can
charge you the difference between their bill and the Plan's Maximum Allowed Amount;
2. You may have higher cost sharing amounts (i.e., Deductibles, Coinsurance, and/or Copayments);
3. You will have to pay for services that are not Medically Necessary;
4. You will have to pay for non-Covered Services;
5. You may have to file claims; and
6. You must make sure any necessary Precertification is done. (Please see this section for more
details.)
We will not deny or restrict Covered Services just because you get treatment from an Out-of-Network
Provider; however, you may have to pay more.
We pay the benefits of this Booklet directly to Out-of-Network Providers, if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of you.
We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services.
How to Find a Provider in the Network
There are three ways you can find out if a Provider or Facility is in the network for this Plan. You can also
find out where they are located and details about their license or training.
See your Plan's directory of n-Network Providers at www.anthem.com, which lists the Doctors,
Providers, and Facilities that participate in this Plan's network.
Call Customer Service to ask for a list of Doctors and Providers that participate in this Plan's network,
based on specialty and geographic area.
Check with your Doctor or Provider.
f you need help choosing a Doctor who is right for you, call the Customer Service number on the back of
your Member dentification Card. TTY/TDD services also are available by dialing 711. A special operator
will get in touch with us to help with your needs.
{Narrow network:
[Please note that we have several networks, and that a Provider that is n-Network for one plan may not
be n-Network for another. Be sure to check your dentification Card or call Customer Service to find out
which network this Plan uses.]

{Tiered pIan:
[Designated Participating Provider Program
Certain Providers are part of our Designated Participating Provider Program, a program aimed at
improving the quality of our Members' health care. Providers in this program agree to coordinate much of
your care and will prepare care plans for Members who have multiple, complex health conditions.]

42
Continuity of Care
f you are getting ongoing care for a medical condition when you first enroll in this coverage, We may be
able to help ease the transition. Examples of ongoing care are prenatal/obstetrical care, Home Care or
Hospice Care. We try to avoid disruption of a new Member's care through Our transition of care policy. f
interested, you or your Provider must review the reference sheet, complete a "Transition of Care Form
and submit them to Us for review. You or your Provider can get these materials by calling Our Customer
Service.
Crediting Prior PIan Coverage
f you were covered by the Group's prior carrier / plan immediately before the Group signs up with us, with
no break in coverage, then you will get credit for any accrued Deductible and, if applicable and approved
by us, Out of Pocket amounts under that other plan. This does not apply to people who were not covered
by the prior carrier or plan on the day before the Group's coverage with us began, or to people who join
the Group later.
f your Group moves from one of our plans to another, (for example, changes its coverage from HMO to
PPO), and you were covered by the other product immediately before enrolling in this product with no
break in coverage, then you may get credit for any accrued Deductible and Out of Pocket amounts, if
applicable and approved by us. Any maximums, when applicable, will be carried over and charged
against the maximums under this Plan.
f your Group offers more than one of our products, and you change from one product to another with no
break in coverage, you will get credit for any accrued Deductible and, if applicable, Out of Pocket
amounts and any maximums will be carried over and charged against maximums under this Plan.
f your Group offers coverage through other products or carriers in addition to ours, and you change
products or carriers to enroll in this product with no break in coverage, you will get credit for any accrued
Deductible, Out of Pocket, and any maximums under this Plan.
This Section Does Not AppIy To You If:
Your Group moves to this Plan at the beginning of a Benefit Period.
You change from one of our individual policies to a group plan;
You change employers; or
You are a new Member of the Group who joins the Group after the Group's initial enrollment with us.
The BIueCard Program
Like all Blue Cross & Blue Shield plans throughout the country, we participate in a program called
"BlueCard." This program lets you get Covered Services at the n-Network cost-share when you are
traveling out of state and need health care, as long as you use a BlueCard Provider. All you have to do is
show your dentification Card to a participating Blue Cross & Blue Shield Provider, and they will send your
claims to us.
f you are out of state and an Emergency or urgent situation arises, you should get care right away.
n a non-Emergency situation, you can find the nearest contracted Provider by visiting the BlueCard
Doctor and Hospital Finder website (www.BCBS.com) or call the number on the back of your dentification
Card.
You can also access Doctors and Hospitals outside of the U.S. The BlueCard program is recognized in
more than 200 countries throughout the world.

43
Care Outside the United States - BIueCard

WorIdwide
Before you travel outside the United States, check with your Group or call Customer Service at the
number on your dentification Card to find out if your plan has BlueCard Worldwide benefits. Your
coverage outside the United States may be different and we suggest:
Before you leave home, call the Customer Service number on your dentification Card for coverage
details.
Always carry your up to date Anthem dentification Card.
n an Emergency, go straight to the nearest Hospital.
The BlueCard Worldwide Service Center is on hand 24 hours a day, seven days a week toll-free at
(800) 810-BLUE (2583) or by calling collect at (804) 673-1177. An assistance coordinator, along with
a health care professional, will arrange a Doctor visit or Hospital stay, if needed.
CaII the Service Center in these non-emergency situations:
You need to find a Doctor or Hospital or need health care. An assistance coordinator, along with a
medical professional, will arrange a Doctor visit or Hospital stay, if needed.
You need npatient care. After calling the Service Center, you must also call us to get approval for
benefits at the phone number on your dentification Card. Note: this number is different than the
phone numbers listed above for BlueCard Worldwide.
Payment DetaiIs
Participating BIueCard WorIdwide HospitaIs. n most cases, when you make arrangements for a
Hospital stay through BlueCard Worldwide, you should not need to pay upfront for npatient care at
participating BlueCard Worldwide hospitals except for the out-of-pocket costs (non-Covered Services,
Deductible, Copayments and Coinsurance) you normally pay. The Hospital should send in your claim
for you.
Doctors and/or non-participating HospitaIs. You will need to pay upfront for outpatient services,
care received from a Doctor, and npatient care not arranged through the BlueCard Worldwide
Service Center. Then you can fill out a BlueCard Worldwide claim form and send it with the original
bill(s) to the BlueCard Worldwide Service Center (the address is on the form).
CIaim FiIing
The Hospital will file your claim if the BlueCard Worldwide Service Center arranged your Hospital
stay. You will need to pay the Hospital for the out-of-pocket costs you normally pay.
You must file the claim for outpatient and Doctor care, or npatient care not arranged through the
BlueCard Worldwide Service Center. You will need to pay the Provider and subsequently send an
international claim form with the original bills to us.
CIaim Forms
You can get international claim forms from us, the BlueCard Worldwide Service Center, or online at
www.bcbs.com/bluecardworldwide. The address for sending in claims is on the form.
Identification Card
We will give an dentification Card to each Member enrolled in the Plan. When you get care, you must
show your dentification Card. Only a Member who has paid the Premiums for this Plan has the right to
services or benefits under this Booklet. f anyone gets services or benefits to which they are not entitled to
under the terms of this Booklet, he/she must pay for the actual cost of the services.

44
Obtain ApprovaI of Benefits
Your Plan includes the processes of Precertification, Predetermination and Post Service Clinical Claims
Review to decide when services should be covered by your Plan. Their purpose is to aid the delivery of
cost-effective health care by reviewing the use of treatments and, when proper, the setting or place of
service that they are performed. Covered Services must be Medically Necessary for benefits to be
covered. When setting or place of service is part of the review, services that can be safely given to you in
a lower cost setting will not be Medically Necessary if they are given in a higher cost setting.
Prior Authorization: n-Network Providers must obtain prior authorization in order for you to get benefits
for certain services. Prior authorization criteria will be based on many sources including medical policy,
clinical guidelines, and pharmacy and therapeutics guidelines. Anthem may decide that a service that was
first prescribed or asked for is not Medically Necessary if you have not tried other treatments which are
more cost effective.
f you have any questions about the information in this section, you may call the Customer Service phone
number on the back of your dentification Card.
Types of Requests
Precertification - A required review of a service, treatment or admission for a benefit coverage
determination which must be done before the service, treatment or admission start date. For
Emergency admissions, you, your authorized representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a reasonable period of time. For labor / childbirth
admissions, Precertification is not needed unless there is a problem and/or the mother and baby are
not sent home at the same time.
Predetermination - An optional, voluntary Prospective or Continued Stay Review request for a
benefit coverage determination for a service or treatment. We will check your Booklet to find out if
there is an Exclusion for the service or treatment. f there is a related clinical coverage guideline, the
benefit coverage review will include a review to decide whether the service meets the definition of
Medical Necessity under this Booklet or is Experimental / nvestigational as that term is defined in this
Booklet.
Post Service CIinicaI CIaims Review - A Retrospective review for a benefit coverage determination
to decide the Medical Necessity or Experimental / nvestigational nature of a service, treatment or
admission that did not need Precertification and did not have a Predetermination review performed.
Medical reviews are done for a service, treatment or admission in which we have a related clinical
coverage guideline and are typically initiated by us.
Typically, n-Network Providers know which services need Precertification and will get any Precertification
or ask for a Predetermination when needed. Your Primary Care Physician / Provider and other n-
Network Providers have been given detailed information about these procedures and are responsible for
meeting these requirements. Generally, the ordering Provider, Facility or attending Doctor will get in touch
with us to ask for a Precertification or Predetermination review ("requesting Provider). We will work with
the requesting Provider for the Precertification request. However, you may choose an authorized
representative to act on your behalf for a specific request. The authorized representative can be anyone
who is 18 years of age or older.

45
Who is responsibIe for Precertification
Services given by an In-
Network Provider
Services given by a BIueCard/Out-of-Network/Non-
Participating Provider
Provider
Member must get Precertification.
f Member fails to get Precertification, Member may be
financially responsible for service and/or setting in
whole or in part.
For Emergency admissions, you, your authorized
representative or Doctor must tell us within 72 hours of
the admission or as soon as possible within a
reasonable period of time.

We use our clinical coverage guidelines, such as medical policy, clinical guidelines, preventative care
clinical coverage guidelines and other applicable policies and procedures to help make our Medical
Necessity decisions, including decisions about Prescription and Specialty Drug services. Medical policies
and clinical guidelines reflect the standards of practice and medical interventions identified as proper
medical practice. We reserve the right to review and update these clinical coverage guidelines from time
to time. Your Booklet and Group Contract take precedence over these guidelines.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning your
request. To ask for this information, call the Precertification phone number on the back of your
dentification Card.
Anthem may, from time to time, waive, enhance, change or end certain medical management processes
(including utilization management, case management, and disease management) if in our discretion,
such change furthers the provision of cost effective, value based and/or quality services.
We may also select certain qualifying Providers to take part in a program that exempts them from certain
procedural or medical management processes that would otherwise apply. We may also exempt your
claim from medical review if certain conditions apply.
Just because Anthem exempts a process, Provider or Claim from the standards which otherwise would
apply, it does not mean that Anthem will do so in the future, or will do so in the future for any other
Provider, claim or Member. Anthem may stop or change any such exemption with or without advance
notice.
You may find out whether a Provider is taking part in certain programs by checking your on-line Provider
Directory or contacting the Customer Service number on the back of your D card.

We also may identify certain Providers to review for potential fraud, waste, abuse or other inappropriate
activity if the claims data suggests there may be inappropriate billing practices. f a Provider is selected
under this program, then we may use one or more clinical utilization management guidelines in the review
of claims submitted by this Provider, even if those guidelines are not used for all Providers delivering
services to this Plan's Members.
Request Categories
Expedited - A request for Precertification or Predetermination that, in the view of the treating
Provider or any Doctor with knowledge of your medical condition, could; without such care or
treatment, seriously threaten your life or health or your ability to regain maximum function; or subject
you to severe pain that cannot be adequately managed without such care or treatment; or if you have

46
a physical or mental disability, create an imminent and substantial limitation on your existing ability to
live independently.
Prospective - A request for Precertification or Predetermination that is conducted before the service,
treatment or admission.
Continued Stay Review - A request for Precertification or Predetermination that is conducted during
the course of outpatient treatment or during an npatient admission.
Retrospective - A request for Precertification that is conducted after the service, treatment or
admission has happened. Post Service Clinical Claims Reviews are also retrospective.
Retrospective review does not include a review that is limited to an evaluation of reimbursement
levels, veracity of documentation, accuracy of coding or adjudication of payment.
Decision and Notice Requirements
We will review requests for benefits according to the timeframes listed below. The timeframes and
requirements listed are based on state and federal laws. Where state laws are stricter than federal laws,
we will follow state laws. f you live in and/or get services in a state other than the state where your
Contract was issued other state-specific requirements may apply. You may call the phone number on the
back of your dentification Card for more details.
Request Category Timeframe Requirement for Decision and
Notification
Prospective Expedited 72 hours from the receipt of request
Prospective Non-Expedited 15 calendar days from the receipt of the request
Continued Stay Review when hospitalized
at the time of the request
72 hours from the receipt of the request and prior to
expiration of current certification.
Continued Stay Review Expedited when
request is received more than 24 hours
before the end of the previous authorization
24 hours from the receipt of the request
Continued Stay Review Expedited when
request is received less than 24 hours
before the end of the previous authorization
or no previous authorization exists
72 hours from the receipt of the request
Continued Stay Review Non-Expedited 15 calendar days from the receipt of the request
Retrospective 30 calendar days from the receipt of the request
f more information is needed to make our decision, we will tell the requesting Provider and send written
notice to you or your authorized representative of the specific information needed to finish the review. f
we do not get the specific information we need or if the information is not complete by the timeframe
identified in the written notice, we will make a decision based upon the information we have.
We will give notice of our decision as required by state and federal law. Notice may be given by the
following methods:
VerbaI: Oral notice given to the requesting Provider by phone or by electronic means if agreed to by
the Provider.
Written: Mailed letter or electronic means including email and fax given to, at a minimum, the
requesting Provider and you or your authorized representative
For benefits to be covered, Precertification wiII consider the foIIowing:
1. You must be eligible for benefits;

47
2. Premium must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under your Plan;
4. The service cannot be subject to an Exclusion under your Plan;
5. You must not have exceeded any applicable limits under your Plan; and
6. You did not perform an act, practice, or omission that constitutes fraud or abuse when requesting the
Precertification.
HeaIth PIan IndividuaI Case Management
Our health plan case management programs (Case Management) help coordinate services for Members
with health care needs due to serious, complex, and/or chronic health conditions. Our programs
coordinate benefits and educate Members who agree to take part in the Case Management program to
help meet their health-related needs.
Our Case Management programs are confidential and voluntary and are made available at no extra cost
to you. These programs are provided by, or on behalf of and at the request of, your health plan case
management staff. These Case Management programs are separate from any Covered Services you are
receiving.
f you meet program criteria and agree to take part, we will help you meet your identified health care
needs. This is reached through contact and team work with you and/or your chosen authorized
representative, treating Doctor(s), and other Providers.
n addition, we may assist in coordinating care with existing community-based programs and services to
meet your needs. This may include giving you information about external agencies and community-
based programs and services.
n certain cases of severe or chronic illness or injury, we may provide benefits for alternate care that is not
listed as a Covered Service through our Case Management program. We may also extend Covered
Services beyond the Benefit Maximums of this Plan. We will make our decision case-by-case, if in our
discretion the alternate or extended benefit is in the best interest of the Member and Anthem. A decision
to provide extended benefits or approve alternate care in one case does not obligate us to provide the
same benefits again to you or to any other Member. We reserve the right, at any time, to alter or stop
providing extended benefits or approving alternate care. n such case, we will notify you or your
authorized representative in writing.


48
Section 7. Benefits/Coverage (What is Covered)
This section describes the Covered Services available under your Plan. Covered Services are subject to
all the terms and conditions listed in this Booklet, including, but not limited to, Benefit Maximums,
Deductibles, Copayments, Coinsurance, Exclusions and Medical Necessity requirements. Please read
the "Schedule of Benefits (Who Pays What)" for details on the amounts you must pay for Covered
Services and for details on any Benefit Maximums. Also be sure to read "How to Access Your Services
and Obtain Approval of Benefits (Applicable to managed care plans)" for more information on your Plan's
rules. Read the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions) section for
important details on Excluded Services.
Your benefits are described below. Benefits are listed alphabetically to make them easy to find. Please
note that several sections may apply to your claims. For example, if you have inpatient surgery, benefits
for your Hospital stay will be described under "npatient Hospital Care "and benefits for your Doctor's
services will be described under "npatient Professional Services. As a result, you should read all
sections that might apply to your claims.
You should also know that many of Covered Services can be received in several settings, including a
Doctor's office, an Urgent Care Facility, an Outpatient Facility, or an npatient Facility. Benefits will often
vary depending on where you choose to get Covered Services, and this can result in a change in the
amount you need to pay. Please see the "Schedule of Benefits (Who Pays What) for more details on
how benefits vary in each setting.
Acupuncture
Please see "Therapy Service later in this section.
AIIergy Services
Your Plan includes benefits for Medically Necessary allergy testing and treatment, including allergy serum
and allergy shots.
AmbuIance Services
Medically Necessary ambulance services are a Covered Service when one or more of the following
criteria are met:
You are transported by a state licensed vehicle that is designed, equipped, and used only to transport
the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other
certified medical professionals. This includes ground, water, fixed wing, and rotary wing air
transportation.
For ground ambulance, you are taken:
! From your home, the scene of an accident or medical Emergency to a Hospital;
! Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an n-Network Hospital
! Between a Hospital and a Skilled Nursing Facility or other approved Facility.
For air or water ambulance, you are taken:
! From the scene of an accident or medical Emergency to a Hospital;
! Between Hospitals, including when we require you to move from an Out-of-Network Hospital to
an n-Network Hospital
! Between a Hospital and an approved Facility.

49
Ambulance services are subject to Medical Necessity reviews by us. When using an air ambulance, we
reserve the right to select the air ambulance Provider. f you do not use the air ambulance Provider we
select, the Out-of-Network Provider may bill you for any charges that exceed the Plan's Maximum
Allowed Amount.
You must be taken to the nearest Facility that can give care for your condition. n certain cases we may
approve benefits for transportation to a Facility that is not the nearest Facility.
Benefits also include Medically Necessary treatment of a sickness or injury by medical professionals from
an ambulance service, even if you are not taken to a Facility.
Ambulance services are not covered when another type of transportation can be used without
endangering your health. Ambulance services for your convenience or the convenience of your family or
Doctor are not a Covered Service.
Other non-covered ambulance services, include but are not limited to, trips to:
A Doctor's office or clinic;
A morgue or funeral home.
Important Notes on Air AmbuIance Benefits
Benefits are only available for air ambulance when it is not appropriate to use a ground or water
ambulance. For example, if using a ground ambulance would endanger your health and your medical
condition requires a more rapid transport to a Facility than the ground ambulance can provide, the Plan
will cover the air ambulance. Air ambulance will also be covered if you are in an area that a ground or
water ambulance cannot reach.
Air ambulance will not be covered if you are taken to a Hospital that is not an acute care Hospital (such
as a Skilled Nursing Facility), or if you are taken to a Physician's office or your home.
HospitaI to HospitaI Transport
f you are moving from one Hospital to another, air ambulance will only be covered if using a ground
ambulance would endanger your health and if the Hospital that first treats cannot give you the medical
services you need. Certain specialized services are not available at all Hospitals. For example, burn
care, cardiac care, trauma care, and critical care are only available at certain Hospitals. To be covered,
you must be taken to the closest Hospital that can treat you. Coverage is not avaiIabIe for air
ambuIance transfers simpIy because you, your famiIy, or your Provider prefers a specific HospitaI
or Physician.
Autism Services
Covered Services are provided for the assessment, diagnosis, and treatment of Autism Spectrum
Disorders (ASD) for a covered child. The following treatments will not be considered Experimental or
nvestigational and will be considered appropriate, effective, or efficient for the treatment of Autism
Spectrum Disorders where We determine such services are Medically Necessary:
Evaluation and assessment services;
Behavior training and behavior management and Applied Behavior Analysis, including but not limited
to consultations, direct care, supervision, or treatment, or any combination thereof, for Autism
Spectrum Disorders provided by Autism Services Providers;
Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy,
or speech therapy, or any combination of those therapies;

50
Prescription Drugs;
Psychiatric care;
Psychological care, including family counseling; and
Therapeutic care.
Treatment for Autism Spectrum Disorders must be prescribed or ordered by a Doctor or psychologist, and
services must be provided by a Provider covered under this Plan and approved to provide those services.
However, behavior training, behavior management, or Applied Behavior Analysis services (whether
provided directly or as part of Therapeutic Care), must be provided by an Autism Services Provider.
Coverage of Autism Spectrum Disorders in this section is in addition to coverage provided for early
intervention and Congenital Defects and Birth Abnormality. Autism services and the Autism Treatment
Plan are subject to review under the "How to Access Your Services and Obtain Approval of Benefits
(Applicable to managed care plans) section.
BehavioraI HeaIth Services
See "Mental Health, Alcohol and Substance Abuse Services later in this section.
Cardiac RehabiIitation
Please see "Therapy Services later in this section.
Chemotherapy
Please see "Therapy Services later in this section.
Chiropractor Services
Please see "Therapy Services later in this section.
CIinicaI TriaIs
Benefits include coverage for services given to you as a participant in an approved clinical trial if the
services are Covered Services under this Plan. An "approved clinical trial means a phase , phase ,
phase , or phase V clinical trial that studies the prevention, detection, or treatment of cancer or other
life-threatening conditions. The term life-threatening condition means any disease or condition from which
death is likely unless the disease or condition is treated.
Benefits are limited to the following trials:
1. Federally funded trials approved or funded by one of the following:
a. The National nstitutes of Health.
b. The Centers for Disease Control and Prevention.
c. The Agency for Health Care Research and Quality.
d. The Centers for Medicare & Medicaid Services.
e. Cooperative group or center of any of the entities described in (a) through (d) or the Department
of Defense or the Department of Veterans Affairs.

51
f. A qualified non-governmental research entity identified in the guidelines issued by the National
nstitutes of Health for center support grants.
g. Any of the following in i-iii below if the study or investigation has been reviewed and approved
through a system of peer review that the Secretary determines 1) to be comparable to the system
of peer review of studies and investigations used by the National nstitutes of Health, and 2)
assures unbiased review of the highest scientific standards by qualified individuals who have no
interest in the outcome of the review.
i. The Department of Veterans Affairs.
ii. The Department of Defense.
iii. The Department of Energy.
2. Studies or investigations done as part of an investigational new drug application reviewed by the
Food and Drug Administration;
3. Studies or investigations done for drug trials which are exempt from the investigational new drug
application.
Your Plan may require you to use an n-Network Provider to maximize your benefits.
When a requested service is part of an approved clinical trial, it is a Covered Service even though it might
otherwise be nvestigational as defined by this Plan. All other requests for clinical trials services that are
not part of approved clinical trials will be reviewed according to our Clinical Coverage Guidelines, related
policies and procedures.
Your Plan is not required to provide benefits for the following services. We reserve our right to exclude
any of the following services:
i. The nvestigational item, device, or service, itself; or
ii. tems and services that are given only to satisfy data collection and analysis needs and that are
not used in the direct clinical management of the patient; or
iii. A service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis;
iv. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial.
DentaI Services
Your DentaI Benefits
Anthem does not determine whether dental services listed in this section are medically necessary to treat
your specific condition or restore your dentition. There is a preset schedule of dental services that are
covered under this Plan. We evaluate the procedures submitted to us on your claim to determine if they
are a covered service under this Plan.

Exception: Claims for orthodontic care will be reviewed to determine if it was Dentally Necessary
Orthodontic Care. See the section "Orthodontic Care for more information.
Your dentist may recommend or prescribe other dental care services that are not covered, are cosmetic in
nature, or exceed the benefit frequencies of this Plan. While these services may be necessary for your
dental condition, they may not be covered by us. There may be an alternative dental care service
available to you that is covered under your Plan. These alternative services are called optional
treatments. f an allowance for an optional treatment is available, you may apply this allowance to the
initial dental service prescribed by your dentist. You are responsible for any costs that exceed the
allowance, in addition to any coinsurance or deductible you may have.

52
The decision as to what dental care treatment is best for you is solely between you and your dentist.
Pretreatment Estimate
A pretreatment estimate is a valuable tool for you and your dentist. t provides you and the dentist with an
idea of what your out of pocket costs will be for the dental care treatment. This will allow the dentist and
you to make any necessary financial arrangements before treatment begins. t is a good idea to get a
pretreatment estimate for dental care that involves major restorative, periodontic, prosthetic, or
orthodontic care
The pretreatment estimate is recommended, but not required for you to receive benefits for covered
dental care services.
A pretreatment estimate does not authorize treatment or determine its medical necessity (except for
orthodontics), and does not guarantee benefits. The estimate will be based on your current eligibility and
the Plan benefits in effect at the time the estimate is submitted to us. This is an estimate only. Our final
payment will be based on the claim that is submitted at the time of the completed dental care service(s).
Submission in other claims, changes to your eligibility or changes to the Plan may affect our final
payment.
You can ask your dentist to submit a pretreatment estimate for you, or you can send it to us yourself.
Please include the procedure codes for the services to be performed (your dentist can tell you what
procedure codes). Pretreatment estimate requests can be sent to the address on your dental D card.
{Pediatric dentaI:
[Pediatric DentaI for Members through Age 18

This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.

Diagnostic and Preventive Services

OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive

Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s)
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.

DentaI CIeaning (ProphyIaxis) Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.

FIuoride Treatment (TopicaI appIication) or fIuoride varnish) Covered 2 times per 12-month period.


53
SeaIants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.

Space Maintainers and Recementation of Space Maintainer - Covered only for premature loss of
primary posterior (back) teeth.

Emergency (PaIIiative) Treatment (for pain relief).

Basic Restorative Services

AmaIgam (siIver) Restoration Treatment to restore decayed or fractured permanent or primary
posterior (back) teeth. Covered once in a 24 month period per tooth surface.

Composite (white) Resin Restorations Covered once in a 24 month period for the same amalgam
restoration.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.

Major Restorative Services

Recement Crown.

Prefabricated StainIess SteeI or Resin Crown - Covered once per tooth in a 24 month period.

Sedative FiIIing.

Pin Retention per tooth in addition to restoration.

OraI Surgery

Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

CompIex SurgicaI Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth

Note: Surgical removal of 3rd molars are covered only if the removal is associated with symptoms of oral
pathology.

Endodontic Services

Therapeutic PuIpotomy - Covered for primary teeth only.

Root CanaI Therapy - Covered for permanent teeth only .


54
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

DentaIIy Necessary Orthodontic Care
To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:
a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth when
you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores at a
level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem that
interferes with the biting function.

Orthodontic treatment may include the following:
Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
nterceptive Treatment - A limited (phase ) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments
Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive ongoing
payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate of
Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued. A
new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve as
the claim form to be submitted 6 months from the date of appliance placement.]


55
{Pediatric/AduIt dentaI:
[DentaI Services
DentaI Services for Members through Age 18
This Plan covers the dental services below for Members through age 18 when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive.
Diagnostic and Preventive Services
OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Comprehensive
Periodic
Limited
Oral evaluation under 3 years of age
Detailed and extensive
Radiographs (X-rays)
Full mouth x-rays (complete series) Once per 60 months and includes bitewings
Periapical(s) 4 single x-rays per 12-month period.
Bitewings 1 series per 12-month period. Please note that this is not a benefit in addition to a full
mouth x-ray.
Panoramic film Once per 60-month period.
DentaI CIeaning (ProphyIaxis) -Covered once per calendar year. Prophylaxis is a procedure to remove
plaque, tartar (calculus), and stain from teeth.
FIuoride Treatment (Topical application) or fluoride varnish) Covered 2 times per 12-month period.
SeaIants Covered only when given on permanent molar teeth with occlusal surfaces intact, no caries
(decay) exists, and/ or there are no restorations. Coverage does not include prep or conditioning of tooth
or any other procedure associated with sealant application. Repair or replacement of sealant on any tooth
will not be covered within 36 months of application. Such repair or replacement given by the same dentist
that applied the sealant is considered included in the allowance for initial placement of sealant.
Space Maintainers and Recementation of Space Maintainer. Covered only for premature loss of
primary posterior (back) teeth.
Emergency (PaIIiative) Treatment (for pain reIief).
Basic Restorative Services
AmaIgam (siIver) Restoration Treatment to restore decayed or fractured permanent or primary teeth
posterior (back) teeth. Covered once in a 24 month period per tooth surface.
Composite (white) Resin Restorations Covered once in a 24 month period per tooth surface.
Anterior Teeth - Treatment to restore decayed or fractured permanent or primary anterior (front) teeth.
Posterior Teeth - Treatment to restore decayed or fractured permanent or primary posterior (back)
teeth. Coverage for a composite restoration on a posterior tooth is an optional treatment and will be

56
equal to that of the amalgam restoration. You are responsible to pay for any difference between the
maximum allowed amount for an amalgam and the actual charge of the optional treatment.
Major Restorative Services
Recement Crown.
Prefabricated StainIess SteeI or Resin Crown. Covered once per tooth in a 24 month period.
Sedative FiIIing.
Pin Retention - per tooth in addition to restoration.
OraI Surgery
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root

CompIex SurgicaI Extractions

Surgical removal of impacted tooth

Note: Surgical removal of 3
rd
molars are covered only if the removal is associated with symptoms
of oral pathology.

Endodontic Services

Therapeutic PuIpotomy. Covered only for primary teeth.

Root CanaI Therapy. Covered for permanent teeth only.
Orthodontic Care

Orthodontic Treatment is the prevention and correction of malocclusion of teeth and associated dental
and facial disharmonies. You should submit your treatment plan to us before you start any orthodontic
treatment to make sure it is covered under this Plan.

DentaIIy Necessary Orthodontic Care

To be considered Dentally Necessary Orthodontic Care, at least one of the following criteria must be
present:

a. There is spacing between adjacent teeth which interferes with the biting function;
b. There is an overbite to the extent that the lower anterior teeth impinge on the roof of the mouth
when you bite;
c. Positioning of the jaws or teeth impair chewing or biting function;
d. On an objective professionally recognized dental orthodontic severity index, the condition scores
at a level consistent with the need for orthodontic care; or
e. Based on a comparable assessment of items a through d, there is an overall orthodontic problem
that interferes with the biting function.


57
Orthodontic treatment may incIude the foIIowing:

Limited Treatment - Treatments which are not full treatment cases and are usually done for minor
tooth movement.
nterceptive Treatment - A limited (phase ) treatment phase used to prevent or assist in the severity
of future treatment.
Comprehensive (complete) Treatment - Full treatment includes all radiographs, diagnostic
casts/models, appliances and visits.
Removable Appliance Therapy - An appliance that is removable and not cemented or bonded to the
teeth.
Fixed Appliance Therapy - A component that is cemented or bonded to the teeth.
Complex Surgical Procedures surgical exposure of impacted or unerupted tooth for orthodontic
reasons; or surgical repositioning of teeth.

Note: Treatment in progress (appliances placed prior to being covered under this Plan will be covered on
a pro-rated basis.

Orthodontic Payments

Because orthodontic treatment normally occurs over a long period of time, payments are made over the
course of your treatment. You must have continuous coverage under this Plan in order to receive
ongoing payments for your orthodontic treatment.

Payments for treatment are made: (1) when treatment begins (appliances are installed), and (2) at six
month intervals thereafter, until treatment is completed or this coverage ends.

Before treatment begins, the treating dentist should submit a pre-treatment estimate to us. An Estimate
of Benefits form will be sent to you and your dentist indicating the estimated maximum allowed amount,
including any amount (Deductible or Coinsurance) you may owe. This form serves as a claim form when
treatment begins.

When treatment begins, the dentist should submit the Estimate of Benefit form with the date of appliance
placement and his/her signature. After benefit and eligibility verification by us, a payment will be issued.
A new/revised Estimate of Benefits form will also be issued to you and your dentist. This again will serve
as the claim form to be submitted 6 months from the date of appliance placement.]
DentaI Services for Members Age 19 and OIder
This Plan covers the dental services below for Members age 19 and older when they are performed by a
licensed dentist and when they are necessary and customary, as determined by the standards of
generally accepted dental practice. f there is more than one professionally acceptable treatment for your
dental condition, the Plan will cover the least expensive treatment.
Diagnostic and Preventive Services
OraI EvaIuations Any type of evaluation (checkup or exam) is covered 2 times per calendar year.
Radiographs (X-rays)
Bitewings - 1 series per 24-month period.
Full Mouth (Complete Series) or Panoramic - Once per 60-month period.
Periapical(s) - 4 single x-rays per 12-month period.
Occlusal - 2 series per 24-month period.

58
DentaI CIeaning (ProphyIaxis) Prophylaxis is a procedure to remove plaque, tartar (calculus), and stain
from teeth. Any combination of this procedure and periodontal maintenance (See "Periodontal Services
below) are covered 2 times per calendar year.
Basic Restorative Services
Emergency Treatment Emergency (palliative) treatment for the temporary relief of pain or infection.
AmaIgam (siIver) Restorations Treatment to restore decayed or fractured permanent or primary teeth.
Composite (white) Resin Restorations
Anterior (front) Teeth - Treatment to restore decayed or fractured permanent or primary anterior
(front) teeth.
Posterior (back) Teeth - Treatment to restore decayed or fractured permanent or primary posterior
(back) teeth.
Benefits will be limited to the same surfaces and allowances for amalgam (silver filling). You must pay
the difference in cost between the Maximum Allowed Amount for the Covered Service and the optional
treatment plus any Deductible and/or Coinsurance.
Benefits for amalgam or composite restorations will be limited to one service per tooth surface per 24-
month period.
Basic Extractions
Removal of coronal remnants (retained pieces of the crown portion of the tooth) on primary teeth
Extraction of erupted tooth or exposed root
Brush Biopsy - Covered once per 36-month period for Members age 20 to 39. Covered once per 12-
month period for Members age 40 and older.
Endodontic Services
Endodontic Therapy on Primary Teeth
Pulpal Therapy
Therapeutic Pulpotomy
Endodontic Therapy on Permanent Teeth
Root Canal Therapy
Root Canal Retreatment
All of the above endodontic services are limited to once per tooth per lifetime.
PeriodontaI Services
PeriodontaI Maintenance A procedure that includes removal of bacteria from the gum pocket areas,
scaling and polishing of the teeth, periodontal evaluation and gum pocket measurements for patients who
have completed periodontal treatment.

59
Benefits for any combination of this procedure and dental cleanings (see "Diagnostic and Preventive
Services section) are limited to 2 times per calendar year.
Basic Non-SurgicaI PeriodontaI Care Treatment of diseases of the gingival (gums) and bone
supporting the teeth.
Periodontal scaling & root planning is covered once per 36 months if the tooth has a pocket depth of
4 millimeters or greater.
Full mouth debridement is covered once per lifetime.
CompIex SurgicaI PeriodontaI Care Surgical treatment of diseases of the gingival (gums) and bone
supporting the teeth. The following services are considered complex surgical periodontal services:
Gingivectomy/gingivoplasty;
Gingival flap;
Apically positioned flap;
Osseous surgery;
Bone replacement graft;
Pedicle soft tissue graft;
Free soft tissue graft;
Subepithelial connective tissue graft;
Soft tissue allograft;
Combined connective tissue and double pedicle graft;
Distal/proximal wedge - Covered on natural teeth only
Complex surgical periodontal services are limited as follows:
Only one complex surgical periodontal service is covered per 36-month period per single tooth; or
Only one complex surgical periodontal service is covered per 36-month period for multiple teeth in the
same quadrant if the pocket depth of the tooth is 5 millimeters or greater.
OraI Surgery Services
CompIex SurgicaI Extractions
Surgical removal of erupted tooth
Surgical removal of impacted tooth
Surgical removal of residual tooth roots
Surgical removals of third molars are only covered if the removal is associated with symptoms of oral
pathology.
Other CompIex SurgicaI Procedures Covered only when required to prepare for dentures and limited to
once in a 60-month period:
Alveoloplasty
Vestibuloplasty
Removal of exostosis-per site
Surgical reduction of osseous tuberosity
SurgicaI Reduction of Fibrous Tuberosity Covered once every 6 months.

60
Adjunctive GeneraI Services
ntravenous Conscious Sedation, V Sedation, and General Anesthesia Covered only when given
with covered complex surgical services. Benefits are not available when given with non-surgical
dental care.
Major Restorative Services
GoId foiI restorations The Plan will cover an amalgam (silver filling) benefit equal to the same number of
surfaces and allowances.
You must pay the difference in cost between the Maximum Allowed Amount for the Covered Services and
optional treatment plus any Deductible and/or Coinsurance that applies. Covered once per 24-month
period.
InIays Benefit will equal an amalgam (silver) restoration for the same number of surfaces.
f an inlay is performed to restore a posterior (back) tooth with a metal, porcelain, or any composite
(white) based resin material, the patient must pay the difference in cost between the Maximum Allowed
Amount for the Covered Service and inlay, plus any Deductible and/or Coinsurance that applies.
OnIays and/or Permanent Crowns Covered once every 7 years if the tooth has extensive loss of natural
tooth structure due to decay or tooth fracture such that a restoration cannot be used to restore the tooth.
We will pay up to the Maximum Allowed Amount for a porcelain to noble metal crown. You must pay the
difference in cost between the porcelain to noble metal crown and the optional treatment, plus any
Deductible and/or Coinsurance that applies.
ImpIant Crowns See "Prosthodontic Services.
Recement InIay, OnIay, and Crowns Covered 6 months after initial placement.
Crown/InIay/OnIay Repair Covered once per 12-month period per tooth when the submitted narrative
from the treating dentist supports the procedure.
Restorative cast post and core buiId-up, incIuding 1 post per tooth and 1 pin per surface Covered
once every 7 years when necessary to retain an indirectly fabricated restoration due to extensive loss of
actual tooth structure due to caries or fracture.
Prosthodontic Services
Tissue Conditioning Covered once per 24-month period.
ReIine and Rebase Covered once per 24-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge).
Repairs, RepIacement of Broken ArtificiaI Teeth, RepIacement of Broken CIasp(s) Covered once per
6-month period when:
The prosthetic appliance (denture, partial or bridge) is the permanent prosthetic appliance;

61
At least 6 months have passed since the initial placement of the prosthetic appliance (denture, partial
or bridge); and
When the submitted narrative from the treating dentist supports the procedure.
Denture Adjustments Covered 2 times per 12-month period when:
The denture is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the denture.
PartiaI and Bridge Adjustments Covered 2 times per 24-month period when:
The partial or bridge is the permanent prosthetic appliance; and
At least 6 months have passed since the initial placement of the partial or bridge.
RemovabIe Prosthetic Services (Dentures and PartiaIs) Covered once per 7 year period:
For the replacement of extracted (removed) permanent teeth;
f 7 years have passed since the last covered removable prosthetic appliance (denture or partial) and
the existing denture or partial cannot be repaired or adjusted.
Fixed Prosthetic Services (Bridge) Covered once every 7 years:
For the replacement of extracted (removed) permanent teeth;
f no more than 3 teeth are missing in the same arch;
A natural, healthy, sound tooth is present to serve as the anterior and posterior retainer;
No other missing teeth in the same arch that have not been replaced with a removable partial
denture;
f none of the individual units of the bridge has been covered previously as a crown or cast restoration
in the last 7 years;
f 7 years have passed since the last covered removable prosthetic appliance (bridge) and the
existing bridge cannot be repaired or adjusted.
f there are multiple missing teeth, benefits may only be paid for a removable partial denture if it would be
the least costly, commonly performed course of treatment. Any optional benefits are subject to all
contract limits on the Covered Service.
Recement Fixed Prosthetic Covered once per 12 months.
SingIe Tooth ImpIant Body, Abutment and Crown Covered once per 7 year period. Coverage includes
only the single surgical placement of the implant body, implant abutment and implant/abutment supported
crown.
Some adjunctive impIant services may not be covered. We recommend that you get a
pretreatment estimate to estimate the amount of payment before you begin treatment.]
DentaI Services (AII Members / AII Ages)
Preparing the Mouth for MedicaI Treatments
Your Plan includes coverage for dental services to prepare the mouth for medical services and treatments
such as radiation therapy to treat cancer and prepare for transplants. Covered Services include:
Evaluation
Dental x-rays

62
Extractions, including surgical extractions
Anesthesia
Accident-ReIated DentaI Services
Benefits are also available for dental work needed to treat injuries to the jaw, sound natural teeth, mouth
or face as a result of an accident. An injury that results from chewing or biting is not considered an
Accidental njury under this Plan, unless the chewing or biting results from a medical or mental condition.
Treatment must begin within 90 days of the injury to be a Covered Service under this Plan.
CIeft PaIate and CIeft Lip Conditions
Benefits are available for inpatient care and outpatient care, including:
Orofacial surgery
Surgical care and follow-up care by plastic surgeons and oral surgeons
Orthodontics and prosthodontic treatment
Prosthetic treatment such as obturators, speech appliances, and prosthodontic
Prosthodontic and surgical reconstruction for the treatment of cleft palate and/or cleft lip
f you have a dental plan, the dental plan would be the main plan and must fully cover orthodontics and
dental care for cleft palate and cleft lip conditions.
DentaI Anesthesia for ChiIdren
Benefits are available for general anesthesia from a Hospital, outpatient surgical Facility or other Facility,
and for the Hospital or Facility charges needed for dental care for a covered Dependent child who:
Has a physical, mental or medically compromising condition
Has dental needs for which local anesthesia is not effective because of acute infection, anatomic
variation or allergy
s extremely uncooperative, unmanageable, uncommunicative or anxious and whose dental needs
are deemed sufficiently important that dental care cannot be deferred
Has sustained extensive orofacial and dental trauma.
Diabetes Equipment, Education, and SuppIies
Your Plan covers diabetes training and medical nutrition therapy if you have diabetes (whether or not it is
insulin dependent), or if you have raised blood glucose levels caused by pregnancy. Other medical
conditions may also qualify. But the services need to be ordered by a Doctor and given by a Provider
who is certified, registered or with training in diabetes. Diabetes training sessions must be provided by a
Provider in an outpatient Facility or in a Doctor's office.
Screenings for gestational diabetes are covered under "Preventive Care later in this section.
Diagnostic Services
Your Plan includes benefits for tests or procedures to find or check a condition when specific symptoms
exist. Tests must be ordered by a Provider and include diagnostic services ordered before a surgery or
Hospital admission. Benefits include the following services:

63
Diagnostic Laboratory and PathoIogy Services
Diagnostic Imaging Services and EIectronic Diagnostic Tests
X-rays / regular imaging services
Ultrasound
Electrocardiograms (EKG)
Electroencephalography (EEG)
Echocardiograms
Hearing and vision tests for a medical condition or injury (not for screenings or preventive care)
Tests ordered before a surgery or admission.
Advanced Imaging Services
Benefits are also available for advanced imaging services, which include but are not limited to:
CT scan
CTA scan
Magnetic Resonance maging (MR)
Magnetic Resonance Angiography (MRA)
Magnetic resonance spectroscopy (MRS)
Nuclear Cardiology
PET scans
PET/CT Fusion scans
QTC Bone Densitometry
Diagnostic CT Colonography
The list of advanced imaging services may change as medical technologies change.
DiaIysis
See "Therapy Services later in this section.
DurabIe MedicaI Equipment and MedicaI Devices, Orthotics,
Prosthetics, and MedicaI and SurgicaI SuppIies
DurabIe MedicaI Equipment and MedicaI Devices
Your Plan includes benefits for durable medical equipment and medical devices when the equipment
meets the following criteria:
s meant for repeated use and is not disposable.
s used for a medical purpose and is of no further use when medical need ends.
s meant for use outside a medical Facility.
s only for the use of the patient.
s made to serve a medical use.
s ordered by a Provider.
Benefits include purchase-only equipment and devices (e.g., crutches and customized equipment),
purchase or rent-to-purchase equipment and devices (e.g., Hospital beds and wheelchairs), and
continuous rental equipment and devices (e.g., oxygen concentrator, ventilator, and negative pressure
wound therapy devices). Continuous rental equipment must be approved by us. We may limit the

64
amount of coverage for ongoing rental of equipment. We may not cover more in rental costs than the cost
of simply purchasing the equipment.
Benefits include repair and replacement costs as well as supplies and equipment needed for the use of
the equipment or device, for example, a battery for a powered wheelchair.
Oxygen and equipment for its administration are also Covered Services. Benefits are also available for
cochlear implants.
Hearing Aid Services
For children under 18, subject to the terms of the Booklet, your Plan covers the following hearing aids and
the services that go with them when provided by or purchased as a result of a written recommendation
from an otolaryngologist or a state-certified audiologist:
Audiological testing to measure the level of hearing loss and to choose the proper make and model of
a hearing aid. These evaluations will be provided under the prior "Diagnostic Services of this
section;
Hearing aids (monaural or binaural) including ear mold(s), the hearing aid instrument, batteries, cords
and other ancillary equipment. The Plan covers auditory training when it is offered using approved
professional standards. nitial and replacement hearing aids will be supplied every 5 years, a new
hearing aid may be a covered service when alterations to your existing hearing aid cannot adequately
meet your needs or be repaired; and
Visits for fitting, counseling, adjustments and repairs after receiving the covered hearing aid.
Orthotics
Benefits are available for certain types of orthotics (braces, boots, splints). Covered Services include the
initial purchase, fitting, and repair of a custom made rigid or semi-rigid supportive device used to support,
align, prevent, or correct deformities or to improve the function of movable parts of the body, or which
limits or stops motion of a weak or diseased body part.
Prosthetics
Your Plan also includes benefits for prosthetics, which are artificial substitutes for body parts for functional
or therapeutic purposes, when they are required to adequately meet your needs.
Benefits include the purchase, fitting, adjustments, repairs and replacements. Covered Services may
include, but are not limited to:
1) Artificial limbs and accessories. For prosthetic arms and legs we cover up to the benefits amounts
provide by federal laws for Medicare or where needed to meet state insurance laws;
2) One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes);
3) Breast prosthesis (whether internal or external) after a mastectomy, as required by the Women's
Health and Cancer Rights Act;
4) Colostomy and other ostomy (surgical construction of an artificial opening) supplies directly related to
ostomy care;
5) Restoration prosthesis (composite facial prosthesis);

65
MedicaI and SurgicaI SuppIies
Your Plan includes coverage for medical and surgical supplies that serve only a medical purpose, are
used once, and are purchased (not rented). Covered supplies include syringes, needles, surgical
dressings, splints, diabetic supplies, and other similar items that serve only a medical purpose. Covered
Services do not include items often stocked in the home for general use like Band-Aids, thermometers,
and petroleum jelly.
BIood and BIood Products
Your Plan also includes coverage for the administration of blood products unless they are received from a
community source, such as blood donated through a blood bank.
Emergency Care Services
Emergency Services
Benefits are available in a Hospital Emergency Room for services and supplies to treat the onset of
symptoms, screen and stabilize an Emergency, which is defined below:
Emergency (Emergency MedicaI Condition)
"Emergency or "Emergency Medical Condition means health care services provided in connection with
any event that a prudent layperson having average knowledge of health services and medicine and acting
reasonably would believe threatens his or her life or limb in such a manner that a need for immediate
medical care is created to prevent death or serious impairment of health.
Emergency Care
"Emergency Care means a medical exam done in the Emergency Department of a Hospital, and
includes services routinely available in the Emergency Department to evaluate an Emergency Condition.
t includes any further medical exams and treatment required to stabilize the patient.
f you are experiencing an Emergency please call 911 or visit the nearest Hospital for treatment.
Medically Necessary services will be covered whether you get care from an n-Network or Out-of-Network
Provider. Emergency Care you get from an Out-of-Network Provider will be covered as an n-Network
service, you will not need to pay more than what you would have if you had seen an n-Network Provider.
f you are admitted to the Hospital from the Emergency Room, be sure that you or your Doctor calls us as
soon as possible. We will review your care to decide if a Hospital stay is needed and how many days you
should stay. See "How to Access Your Services and Obtain Approval of Benefits (Applicable to managed
care plans) for more details. f you or your Doctor do not call us, you may have to pay for services that
are determined to be not Medically Necessary.
With respect to an Emergency, stabilize means to provide such medical treatment of the condition as may
be necessary to assure, within reasonable medical probability, that no material deterioration of the
condition is likely to result from or occur during the transfer of the Member from a facility. With respect to
a pregnant woman who is having contractions, the term "stabilize also means to deliver (including the
placenta), if there is inadequate time to effect a safe transfer to another Hospital before delivery or
transfer may pose a threat to the health or safety of the woman or the unborn child. Treatment you get
after your condition has stabilized is not Emergency Care. f you continue to get care from an Out-of-
Network Provider, Covered Services will be covered at the Out-of-Network level unless we agree to cover
it as an Authorized Service.

66
Home Care Services
Benefits are available for Covered Services performed by a Home Health Care Agency or other Provider
in your home. To be eligible for benefits, you must essentially be confined to the home, as an alternative
to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis.
Services must be prescribed by a Doctor and the services must be so inherently complex that they can be
safely and effectively performed only by qualified, technical, or professional health staff.
Covered Services include but are not limited to:
ntermittent skilled nursing services by an R.N. or L.P.N.
Medical / social services
Diagnostic services
Nutritional guidance
Training of the patient and/or family/caregiver
Home health aide services. You must be receiving skilled nursing or therapy. Services must be given
by appropriately trained staff working for the Home Health Care Provider. Other organizations may
give services only when approved by us, and their duties must be assigned and supervised by a
professional nurse on the staff of the Home Health Care Provider.
Therapy Services of physical, occupational, speech and language, respiratory and inhalation (except
for Manipulation Therapy which will not be covered when given in the home)
Medical supplies
Durable medical equipment, prosthetics and orthopedic appliances
Private duty nursing in the home
Home Infusion Therapy
See "Therapy Services later in this section.
Hospice Care
The services and supplies listed below are Covered Services when given by a Hospice for the palliative
care of pain and other symptoms that are part of a terminal disease. Palliative care means care that
controls pain and relieves symptoms, but is not meant to cure a terminal illness. Hospice care includes
routine home care, constant home care, inpatient Hospice and inpatient respite. Covered Services
include:
Care from an interdisciplinary team with the development and maintenance of an appropriate plan of
care.
Short-term npatient Hospital care when needed in periods of crisis or as respite care.
Skilled nursing services, home health aide services, and homemaker services given by or under the
supervision of a registered nurse.
Doctor services and diagnostic testing.
Social services and counseling services from a licensed social worker.
Nutritional support such as intravenous feeding and feeding tubes and nutritional counseling.
Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed
therapist.
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition,
including oxygen and related respiratory therapy supplies.
Prosthetics and orthopedic appliances.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Member's death.
Bereavement services are available to the patient/family consisting of those individuals who are

67
closely linked to the patient, including the immediate family, the primary or designated care giver and
individuals with significant personal ties.
Transportation.
Your Doctor and Hospice medical director must certify that you are terminally ill and likely have less than
six months to live. Your Doctor must agree to care by the Hospice and must be consulted in the
development of the care plan. The Hospice must keep a written care plan on file and give it to us upon
request.
Benefits for Covered Services beyond those listed above, such as chemotherapy and radiation therapy
given as palliative care, are available to a Member in Hospice. These additional Covered Services will be
covered under other parts of this Plan. Any care you get that has to do with an unrelated illness or
medical condition will be subject to the provisions of this plan that deals with that illness.
Human Organ and Tissue TranspIant (Bone Marrow / Stem CeII)
Services
Your Plan includes coverage for Medically Necessary human organ and tissue transplants. Certain
transplants (e.g., cornea and kidney) are covered like any other surgery, under the regular inpatient and
outpatient benefits described elsewhere in this Booklet.
This section describes benefits for certain Covered Transplant Procedures that you get during the
Transplant Benefit Period. Any Covered Services related to a Covered Transplant Procedure, received
before or after the Transplant Benefit Period, are covered under the regular npatient and outpatient
benefits described elsewhere in this Booklet.
n this section you will see some key terms, which are defined below:
Covered TranspIant Procedure
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and infusions including necessary acquisition procedures, mobilization, harvest and storage.
t also includes Medically Necessary myeloablative or reduced intensity preparative chemotherapy,
radiation therapy, or a combination of these therapies.
As decided by us, any Medically Necessary human organ, tissue, and stem cell / bone marrow
transplants and transfusions including necessary acquisition procedures, harvest and storage, and
including Medically Necessary preparatory myeloablative therapy.
In-Network TranspIant Provider
A Provider that we have chosen as a Center of Excellence and/or a Provider selected to take part as an
n-Network Transplant Provider by a designee. The Provider has entered into a Transplant Provider
Agreement to give Covered Transplant Procedures to you and take care of certain administrative duties
for the transplant network. A Provider may be an n-Network Transplant Provider for:
Certain Covered Transplant Procedures; or
All Covered Transplant Procedures.
Out-of-Network TranspIant Provider
Any Provider that has NOT been chosen as a Center of Excellence by us or has not been selected to
take part as an n-Network Transplant Provider by a designee.

68
TranspIant Benefit Period
At an n-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts for the applicable case rate / global time period. The number of
days will vary depending on the type of transplant received and the n-Network Transplant Provider
agreement. Call the Case Manager for specific n-Network Transplant Provider details for services
received at or coordinated by an n-Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
Prior ApprovaI and Precertification
To maximize your benefits, you shouId caII our TranspIant Department as soon as you think you
may need a transpIant to taIk about your benefit options. You must do this before you have an
evaIuation and/or work-up for a transpIant. We will help you maximize your benefits by giving you
coverage information, including details on what is covered and if any clinical coverage guidelines, medical
policies, n-Network Transplant Provider rules, or Exclusions apply. Call the Customer Service phone
number on the back of your dentification Card and ask for the transplant coordinator. Even if we give a
prior approval for the Covered Transplant Procedure, you or your Provider must call our Transplant
Department for Precertification prior to the transplant whether this is performed in an npatient or
Outpatient setting.
Precertification is required before we will cover benefits for a transplant. Your Doctor must certify, and we
must agree, that the transplant is Medically Necessary. Your Doctor should send a written request for
Precertification to us as soon as possible to start this process. Not getting Precertification will result in a
denial of benefits.
Please note that there are cases where your Provider asks for approval for HLA testing, donor searches
and/or a harvest and storage of stem cells prior to the final decision as to what transplant procedure will
be needed. n these cases, the HLA testing and donor search charges will be covered as routine
diagnostic tests. The harvest and storage request will be reviewed for Medical Necessity and may be
approved. However, such an approval for HLA testing, donor search and/or harvest and storage is NOT
an approval for the later transplant. A separate Medical Necessity decision will be needed for the
transplant.
Donor Benefits
Benefits for an organ donor are as follows:
When both the person donating the organ and the person getting the organ are our covered
Members, each will get benefits under their Plan.
When the person getting the organ is our covered Member, but the person donating the organ is not,
benefits under this Plan are limited to benefits not available to the donor from any other source. This
includes, but is not limited to, other insurance, grants, foundations, and government programs.
f our covered Member is donating the organ to someone who is not a covered Member, benefits are
not available under this Plan.
Transportation and Lodging
We will cover the cost of reasonable and necessary travel costs when you get prior approval and need to
travel more than 75 miles from your permanent home to reach the Facility where the Covered Transplant
Procedure will be performed. Our help with travel costs includes transportation to and from the Facility,
and lodging for the patient and one companion. f the Member receiving care is a minor, then reasonable

69
and necessary costs for transportation and lodging may be allowed for two companions. You must send
itemized receipts for transportation and lodging costs in a form satisfactory to us when claims are filed.
Call us for complete information.
For lodging and ground transportation benefits, we will cover costs up to the current limits set forth in the
nternal Revenue Code.
Non-Covered Services for transportation and lodging include, but are not limited to:
Child care,
Mileage within the medical transplant Facility city,
Rental cars, buses, taxis, or shuttle service, except as specifically approved by us,
Frequent Flyer miles,
Coupons, Vouchers, or Travel tickets,
Prepayments or deposits,
Services for a condition that is not directly related, or a direct result, of the transplant,
Phone calls,
Laundry,
Postage,
Entertainment,
Travel costs for donor companion/caregiver,
Return visits for the donor for a treatment of an illness found during the evaluation,
Meals.
InfertiIity Services
Please see "Maternity and Reproductive Health Services later in this section.
Inpatient Services
Inpatient HospitaI Care
Covered Services include acute care in a Hospital setting.
Benefits for room, board, and nursing services include:
A room with two or more beds.
A private room. The most the Plan will cover for private rooms is the Hospital's average semi-private
room rate unless it is Medically Necessary that you use a private room for isolation and no isolation
facilities are available.
A room in a special care unit approved by us. The unit must have facilities, equipment, and supportive
services for intensive care or critically ill patients.
Routine nursery care for newborns during the mother's normal Hospital stay.
Newborn care for during and after the mother's maternity Hospital stay for treatment of injury and
sickness and medically diagnosed Congenital Defects and Birth Abnormalities.
Meals, special diets.
General nursing services.

70
Benefits for ancillary services include:
Operating, childbirth, and treatment rooms and equipment.
Prescribed Drugs.
Anesthesia, anesthesia supplies and services given by the Hospital or other Provider.
Medical and surgical dressings and supplies, casts, and splints.
Diagnostic services.
Therapy services.
Inpatient ProfessionaI Services
Covered Services include:
Medical care visits.
ntensive medical care when your condition requires it.
Treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for
surgery. Benefits include treatment by two or more Doctors during one Hospital stay when the nature
or severity of your health problem calls for the skill of separate Doctors.
A personal bedside exam by another Doctor when asked for by your Doctor. Benefits are not
available for staff consultations required by the Hospital, consultations asked for by the patient,
routine consultations, phone consultations, or EKG transmittals by phone.
Surgery and general anesthesia.
Newborn exam. A Doctor other than the one who delivered the child must do the exam.
Professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology.
Maternity and Reproductive HeaIth Services
Maternity Services
Covered Services include services needed during a normal or complicated pregnancy and for services
needed for a miscarriage. Covered maternity services include:
Professional and Facility services for childbirth in a Facility or the home including the services of an
appropriately licensed nurse midwife;
Routine nursery care for the newborn during the mother's normal Hospital stay, including circumcision
of a covered male Dependent;
Prenatal and postnatal services; and
Fetal screenings, which are genetic or chromosomal tests of the fetus, as allowed by us.
f you are pregnant on your Effective Date and in the first trimester of the pregnancy, you must change to
an n-Network Provider to have Covered Services covered at the n-Network level. f you are pregnant on
your Effective Date and in your second or third trimester of pregnancy (13 weeks or later) as of the
Effective Date, benefits for obstetrical care will be available at the n-Network level even if an Out-of-
Network Provider is used if you fill out a Continuation of Care Request Form and send it to us. Covered
Services will include the obstetrical care given by that Provider through the end of the pregnancy and the
immediate post-partum period.
Important Note About Maternity Admissions: Under federal law, we may not limit benefits for any
Hospital length of stay for childbirth for the mother or newborn to less than 48 hours after vaginal birth, or
less than 96 hours after a cesarean section (C-section). f the baby is born between 8:00 p.m. and 8:00
a.m., coverage will continue until 8:00 a.m. on the morning after the 48 or 96 hours timeframe. However,
federal law as a rule does not stop the mother's or newborn's attending Provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours, or 96 hours, as applicable. n
any case, as provided by federal law, we may not require a Provider to get authorization from us before

71
prescribing a length of stay which is not more than 48 hours for a vaginal birth or 96 hours after a C-
section.
Contraceptive Benefits
Benefits include oral contraceptive Drugs, injectable contraceptive Drugs and patches. Benefits also
include contraceptive devices such as diaphragms, intra uterine devices (UDs), and implants. Certain
contraceptives are covered under the "Preventive Care benefit. Please see that section for further
details.
SteriIization Services
Benefits include sterilization services and services to reverse a non-elective sterilization that resulted from
an illness or injury. Reversals of elective sterilizations are not covered. Sterilizations for women are
covered under the "Preventive Care benefit.
Abortion Services
Benefits include services for therapeutic or elective abortion regardless if Medically Necessary, unless
applicable law or regulation prohibits the Group from providing such coverage (in which case, Covered
Services are provided only to the extent necessary to prevent the death of the mother or unborn baby).
InfertiIity Services
Important Note: Although this Plan offers limited coverage of certain infertility services, it does not cover
all forms of infertility treatment. Benefits do not include assisted reproductive technologies (ART) or the
diagnostic tests and Drugs to support it. Examples of ART include artificial insemination, in-vitro
fertilization, zygote intrafallopian transfer (ZFT), or gamete intrafallopian transfer (GFT).
Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy,
endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical
conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).
Fertility treatments such as artificial insemination and in-vitro fertilization are not a Covered Service.
MentaI HeaIth, AIcohoI and Substance Abuse Services
Covered Services include the following:

Inpatient Services in a Hospital or any facility that we must cover per state law. npatient benefits
include psychotherapy, psychological testing, electroconvulsive therapy, and detoxification.

Outpatient Services including office visits and treatment in an outpatient department of a Hospital or
outpatient Facility, such as partial hospitalization programs and intensive outpatient programs.

ResidentiaI Treatment which is specialized 24-hour treatment in a licensed residential treatment
center. t offers individualized and intensive treatment and includes:

Observation and assessment by a psychiatrist weekly or more often,
Rehabilitation, therapy, and education.

You can get Covered Services under this section from the following Providers:

Psychiatrist,
Psychologist,

72
Neuropsychologist,
Licensed clinical social worker (L.C.S.W.),
Mental health clinical nurse specialist,
Licensed marriage and family therapist (L.M.F.T.),
Licensed professional counselor (L.P.C) or
Any agency licensed by the state to give these services, when we have to cover them by law!
OccupationaI Therapy
Please see "Therapy Services later in this section.
Office Visits and Doctor Services
Covered Services include:
Office Visits for medical care (including second surgical opinions) to examine, diagnose, and treat an
illness or injury.
Home Visits for medical care to examine, diagnose, and treat an illness or injury. Please note that
Doctor visits in the home are different than the "Home Care Services benefit described earlier in this
Booklet.
RetaiI HeaIth CIinic Care for limited basic health care services to Members on a "walk-in basis. These
clinics are normally found in major pharmacies or retail stores. Health care services are typically given by
Physician's Assistants or Nurse Practitioners. Services are limited to routine care and treatment of
common illnesses for adults and children.
WaIk-In Doctor's Office for services limited to routine care and treatment of common illnesses for adults
and children. You do not have to be an existing patient or have an appointment to use a walk-in Doctor's
office.
Urgent Care as described in "Urgent Care Services later in this section.
OnIine Care Visits when available in your area. Covered Services include a medical visit with the Doctor
using the internet by a webcam, chat or voice. Online care visits do not include reporting normal lab or
other test results, requesting office visits, getting answers to billing, insurance coverage or payment
questions, asking for referrals to doctors outside the online care panel, benefit precertification, or Doctor
to Doctor discussions.
Hearing Exams and tests to determine the need for hearing correction. For additional information on
hearing aid services, please see "Durable Medical Equipment and Medical Devices, Orthotics,
Prosthetics, and Medical and Surgical Supplies earlier in this section.
Prescription Drugs Administered in the Office
Orthotics
See "Durable Medical Equipment and Medical Devices, Orthotics, Prosthetics, and Medical and Surgical
Supplies earlier in this section.

73
Outpatient FaciIity Services
Your Plan includes Covered Services in an:
Outpatient Hospital,
Ambulatory Surgical Facility,
Mental Health / Substance Abuse Facility, or
Other Facilities approved by us.
Benefits include Facility and related (ancillary) charges, when proper, such as:
Surgical rooms and equipment,
Prescription Drugs, including Specialty Drugs,
Anesthesia and anesthesia supplies and services given by the Hospital or other Facility,
Medical and surgical dressings and supplies, casts, and splints,
Diagnostic services,
Therapy services.
PhysicaI Therapy
Please see "Therapy Services later in this section.
Preventive Care
Preventive care includes screenings and other services for adults and children with no current symptoms
or history of a health problem.
Members who have current symptoms or a diagnosed health problem will get benefits under the
"Diagnostic Services benefit, not this benefit.
Preventive care services will meet the requirements of federal and state law. Many preventive care
services are covered with no Deductible, Copayments or Coinsurance when you use an n-Network
Provider. That means we cover 100% of the Maximum Allowed Amount. Covered Services fall under
four broad groups:
1. Services with an "A or "B rating from the United States Preventive Services Task Force. Examples
include screenings for:
a. Breast cancer,
b. Cervical cancer,
c. Colorectal cancer,
d. High blood pressure,
e. Type 2 Diabetes Mellitus,
f. Cholesterol,
g. Child and adult obesity.
Smoking cessation counseling and intervention is also covered.
2. mmunizations for children, adolescents, and adults recommended by the Advisory Committee on
mmunization Practices of the Centers for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as listed in the guidelines
supported by the Health Resources and Services Administration; and

74
4. Preventive care and screening for women as listed in the guidelines supported by the Health
Resources and Services Administration, including:
a. Women's contraceptives, sterilization treatments, and counseling. This includes Generic and
single-source Brand Drugs as well as injectable contraceptives and patches. Contraceptive
devices such as diaphragms, intra uterine devices (UDs), and implants are also covered. Multi-
source Brand Drugs will be covered under the "Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy.
b. Breastfeeding support, supplies, and counseling. Benefits for breast pumps are limited to one
pump per pregnancy.
c. Gestational diabetes screening.
You may call Customer Service at the number on your dentification Card for more details about these
services or view the federal government's web sites,https://www.healthcare.gov/what-are-my-preventive-
care-benefits, http://www.ahrq.gov, and http://www.cdc.gov/vaccines/acip/index.html.
Prosthetics
See "Durable Medical Equipment and Medical Devices, Orthotics, and Medical and Surgical Supplies
earlier in this section.
PuImonary Therapy
Please see "Therapy Services later in this section.
Radiation Therapy
Please see "Therapy Services later in this section.
RehabiIitation Services
Benefits include services in a Hospital, free-standing Facility, Skilled Nursing Facility, or in an outpatient
day rehabilitation program.
Covered Services involve a coordinated team approach and several types of treatment, including skilled
nursing care, physical, occupational, and speech therapy, and services of a social worker or psychologist.
To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period
of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing
toward those goals.
HabiIitative Services
Benefits also include Habilitative Services that help you keep, learn or improve skills and functioning for
daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These
services may include physical and occupational therapy, speech-language pathology and other services
for people with disabilities in a variety of inpatient and/or outpatient settings.
Respiratory Therapy
Please see "Therapy Services later in this section.

75
SkiIIed Nursing FaciIity
When you require npatient skilled nursing and related services for convalescent and rehabilitative or
habilitative care, Covered Services are available if the Facility is licensed or certified under state law as a
Skilled Nursing Facility, or is otherwise licensed to provide the services. Custodial Care is not a Covered
Service.
Smoking Cessation
Please see "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy later in this
Booklet.
Speech Therapy
Please see "Therapy Services later in this section.
Surgery
Your Plan covers surgical services on an npatient or outpatient basis, including office surgeries.
Covered Services include:
Accepted operative and cutting procedures;
Other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain
or spine;
Endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy;
Treatment of fractures and dislocations;
Anesthesia and surgical support when Medically Necessary;
Medically Necessary pre-operative and post-operative care.
OraI Surgery
Important Note: Although this Plan covers certain oral surgeries, many oral surgeries (e.g. removal of
wisdom teeth) are not covered, except as listed in this Booklet.
Benefits are limited to certain oral surgeries including:
Treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia;
Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or
lower jaw and is Medically Necessary to attain functional capacity of the affected part.
Oral / surgical correction of accidental injuries as indicated in the "Dental Services (All Members/All
Ages) section.
Treatment of non-dental lesions, such as removal of tumors and biopsies.
ncision and drainage of infection of soft tissue not including odontogenic cysts or abscesses
Your Plan also covers certain oral surgeries for children. Please refer to "Pediatric Dental Services for
Members through Age 18 for details.
Reconstructive Surgery
Benefits include reconstructive surgery to correct significant deformities caused by congenital or
developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal
appearance. Benefits include surgery performed to restore symmetry after a mastectomy. Reconstructive

76
services needed as a result of an earlier treatment are covered only if the first treatment would have been
a Covered Service under this Plan.
Note: This section does not apply to orthognathic surgery. See the "Oral Surgery section above for that
benefit.
Mastectomy Notice
A Member who is getting benefits for a mastectomy or for follow-up care for a mastectomy and who
chooses breast reconstruction, will also get coverage for:
Reconstruction of the breast on which the mastectomy has been performed;
Surgery and reconstruction of the other breast to give a symmetrical appearance; and
Prostheses and treatment of physical problems of all stages of mastectomy, including lymphedemas.
When due to breast cancer, reconstructive and surgical coverage will be provided in a manner
determined in consultation with the attending Physician and the Member. Members will have to pay the
same Deductible, Coinsurance, and/or Copayments that normally apply to surgeries in this Plan.
Transgender Surgery
This Plan provides benefits for many of the charges for transgender surgery (also known as sex
reassignment surgery). Benefits must be approved by us for the type of transgender surgery requested
and must be authorized prior to being performed. Changes for services that are not authorized for the
transgender surgery requested wiII not be considered Covered Services. Some conditions appIy,
and aII services must be authorized by us as outIined in the "How to Access Your Services and
Obtain ApprovaI of Benefits" section.
TeIemedicine
When you cant travel to a Providers office, telemedicine benefits might be available when provided by
covered Providers. Telemedicine is the real-time transfer of health data and help. Services include the
use of interactive audio, video, or other electronic media to discuss and treat your health problem.
Typically, you communicate through an interactive means that is enough to start a link to the Provider
who is working at a different location from you. These services are covered if they would be Covered
Services when given in a face-to-face meeting with the Provider.
There are limits. Telemedicine does not include the use of phones or fax machines. t also is not
covered if you can go into the office of an n-Network Provider in the area where you live. Telemedicine
benefits may also be limited to only certain areas in Colorado. Please check with Customer Services to
see if your area is eligible.
Non-covered services are:
Reporting normal lab or other test results;
Office appointment requests;
Billing, insurance coverage or payment questions;
Requests for referrals to doctors outside the online care panel;
Benefit Preauthorization; Doctor talking to another Doctor.

77
TemporomandibuIar Joint (TMJ) and CraniomandibuIar Joint Services
Benefits are available to treat temporomandibular and craniomandibular disorders. The
temporomandibular joint connects the lower jaw to the temporal bone at the side of the head and the
craniomandibular joint involves the head and neck muscles.
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care,
and diagnostic services. Covered Services do not include fixed or removable appliances that involve
movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).
Therapy Services
PhysicaI Medicine Therapy Services
Your Plan includes coverage for the therapy services described below. To be a Covered Service, the
therapy must improve your level of function within a reasonable period of time.
For children under age 6, your Plan covers at least 20 visits, each, of physical, speech and occupational
therapy. Benefits include the treatment of Congenital Defects and Birth Abnormalities, even if it is a long
term condition. t also doesnt matter if the reason for the therapy is to maintain (not improve) the childs
skills.
Covered Services include:
PhysicaI therapy The treatment by physical means to ease pain, restore health, and to avoid
disability after an illness, injury, or loss of an arm or a leg. t includes hydrotherapy, heat, physical
agents, bio-mechanical and neuro-physiological principles and devices.
Speech therapy and speech-Ianguage pathoIogy (SLP) services Services to identify, assess,
and treat speech, language, and swallowing disorders in children and adults. Therapy will develop or
treat communication or swallowing skills to correct a speech impairment.
OccupationaI therapy Treatment to restore a physically disabled person's ability to do activities of
daily living, such as walking, eating, drinking, dressing, using the toilet, moving from a wheelchair to a
bed, and bathing. t also includes therapy for tasks needed for the person's job. Occupational therapy
does not include recreational or vocational therapies, such as hobbies, arts and crafts.
Chiropractic / Osteopathic / ManipuIation therapy ncludes therapy to treat problems of the
bones, joints, and the back. The two therapies are similar, but chiropractic therapy focuses on the
joints of the spine and the nervous system, while osteopathic therapy also focuses on the joints and
surrounding muscles, tendons and ligaments.
Massage therapy - njury or illness for which massage has a therapeutic result. Coverage is provided
for up to a 60 minute session per visit. Some Covered Services include acupressure and deep tissue
massage, or other approved services.
Acupuncture - Treatment of neuromusculoskeletal pain by an acupuncturist who acts within the
scope of their license. Treatment involves using needles along specific nerve pathways to ease pain.
EarIy Intervention Services
From the Member's birth until the Member's third (3rd) birthday, this Plan covers Early ntervention
Services (as defined in this Booklet and by Colorado law in accordance with part C), that are authorized
through an eligible child's individualized family service plan (FSP) and delivered by a Qualified Early
ntervention Service Provider to an eligible child, to the extent required by applicable law. The services
stated in an FSP will be considered Medically Necessary. Coverage for early intervention services does
not include: nonemergency medical transportation; respite care; service coordination, as defined in
federal law; or assistive technology (unless covered under the applicable insurance policy as durable

78
medical equipment). Coverage is limited to up to 45 visits, in 15 minute increments, per Benefit Period.
A 45 minute visit counts as 3 billing increments.
This visit limit does not apply to rehabilitation or therapeutic services that are necessary as the result of
an acute medical condition or post-surgical rehabilitation or services provided to a child who is not
participating in part C. The coverage for Early ntervention Services is in addition to any other coverage
provided under this Booklet for congenital defects or birth abnormalities.
Other Therapy Services
Benefits are also available for:
Cardiac RehabiIitation - Medical evaluation, training, supervised exercise, and psychosocial
support to care for you after a cardiac event (heart problem). Benefits do not include home programs,
on-going conditioning, or maintenance care.
Chemotherapy Treatment of an illness by chemical or biological antineoplastic agents. See the
section "Prescription Drugs Administered by a Medical Provider for more details.
DiaIysis - Services for acute renal failure and chronic (end-stage) renal disease, including
hemodialysis, home intermittent peritoneal dialysis (PD), home continuous cycling peritoneal dialysis
(CCPD), and home continuous ambulatory peritoneal dialysis (CAPD). Covered Services include
dialysis treatments in an outpatient dialysis Facility. Covered Services also include home dialysis and
training for you and the person who will help you with home self-dialysis.
Infusion Therapy Nursing, durable medical equipment and Drug services that are delivered and
administered to you through an .V. in your home. Also includes Total Parenteral Nutrition (TPN),
Enteral nutrition therapy, antibiotic therapy, pain care and chemotherapy. May include injections
(intra-muscular, subcutaneous, continuous subcutaneous). See the section "Prescription Drugs
Administered by a Medical Provider for more details.
PuImonary RehabiIitation ncludes outpatient short-term respiratory care to restore your health
after an illness or injury.
Radiation Therapy Treatment of an illness by x-ray, radium, or radioactive isotopes. Covered
Services include treatment (teletherapy, brachytherapy and intraoperative radiation, photon or high
energy particle sources), materials and supplies needed, and treatment planning.
Respiratory Therapy ncludes the use of dry or moist gases in the lungs, nonpressurized
inhalation treatment; intermittent positive pressure breathing treatment, air or oxygen, with or without
nebulized medication, continuous positive pressure ventilation (CPAP); continuous negative pressure
ventilation (CNP); chest percussion; therapeutic use of medical gases or Drugs in the form of
aerosols, and equipment such as resuscitators, oxygen tents, and incentive spirometers; broncho-
pulmonary drainage and breathing exercises.
TranspIant Services
See "Human Organ and Tissue Transplant earlier in this section.
Urgent Care Services
Often an urgent rather than an Emergency health problem exists. An urgent health problem is an
unexpected illness or injury that calls for care that cannot wait until a regularly scheduled office visit.
Urgent health problems are not life threatening and do not call for the use of an Emergency Room.
Urgent health problems include earache, sore throat, and fever (not above 104 degrees).
Benefits for urgent care include:
X-ray services;
Care for broken bones;

79
Tests such as flu, urinalysis, pregnancy test, rapid strep;
Lab services;
Stitches for simple cuts; and
Draining an abscess.

{Pediatric vision exam onIy:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.]

{Pediatric vision fuII coverage:
[Vision Services For Members Through Age 18
The vision benefits described in this section only apply to Members through age 18.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
EyegIass Lenses
This Plan also covers a choice of eyeglass lenses. Benefits include polycarbonate, photochromic and
factory scratch coating when n-Network.

Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:

Single vision
Bifocal
Trifocal (FT 25-28)
Progressive
Frames
A selection of frames is covered under this Plan. Members must choose a frame from the Anthem
formulary.
Contact Lenses
The Plan offers the following benefits for contact lenses:

Elective Contact Lenses Contacts chosen for comfort or appearance;

Non-Elective Contact Lenses Only for the following medical conditions:

Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.

80
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.

SpeciaI Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASK.

This Plan only covers a choice of contact lenses or eyeglasses, but not both. f you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglasses until the next Benefit Period. f
you choose eyeglasses during a Benefit Period, no benefits will be available for contact lenses until the
next Benefit Period.]

{AduIt vision:
[Vision Services for Members Age 19 and OIder
The vision benefits described in this section only apply to Members age 19 or older.
Routine Eye Exam
This Plan covers a complete eye exam with refraction and dilation, as needed. The exam is used to check
all aspects of your vision, including the structure of the eyes, wellness and how well they work together.
EyegIass Lenses
This Plan also covers a choice of eyeglass lenses. Lens benefits include factory scratch coating when n-
Network. Photochromic lenses are also available.
Covered eyeglass lenses include standard plastic (CR39) lenses up to 55mm in:
Single vision
Bifocal
Trifocal (FT 25-28)
Frames
A selection of frames is covered under this Plan. Members will get a benefit allowance toward the
purchase of any frame. f the frame you choose costs more than the Plan's allowance, you will have to
pay the amount over the Plan's allowance.
Contact Lenses
The Plan offers the following benefits for contact lenses:
Elective Contact Lenses Contacts chosen for comfort or appearance;
Non-Elective Contact Lenses Only for the following medical conditions:
Keratoconus when your vision is not correctable to 20/40 in either or both eyes using standard
spectacle lenses.
High Ametropia exceeding -12D or +9D in spherical equivalent.
Anisometropia of 3D or more.
When your vision can be corrected three lines of improvement on the visual acuity chart when
compared to best corrected standard spectacle lenses.
SpeciaI Note: Benefits are not available for non-elective contact lenses if the Member has undergone
prior elective corneal surgery, such as radial keratotomy (RK), photorefractive keratectomy (PRK), or
LASK.

81
This Plan only covers a choice of contact lenses or eyeglass lenses, but not both. f you choose contact
lenses during a Benefit Period, no benefits will be available for eyeglass lenses until the next Benefit
Period. f you choose eyeglass lenses during a Benefit Period, no benefits will be available for contact
lenses until the next Benefit Period.]
Vision Services (AII Members / AII Ages)
Benefits include medical and surgical treatment of injuries and illnesses of the eye. Certain vision
screenings required by Federal law are covered under the "Preventive Care benefit.
Benefits do not include glasses or contact lenses except as listed in the "Prosthetics benefit.

82
Prescription Drugs Administered by a MedicaI Provider
Your Plan covers Prescription Drugs when they are administered to you as part of a doctor's visit, home
care visit, or at an outpatient Facility. This includes Drugs for infusion therapy, chemotherapy, Specialty
Drugs, blood products, and office-based injectables that must be administered by a Provider. This
section applies when your Provider orders the Drug and administers it to you. Benefits for Drugs that you
can inject or get at a Pharmacy (i.e., self-administered injectable Drugs) are not covered under this
section. Benefits for those Drugs are described in the "Prescription Drug Benefit at a Retail or Home
Delivery (Mail Order) Pharmacy section.
Note: When Prescription Drugs are covered under this benefit, they will not also be covered under the
"Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit. Also, if
Prescription Drugs are covered under the "Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, they will not be covered under this benefit.
Important DetaiIs About Prescription Drug Coverage
Your Plan includes certain features to determine when Prescription Drugs should be covered, which are
described below. As part of these features, your prescribing Doctor may be asked to give more details
before we can decide if the Drug is Medically Necessary. We may also set quantity and/or age limits for
specific Prescription Drugs or use recommendations made as part of our Medical Policy and Technology
Assessment Committee and/or Pharmacy and Therapeutics Process.
Prior Authorization
Prior authorization may be needed for certain Prescription Drugs to make sure proper use and guidelines
for Prescription Drug coverage are followed. We will contact your Provider to get the details we need to
decide if prior authorization should be given. We will give the results of our decision to both you and your
Provider.
f prior authorization is denied you have the right to file a Grievance as outlined in the "Appeals and
Complaints section of this Booklet.
For a list of Drugs that need prior authorization, please call the phone number on the back of your
dentification Card. The list will be reviewed and updated from time to time. ncluding a Drug or related
item on the list does not promise coverage under your Plan. Your Provider may check with us to verify
Drug coverage, to find out whether any quantity (amount) and/or age limits apply, and to find out which
brand or generic Drugs are covered under the Plan.
Step Therapy
Step therapy is a process in which you may need to use one type of Drug before we will cover another.
We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These
guidelines help you get high quality and cost effective Prescription Drugs. f a Doctor decides that a
certain Drug is needed, the prior authorization will apply.
Therapeutic Substitution
Therapeutic substitution is an optional program that tells you and your Doctors about alternatives to
certain prescribed Drugs. We may contact you and your Doctor to make you aware of these choices.
Only you and your Doctor can determine if the therapeutic substitute is right for you. We have a
therapeutic Drug substitutes list, which we review and update from time to time. For questions or issues
about therapeutic Drug substitutes, call Customer Service at the phone number on the back of your
dentification Card.

83
Prescription Drug Benefit at a RetaiI or Home DeIivery (MaiI Order)
Pharmacy
Your Plan also includes benefits for Prescription Drugs you get at a Retail or Mail Order Pharmacy. We
use a Pharmacy Benefits Manager (PBM) to manage these benefits. The PBM has a network of Retail
Pharmacies, a Home Delivery (Mail Order) Pharmacy, and a Specialty Pharmacy. The PBM works to
make sure Drugs are used properly. This includes checking that Prescriptions are based on recognized
and appropriate doses and checking for Drug interactions or pregnancy concerns.
PIease note: Benefits for Prescription Drugs, including Specialty Drugs, which are administered to you in
a medical setting (e.g., doctor's office, home care visit, or outpatient Facility) are covered under the
"Prescription Drugs Administered by a Medical Provider benefit. Please read that section for important
details.
Prescription Drug Benefits
As described in the "Prescription Drugs Administered by a Medical Provider section, Prescription Drug
benefits may depend on reviews to decide when Drugs should be covered. These reviews may include
prior authorization, step therapy, use of a Prescription Drug List, Therapeutic Substitution, day / supply
limits, and other utilization reviews. Your n-Network Pharmacist will be told of any rules when you fill a
Prescription, and will be also told about any details we need to decide benefits.
Covered Prescription Drugs
To be a Covered Service, Prescription Drugs must be approved by the Food and Drug Administration
(FDA) and, under federal law, require a Prescription. Prescription Drugs must be prescribed by a
licensed Provider and you must get them from a licensed Pharmacy.
Benefits are available for the following:
Prescription Legend Drugs from either a Retail Pharmacy or the PBM's Home Delivery Pharmacy;
Specialty Drugs;
Self-administered injectable Drugs. These are Drugs that do not need administration or monitoring by
a Provider in an office or Facility. Office-based injectables and infused Drugs that need Provider
administration and/or supervision are covered under the "Prescription Drugs Administered by a
Medical Provider benefit;
Self-injectable insulin and supplies and equipment used to administer insulin;
Self-administered contraceptives, including oral contraceptive Drugs, self-injectable contraceptive
Drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the
"Preventive Care benefit. Please see that section for more details;
Special food products or supplements, including metabolic formulas, when prescribed by a Doctor if
we agree they are Medically Necessary,
Flu Shots (including administration). These will be covered under the "Preventive Care benefit;
Prescription Drugs that help you stop smoking or reduce your dependence on tobacco products.
These Drugs will be covered under the "Preventive Care benefit;
FDA-approved smoking cessation products, including over the counter nicotine replacement
products, when obtained with a Prescription for a Member age 18 or older. These products will be
covered under the "Preventive Care benefit.
Certain Legend Drugs, including orally administered anticancer medication, may also be used for
treatment of cancer even though it has not been approved by the Food and Drug Administration (FDA) for
treatment of a specific type of cancer, if the following conditions are met:

84
the off-label use of the FDA approved drug is supported for the treatment of cancer by the
authoritative reference compendia identified by the Department of Health and Human Services; and
the condition being treated is covered under this Booklet.
Where You Can Get Prescription Drugs
In-Network Pharmacy
You can visit one of the local Retail Pharmacies in our network. Give the Pharmacy the prescription from
your Doctor and your dentification Card and they will file your claim for you. You will need to pay any
Copayment, Coinsurance, and/or Deductible that applies when you get the Drug. f you do not have your
dentification Card, the Pharmacy will charge you the full retail price of the Prescription and will not be
able to file the claim for you. You will need to ask the Pharmacy for a detailed receipt and send it to us
with a written request for payment.
SpeciaIty Pharmacy
f you need a Specialty Drug, you or your Doctor should order it from the PBM's Specialty Pharmacy. We
keep a list of Specialty Drugs that may be covered based upon clinical findings from the Pharmacy and
Therapeutics (P&T) Process, and where appropriate, certain clinical economic reasons. This list will
change from time to time.
The PBM's Specialty Pharmacy has dedicated patient care coordinators to help you take charge of your
health problem and offers toll-free twenty-four hour access to nurses and pharmacists to answer your
questions about Specialty Drugs.
When you use the PBM's Specialty Pharmacy a patient care coordinator will work with you and your
Doctor to get prior authorization and to ship your Specialty Drugs to you or your Doctor's office. Your
patient care coordinator will also tell you when it is time to refill your prescription.
You can get the list of covered Specialty Drugs by calling Customer Service at the phone number on the
back of your dentification Card or check our website at www.anthem.com.
Home DeIivery Pharmacy
The PBM also has a Home Delivery Pharmacy which lets you get certain Drugs by mail if you take them
on a regular basis. You will need to contact the PBM to sign up when you first use the service. You can
mail written prescriptions from your Doctor or have your Doctor send the prescription to the Home
Delivery Pharmacy. Your Doctor may also call the Home Delivery Pharmacy. You will need to send in
any Copayments, Deductible, or Coinsurance amounts that apply when you ask for a prescription or refill.
Out-of-Network Pharmacy
You may also use a Pharmacy that is not in our network. You will be charged the full retail price of the
Drug and you will have to send your claim for the Drug to us. (Out-of-Network Pharmacies won't file the
claim for you.) You can get a claims form from us or the PBM. You must fill in the top section of the form
and ask the Out-of-Network Pharmacy to fill in the bottom section. f the bottom section of this form
cannot be filled out by the pharmacist, you must attach a detailed receipt to the claim form. The receipt
must show:
Name and address of the Out-of-Network Pharmacy;
Patient's name;
Prescription number;
Date the prescription was filled;
Name of the Drug;

85
Cost of the Drug;
Quantity (amount) of each covered Drug or refill dispensed.
You must pay the amount shown in the "Schedule of Benefits (Who Pays What). This is based on the
Maximum Allowed Amount as determined by our normal or average contracted rate with network
pharmacies on or near the date of service.
What You Pay for Prescription Drugs
Tiers
Your share of the cost for Prescription Drugs may vary based on the tier the Drug is in.
Tier 1 Drugs have the lowest Coinsurance or Copayment. This tier contains low cost and preferred
Drugs that may be Generic, single source Brand Drugs, or multi-source Brand Drugs.
Tier 2 Drugs have a higher Coinsurance or Copayment than those in Tier 1. This tier contains
preferred Drugs that may be Generic, single source, or multi-source Brand Drugs.
Tier 3 Drugs have a higher Coinsurance or Copayment than those in Tier 2. This tier contains non-
preferred and high cost Drugs. This includes Drugs considered Generic, single source brands, and
multi-source brands.
Tier 4 Drugs have a higher Coinsurance or Copayment than those in Tier 3.
We assign drugs to tiers based on clinical findings from the Pharmacy and Therapeutics (P&T) Process.
We retain the right, at our discretion, to decide coverage for doses and administration (i.e., by mouth,
shots, topical, or inhaled). We may cover one form of administration instead of another, or put other forms
of administration in a different tier.
Prescription Drug List
We also have an Anthem Prescription Drug List, (a formulary), which is a list of FDA-approved Drugs that
have been reviewed and recommended for use based on their quality and cost effectiveness. Benefits
may not be covered for certain Drugs if they are not on the Prescription Drug List.
The Drug List is developed by us based upon clinical findings, and where proper, the cost of the Drug
relative to other Drugs in its therapeutic class or used to treat the same or similar condition. t is also
based on the availability of over the counter medicines, Generic Drugs, the use of one Drug over another
by our Members, and where proper, certain clinical economic reasons.
We retain the right, at our discretion, to decide coverage for doses and administration methods (i.e., by
mouth, shots, topical, or inhaled) and may cover one form of administration instead of another as
Medically Necessary.
AdditionaI Features of Your Prescription Drug Pharmacy Benefit
Day SuppIy and RefiII Limits
Certain day supply limits apply to Prescription Drugs as listed in the "Schedule of Benefits (Who Pays
What). n most cases, you must use a certain amount of your prescription before it can be refilled. n
some cases we may let you get an early refill. For example, we may let you refill your prescription early if
it is decided that you need a larger dose. We will work with the Pharmacy to decide when this should
happen.

86
f you are going on vacation and you need more than the day supply allowed, you should ask your
pharmacist to call our PBM and ask for an override for one early refill. f you need more than one early
refill, please call Customer Service at the number on the back of your dentification Card.
HaIf-TabIet Program
The Half-Tablet Program lets you pay a reduced Copayment on selected "once daily dosage Drugs on
our approved list. The program lets you get a 30-day supply (15 tablets) of the higher strength Drug
when the Doctor tells you to take a " tablet daily. The Half-Tablet Program is strictly voluntary and you
should talk to your Doctor about the choice when it is available. To get a list of the Drugs in the program
call the number on the back of your dentification Card.
SpeciaI Programs
From time to time we may offer programs to support the use of more cost-effective or clinically effective
Prescription Drugs including Generic Drugs, Home Delivery Drugs, over the counter Drugs or preferred
products. Such programs may reduce or waive Copayments or Coinsurance for a limited time. We may
discontinue a program at any time. f you are participating in a program that We discontinue, We will
provide you at least a 30 day advance written notice of the discontinuance.

87
Section 8. Limitations/ExcIusions (What is Not Covered and
Pre-Existing Conditions)
n this section you will find a review of items that are not covered by your Plan. Excluded items will not be
covered even if the service, supply, or equipment is Medically Necessary. This section is only meant to be
an aid to point out certain items that may be misunderstood as Covered Services. This section is not
meant to be a complete list of all the items that are excluded by your Plan.

We will have the right to make the final decision about whether services or supplies are Medically
Necessary and if they will be covered by your Plan.
1) Acts of War, Disasters, or NucIear Accidents n the event of a major disaster, epidemic, war, or
other event beyond our control, we will make a good faith effort to give you Covered Services. We will
not be responsible for any delay or failure to give services due to lack of available Facilities or staff.
Benefits will not be given for any illness or injury that is a result of war, service in the armed forces, a
nuclear explosion, nuclear accident, release of nuclear energy, a riot, or civil disobedience.
2) Administrative Charges
a) Charges to complete claim forms,
b) Charges to get medical records or reports,
c) Membership, administrative, or access fees charged by Doctors or other Providers. Examples
include, but are not limited to, fees for educational brochures or calling you to give you test
results.
3) AIternative / CompIementary Medicine Services or supplies for alternative or complementary
medicine, regardless of the Provider rendering such services or supplies. This includes, but is not
limited to:
a. Holistic medicine,
b. Homeopathic medicine,
c. Hypnosis,
d. Aroma therapy,
e. Reiki therapy,
f. Herbal, vitamin or dietary products or therapies,
g. Naturopathy,
h. Thermography,
i. Orthomolecular therapy,
j. Contact reflex analysis,
k. Bioenergial synchronization technique (BEST),
l. ridology-study of the iris,
m. Auditory integration therapy (AT),
n. Colonic irrigation,
o. Magnetic innervation therapy,
p. Electromagnetic therapy,
q. Neurofeedback / Biofeedback.
4) Before Effective Date or After Termination Date Charges for care you get before your Effective
Date or after your coverage ends, except as written in this Plan.

88
5) Certain Providers Services you get from Providers that are not licensed by law to provide Covered
Services as defined in this Booklet. .
6) Charges Over the Maximum AIIowed Amount Charges over the Maximum Allowed Amount for
Covered Services, except as written in this Plan.
7) Charges Not Supported by MedicaI Records Charges for services not described in your medical
records.
8) CompIications of Non-Covered Services Care for problems directly related to a service that is not
covered by this Plan. Directly related means that the care took place as a direct result of the non-
Covered Service and would not have taken place without the non-Covered Service.
9) Cosmetic Services Treatments, services, Prescription Drugs, equipment, or supplies given for
cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or
are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or
treatments to change the texture or look of your skin or to change the size, shape or look of facial or
body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).
10) Court Ordered Testing Court ordered testing or care unless the testing or care is Medically
Necessary and otherwise a Covered Service under this Booklet.
11) Crime Treatment of an injury or illness that results from a crime you committed, or tried to commit.
This Exclusion does not apply if your involvement in the crime was solely the result of a medical or
mental condition, or where you were the victim of a crime, including domestic violence.
12) CustodiaI Care Custodial Care, convalescent care or rest cures. This Exclusion does not apply to
Hospice services.
13) [DentaI Services
a) {Pediatric dentaI: [Dental services for Members age 19 or older, unless listed as covered in this
Booklet]
b) Dental services not listed as covered in this Booklet.
c) New, experimental or investigational dental techniques or services may be denied until there is, to
our satisfaction, an established scientific basis for recommendation.
d) Dental services completed prior to the date the member became eligible for coverage.
e) Services of anesthesiologists.
f) Analgesia, analgesia agents, anxiolysis, nitrous oxide, medicines, or drugs for non-surgical or
dental care
g) ntravenous conscious sedation, V sedation and general anesthesia are not covered when given
with non-surgical dental care. EXCEPTON: General anesthesia for dental services for members
under age 19 years of age when rendered in a hospital, outpatient surgical facility or other facility
licensed pursuant to Section 25-3-101 of the Colorado Revised Statutes if the child, in the opinion
of the treating Dentist, satisfies one or more of the following criteria: (a) the child has a physical,
mental, or medically compromising condition; (b) the child has dental needs for which local
anesthesia is ineffective because of acute infection, anatomic variations, or allergy; (c) the child is
an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent
with dental needs deemed sufficiently important that dental care cannot be deferred; or (d) the
child has sustained extensive orofacial and dental trauma.
h) Dental services performed other than by a licensed dentist, licensed physician, his or her
employees, or a licensed Provider acting within the scope of the Provider's license.
i) Dental services, appliances or restorations that are necessary to alter, restore or maintain
occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth
structure lost by attrition, realignment of teeth, periodontal splinting and gnathologic recordings.

89
j) Services or supplies that have the primary purpose of improving the appearance of your teeth.
This includes but is not limited to tooth whitening agents or tooth bonding and veneer covering of
the teeth.
k) Restorations placed for preventative or cosmetic purposes.
l) Occlusal or athletic mouth guards
m) Prosthodontic services, such as dentures or bridges {AduIt dentaI: [for members through age
18].
n) Periodontal services {AduIt dentaI: [for members through age 18].
o) Retreatment or additional treatment necessary to correct or relieve the results of treatment
previously covered under the Plan.
p) Separate services billed when they are an inherent component of another covered service.
q) Temporomandibular Joint Disorder (TMJ) except as covered under your medical coverage.
r) Oral hygiene instructions.
s) Surgical exposure of impacted or unerupted teeth for orthodontic reasons, except as listed in this
Booklet.
t) Surgical repositioning of teeth, except as listed in this Booklet.
u) Case presentations, office visits and consultations.
v) mplant services, except as listed in this Booklet.
w) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or non-resorbable filling
material(s) and the procedures used to prepare and place material(s) in the canals (root).
x) Root canal obstruction, internal root repair of perforation defects, incomplete endodontic
treatment and bleaching of discolored teeth.
y) ncomplete root canals.
z) Procedures designed to enable prosthetic or restorative services to be performed such as a
crown lengthening.
aa) Services or supplies that are medical in nature, including dental oral surgery services performed
in a hospital, except as covered under your medical coverage.
bb) Adjunctive diagnostic tests.]
14) EducationaI Services Services or supplies for teaching, vocational, or self-training purposes, except
as listed in this Booklet.
15) ExperimentaI or InvestigationaI Services Services or supplies that we find are Experimental /
nvestigational. This also applies to services related to Experimental / nvestigational services,
whether you get them before, during, or after you get the Experimental / nvestigational service or
supply.
The fact that a service or supply is the only available treatment will not make it Covered Service if we
conclude it is Experimental / nvestigational.
16) EyegIasses and Contact Lenses Eyeglasses and contact lenses to correct your eyesight unless
listed as covered in this Booklet. This Exclusion does not apply to lenses needed after a covered eye
surgery.
17) Eye Exercises Orthoptics and vision therapy.
18) Eye Surgery Eye surgery to fix errors of refraction, such as near-sightedness. This includes, but is
not limited to, LASK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy.

90
19) FamiIy Members Services prescribed, ordered, referred by or given by a member of your immediate
family, including your spouse, child, brother, sister, parent, in-law, or self.
20) Foot Care Routine foot care unless Medically Necessary. This Exclusion applies to cutting or
removing corns and calluses; trimming nails; cleaning and preventive foot care, including but not
limited to:
a) Cleaning and soaking the feet.
b) Applying skin creams to care for skin tone.
c) Other services that are given when there is not an illness, injury or symptom involving the foot.
21) Foot Orthotics Foot orthotics, orthopedic shoes or footwear or support items unless used for an
illness affecting the lower limbs, such as severe diabetes.
22) Foot Surgery Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet;
tarsalgia; metatarsalgia; hyperkeratoses.
23) Free Care Services you would not have to pay for if you didn't have this Plan. This includes, but is not
limited to government programs, services during a jail or prison sentence, services you get from
Workers Compensation, and services from free clinics.
f Workers' Compensation benefits are not available to you, this Exclusion does not apply. This
Exclusion will apply if you get the benefits in whole or in part.
24) Hearing Aids Hearing aids or exams to prescribe or fit hearing aids, unless listed as covered in this
Booklet. This Exclusion does not apply to cochlear implants.
25) HeaIth CIub Memberships and Fitness Services Health club memberships, workout equipment,
charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or
facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health
spas.
26) IntractabIe Pain and/or Chronic Pain Charges for a pain state in which the cause of the pain cannot
be removed and which in the course of medical practice no relief or cure of the cause of the pain is
possible, or none has been found after reasonable efforts. t is pain that lasts more than 6 months, is
not life threatening, and may continue for a lifetime, and has not responded to current treatment.
27) Maintenance Therapy Treatment given when no further gains are clear or likely to occur.
Maintenance therapy includes care that helps you keep your current level of function and prevents
loss of that function, but does not result in any change for the better.
28) MedicaI Equipment and SuppIies
a) Replacement or repair of purchased or rental equipment because of misuse, or loss.
b) Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury.
c) Non-Medically Necessary enhancements to standard equipment and devices.
29) Medicare For which benefits are payable under Medicare Parts A, B, and/or D, or would have been
payable if you had applied for Parts A and/or B, except as listed in this Booklet or as required by
federal law, as described in the section titled "Medicare" in General Provisions. f you do not enroll in
Medicare Part B, We will calculate benefits as if you had enrolled. You should sign up for Medicare
Part B as soon as possible to avoid large out of pocket costs.
30) Missed or CanceIIed Appointments Charges for missed or cancelled appointments.
31) Non-MedicaIIy Necessary Services Services we conclude are not Medically Necessary. This
includes services that do not meet our medical policy, clinical coverage, or benefit policy guidelines.
32) NutritionaI or Dietary SuppIements Nutritional and/or dietary supplements, except as described in
this Booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional

91
formulas and dietary supplements that you can buy over the counter and those you can get without a
written Prescription or from a licensed pharmacist.
33) OraI Surgery Extraction of teeth, surgery for impacted teeth, jaw augmentation or reduction
(orthognathic Surgery), and other oral surgeries to treat the teeth, jaw or bones and gums directly
supporting the teeth, except as listed in this Booklet.
34) Orthodontic Care
a) Monthly treatment visits that are inclusive of treatment cost,
b) Repair or replacement of lost/broken/stolen appliances,
c) Orthodontic retention/retainer as a separate service,
d) Retreatment and/or services for any treatment due to relapse,
e) npatient or outpatient hospital expenses (please refer to your medical coverage to determine if
this is a covered medical service),
f) Provisional splinting, temporary procedures or interim stabilization of teeth,
g) Dental services or health care services not specifically covered under this Booklet (including any
hospital charges, prescription drug charges and dental services or supplies that are medical in
nature).
35) PersonaI Care and Convenience
a) tems for personal comfort, convenience, protection, cleanliness such as air conditioners,
humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs,
b) First aid supplies and other items kept in the home for general use (bandages, cotton-tipped
applicators, thermometers, petroleum jelly, tape, non-sterile gloves, heating pads),
c) Home workout or therapy equipment, including treadmills and home gyms,
d) Pools, whirlpools, spas, or hydrotherapy equipment.
e) Hypo-allergenic pillows, mattresses, or waterbeds,
f) Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs,
escalators, elevators, stair glides, emergency alert equipment, handrails).
36) Private Duty Nursing Private Duty Nursing Services, except as specifically stated in this Booklet.
37) Prosthetics Prosthetics for sports or cosmetic purposes. This includes wigs and scalp hair
prosthetics.
38) SexuaI Dysfunction Services or supplies for male or female sexual problems.
39) Smoking Cessation Programs Programs to help you stop smoking if the program is not affiliated
with Anthem.
40) Stand-By Charges Stand-by charges of a Doctor or other Provider.
41) SteriIization Services to reverse an elective sterilization.
42) Surrogate Mother Services Services or supplies for a person not covered under this Plan for a
surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an
infertile couple).
43) TemporomandibuIar Joint Treatment Fixed or removable appliances which move or reposition the
teeth, fillings, or prosthetics (crowns, bridges, dentures).
44) TraveI Costs Mileage, lodging, meals, and other Member-related travel costs except as described in
this Plan.

92
45) Vein Treatment Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any
method (including sclerotherapy or other surgeries) for cosmetic purposes.
46) {Pediatric vision exam onIy: [Vision Services
Vision services for Members age 19 or older, unless listed as covered in this Booklet
Eyeglass lenses, frames, or contact lenses.
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.]
{Pediatric/aduIt vision: [Vision Services
Vision services not listed as covered in this Booklet.
For services or supplies combined with any other offer, coupon or in-store advertisement.
Safety glasses and accompanying frames.
For two pairs of glasses in lieu of bifocals.
Plano lenses (lenses that have no refractive power)
Lost or broken lenses or frames if the Member has already received benefits during a Benefit
Period.
Vision services not listed as covered in this Booklet.
Cosmetic lenses or options.
Blended lenses.
Oversize lenses.
Sunglasses and accompanying frames.
For Members through age 18, no benefits are available for frames not on the Anthem
formulary.
Certain frames in which the manufacturer imposes a no discount policy.]
47) Weight Loss Programs Programs, whether or not under medical supervision, unless listed as
covered in this Booklet.
This Exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
48) Weight Loss Surgery Bariatric surgery. This includes but is not limited to Roux-en-Y (RNY),
Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgeries lower stomach
capacity and divert partly digested food from the duodenum to the jejunum, the section of the small
intestine extending from the duodenum), or Gastroplasty, (surgeries that reduce stomach size), or
gastric banding procedures.
What's Not Covered Under Your Prescription Drug RetaiI or Home
DeIivery (MaiI Order) Pharmacy Benefit
n addition to the above Exclusions, certain items are not covered under the Prescription Drug Retail or
Home Delivery (Mail Order) Pharmacy benefit:
1. Administration Charges Charges for the administration of any Drug except for covered
immunizations as approved by us or the PBM.

93
2. CIinicaIIy-EquivaIent AIternatives Certain Prescription Drugs may not be covered if you could use a
clinically equivalent Drug, unless required by law. "Clinically equivalent means Drugs that for most
Members, will give you similar results for a disease or condition. f you have questions about whether
a certain Drug is covered and which Drugs fall into this group, please call the number on the back of
your dentification Card, or visit our website at www.anthem.com.
3. Compound Drugs Compound Drugs unless its primary ingredient (the highest cost ingredient) is
FDA approved and requires a prescription to dispense, and the Compound Drug is not essentially the
same as an FDA-approved product from a drug manufacturer.
4. Contrary to Approved MedicaI and ProfessionaI Standards Drugs given to you or prescribed in a
way that is against approved medical and professional standards of practice.
5. DeIivery Charges Charges for delivery of Prescription Drugs.
6. Drugs Given at the Provider's Office / FaciIity Drugs you take at the time and place where you are
given them or where the Prescription Order is issued. This includes samples given by a Doctor. This
Exclusion does not apply to Drugs used with a diagnostic service, Drugs given during chemotherapy
in the office as described in the "Prescription Drugs Administered by a Medical Provider section, or
Drugs covered under the "Medical and Surgical Supplies benefit they are Covered Services.
7. Drugs Not on the Anthem Prescription Drug List (a formuIary) You can get a copy of the list by
calling us or visiting our website at www.anthem.com.
8. Drugs That Do Not Need a Prescription Drugs that do not need a prescription by federal law
(including Drugs that need a prescription by state law, but not by federal law), except for injectable
insulin.
9. Drugs Over Quantity or Age Limits Drugs in quantities which are over the limits set by the Plan, or
which are over any age limits set by us.
10. Drugs Over the Quantity Prescribed or RefiIIs After One Year Drugs in amounts over the quantity
prescribed, or for any refill given more than one year after the date of the original Prescription Order.
11. FIuoride Treatments Topical and oral fluoride treatments. While these services are not covered
under the "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit,
they may be covered under the "Pediatric Dental Services for Members through Age 18 benefit.
Please see that section for further details.
12. InfertiIity Drugs Drugs used in assisted reproductive technology procedures to achieve conception
(e.g., VF, ZFT, GFT).
13. Items Covered as DurabIe MedicaI Equipment (DME) Therapeutic DME, devices and supplies
except peak flow meters, spacers, and blood glucose monitors. tems not covered under the
Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit may be covered
under the "Durable Medical Equipment and Medical Devices benefit. Please see that section for
details.
14. Items Covered as MedicaI SuppIies Oral immunizations and biologicals, even if they are federal
legend Drugs, are covered as medical supplies based on where you get the service or item. Over the
counter Drugs, devices or products, are not Covered Services unless we must cover them under
federal law.
15. Items Covered Under the "AIIergy Services" Benefit Allergy desensitization products or allergy
serum. While not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail
Order) Pharmacy benefit, these items may be covered under the "Allergy Services benefit. Please
see that section for details.
16. Lost or StoIen Drugs Refills of lost or stolen Drugs.
17. MaiI Order Providers other than the PBM's Home DeIivery MaiI Order Provider Prescription
Drugs dispensed by any Mail Order Provider other than the PBM's Home Delivery Mail Order
Provider, unless we must cover them by law.

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18. Non-approved Drugs Drugs not approved by the FDA.
19. Off IabeI use Off label use, unless we must cover the use by law or if we, or the PBM, approve it.
20. Onychomycosis Drugs Drugs for Onchomycosis (toenail fungus) except when we allow it to treat
Members who are immuno-compromised or diabetic.
21. Over-the-Counter Items Drugs, devices and products, or Prescription Legend Drugs with over the
counter equivalents and any Drugs, devices or products that are therapeutically comparable to an
over the counter Drug, device, or product. This includes Prescription Legend Drugs when any version
or strength becomes available over the counter.
This Exclusion does not apply to over-the-counter products that we must cover under federal law with
a Prescription.
22. Sex Change Drugs Drugs for sex change surgery, unless we must cover such drugs under
applicable law.
23. SexuaI Dysfunction Drugs Drugs to treat sexual or erectile problems.
24. Syringes Hypodermic syringes except when given for use with insulin and other covered self-
injectable Drugs and medicine.
25. Weight Loss Drugs Any Drug mainly used for weight loss.
Pre-existing Conditions
Not applicable, plan does not impose limitation period for pre-existing conditions.

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Section 9. Member Payment ResponsibiIity
Your Cost-Shares
Your Plan may involve Copayments, Deductibles, and/or Coinsurance, which are charges that you must
pay when receiving Covered Services. Your Plan may also have an Out-of-Pocket Limit, which limits the
cost-shares you must pay. Please read the "Schedule of Benefits (Who Pays What) for details on your
cost-shares. Also read the "Definitions section for a better understanding of each type of cost share.
Maximum AIIowed Amount
GeneraI
This section describes how we determine the amount of reimbursement for Covered Services.
Reimbursement for services rendered by n-Network and Out-of-Network Providers is based on this
Booklet's Maximum Allowed Amount for the Covered Service that you receive. Please see the "Claims
Procedure (How to File a Claim) section for additional information.
The Maximum Allowed Amount for this Booklet is the maximum amount of reimbursement we will allow
for services and supplies:
That meet our definition of Covered Services, to the extent such services and supplies are covered
under your Booklet and are not excluded;
That are Medically Necessary; and
That are provided in accordance with all applicable preauthorization, utilization management or other
requirements set forth in your Booklet.
You will be required to pay a portion of the Maximum Allowed Amount to the extent you have not met
your Deductible or have a Copayment or Coinsurance. n addition, when you receive Covered Services
from an Out-of-Network Provider, you may be responsible for paying any difference between the
Maximum Allowed Amount and the Provider's actual charges. This amount can be significant.
When you receive Covered Services from a Provider, we will, to the extent applicable, apply claim
processing rules to the claim submitted for those Covered Services. These rules evaluate the claim
information and, among other things, determine the accuracy and appropriateness of the procedure and
diagnosis codes included in the claim. Applying these rules may affect our determination of the Maximum
Allowed Amount. Our application of these rules does not mean that the Covered Services you received
were not Medically Necessary. t means we have determined that the claim was submitted inconsistent
with procedure coding rules and/or reimbursement policies. For example, your Provider may have
submitted the claim using several procedure codes when there is a single procedure code that includes
all of the procedures that were performed. When this occurs, the Maximum Allowed Amount will be
based on the single procedure code rather than a separate Maximum Allowed Amount for each billed
code.
Likewise, when multiple procedures are performed on the same day by the same Doctor or other
healthcare professional, we may reduce the Maximum Allowed Amounts for those secondary and
subsequent procedures because reimbursement at 100% of the Maximum Allowed Amount for those
procedures would represent duplicative payment for components of the primary procedure that may be
considered incidental or inclusive.

96
Provider Network Status
The Maximum Allowed Amount may vary depending upon whether the Provider is an n-Network Provider
or an Out-of-Network Provider.
An n-Network Provider is a Provider who is in the managed network for this specific product or in a
special Center of Excellence/or other closely managed specialty network, or who has a participation
contract with us. For Covered Services performed by an n-Network Provider, the Maximum Allowed
Amount for this Booklet is the rate the Provider has agreed with us to accept as reimbursement for the
Covered Services. Because n-Network Providers have agreed to accept the Maximum Allowed Amount
as payment in full for those Covered Services, they should not send you a bill or collect for amounts
above the Maximum Allowed Amount. However, you may receive a bill or be asked to pay all or a portion
of the Maximum Allowed Amount to the extent you have not met your Deductible or have a Copayment or
Coinsurance. Please call Customer Service for help in finding an n-Network Provider or visit
www.anthem.com.
Providers who have not signed any contract with us and are not in any of our networks are Out-of-
Network Providers, subject to Blue Cross Blue Shield Association rules governing claims filed by certain
ancillary providers.
For Covered Services you receive from an Out-of-Network Provider, the Maximum Allowed Amount for
this Booklet will be one of the following as determined by us:
1. An amount based on Anthem's non-participating Provider fee schedule/rate, which is established at
Anthem's discretion, and which Anthem may modify from time to time, after considering one or more
of the following: reimbursement amounts accepted by like/similar Providers contracted with Anthem,
reimbursement amounts paid by the Centers for Medicare and Medicaid Services (CMS) for the same
services or supplies, and other industry cost, reimbursement and utilization data; or
2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid
Services ("CMS). When basing the Maximum Allowed amount upon the level or method of
reimbursement used by CMS, Anthem will update such information, which is unadjusted for
geographic locality, no less than annually; or
3. An amount based on information provided by a third party vendor, which may reflect one or more of
the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience
required for the treatment; or (3) comparable Providers' fees and costs to deliver care, or
4. An amount negotiated by us or a third party vendor which has been agreed to by the Provider. This
may include rates for services coordinated through case management, or
5. An amount based on or derived from the total charges billed by the Out-of-Network Provider.
Unlike n-Network Providers, Out-of-Network Providers may send you a bill and collect for the amount of
the Provider's charge that exceeds our Maximum Allowed Amount. You are responsible for paying the
difference between the Maximum Allowed Amount and the amount the Provider charges. This amount
can be significant. Choosing an n-Network Provider will likely result in lower out of pocket costs to you.
Please call Customer Service for help in finding an n-Network Provider or visit our website at
www.anthem.com.
Customer Service is also available to assist you in determining this Booklet's Maximum Allowed Amount
for a particular service from an Out-of-Network Provider. n order for us to assist you, you will need to
obtain from your Provider the specific procedure code(s) and diagnosis code(s) for the services the
Provider will render. You will also need to know the Provider's charges to calculate your out of pocket
responsibility. Although Customer Service can assist you with this pre-service information, the final
Maximum Allowed Amount for your claim will be based on the actual claim submitted by the Provider.

97
For Prescription Drugs, the Maximum Allowed Amount is the amount determined by us using Prescription
Drug cost information provided by the Pharmacy Benefits Manager.
Member Cost Share
For certain Covered Services and depending on your Plan design, you may be required to pay a part of
the Maximum Allowed Amount as your cost share amount (for example, Deductible, Copayment, and/or
Coinsurance).
Your cost share amount and Out-of-Pocket Limits may vary depending on whether you received services
from an n-Network or Out-of-Network Provider. Specifically, you may be required to pay higher cost
sharing amounts or may have limits on your benefits when using Out-of-Network Providers. Please see
the "Schedule of Benefits (Who Pays What) in this Booklet for your cost share responsibilities and
limitations, or call Customer Service to learn how this Booklet's benefits or cost share amounts may vary
by the type of Provider you use.
We will not provide any reimbursement for non-Covered Services. You may be responsible for the total
amount billed by your Provider for non-Covered Services, regardless of whether such services are
performed by an n-Network or Out-of-Network Provider. Non-covered services include services
specifically excluded from coverage by the terms of your Plan and received after benefits have been
exhausted Benefits may be exhausted by exceeding, for example, benefit caps or day/visit limits.
n some instances you may only be asked to pay the lower n-Network cost sharing amount when you use
an Out-of-Network Provider. For example, if you go to an n-Network Hospital or Provider Facility and
receive Covered Services from an Out-of-Network Provider such as a radiologist, anesthesiologist or
pathologist who is employed by or contracted with an n-Network Hospital or Facility, you will pay the n-
Network cost share amounts for those Covered Services. You will not have to pay more for the Covered
Services than you would have had to pay if it had been received from an n-Network Provider.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklet's cost share amounts; see your 'Schedule of Benefits (Who Pays What)" for
your applicable amounts.
Example: Your Plan has a Coinsurance cost share of 20% for In-Network services, and 30% for Out-of-
Network services after the In-Network or Out-of-Network Deductible has been met.
You undergo a surgical procedure in an In-Network Hospital. The Hospital has contracted with an Out-of-
Network anesthesiologist to perform the anesthesiology services for the surgery. You have no control
over the anesthesiologist used.
The Out-of-Network anesthesiologist's charge for the service is $1200, your coinsurance responsibility
is 20% of $1200, or $240.
You choose an In-Network surgeon. The charge was $2500. The Maximum Allowed Amount for the
surgery is $1500; your Coinsurance responsibility when an In-Network surgeon is used is 20% of
$1500, or $300. We allow 80% of $1500, or $1200. The In-Network surgeon accepts the total of
$1500 as reimbursement for the surgery regardless of the charges. Your total out of pocket
responsibility would be $300.
Authorized Services
n some circumstances, such as where there is no n-Network Provider available, or if we don't have an
n-Network Provider within a reasonable number of miles from your home, for the Covered Service, we
may authorize the n-Network cost share amounts (Deductible, Copayment, and/or Coinsurance) to apply
to a claim for a Covered Service you receive from an Out-of-Network Provider. n such circumstances,
you must contact us in advance of obtaining the Covered Service. f approved, we will pay the Out-of-

98
Network Provider at the n-Network level of benefits and you won't need to pay more for the services than
if the services had been received from an n-Network Provider. A precertification or preauthorization is not
the same thing as an Authorized Service; we must specifically authorize the service from an Out-of-
Network Provider at the n-Network cost share amounts.
Sometimes you may need to travel a reasonable distance to get care from an n-Network Provider. This
does not apply if care is for an Emergency.
f you do not receive a preauthorized network exception to obtain Covered Services from an Out-of-
Network Provider at the n-Network cost share amounts, the claim will be processed using your Out-of-
Network cost shares.
The following are examples for illustrative purposes only; the amounts shown may be different
than this Booklet's cost share amounts; see your 'Schedule of Benefits (Who Pays What)" for
your applicable amounts.
Example:
You require the services of a specialty Provider; but there is no In-Network Provider for that specialty in
your state of residence. You contact us in advance of receiving any Covered Services, and we authorize
you to go to an available Out-of-Network Provider for that Covered Service and we agree that the In-
Network cost share will apply.
Your Plan has a $45 Copayment for Out-of-Network Providers and a $25 Copayment for In-Network
Providers for the Covered Service. The Out-of-Network Provider's charge for this service is $500. The
Maximum Allowed Amount is $200.
Because we have authorized the In-Network cost share amount to apply in this situation, you will be
responsible for the In-Network Copayment of $25 and we will be responsible for the remaining $475.
CIaims Review
Anthem has processes to review claims before and after payment to detect fraud, waste, abuse and other
inappropriate activity. Members seeking services from Out-of Network Providers could be balance billed
by the Out-of-Network Provider for those services that are determined to be not payable as a result of
these review processes. A claim may also be determined to be not payable due to a Provider's failure to
submit medical records with the claims that are under review in these processes.


99
Section 10. CIaims Procedure (How to FiIe a CIaim)
This section describes how we reimburse claims and what information is needed when you submit a
claim. When you receive care from an n-Network Provider, you do not need to file a claim because the
n-Network Provider will do this for you. f you receive care from an Out-of-Network Provider, you will
need to make sure a claim is filed. Many Out-of-Network Hospitals, Doctors and other Providers will file
your claim for you, although they are not required to do so. f you file the claim, use a claim form as
described later in this section.
Notice of CIaim & Proof of Loss
After you get Covered Services, we must receive written notice of your claim within 365 days in order for
benefits to be paid. The claim must have the information we need to determine benefits. f the claim
does not include enough information, we will ask for more details and it must be sent to us within the time
listed below or no benefits will be covered, unless required by law.
n certain cases, you may have some extra time to file a claim. f we did not get your claim within 365
days, but it is sent in as soon as reasonably possible and within one year after the 365-day period ends
(i.e., within 24 months), you may still be able to get benefits. However, any cIaims, or additionaI
information on cIaims, sent in more than 24 months after you get Covered Services wiII be denied.
CIaim Forms
Claim forms will usually be available from most Providers. f forms are not available, either send a written
request for a claims form to us, or contact Customer Service and ask for a claims form to be sent to you.
f you do not receive the claims form within 15 days of notifying us, written notice of services rendered
may be submitted to us without the claim form. The same information that would be given on the claim
form must be included in the written notice of claim. This includes:
Name of patient.
Patient's relationship with the Subscriber.
dentification number.
Date, type, and place of service.
Your signature and the Provider's signature.
Member's Cooperation
You will be expected to complete and submit to us all such authorizations, consents, releases,
assignments and other documents that may be needed in order to obtain or assure reimbursement under
Medicare, Workers' Compensation or any other governmental program. f you fail to cooperate (including
if you fail to enroll under Part B of the Medicare program where Medicare is the responsible payor), you
will be responsible for any charge for services.
Payment of Benefits
We will make benefit payments directly to Network Providers for Covered Services. f you use an Out-of-
Network Provider, however, we may make benefit payments to you unless if you have authorized an
assignment of benefits. An assignment of benefits means you want Us to pay the Provider instead of
you. We may require a copy of the assignment of benefits for Our records. These payments fulfill our
obligation to you for those services. Payments may also be made to, and notice regarding the receipt
and/or adjudication of claims sent to, an Alternate Recipient (any child of a Subscriber who is recognized,
under a Qualified Medical Child Support Order (QMSCO), as having a right to enrollment under the
Group's Contract), or that person's custodial parent or designated representative. Any benefit payments

100
made by us will discharge our obligation for Covered Services. You cannot assign your right to benefits
to anyone else, except as required by a "Qualified Medical Child Support Order as defined by ERSA or
any applicable state law.
Once a Provider performs a Covered Service, we will not honor a request for us to withhold payment of
the claims submitted.
Inter-PIan Programs
Out-of-Area Services
Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to
generally as "nter-Plan Programs. Whenever you obtain healthcare services outside of Anthem's
Service Area, the claims for these services may be processed through one of these nter-Plan Programs,
which include the BlueCard Program and may include negotiated National Account arrangements
available between Anthem and other Blue Cross and Blue Shield Licensees.
Typically, when accessing care outside Anthem's Service Area, you will obtain care from healthcare
Providers that have a contractual agreement (i.e., are "participating Providers) with the local Blue Cross
and/or Blue Shield Licensee in that other geographic area ("Host Blue). n some instances, you may
obtain care from nonparticipating healthcare Providers. Anthem's payment practices in both instances are
described below.
BIueCard

Program
Under the BlueCard

Program, when you access covered healthcare services within the geographic area
served by a Host Blue, Anthem will remain responsible for fulfilling Anthem's contractual obligations.
However, the Host Blue is responsible for contracting with and generally handling all interactions with its
participating healthcare Providers.
Whenever you access covered healthcare services outside Anthem's Service Area and the claim is
processed through the BlueCard Program, the amount you pay for covered healthcare services is
calculated based on the lower of:
The billed covered charges for your Covered Services; or
The negotiated price that the Host Blue makes available to Anthem.
Often, this "negotiated price will be a simple discount that reflects an actual price that the Host Blue pays
to your healthcare Provider. Sometimes, it is an estimated price that takes into account special
arrangements with your healthcare Provider or Provider group that may include types of settlements,
incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on
a discount that results in expected average savings for similar types of healthcare Providers after taking
into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for
over- or underestimation of modifications of past pricing for the types of transaction modifications noted
above. However, such adjustments will not affect the price Anthem uses for your claim because they will
not be applied retroactively to claims already paid.
Federal law or the law in a small number of states may require the Host Blue to add a surcharge to your
calculation. f federal law or any state laws mandate other liability calculation methods, including a
surcharge, we would then calculate your liability for any covered healthcare services according to
applicable law.

101
Non-Participating HeaIthcare Providers Outside Our Service Area
Member LiabiIity CaIcuIation
When covered healthcare services are provided outside of our Service Area by non-participating
healthcare providers, the amount you pay for such services will generally be based on either the Host
Blue's nonparticipating healthcare provider local payment or the pricing arrangements required by
applicable state law. n these situations, you may be liable for the difference between the amount that the
non-participating healthcare provider bills and the payment we will make for the Covered Services as set
forth in this paragraph.
Exceptions
n certain situations, we may use other payment bases, such as billed covered charges, the payment we
would make if the healthcare services had been obtained within our Service Area, or a special negotiated
payment, as permitted under nter-Plan Programs Policies, to determine the amount we will pay for
services rendered by nonparticipating healthcare providers. n these situations, you may be liable for the
difference between the amount that the non-participating healthcare provider bills and the payment we
will make for the Covered Services as set forth in this paragraph.
f you obtain services in a state with more than one Blue Plan network, an exclusive network arrangement
may be in place. f you see a Provider who is not part of an exclusive network arrangement, that
Provider's service(s) will be considered Non-Network care, and you may be billed the difference between
the charge and the Maximum Allowable Amount. You may call the Customer Service number on your D
card for more information about such arrangements.


102
Section 11. GeneraI PoIicy Provisions
Assignment
The Group cannot legally transfer this Booklet, without obtaining written permission from us. Members
cannot legally transfer the coverage. Benefits available under this Booklet are not assignable by any
Member without obtaining written permission from us, unless in a way described in the "How to Access
Your Services and Obtain Approval of Benefits (Applicable to Managed Care Plans) and in "Claims
Procedure (How to File a Claim) sections.
AutomobiIe Insurance Provisions
We will coordinate the benefits of this Booklet with the benefits of a complying auto insurance policy.
A complying automobile insurance policy is an auto policy approved by the Colorado Division of
nsurance that provides at least the minimum coverage required by law, and one which is subject to the
Colorado Auto Accident Reparations Act or Colorado Revised Statutes 10-4-601 et seq. Any state or
federal law requiring similar benefits through legislation or regulation is also considered a complying auto
policy.
How We Coordinate Benefits with Auto PoIicies - Your benefits under this Booklet may be coordinated
with the coverage's afforded by an auto policy. After any primary coverage's offered by the auto policy
are exhausted, including without limitation any no-fault, personal injury protection, or medical payment
coverages, We will pay benefits subject to the terms and conditions of this Booklet. f there is more than
one auto policy that offers primary coverage, each will pay its maximum coverage before We are liable for
any further payments.
You, your representative, agents and heirs must fully cooperate with Us to make sure that the auto policy
has paid all required benefits. We may require you to take a physical examination in disputed cases. f
there is an auto policy in effect, and you waive or fail to assert your rights to such benefits, this plan will
not pay those benefits that could be available under an auto policy.
We may require proof that the auto policy has paid all primary benefits before making any payments
under this Booklet. On the other hand, we may but are not required to pay benefits under this Booklet,
and later coordinate with or seek reimbursement under the auto policy. n all cases, upon payment, we
are entitled to exercise Our rights under this Booklet and under applicable law against any and all
potentially responsible parties or insurers. n that event, we may exercise the rights found in this section.
What Happens If You Do Not Have Another PoIicy - We will pay benefits if you are injured while you
are riding in or driving a motor vehicle that you own if it is not covered by an auto policy.
Similarly if not covered by an auto policy, we will also pay benefits for your injuries if as a non-owner or
driver, passenger or when walking you were in a motor vehicle accident. n that event, we may exercise
the rights found in this section.
CIericaI Error
A clerical error will never disturb or affect your coverage, as long as your coverage is valid under the rules
of the Plan. This rule applies to any clerical error, regardless of whether it was the fault of the Group or
us.

103
ConfidentiaIity and ReIease of Information
We will use reasonable efforts, and take the same care to preserve the confidentiality of your medical
information. We may use data collected in the course of providing services hereunder for statistical
evaluation and research. f such data is ever released to a third party, it shall be released only in
aggregate statistical form without identifying you. Medical information may be released only with your
written consent or as required by law. t must be signed, dated and must specify the nature of the
information and to which persons and organizations it may be disclosed. You may access your own
medical records.
We may release your medical information to professional peer review organizations and to the Group for
purposes of reporting claims experience or conducting an audit of our operations, provided the
information disclosed is reasonably necessary for the Group to conduct the review or audit.
A statement describing our policies and procedures for preserving the confidentiality of medical records is
available and will be furnished to you upon request.
Conformity with Law
Any term of the Plan which is in conflict with the laws of the state in which the Group Contract is issued,
or with federal law, will hereby be automatically amended to conform with the minimum requirements of
such laws.
Contract with Anthem
The Group, on behalf of itself and its participants, hereby expressly acknowledges its understanding that
this Plan constitutes a Contract solely between the Group and us, Anthem Blue Cross and Blue Shield
(Anthem), and that we are an independent corporation licensed to use the Blue Cross and Blue Shield
names and marks in the state of Colorado. The Blue Cross Blue Shield marks are registered by the Blue
Cross and Blue Shield Association, an association of independently licensed Blue Cross and Blue Shield
plans, with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries. Further, we
are not contracting as the agent of the Blue Cross and Blue Shield Association or any other Blue Cross
and/or Blue Shield plan or licensee. The Group, on behalf of itself and its participants, further
acknowledges and agrees that it has not entered into this Contract based upon representations by any
person other than Anthem Blue Cross and Blue Shield (Anthem) and that no person, entity, or
organization other than Anthem Blue Cross and Blue Shield (Anthem) shall be held accountable or liable
to the Group for any of Anthem Blue Cross and Blue Shield (Anthem)'s obligations to the Group created
under the Contract. This paragraph shall not create any additional obligations whatsoever on our part
other than those obligations created under other terms of this agreement.
Entire Contract
Note: The laws of the state in which the Group Contract is issued will apply unless otherwise stated
herein.
This Booklet, any riders, endorsements or attachments, and the individual applications of the Subscriber
and Dependents constitute the entire Contract between the Group and us and as of the Effective Date,
supersede all other agreements. n addition the Group has a Group Contract and Group application
which includes terms that apply to this coverage. Any and all statements made to us by the Group and
any and all statements made to the Group by us are representations and not warranties. No such
statement, unless it is contained in a written application for coverage under this Booklet, shall be used in
defense to a claim under this Booklet.

104
Form or Content of BookIet
No agent or employee of ours is authorized to change the form or content of this Booklet. Changes can
only be made through a written authorization, signed by an officer of Anthem. Changes are further noted
in "Modifications below this section.
Government Programs
The benefits under this Plan shall not duplicate any benefits that you are entitled to, or eligible for, under
any other governmental program. This does not apply if any particular laws require us to be the primary
payor. f we have duplicated such benefits, all money paid by such programs to you for services you
have or are receiving, shall be returned by or on your behalf to us.
MedicaI PoIicy and TechnoIogy Assessment
Anthem reviews and evaluates new technology according to its technology evaluation criteria developed
by its medical directors. Technology assessment criteria are used to determine the Experimental /
nvestigational status or Medical Necessity of new technology. Guidance and external validation of
Anthem's medical policy is provided by the Medical Policy and Technology Assessment Committee
(MPTAC) which consists of approximately 20 Doctors from various medical specialties including Anthem's
medical directors, Doctors in academic medicine and Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Medicare
Any benefits covered under both this Plan and Medicare will be covered according to Medicare
Secondary Payor legislation, regulations, and Centers for Medicare & Medicaid Services guidelines,
subject to federal court decisions. Federal law controls whenever there is a conflict among state law,
Booklet terms, and federal law.
Except when federal law requires us to be the primary payor, the benefits under this Plan for Members
age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which
Members are entitled under Medicare, including Part B. Where Medicare is the responsible payor, all
sums payable by Medicare for services provided to you shall be reimbursed by or on your behalf to us, to
the extent we have made payment for such services. For the purposes of the calculation of benefits, if
you have not enrolled in Medicare Parts B and/or D, we will calculate benefits as if you had enrolled. You
shouId enroII in Medicare Part B as soon as possibIe to avoid potentiaI IiabiIity. For Medicare Part
D we will calculate benefits as if you had enrolled in the Standard Basic Plan.
Modifications
This Booklet allows the Group to make Plan coverage available to eligible Members. However, this
Booklet shall be subject to amendment, modification, and termination in accordance with any of its terms,
the Group Contract, or by mutual agreement between the Group and us without the permission or
involvement of any Member. Changes will not be effective until the date specified in the written notice we
give to the Group about the change. By electing medical and Hospital coverage under the Plan or
accepting Plan benefits, all Members who are legally capable of entering into a contract, and the legal
representatives of all Members that are incapable of entering into a contract, agree to all terms and
conditions in this Booklet.

105
For employer groups of one to 50, if we amend this Booklet to change benefits, notice of the amendment
will be given to the employer no less than 90 days before to the Effective Date of such change and the
amendment(s) will be effective for each group on the renewal or anniversary date of the Group Contract.
For all other changes, such as changes due to state or federal law or regulation, we may amend this
Booklet when authorized by one of our officers and, to the extent required by law, will provide the Group
60 days' notice of such changes. We will then provide the Group with any amendments within 60 days
following the effective date of the amendment. f the Group requests a change that reduces or eliminates
coverage, such change must be requested in writing or signed by the Group. The Group will notify you of
such change(s) to coverage. We or the Group will later send or make available to you an amendment to
this Booklet or a new Booklet.
Network Access PIan
We strive to provide Provider networks in Colorado that addresses your health care needs. The Network
Access Plan describes our Provider network standards for network sufficiency in service, access and
availability, as well as assessment procedures we follow in our effort to maintain adequate and accessible
networks. To request a copy of this document, call customer service. This document is also available on
our website or for in-person review at 700 Broadway in Denver, Colorado.
Not LiabIe for Provider Acts or Omissions
We are not responsible for the actual care you receive from any person. This Booklet does not give
anyone any claim, right, or cause of action against Anthem based on the actions of a Provider of health
care, services, or supplies.
PoIicies and Procedures
We are able to introduce new policies, procedures, rules and interpretations, as long as they are
reasonable. Such changes are introduced to make the Plan more orderly and efficient. Members must
follow and accept any new policies, procedures, rules, and interpretations.
Under the terms of the Group Contract, we have the authority, in our sole discretion, to introduce or
terminate from time to time, pilot or test programs for disease management or wellness initiatives which
may result in the payment of benefits not otherwise specified in this Booklet. We reserve the right to
discontinue a pilot or test program at any time. We will give thirty (30) days advance written notice to the
Group of the introduction or termination of any such program.
ReIationship of Parties (Group-Member-Anthem)
The Group is responsible for passing information to you. For example, if we give notice to the Group, it is
the Group's responsibility to pass that information to you. The Group is also responsible for passing
eligibility data to us in a timely manner. f the Group does not give us with timely enrollment and
termination information, we are not responsible for the payment of Covered Services for Members.
ReIationship of Parties (Anthem and In-Network Providers)
The relationship between Anthem and n-Network Providers is an independent contractor relationship. n-
Network Providers are not agents or employees of ours, nor is Anthem, or any employee of Anthem, an
employee or agent of n-Network Providers.
Your health care Provider is solely responsible for all decisions regarding your care and treatment,
regardless of whether such care and treatment is a Covered Service under this Plan. We shall not be

106
responsible for any claim or demand on account of damages arising out of, or in any manner connected
with, any injuries suffered by you while receiving care from any n-Network Provider or in any n-Network
Provider's Facilities.
Your n-Network Provider's agreement for providing Covered Services may include financial incentives or
risk sharing relationships related to the provision of services or referrals to other Providers, including n-
Network Providers, Out-of-Network Providers, and disease management programs. f you have
questions regarding such incentives or risk sharing relationships, please contact your Provider or us.
Reservation of Discretionary Authority
This section only applies when the interpretation of this Booklet is governed by the Employee Retirement
ncome Security Act (ERSA), 29 U.S.C. 1001 et seq.
We, or anyone acting on our behalf, shall determine the administration of benefits and eligibility for
participation in such a manner that has a rational relationship to the terms set forth herein. However, we,
or anyone acting on our behalf, have complete discretion to determine the administration of your benefits.
Our determination shall be final and conclusive and may include, without limitation, determination of
whether the services, care, treatment, or supplies are Medically Necessary, Experimental /
nvestigational, whether surgery is cosmetic, and whether charges are consistent with the Maximum
Allowable Amount. However, a Member may utilize all applicable complaint and appeals procedures, and
where required by applicable law, Our determination may be reviewed de novo (as if for the first time) in a
later appeal or legal action.
We, or anyone acting on our behalf, shall have all the powers necessary or appropriate to enable us to
carry out the duties in connection with the operation and administration of the Plan. This includes, without
limitation, the power to construe the Contract, to determine all questions arising under the Booklet and to
make, establish and amend the rules, regulations, and procedures with regard to the interpretation and
administration of the provisions of this Plan. However, these powers shall be exercised in such a manner
that has reasonable relationship to the provisions of the Contract, the Booklet, Provider agreements, and
applicable state or federal laws. A specific limitation or exclusion will override more general benefit
language.
Right of Recovery
Whenever payment has been made in error, we will have the right to recover such payment from you or, if
applicable, the Provider. n the event we recover a payment made in error from the Provider, except in
cases of fraud, we will only recover such payment from the Provider during the 24 months after the date
we made the payment on a claim submitted by the Provider, unless the law permits a different timeframe
in which to recover. We reserve the right to deduct or offset any amounts paid in error from any pending
or future claim. The cost share amount shown in your Explanation of Benefits is the final determination
and you will not receive notice of an adjusted cost share amount as a result of such Recovery activity.
We have oversight responsibility for compliance with Provider and vendor contracts. We may enter into a
settlement or compromise regarding enforcement of these contracts and may retain any recoveries made
from a Provider or vendor resulting from these audits if the return of the overpayment is not feasible. We
have established Recovery policies to determine which recoveries are to be pursued, when to incur costs
and expenses and settle or compromise Recovery amounts. We will not pursue recoveries for
overpayments if the cost of collection exceeds the overpayment amount. We may not give you notice of
overpayments made by us or you if the Recovery method makes providing such notice administratively
burdensome.

107
Unauthorized Use of Identification Card
f you permit your dentification Card to be used by someone else or if you use the card before coverage
is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting
from the unauthorized use. Fraudulent misuse could also result in termination of the coverage.
VaIue-Added Programs
We may offer health or fitness related programs to our Members, through which you may access
discounted rates from certain vendors for products and services available to the general public. Products
and services available under this program are not Covered Services under your Plan but are in addition to
Plan benefits. As such, program features are not guaranteed under your health Plan Contract and could
be discontinued at any time. We do not endorse any vendor, product or service associated with this
program. Program vendors are solely responsible for the products and services you receive.
VaIue of Covered Services
For purposes of subrogation, reimbursement of excess benefits, or reimbursement under any Workers'
Compensation or Employer Liability Law, the value of Covered Services shall be the amount we paid for
the Covered Services.
VoIuntary CIinicaI QuaIity Programs
We may offer additional opportunities to assist you in obtaining certain covered preventive or other care
(e.g., well child check-ups or certain laboratory screening tests) that you have not received in the
recommended timeframe. These opportunities are called voluntary clinical quality programs. They are
designed to encourage you to get certain care when you need it and are separate from Covered Services
under your Plan. These programs are not guaranteed and could be discontinued at any time. We will
give you the choice and if you choose to participate in one of these programs, and obtain the
recommended care within the program's timeframe, you may receive incentives such as gift cards. Under
other clinical quality programs, you may receive a home test kit that allows you to collect the specimen for
certain covered laboratory tests at home and mail it to the laboratory for processing. You may need to
pay any cost shares that normally apply to such covered laboratory tests (e.g., those applicable to the
laboratory processing fee) but will not need to pay for the home test kit. (f you receive a gift card and use
it for purposes other than for qualified medical expenses, this may result in taxable income to you. For
additional guidance, please consult your tax advisor.)
VoIuntary WeIIness Incentive Programs
We may offer health or fitness related program options for purchase by your Group to help you achieve
your best health. These programs are not Covered Services under your Plan, but are separate
components, which are not guaranteed under this Plan and could be discontinued at any time. f your
Group has selected one of these options to make available to all employees, you may receive incentives
such as gift cards by participating in or completing such voluntary wellness promotion programs as health
assessments, weight management or tobacco cessation coaching. Under other options a Group may
select, you may receive such incentives by achieving specified standards based on health factors under
wellness programs that comply with applicable law. f you think you might be unable to meet the
standard, you might qualify for an opportunity to earn the same reward by different means. You may
contact us at the customer service number on your D card and we will work with you (and, if you wish,
your Doctor) to find a wellness program with the same reward that is right for you in light of your health
status. (f you receive a gift card as a wellness reward and use it for purposes other than for qualified
medical expenses, this may result in taxable income to you. For additional guidance, please consult your
tax advisor.)

108
Waiver
No agent or other person, except an authorized officer of Anthem, is able to disregard any conditions or
restrictions contained in this Booklet, to extend the amount of time for making a payment to us, or to bind
us by making any promise or representation or by giving or receiving any information.
Workers' Compensation
The benefits under this Plan are not designed to duplicate benefits that you are eligible for under
Workers' Compensation Law. All money paid or owed by Workers' Compensation for services provided
to you shall be paid back by you, or on your behalf, to us if we have made or make payment for the
services received. t is understood that coverage under this Plan does not replace or affect any Workers'
Compensation coverage requirements.
Subrogation and Reimbursement
This section applies when we pay benefits as a result of injuries or illness and another party or party(ies)
agrees or is ordered to pay money because of these injuries or when the Member received or is entitled
to receive a Recovery because of these injuries or illnesses. Reimbursement or subrogation under this
Booklet may only be permitted if you have been fully compensated, and, the amount recoverable by us
may be reduced by a proportionate share of your attorney fees and costs, if state law so requires.
Subrogation
We have the right to recover payments we make on your behalf. The following apply:
f you have been fully compensated, we have a lien against all or a portion of the benefits that have
been paid to you from the following parties, including, but not limited to, the party or parties who
caused the injuries or illness, the insurer or other indemnifier of the party or parties who caused the
injuries or illness, a guarantor of the party or parties who caused the injuries or illness, your own
insurer (for example, uninsured, underinsured, medical payments or no-fault coverage, or a worker's
compensation insurer), or any other person, entity, policy or plan that may be liable or legally
responsible in relation to the injuries or illness. However, our Recovery cannot exceed the amount
actually paid by us under this Booklet as it relates to the injuries or illness that are the subject of the
subrogation action; and
You and your legal representative must do whatever is necessary to enable us to exercise our rights
and do nothing to prejudice them. f you have not pursued a claim against a third party allegedly at
fault for your injuries by the date that is sixty (60) days before to the date on which the applicable
statute of limitations expires, we have a right to bring legal action against the at-fault party.
Reimbursement
f you, a person who represents your legal interest, or beneficiary have been fully compensated and We
have not been repaid for the health insurance benefits we paid on the Member's behalf, we shall have a
right to be repaid from the Recovery in the amount of the health insurance benefits we paid on your
behalf and the following apply:
You must reimburse us to the extent of the health insurance benefits we paid on the Member's behalf
from any Recovery, including, but not limited to, the party or parties who caused the injuries or illness,
the insurer or other indemnifier of the party or parties who caused the injuries or illness, a guarantor
of the party or parties who caused the injuries or illness, your own insurer (for example, underinsured,
medical payments, or a worker's compensation insurer), or any other person, entity, policy or plan
that may be liable or legally responsible in relation to the injuries or illness;

109
Notwithstanding any allocation made in a settlement agreement or court order, we shall have a right
of reimbursement; and
You, a person who represents your legal interest, or beneficiary must hold in trust for us right away
the amount recovered in gross that is to be paid to us. The amount recovered in gross is the total
amount of your Recovery reduced by your lawyer fees and costs.
The Member's Duties
You, a person who represents your legal interest, or beneficiary must tell us right away the how, when
and where an accident or event that resulted in your injury or illness. We must find out what
happened and get all the details about the parties involved;
You, a person who represents your legal interest, or beneficiary must work with us in investigating,
settling and protecting rights;
You, a person who represents your legal interest, or beneficiary must send us copies of all police
reports, notices or other papers received in connection with the accident or incident resulting in
personal injury or illness;
You, a person who represents your legal interest, or beneficiary must promptly notify us if you retain
an attorney or if a lawsuit is filed;
f you, a person who represents your legal interest, or beneficiary gets a Recovery that is less than
the sum of all your damages incurred by you, you are required to tell us within 60 days of your receipt
of the Recovery. The notice to us must include:
! Total amount and source of the Recovery;
! Coverage limits applicable to any available insurance policy, contract or benefit plan; and
! The amount of any costs charged to you.
f we receive your notice that you have not been fully paid, we have the right to dispute that
determination;
f we dispute whether your Recovery is less than the sum of all your damages, such dispute must be
resolved through arbitration; and
f you, a person who represents your legal interest, or beneficiary resides in a state where automobile
personal injury protection or medical payment coverage is mandatory, that coverage is primary and
the Booklet takes secondary status. The Booklet will reduce benefits for an amount equal to, but not
less than, that state's mandatory minimum personal injury protection or medical payment
requirement.
Coordination of Benefits When Members Are Insured Under More
Than One PIan
We may coordinate benefits when you have coverage with more than one health coverage.
DupIicate Coverage
Duplicate coverage is the term used to describe when you are covered by this Booklet and also covered
by another:
Group or group-type health insurance;
Health benefits coverage; or

110
Blanket coverage.
The total benefits received by you, or on your behalf, from all coverage's combined for any claim for
Covered Services will not exceed 100 percent of the total covered charges.
Order of Benefit Determination RuIes - The foIIowing ruIes are used in the order as Iisted:
How We Determine Which Coverage is Primary and Which is Secondary
We will determine the primary coverage and secondary coverage according to the following rule: A plan
that does not have order of benefit determination rules or if it has rules will always be primary unless the
provisions of both plans state that the plan is primary.
Non-Dependent or Dependent
The plan that covers the person other than as a dependent, for example as an employee, member,
subscriber or retiree, is primary and the plan that covers the person, as a dependent, is secondary. f the
person is a Medicare beneficiary, please refer to the section below of "Determining Primacy Between
Medicare and Us for primary and secondary payer rules.
Active EmpIoyee, Retired or Laid-Off EmpIoyee
a. The plan that covers a person as an active employee, who is not laid off or retired, or a dependent of
an active employee, is the primary plan.
b. f the secondary, or other plan, does not have this rule, and as result the plans do not agree on the
order of benefits, this rule is ignored.
c. This rule does not apply if the section above of "Non-Dependent or Dependent can determine the
order of benefits.
COBRA or State Continuation Coverage
a. f a person whose coverage is provided in accordance with COBRA, or under a right of continuation
according to state or federal law is covered under another plan, the plan covering the person as an
employee, member, subscriber or retiree or covering the person as a dependent of an employee,
member, subscriber, or retiree, is the primary plan and the plan covering that same person in
accordance with COBRA, or under a right of continuation in accordance with state or other federal
law, is the secondary plan.
b. f the other plan does not have this rule, and if, as a result, the plans do not agree on the order of
benefits, this rule is ignored.
c. This rule does not apply if the section above of "Non-Dependent or Dependent can determine the
order of benefits.
Longer or Shorter Length of Coverage
a. f the rules above do not determine the order of benefits, the plan that covered the person for the
longer period of time is primary plan and the plan that covered the person for the shorter period of
time is the secondary plan.
b. To determine the length of time a person has been covered under a plan, two (2) successive plans
will be treated as one if the covered person was eligible under the second within twenty-four (24)
hours after the first ended.
c. The start of a new plan does not include:
(1) A change in the amount or scope of a plan's benefits;

111
(2) A change in the entity that pays, provides or administers the plan's benefits; or
(3) A change from one type of plan to another (such as, from a single employer plan to that of a
multiple employer plan).
d. The person's length of time covered under a plan is measured from the person's first date of
coverage under that plan. f that date is not readily available for a group plan, the date the person first
became a member of the group will be used as the date from which to determine the length of time
the person's coverage under the present plan has been in force.
f none of the rules above determine the primary plan, the allowable expenses will be shared equally
between the plans.
Dependent ChiId Covered Under More Than One PIan
Unless there is a court decree stating otherwise, plans covering a dependent child will determine the
order of benefits as follows:
a. For a dependent child whose parents are married or are living together, whether or not they have
been married:
(1) The plan of the parent whose birthday falls earlier in the calendar year, by month and day, is the
primary plan; or
(2) f both parents have the same birthday, the plan that has covered the parent the longest is the
primary plan.
b. For a dependent child whose parents are divorced or separated or are not living together, whether or
not they have ever been married:
(1) f the court decree states that one of the parents is responsible for the dependent child's health
care expenses or health care coverage, and the plan of that parent has actual knowledge of
those terms, that plan is primary. f the parent with financial responsibility has no health care
coverage for the dependent child's health care, but that parent's spouse does, the spouse's plan
is primary. This item will not apply with respect to a plan year during which benefits are paid or
provided before the entity has actual knowledge of the court decree provision;
(2) f the court decree states that both parents are responsible for the dependent child's health care
expenses or health care coverage, paragraph a above will determine the order of benefits;
(3) f the divorce decree states that the parents have joint custody without specifying that one parent
has responsibility for the health care expenses or health care coverage of the depend child,
paragraph a above will determine the order of benefits; or
(4) f there is no court decree allocating responsibility for the child's health care expenses of health
care coverage, the order of benefits for the child are as follows:
(a) The plan of the custodial parent;
(b) The plan of the spouse of the custodial parent;
(c) The plan of the noncustodial parent; and then
(d) The plan of the spouse of the noncustodial parent.
c. For a dependent child covered under more than one plan of individuals who are not parents of the
child, the order of benefits will be determined, as applicable, according to paragraph a. or b. above as
if those individuals were the parents of the child.
d. For a dependent child who has coverage under either or both parents' plans and also has his or her
own coverage as a dependent under a spouse's plan, the rule in the section above for "Longer or
Shorter Length of Coverage applies.

112
n the event the dependent child's coverage under the spouse's plan began on the same date as the
dependent child's coverage under either or both parents' plans, the order of benefits will be determined by
applying the birthday rule to the dependent child's parent(s) and the dependent's spouse.
RuIes for Coordination of Benefits
When a person is covered by two (2) or more plans, the rules for determining the order of benefit
payments are as follows:
1. The primary plan must pay or provide its benefits as if the secondary plan or plans did not exist.
2. f the primary plan is a Closed Panel Plan, and the secondary plan is not a Closed Panel Plan, the
secondary plan will pay or provide benefits as if it were the primary plan when a covered person uses
a non-panel provider, except for emergency services or authorized referrals that are paid or provided
by the primary provider.
3. When multiple contracts providing coordinated coverage are treated as a single plan, this section only
applies to the plan as a whole, and coordination among the component contracts is governed by the
terms of the contracts.
4. f a person is covered by more than one secondary plan, each secondary plan will take into
consideration the benefits of the primary plan, or plans, and the benefits of any other plan, which, has
its benefits determined before those of that secondary plan.
5. Under the terms of a Closed Panel Plan, benefits are not payable if the covered person does not use
the services of a closed panel provider, with the exceptions of medical emergencies and if there are
allowable benefits available. n most instances, Coordination of Benefits does not occur if a covered
person is enrolled in two (2) or more Closed Panel Plans and obtains services from a provider in one
of the Closed Panel Plans because the other Closed Panel Plan (the one whose providers were not
used) has no liability. However, Coordination of Benefits may occur during the claim determination
period when the covered person receives emergency services that would have been covered by both
plans.
Determining Primacy Between Medicare and Us
We will be the primary payer for persons with Medicare age 65 and older if the policyholder is actively
working for an employer who is providing the policy holder's health insurance and the employer has 20 or
more employees. Medicare will be the primary payer for persons with Medicare age 65 and older if the
policyholder is not actively working and the Member is enrolled in Medicare. Medicare will be the primary
payer for persons with Medicare age 65 and older if the employer has less than 20 employees and the
Member is enrolled in Medicare.
We will be the primary payer for persons enrolled with Medicare under age 65 when Medicare coverage
is due to disability if the policyholder is actively working for an employer who is providing the
policyholder's health insurance and the employer has 100 or more employees. Medicare will be the
primary payer for persons enrolled in Medicare due to disability if the policyholder is not actively working
or the employer has less than 100 employees.
We will be the primary payer for persons with Medicare under age 65 when Medicare coverage is due to
End Stage Renal Disease (ESRD), for the first 30 months from the entitIement to or eIigibiIity for
Medicare (whether or not Medicare is taken at that time). After 30 months, Medicare will become the
primary payer if Medicare is in effect (30-month coordination period).
When a Member becomes eligible for Medicare due to a second entitlement, such as age, We remain
primary. But this will only apply if the group health coverage was primary at the point when the second
entitlement took effect, for the duration of 30 months after becoming Medicare entitled or eligible due to
ESRD. f Medicare was primary at the point of the second entitlement, then Medicare remains primary.
There will be no 30-month coordination period for ESRD.

113
Members with Medicare and Two Group Insurance PoIicies
Based on the primacy rules, if Medicare is secondary to a group coverage (see Medicare primacy rules),
the primary coverage covering the Member will pay first. Medicare will then pay second, and the
coverage covering the Member as a retiree or inactive employee or Dependent will pay third. The order
of primacy is not based on the policyholder of the group health insurance.
f Medicare is the primary payer due to Medicare primacy rules, then the rules of primacy for employees
and their spouses will be used to determine the coverage that will pay second and third.
Your ObIigations
You have an obligation to provide us with current and accurate information regarding the existence of
other coverage.
Benefits payable under another coverage include benefits that would be paid by that coverage, whether
or not a claim is made. t also includes benefits that would have been paid but were refused. This is due
to the claim not being sent to the Provider of other coverage on a timely basis.
Your benefits under this Booklet will be reduced by the amount that such benefits would duplicate
benefits payable under the primary coverage.
Our Rights to Receive and ReIease Necessary Information
We may release to, or obtain, from any insurance company or other organization or person any
information which we may need to carry out the terms of this Booklet. Members will furnish to us such
information as may be necessary to carry out the terms of this Booklet.
Payment of Benefits to Others
When payments that should have been made under this Booklet were made under any other coverage, we will
have the right to pay to the other coverage any amount we determine to be warranted to satisfy the intent of
this provision. Any amount so paid will be considered to be benefits paid under this Booklet, and with that
payment we will fully satisfy our liability under this provision.
DupIicate Coverage and Coordination of Benefits Overpayment Recovery
f we have overpaid for Covered Services under this section, we will have the right, by offset or otherwise, to
recover the excess amount from you or any person or entity to which, or in whose behalf, the payments were
made.

114
Section 12. Termination/NonrenewaI/Continuation
Termination
Except as otherwise provided, your coverage may terminate in the following situations:
When the Contract between the Group and us terminates. f your coverage is through an association,
your coverage will terminate when the Contract between the association and us terminates, or when
your Group leaves the association. t will be the Group's responsibility to notify you of the termination
of coverage.
f you choose to terminate your coverage.
f you or your Dependents cease to meet the eligibility requirements of the Plan, subject to any
applicable continuation requirements. f you cease to be eligible, the Group and/or you must notify us
immediately. The Group and/or you shall be responsible for payment for any services incurred by you
after you cease to meet eligibility requirements.
f you elect coverage under another carrier's health benefit plan, which is offered by the Group as an
option instead of this Plan, subject to the consent of the Group. The Group agrees to immediately
notify us that you have elected coverage elsewhere.
f you perform an act, practice, or omission that constitutes fraud or make an intentional
misrepresentation of material fact, as prohibited by the terms of your Plan, your coverage and the
coverage of your Dependents can be retroactively terminated or rescinded. A rescission of coverage
means that the coverage may be legally voided back to the start of your coverage under the Plan, just
as if you never had coverage under the Plan. You will be provided with a 30 calendar day advance
notice with appeal rights before your coverage is retroactively terminated or rescinded. You are
responsible for paying us for the cost of previously received services based on the Maximum Allowable
Amount for such services, less any Copayments made or Premium paid for such services.
f you fail to pay or fail to make satisfactory arrangements to pay your portion of the Premium, we may
terminate your coverage and may also terminate the coverage of your Dependents.
f you permit the fraudulent use of your or any other Member's Plan dentification Card by any other
person; use another person's dentification Card; or use an invalid dentification Card to obtain
services, your coverage will terminate immediately upon our written notice to the Group. Anyone
involved in the misuse of a Plan dentification Card will be liable to and must reimburse us for the
Maximum Allowed Amount for services received through such misuse.
f you are a partner to a civil union, recognized domestic partnership, or other relationship recognized
as a spousal relationship in the state where the subscriber resides, on the date such union or
relationship is revoked or terminated. Also, if there is coverage for designated beneficiaries, on the date
a Recorded Designated Beneficiary Agreement is revoked or terminated. Where permitted by law,
such a Dependent may be able to seek COBRA or state continuation coverage, subject to the terms of
this Booklet.
You will be notified in writing of the date your coverage ends by either us or the Group.
RemovaI of Members
Upon written request through the Group, you may cancel your coverage and/or your Dependent's
coverage from the Plan. f this happens, no benefits will be provided for Covered Services after the
termination date even if we have preauthorized the service, unless the Provider confirmed eligibility within
two business days before the service is received.

115
SpeciaI RuIes if Your Group HeaIth PIan is Offered Through an
Exchange
f your Plan is offered through an Exchange, either you or your Group may cancel your coverage and/or
your Dependent's coverage through the Exchange. Each Exchange will have rules on how to do this.
You may cancel coverage by sending a written notice to either the Exchange or us. The date that
coverage will end will be either:
The date that you ask for coverage to end, if you provide written notice within 14 days of that date; or
14 days after you ask for coverage to end, if you ask for a termination date more than 14 days before
you gave written notice. We may agree in certain circumstances to allow an earlier termination date
that you request.
Continuation of Coverage Under FederaI Law (COBRA)
The following applies if you are covered by a Group that is subject to the requirements of the
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended.
COBRA continuation coverage can become available to you when you would otherwise lose coverage
under your Group's health Plan. t can also become available to other Members of your family, who are
covered under the Group's health Plan, when they would otherwise lose their health coverage. For
additional information about your rights and duties under federal law, you should contact the Group.
QuaIifying events for Continuation Coverage under FederaI Law (COBRA)
COBRA continuation coverage is available when your coverage would otherwise end because of certain
"qualifying events. After a qualifying event, COBRA continuation coverage must be offered to each
person who is a "qualified beneficiary. You, your spouse and your Dependent children could become
qualified beneficiaries if you were covered on the day before the qualifying event and your coverage
would be lost because of the qualifying event. Qualified beneficiaries who elect COBRA must pay for this
COBRA continuation coverage.
This benefit entitles each Member of your family who is enrolled in the Plan to elect continuation
independently. Each qualified beneficiary has the right to make independent benefit elections at the time
of annual enrollment. Covered Subscribers may elect COBRA continuation coverage on behalf of their
spouses, and parents or legal guardians may elect COBRA continuation coverage on behalf of their
children. A child born to, or placed for adoption with, a covered Subscriber during the period of
continuation coverage is also eligible for election of continuation coverage.


116
InitiaI QuaIifying Event Length of AvaiIabiIity of Coverage

For Subscribers:

Voluntary or nvoluntary Termination (other than
gross misconduct) or Reduction n Hours Worked





18 months


For Dependents:

A Covered Subscriber's Voluntary or nvoluntary
Termination (other than gross misconduct) or
Reduction n Hours Worked

Covered Subscriber's Entitlement to Medicare

Divorce or Legal Separation

Death of a Covered Subscriber






18 months

36 months

36 months

36 months

For Dependent ChiIdren:

Loss of Dependent Child Status



36 months


COBRA coverage will end before the end of the maximum continuation period listed above if you become
entitled to Medicare benefits. n that case a qualified beneficiary other than the Medicare beneficiary
is entitled to continuation coverage for no more than a total of 36 months. (For example, if you become
entitled to Medicare prior to termination of employment or reduction in hours, COBRA continuation
coverage for your spouse and children can last up to 36 months after the date of Medicare entitlement.)
If Your Group Offers Retirement Coverage
f you are a retiree under this Plan, filing a proceeding in bankruptcy under Title 11 of the United States
Code can be a qualifying event. f a proceeding in bankruptcy is filed with respect to your Group, and that
bankruptcy results in the loss of coverage, you will become a qualified beneficiary with respect to the
bankruptcy. Your Dependents will also become qualified beneficiaries if bankruptcy results in the loss of
their coverage under this Plan. f COBRA coverage becomes available to a retiree and his or her covered
family members as a result of a bankruptcy filing, the retiree may continue coverage for life and his or her
Dependents may also continue coverage for a maximum of up to 36 months following the date of the
retiree's death.
Second quaIifying event
f your family has another qualifying event (such as a legal separation, divorce, etc.) during the initial 18
months of COBRA continuation coverage, your Dependents can receive up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months from the original qualifying event. Such
additional coverage is only available if the second qualifying event would have caused your Dependents
to lose coverage under the Plan had the first qualifying event not occurred.

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Notification Requirements
The Group will offer COBRA continuation coverage to qualified beneficiaries only after the Group has
been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the Subscriber, commencement of a proceeding in
bankruptcy with respect to the employer, or the Subscriber's becoming entitled to Medicare benefits
(under Part A, Part B, or both), the Group will notify the COBRA Administrator (e.g., Human Resources or
their external vendor) of the qualifying event.
You Must Give Notice of Some QuaIifying Events
For other qualifying events (e.g., divorce or legal separation of the Subscriber and spouse or a
Dependent child's losing eligibility for coverage as a Dependent child), you must notify the Group within
60 days after the qualifying event occurs.
EIecting COBRA Continuation Coverage
To continue your coverage, you or an eligible family Member must make an election within 60 days of the
date your coverage would otherwise end, or the date the company's benefit Plan Administrator notifies
you or your family Member of this right, whichever is later. You must pay the total Premium appropriate
for the type of benefit coverage you choose to continue. f the Premium rate changes for active
associates, your monthly Premium will also change. The Premium you must pay cannot be more than
102% of the Premium charged for Employees with similar coverage, and it must be paid to the company's
benefit plan administrator within 30 days of the date due, except that the initial Premium payment must be
made before 45 days after the initial election for continuation coverage, or your continuation rights will be
forfeited.
DisabiIity extension of 18-month period of continuation coverage
For Subscribers who are determined, at the time of the qualifying event, to be disabled under Title
(OASD) or Title XV (SS) of the Social Security Act, and Subscribers who become disabled during the
first 60 days of COBRA continuation coverage, coverage may continue from 18 to 29 months. These
Subscribers' Dependents are also eligible for the 18- to 29-month disability extension. (This also applies
if any covered family Member is found to be disabled.) This would only apply if the qualified beneficiary
gives notice of disability status within 60 days of the disabling determination. n these cases, the
Employer can charge 150% of Premium for months 19 through 29. This would allow health coverage to
be provided in the period between the end of 18 months and the time that Medicare begins coverage for
the disabled at 29 months. (f a qualified beneficiary is determined by the Social Security Administration to
no longer be disabled, such qualified beneficiary must notify the Plan Administrator of that fact in writing
within 30 days after the Social Security Administration's determination.)
Trade Adjustment Act EIigibIe IndividuaI
f you don't initially elect COBRA coverage and later become eligible for trade adjustment assistance
under the U.S. Trade Act of 1974 due to the same event which caused you to be eligible initially for
COBRA coverage under this Plan, you will be entitled to another 60-day period in which to elect COBRA
coverage. This second 60-day period will commence on the first day of the month on which you become
eligible for trade adjustment assistance. COBRA coverage elected during this second election period will
be effective on the first day of the election period. You may also be eligible to receive a tax credit equal
to 65% of the cost for health coverage for you and your Dependents charged by the Plan. This tax credit
also may be paid in advance directly to the health coverage Provider, reducing the amount you have to
pay out of pocket.

118
When COBRA Coverage Ends
COBRA benefits are available without proof of insurability and coverage will end on the earliest of the
following:
A covered individual reaches the end of the maximum coverage period;
A covered individual fails to pay a required Premium on time;
A covered individual becomes covered under any other group health plan after electing COBRA. f
the other group health plan contains any exclusion or limitation on a pre-existing condition that
applies to you, you may continue COBRA coverage only until these limitations cease;
A covered individual becomes entitled to Medicare after electing COBRA; or
The Group terminates all of its group welfare benefit plans.
If You Have Questions
Questions concerning your Group's health Plan and your COBRA continuation coverage rights should be
addressed to the Group. For more information about your rights under ERSA, including COBRA, the
Health nsurance Portability and Accountability Act (HPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits
Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses
and phone numbers of Regional and District EBSA Offices are available through EBSA's website.)
Continuation of Coverage Under State Law
Groups with less than 20 employees who provide health care coverage for their employees are subject to
state law for continuation of coverage. The state continuation coverage period will not exceed 18 months
for you and/or any Dependents. State continuation coverage for you and your Dependents will start on
the date of the earliest of the following qualifying events:
Your termination of employment. To qualify, you must have been covered by the Group health
coverage for at least (6) six straight months;
Your reduction in working hours which results in loss of coverage. Reduction in working hours would
include circumstances resulting from economic conditions, injury, disability, or chronic health
conditions;
Your death; or
Divorce or legal separation of you and the spouse.
State Continuation Coverage Notification
Unless termination or reduction in working hours is the qualifying event, a Subscriber, spouse or
Dependent child must tell the Group of their choice to keep coverage within 30 days after being eligible.
The Group is responsible for telling the Subscriber, spouse and/or Dependent child of how to choose
state continuation. Once the Group has given notice to the Subscriber, spouse and/or Dependent child,
we must get timely notice from the Group that you want state continuation. We must also get timely
payment of Premiums from the Group when paid by the Subscriber.
We should get the notice from the Group and your first no later than 30 days after the qualifying event. f
the group fails to give timely notice to you of your rights, this deadline may extend to 60 days after the
qualifying event. For more, contact your Group.

119
When State Continuation Coverage Ends
Your state continuation coverage ends upon the earlier of the following:
A covered individual reaches the end of the maximum coverage period;
The Group Master Contract between Us and your employer ends. f the employer gets other group
coverage, continuation coverage will continue under the new plan;
A covered individual fails to pay Premium timely;
You are eligible for another group health plan unless the other plan does not cover something that is
covered by the continuation coverage. n that case, the state continuation coverage lasts until the
continuation period ends or the other plan covers the excluded condition;
f you are covered as a Designated Beneficiary, on the date the Recorded Designated Beneficiary
Agreement is revoked or terminated;
The date the spouse remarries and becomes eligible for coverage under the new spouse's group
health plan;
You get Medicare or Medicaid; or
You tell us in writing to cancel.
Continuation of Coverage Due To MiIitary Service
Under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), the
Subscriber or his / her Dependents may have a right to continue health care coverage under the Plan if
the Subscriber must take a leave of absence from work due to military leave.
Employers must give a cumulative total of five years and in certain instances more than five years, of
military leave.
"Military service means performance of duty on a voluntary or involuntary basis and includes active duty,
active duty for training, initial active duty for training, inactive duty training, and full-time National Guard
duty.
During a military leave covered by USERRA, the law requires employers to continue to give coverage
under this Plan to its Members. The coverage provided must be identical to the coverage provided to
similarly situated, active employees and Dependents. This means that if the coverage for similarly
situated, active employees and Dependents is modified, coverage for you (the individual on military leave)
will be modified.
You may elect to continue to cover yourself and your eligible Dependents by notifying your employer in
advance and submitting payment of any required contribution for health coverage. This may include the
amount the employer normally pays on your behalf. f your military service is for a period of time less
than 31 days, you may not be required to pay more than the active Member contribution, if any, for
continuation of health coverage. For military leaves of 31 days or more, you may be required to pay up to
102% of the full cost of coverage, i.e., the employee and employer share.
The amount of time you continue coverage due to USERRA will reduce the amount of time you will be
eligible to continue coverage under COBRA.

120
Maximum Period of Coverage During a MiIitary Leave
Continued coverage under USERRA will end on the earlier of the following events:
1. The date you fail to return to work with the Group following completion of your military leave.
Subscribers must return to work within:
a) The first full business day after completing military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service.
b) 14 days after completing military service for leaves of 31 to 180 days,
c) 90 days after completing military service for leaves of more than 180 days; or
2. 24 months from the date your leave began.
Reinstatement of Coverage FoIIowing a MiIitary Leave
Regardless of whether you continue coverage during your military leave, if you return to work your health
coverage and that of your eligible Dependents will be reinstated under this Plan if you return within:
1. The first full business day of completing your military service, for leaves of 30 days or less. A
reasonable amount of travel time will be allowed for returning from such military service;
2. 14 days of completing your military service for leaves of 31 to 180 days; or
3. 90 days of completing your military service for leaves of more than 180 days.
f, due to an illness or injury caused or aggravated by your military service, you cannot return to work
within the time frames stated above, you may take up to:
1. Two years; or
2. As soon as reasonably possible if, for reasons beyond your control you cannot return within two years
because you are recovering from such illness or injury.
f your coverage under the Plan is reinstated, all terms and conditions of the Plan will apply to the extent
that they would have applied if you had not taken military leave and your coverage had been continuous.
Any waiting/probationary periods will apply only to the extent that they applied before.
Please note that, regardless of the continuation and/or reinstatement provisions listed above, this Plan
will not cover services for any illness or injury caused or aggravated by your military service, as indicated
in the "Limitations/Exclusions (What is Not Covered and Pre-Existing Conditions)" section.
FamiIy and MedicaI Leave Act of 1993
A Subscriber who takes a leave of absence under the Family and Medical Leave Act of 1993 (the Act) will
still be eligible for this Plan during their leave. We will not consider the Subscriber and his or her
Dependents ineligible because the Subscriber is not at work.
f the Subscriber ends their coverage during the leave, the Subscriber and any Dependents who were
covered immediately before the leave may be added back to the Plan when the Subscriber returns to
work without medical underwriting. To be added back to the Plan, the Group may have to give us
evidence that the Family and Medical Leave Act applied to the Subscriber. We may require a copy of the
health care Provider statement allowed by the Act.

121
Benefits After Termination Of Coverage
Except as stated below, we will not pay for any services given to you after your coverage ends even if we
preauthorized the service, unless the Provider confirmed your eligibility within two business days before
each service received. Benefits cease on the date your coverage ends as described above. You may be
responsible for benefit payments made by us on your behalf for services provided after your coverage
has ended.
When your coverage ends for any reason other than for nonpayment of Premium, fraud or abuse, We will
continue coverage if you are being treated at an inpatient facility, until you are discharged or transferred
to another level of care. This is subject to the terms of this Booklet. The discharge date is seen as the
first date on which you are discharged from the facility or transferred to another level of care. We will not
cover the services you get after your discharge date.
Unless a law requires, we do not cover services after your date of termination even if:
We approved the services; or
The services were made necessary by an accident, illness or other event that occurred while coverage
was in effect.

122
Section 13. AppeaIs and CompIaints
We want your experience with us to be as positive as possible. There may be times, however, when you
have a complaint, problem, or question about your Plan or a service you have received. n those cases,
please contact Customer Service by calling the number on the back of your D card. We will try to resolve
your complaint informally by talking to your Provider or reviewing your claim. f you are not satisfied with
the resolution of your complaint, you have the right to file a Grievance / Appeal, which is defined as
follows:
We may have turned down your claim for benefits. We may have also denied your request to
preauthorize or receive a service or a supply. f you disagree with Our decision you can:
1. File a complaint
2. File an appeal; or
3. File a grievance.

CompIaints
f you want to file a complaint about our customer service or how we processed your claim, please call
customer services. A trained staff member will try to clear up any confusion about the matter. They will
also try to resolve your complaint. f you prefer, you can send a written complaint to this address:
For services that are not dentaI or vision send to:
Anthem
Customer Services Department
P.O. Box 17549
Denver, CO 80217-0549
For dentaI benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:
Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
f your complaint isn't solved either by writing or calling, or if you don't want to file a complaint, you can file
an appeal. We'll tell you how to do that next, in the Appeals section below.
Note: More details on the complaints and appeals process and time periods can be found in the Appeals
Guide. You may get a copy of the Appeals Guide by visiting www.anthem.com or you can call customer
service.



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AppeaIs
f we have denied a claim that you feel should have been covered, or handled in a different way, or had
your coverage cancelled retroactively for a reason that it not because of your failure to pay premiums, you
can file an appeal. You can appeal a denial that was made by us before the service is received. You can
also appeal a denial on a service after it is received. You may also appeal an eligibility determination
made by us.
While we encourage you to file an appeal within 60 days of the unfavorable benefit determination, the
written or oral appeal must be received by us within 180 days of the unfavorable benefit determination.
We will assign an employee to help you in the appeal process. An appeal can be filed verbally by calling
customer service.
An appeaI can be fiIed by writing to this address for services that are not a dentaI or vision
service:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway
Denver, CO 80273
For dentaI benefit issues send to:
Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122
For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
You don't have to file a complaint before you file an appeal. n your appeal, please state as plainly as
possible why you think we shouldn't have denied your claim for benefits. nclude any documents you
didn't submit with the original claim or service/supply request. Also send any other documents that
support your appeal. You don't have to file the appeal yourself. Someone else, like your Doctor or
another representative, can file an appeal for you. Just let us know in writing who will be filing the appeal
for you.
The appeals process allows you to request an internal appeal, and in certain cases, an independent
external appeal.
InternaI AppeaIs
We have an internal process that We follow when reviewing your appeal. Members of our staff, who were
not involved when your claim was first denied, will review the appeal. They may also talk with co-workers
to assist in the review.
f your first internal appeal is denied, you can ask for a second level appeal. But you don't have to file a
second level appeal with Us before requesting an independent external review appeal or pursuing legal
action.
Expedited internaI appeaI - f you have an urgent case, you may request that your internal appeal be
reviewed in a shorter time period. This is called an expedited internal appeal. You or your representative

124
can ask for an expedited appeal if you had Emergency services but haven't been discharged from the
Facility. Also, you can ask for an expedited appeal if the regular appeal schedule would:
Seriously jeopardize your life or health;
Jeopardize your ability to regain maximum function;
Create an immediate and substantial limitation on your ability to live independently, if you're disabled;
or
n the opinion of a Doctor with knowledge of your condition, would subject you to severe pain that can't
be adequately managed without the service in question.
Independent ExternaI AppeaIs
For claims based on Utilization Review, or a rescission or retroactive cancellation of coverage for reasons
other than nonpayment of premium, you can request an independent external appeal. Utilization Review
includes claims we denied as Experimental or nvestigational or not Medically Necessary. t also includes
claims where we reviewed your medical circumstances to decide if an exclusion applied. For these
appeals, your case is reviewed by an external review entity, selected by the Colorado Division of
nsurance.
Your request for independent external review must be made within 4 months of our appeal decision.
Generally, you have to have completed at least the first level internal appeal. But if we fail to handle the
appeal according to applicable Colorado insurance law and regulations, you will be eligible to request
independent external review.
Expedited externaI appeaI You or your representative can request an expedited independent external
review, but only in certain cases:
You had Emergency services but haven't been discharged from the Facility.
A Doctor certifies to us that you have a medical condition where following the normal external review
appeal process would seriously jeopardize your life or health, would jeopardize your ability to regain
maximum function or, if you're disabled, would create an imminent and substantial limitation of your
ability to live independently; or
We denied coverage for a requested medical service as being Experimental or nvestigational, your
treating physician certifies in writing that the requested service would be significantly less effective if
not promptly initiated and certifies that either:
! Standard health care services or treatments have not been effective in improving your condition
or are not medically appropriate for you; or
! The Doctor is a licensed, board-certified or board-eligible physician qualified to practice in the
area of medicine appropriate to treat your condition, there is no available standard health care
service or treatment covered by this Booklet that is more beneficial than the requested service,
and scientifically valid studies using accepted protocols demonstrate that the requested service is
likely to be more beneficial to you than any available standard services.
f it meets these conditions, your request for expedited external appeal can be filed at the same time as
your request for an expedited internal appeal.
For more information on where and how to request an internal or external appeal, please consult the
Appeals Guide available at www.anthem.com, or call customer service.

125
Grievances
f you have an issue or concern about the quality or services you receive from an n-Network Provider or
Facility, you can file a grievance. The quality management department strives to resolve grievances fairly
and quickly.
You may caII customer service or send a written grievance for services that are not a, dentaI or
vision service to:
Anthem Blue Cross and Blue Shield
Attn: Grievance and Appeals Department
700 Broadway

Denver, CO 80273-0001
For dentaI benefit issues send to:

Anthem Blue Cross and Blue Shield
P.O. Box 1122
Minneapolis, Minnesota
55440-1122

For vision benefit issues send to:

Anthem Blue Cross and Blue Shield / Blue View Vision
555 Middle Creek Parkway
Colorado Springs, CO 80921
Our quality management department will acknowledge that we've received your grievance. They'll also
investigate it. We treat every grievance confidentially.
Division of Insurance Inquiries
For inquiries about health care coverage in Colorado, you may call the Division of nsurance between
8:00 a.m. and 5:00 p.m., Monday through Friday, at (303) 894-7490, or write to the Division of nsurance
to the attention of the CARE Section, 1560 Broadway, Suite 850, Denver, Colorado 80202.
Binding Arbitration
The binding arbitration provision under this Booklet is applicable to claims arising under all individual
plans, governmental plans, church plans, plans or claims to which ERSA preemption does not apply, and
plans maintained outside the United States. Any such arbitration will be governed by the procedures and
rules established by the American Arbitration Association. You may obtain a copy of the Rules of
Arbitration by calling our customer services. The law of the state in which the policy was issued and
delivered to you shall govern the dispute. The arbitration decision is binding on both you and us.
Judgment on the award made in arbitration may be enforced in any court with proper jurisdiction. f any
person subject to this arbitration clause initiates legal action of any kind, the other party may apply for a
court of competent jurisdiction to enjoin, stay or dismiss any such action and direct the parties to arbitrate
in accordance with this section.
LegaI Action
Before you take legal action on a claim decision, you must first follow the process found in this section.
You must meet all the requirements of this Booklet.

126
No action in law or in equity shall be brought to recover on this Booklet before the expiration of 60
calendar days after a claim has been filed according to the requirements of this Booklet. f you have
exhausted all mandatory levels of review in your appeal, you may be entitled to have the claim decision
reviewed de novo (as if for the first time) in any court with jurisdiction and to a trial by jury.
No such action shall be brought at all unless brought within three years after claim has been filed as
required by the Booklet.

127
Section 14. Information on PoIicy and Rate Changes
Insurance Premiums
How Premiums are EstabIished and Changed - Premiums are the monthly charges you and/or the
Group must pay us to get coverage. We figure out and set the required Premiums.
The Group is responsible for paying the employee's Premium to us according to the terms of the Group
Contract. Groups may have you contribute to the Premium cost through payroll deduction. Some Groups
may choose to have your Premium determined by the age of the Subscriber, with Premium set by age
brackets. We may change membership Premiums on the annual date on which the Group renews its
coverage, which we may assess when a Subscriber changes to a new five-year increment age bracket,
e.g., age 25 through age 29. f the age of the Subscriber is misstated at enrollment, all amounts payable
for the correct age will be adjusted and billed to the Group.
Grace Period - f a Group fails to submit Premium payments to us in a timely manner, the Group is
entitled to a grace period of 31 days for the payment of such Premium. During the grace period, our
contract with the Group shall continue in force unless the Group gives us written notice of termination of
the contract. f the Group has obtained replacement coverage during the grace period, the contract with
us will be terminated as of the last day for which we have received Premium, and any and aII cIaims paid
during the grace period wiII be retroactiveIy adjusted to deny. These claims that we retroactively
deny should be submitted to the replacement carrier. f the Group has not obtained replacement
coverage during the grace period, or fails to inform Us that the employer has not obtained replacement
coverage, we will process any and all claims with dates of service during the grace period in accordance
with the terms of this Booklet.

128
Section 15. Definitions
f a word or phrase in this Booklet has a special meaning, such as Medical Necessity or Experimental /
nvestigational, it will start with a capital letter, and be defined below. f you have questions on any of
these definitions, please call Customer Service at the number on the back of your dentification Card.
AccidentaI Injury
An unexpected njury for which you need Covered Services while enrolled in this Plan. t does not include
injuries that you get benefits for under any Workers' Compensation, Employer's liability or similar law.
AmbuIatory SurgicaI FaciIity
A freestanding Facility, with a staff of Doctors, that:
1. s licensed as required;
2. Has permanent facilities and equipment to perform surgical procedures on an Outpatient basis;
3. Gives treatment by or under the supervision of Doctors, and nursing services when the patient is in
the Facility;
4. Does not have npatient accommodations; and
5. s not, other than incidentally, used as an office or clinic for the private practice of a Doctor or other
professional Provider.
AppIied BehavioraI AnaIysis
The use of behavior analytic methods and research findings to change socially important behaviors in
meaningful ways.
Authorized Service(s)
A Covered Service you get from an Out-of-Network Provider that we have agreed to cover at the n-
Network level. You will not have to pay any more than the n-Network Deductible, Coinsurance, and/or
Copayment(s) that apply. Please see "Claims Procedure (How to File a Claim) for more details.
Autism Services Provider
A person who provides services to a Member with Autism Spectrum Disorders. The Provider must be
licensed, certified, or registered by the applicable state licensing board or by a nationally recognized
organization, and who meets the requirements as defined by state law:
Autism Spectrum Disorders or ASD
ncludes the following neurobiological disorders: autistic disorder, Asperger's disorder, and atypical
autism as a diagnosis within pervasive developmental disorder not otherwise specified, as defined in the
most recent edition of the diagnostic and statistical manual of mental disorders, at the time of the
diagnosis.
Autism Treatment PIan
A plan for a Member by an Autism Services Provider and prescribed by a Doctor or psychologist in line
with evaluating or again reviewing a Member's diagnosis; proposed treatment by type, frequency, and
expected treatment; the expected outcomes stated as goals; and the rate by which the treatment plan will
be updated. The treatment plan is in line with the patient-centered medical home as defined in state law.

129
Benefit Period
The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit
Period starts on January 1
st
and ends on December 31
st
. For Plan Year plans, the Benefit Period starts
on your Group's effective or renewal date and lasts for 12 months. (See your Group for details.) The
"Schedule of Benefits (Who Pays What) shows if your Plan's Benefit Period is a Calendar Year or a Plan
Year. f your coverage ends before the end of the year, then your Benefit Period also ends.
Benefit Period Maximum
The most we will cover for a Covered Service during a Benefit Period.
BookIet
This document (also called the certificate), which describes the terms of your benefits. t is part of the
Group Contract with your Employer, and is also subject to the terms of the Group Contract.
Brand Name Drug
Prescription Drugs that the PBM has classified as Brand Name Drugs through use of an independent
proprietary industry database.
Centers of ExceIIence (COE) Network
A network of health care facilities, which have been selected to give specific services to our Members
based on their experience, outcomes, efficiency, and effectiveness. An n-Network Provider under this
Plan is not necessarily a COE. To be a COE, the Provider must have signed a Center of Excellence
Agreement with us.
CIosed PaneI PIan
A health maintenance organization (HMO), preferred provider organization (PPO) or other plan that
provides health benefits to covered persons primarily in the form of services through a panel of providers
that have contracted with either directly, indirectly, or are employed by the plan, and that limits or
excludes benefits for services provided by other providers, except in cases of emergency or referral by a
panel provider.
Coinsurance
Your share of the cost for Covered Services, which is a percent of the Maximum Allowed Amount. You
normally pay Coinsurance after you meet your Deductible. For example, if your Plan lists 20%
Coinsurance on office visits, and the Maximum Allowed Amount is $100, your Coinsurance would be $20
after you meet the Deductible. The Plan would then cover the rest of the Maximum Allowed Amount.
See the "Schedule of Benefits (Who Pays What) for details. Your Coinsurance will not be reduced by
any refunds, rebates, or any other form of negotiated post-payment adjustments.
CongenitaI Defect
A defect or anomaly existing before birth, such as cleft lip or club foot. Disorders of growth and
development over time are not considered congenital.

130
Copayment
A fixed amount you pay toward a Covered Service. You normally have to pay the Copayment when you
get health care. The amount can vary by the type of Covered Service you get. For example, you may
have to pay a $15 Copayment for an office visit, but a $150 Copayment for Emergency Room Services.
See the "Schedule of Benefits (Who Pays What) for details. Your Copayment will be the lesser of the
amount shown in the "Schedule of Benefits (Who Pays What)" or the amount the Provider charges.
Covered Services
Health care services, supplies, or treatment described in this Booklet that are given to you by a Provider.
To be a Covered Service the service, supply or treatment must be:
Medically Necessary or specifically included as a benefit under this Booklet.
Within the scope of the Provider's license.
Given while you are covered under the Plan.
Not Experimental / nvestigational, excluded, or limited by this Booklet, or by any amendment or rider
to this Booklet.
Approved by us before you get the service if prior authorization is needed.
A charge for a Covered Service will apply on the date the service, supply, or treatment was given to you.
Covered Services do not include services or supplies not described in the Provider records.
Covered TranspIant Procedure
Please see the "Benefits/Coverage (What is Covered) section for details.
CustodiaI Care
Any type of care, including room and board, that (a) does not require the skills of professional or technical
workers; (b) is not given to you or supervised by such workers or does not meet the rules for post-
Hospital Skilled Nursing Facility care; (c) is given when you have already reached the greatest level of
physical or mental health and are not likely to improve further.
Custodial Care includes any type of care meant to help you with activities of daily living that does not
require the skill of trained medical or paramedical workers. Examples of Custodial Care include:
Help in walking, getting in and out of bed, bathing, dressing, eating, or using the toilet,
Changing dressings of non-infected wounds, after surgery or chronic conditions,
Preparing meals and/or special diets,
Feeding by utensil, tube, or gastrostomy,
Common skin and nail care,
Supervising medicine that you can take yourself,
Catheter care, general colostomy or ileostomy care,
Routine services which we decide can be safely done by you or a non-medical person without the
help of trained medical and paramedical workers,
Residential care and adult day care,
Protective and supportive care, including education,
Rest and convalescent care.
Care can be Custodial even if it is recommended by a professional or performed in a Facility, such as a
Hospital or Skilled Nursing Facility, or at home.

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DeductibIe
The amount you must pay for Covered Services before benefits begin under this Plan. For example, if
your Deductible is $1,000, your Plan won't cover anything until you meet the $1,000 Deductible. The
Deductible may not apply to all Covered Services. Please see the "Schedule of Benefits (Who Pays
What) for details.
Dependent
A member of the Subscriber's family who meets the rules listed in the "Eligibility section and who has
enrolled in the Plan.
{Tiered network:
[Designated Participating Provider
A Physician, advanced nurse practitioner, nurse practitioner, clinical nurse specialist, physician assistant,
or any other Provider licensed by law and allowed under the Plan, who gives, directs, or helps you get a
range of health care services.]
Doctor
See the definition of "Physician.
EarIy Intervention Services
Services, as defined by Colorado law in accordance with part C, that are authorized through an Eligible
Child's FSP but that exclude: nonemergency medical transportation; respite care; service coordination,
as defined in federal law; and assistive technology (unless covered under this Booklet as durable medical
equipment).
Eligible Child - means an infant or toddler, from birth through two years of age, who is an eligible
Dependent and who, as defined by Colorado law, has significant delays in development or has a
diagnosed physical or mental condition that has a high probability of resulting in significant delays in
development or who is eligible for services pursuant to Colorado law.
ndividualized family service plan or FSP - means a written plan developed pursuant to federal law
that authorizes early intervention services to an Eligible Child and the child's family. An FSP shall
serve as the individualized plan for an Eligible Child from birth through two years of age.
Effective Date
The date your coverage begins under this Plan.
Emergency (Emergency MedicaI Condition)
Please see the "Benefits/Coverage (What is Covered)" section.
Emergency Care
Please see the "Benefits/Coverage (What is Covered)" section.

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EnroIIment Date
The first day you are covered under the Plan or, if the Group imposes a waiting period, the first day of
your waiting period.
ExcIuded Services (ExcIusion)
Health care services your Plan doesn't cover.
ExperimentaI or InvestigationaI (ExperimentaI / InvestigationaI)
(a) Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply
used in or directly related to the diagnosis, evaluation or treatment of a disease, injury, illness or other
health condition which we determine in our sole discretion to be Experimental or nvestigational.
We will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or
supply to be Experimental or nvestigational if we determine that one or more of the following criteria
apply when the service is rendered with respect to the use for which benefits are sought.
The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply:
Cannot be legally marketed in the United States without the final approval of the Food and Drug
Administration (FDA) or any other state or federal regulatory agency, and such final approval has not
been granted;
Has been determined by the FDA to be contraindicated for the specific use;
s provided as part of a clinical research protocol or clinical trial (except as noted in the Clinical Trials
section under Covered Services in this Booklet as required by state law), or is provided in any other
manner that is intended to evaluate the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply; or is subject to review and
approval of an nstitutional Review Board (RB) or other body serving a similar function; or
s provided pursuant to informed consent documents that describe the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply as Experimental or
nvestigational, or otherwise indicate that the safety, toxicity or efficacy of the drug, biologic, device,
diagnostic, product, equipment, procedure, treatment, service or supply is under evaluation.
(b) Any service not deemed Experimental or nvestigational based on the criteria in subsection (a) may
still be deemed to be Experimental or nvestigational by us. n determining whether a service is
Experimental or nvestigational, we will consider the information described in subsection (c) and assess
all of the following:
Whether the scientific evidence is conclusory concerning the effect of the service on health outcomes;
Whether the evidence demonstrates that the service improves the net health outcomes of the total
population for whom the service might be proposed as any established alternatives; or
Whether the evidence demonstrates the service has been shown to improve the net health outcomes
of the total population for whom the service might be proposed under the usual conditions of medical
practice outside clinical investigatory settings.
(c) The information we consider or evaluate to determine whether a drug, biologic, device, diagnostic,
product, equipment, procedure, treatment, service or supply is Experimental or nvestigational under
subsections (a) and (b) may include one or more items from the following list, which is not all-inclusive:
Randomized, controlled, clinical trials published in authoritative, peer-reviewed United States medical
or scientific journal;

133
Evaluations of national medical associations, consensus panels and other technology evaluation
bodies;
Documents issued by and/or filed with the FDA or other federal, state or local agency with the
authority to approve, regulate or investigate the use of the drug, biologic, device, diagnostic, product,
equipment, procedure, treatment, service or supply;
Documents of an RB or other similar body performing substantially the same function;
Consent documentation(s) used by the treating Physicians, other medical professionals or facilities,
or by other treating Physicians, other medical professionals or facilities studying substantially the
same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
The written protocol(s) used by the treating Physicians, other medical professionals or facilities or by
other treating Physicians, other medical professionals or facilities studying substantially the same
drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply;
Medical records; or
The opinions of consulting Providers and other experts in the field.
(d) We have the sole authority and discretion to identify and weigh all information and determine all
questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure,
treatment, service or supply is Experimental or nvestigational.
FaciIity
A facility including but not limited to, a Hospital, Ambulatory Surgical Facility, Chemical Dependency
Treatment Facility, Skilled Nursing Facility, Home Health Care Agency or mental health facility, as defined
in this Booklet. The Facility must be licensed, registered or approved by the Joint Commission on
Accreditation of Hospitals or meet specific rules set by us.
Generic Drugs
Prescription Drugs that the PBM has classified as Generic Drugs through use of an independent
proprietary industry database. Generic Drugs have the same active ingredients, must meet the same
FDA rules for safety, purity and potency, and must be given in the same form (tablet, capsule, cream) as
the Brand Name Drug.
Group
The employer or other organization (e.g., association), which has a Group Contract with us, Anthem for
this Plan.
Group Contract (or Contract)
The Contract between us, Anthem, and the Group (also known as the Group Master Contract). t
includes this Booklet, your application, any application or change form, your dentification Card, any
endorsements, riders or amendments, and any legal terms added by us to the original Contract.
The Group Master Contract is kept on file by the Group. f a conflict occurs between the Group Master
Contract and this Booklet, the Group Master Contract controls.
HabiIitative Services
Habilitative Services help you keep, learn or improve skills and functioning for daily living. Examples
include therapy for a child who isn't walking or talking at the expected age.

134
Home HeaIth Care Agency
A Facility, licensed in the state in which it is located, that:
1. Gives skilled nursing and other services on a visiting basis in your home; and
2. Supervises the delivery of services under a plan prescribed and approved in writing by the attending
Doctor.
Hospice
A Provider that gives care to terminally ill patients and their families, either directly or on a consulting
basis with the patient's Doctor. t must be licensed by the appropriate agency.
HospitaI
A Provider licensed and operated as required by law, which has:
1. Room, board, and nursing care;
2. A staff with one or more Doctors on hand at all times;
3. 24 hour nursing service;
4. All the facilities on site are needed to diagnose, care, and treat an illness or injury; and
5. s fully accredited by the Joint Commission on Accreditation of Health Care Organizations.
The term Hospital does not include a Provider, or that part of a Provider, used mainly for:
1. Nursing care
2. Rest care
3. Convalescent care
4. Care of the aged
5. Custodial Care
6. Educational care
7. Subacute care
8. Treatment of alcohol abuse
9. Treatment of drug abuse
Identification Card
The card we give you that shows your Member identification, Group numbers, and the plan you have.
In-Network Provider
A Provider that has a contract, either directly or indirectly, with us, or another organization, to give
Covered Services to Members through negotiated payment arrangements.
In-Network TranspIant Provider
Please see the "Benefits/Coverage (What is Covered) section for details.
Inpatient
A Member who is treated as a registered bed patient in a Hospital and for whom a room and board
charge is made.

135
Late EnroIIees
Subscribers or Dependents who enroll in the Plan after the initial enrollment period. A person will not be
considered a Late Enrollee if he or she enrolls during a Special Enrollment period. Please see the
"Eligibility section for further details.

Maintenance Medications
Please see the "Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section for
details.
Maximum AIIowed Amount
The maximum payment that we will allow for Covered Services. For more information, see the "Member
Payment Responsibility section.
MedicaI Necessity (MedicaIIy Necessary)
The diagnosis, evaluation and treatment of a condition, illness, disease or injury that we solely decide to be:
Medically appropriate for and consistent with your symptoms and proper diagnosis or treatment of
your condition, illness, disease or injury;
Obtained from a Doctor or Provider;
Provided in line with medical or professional standards;
Known to be effective, as proven by scientific evidence, in improving health;
The most appropriate supply, setting or level of service that can safely be provided to you and which
cannot be omitted. t will need to be consistent with recognized professional standards of care. n
the case of a Hospital stay, also means that safe and adequate care could not be obtained as an
outpatient;
Cost-effective compared to alternative interventions, including no intervention. Cost effective does not
always mean lowest cost" t does mean that as to the diagnosis or treatment of your illness, injury or
disease, the service is: (1) not more costly than an alternative service or sequence of services that is
medically appropriate, or (2) the service is performed in the least costly setting that is medically
appropriate;
Not Experimental or nvestigational;
Not primarily for you, your families, or your Provider's convenience; and
Not otherwise an exclusion under this Booklet.
The fact that a Doctor or Provider may prescribe, order, recommend or approve care, treatment, services or
supplies does not, of itself, make such care, treatment, services or supplies Medically Necessary.
Member
People, including the Subscriber and his or her Dependents, who have met the eligibility rules, applied for
coverage, and enrolled in the Plan. Members are called "you and "your in this Booklet.

136
MentaI HeaIth and Substance Abuse
A condition that is listed in the current edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM) as a mental health or substance abuse condition. t does not include Autism Spectrum Disorder,
which under state law is considered a medical condition.
Open EnroIIment
A period of time in which eligible people or their dependents can enroll without penalty after the initial
enrollment. See the "Eligibility section for more details.
Out-of-Network Provider
A Provider that does not have an agreement or contract with us, or our subcontractor(s) to give services
to our Members.
You will often get a lower level of benefits when you use Out-of-Network Providers.
Out-of-Network TranspIant Provider
Please see the "Benefits/Coverage (What is Covered) section for details.
Out-of-Pocket Limit
The most you pay in Copayments, Deductibles, and Coinsurance during a Benefit Period for Covered
Services. The Out-of-Pocket limit does !"# include your Premium, amounts over the Maximum Allowed
Amount, or charges for health care that your Plan doesn't cover. Please see the "Schedule of Benefits
(Who Pays What) for details.
Pharmacy
A place licensed by state law where you can get Prescription Drugs and other medicines from a licensed
pharmacist when you have a prescription from your Doctor.
Pharmacy and Therapeutics (P&T) Process
A process to make clinically based recommendations that will help you access quality, low cost medicines
within your Plan. The process includes health care professionals such as nurses, pharmacists, and
Doctors. The committees of the WellPoint National Pharmacy and Therapeutics Process meet regularly
to talk about and find the clinical and financial value of medicines for our Members. This process first
evaluates the clinical evidence of each product under review. The clinical review is then combined with
an in-depth review of the market dynamics, Member impact and financial value to make choices for the
formulary. Our programs may include, but are not limited to, Drug utilization programs, prior authorization
criteria, therapeutic conversion programs, cross-branded initiatives, and Drug profiling initiatives.
Physician (Doctor)
ncludes the following when licensed by law:
Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery,
Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O.,
Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor;
Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and

137
Doctor of Dental Medicine (D.D.M.), Doctor of Dental Surgery (D.D.S.), legally entitled to provide
dental services.
Optometrists, Clinical Psychologists (PhD), and surgical chiropodists are also Providers when legally
licensed and giving Covered Services within the scope of their licenses.
PIan
The benefit plan your Group has purchased, which is described in this Booklet.
Precertification
Please see the section "How to Access Your Services and Obtain Approval of Benefits for details.
Predetermination
Please see the section "How to Access Your Services and Obtain Approval of Benefits for details.
Premium
The amount that you and/or the Group must pay to be covered by this Plan. This may be based on your
age and will depend on the Group's Contract with us.
Prescription Drug (Drug)
A medicine that is made to treat illness or injury. Under the Federal Food, Drug & Cosmetic Act, such
substances must bear a message on its original packing label that says, "Caution: Federal law prohibits
dispensing without a prescription. This includes the following:
1. Compounded (combination) medications, when the primary ingredient (the highest cost ingredient) is
FDA-approved and requires a prescription to dispense, and is not essentially the same as an FDA-
approved product from a drug manufacturer.
2. nsulin, diabetic supplies, and syringes.
Primary Care Physician / Provider ("PCP")
A Provider who gives or directs health care services for you. The Provider may work in family practice,
general practice, internal medicine, pediatrics or any other practice allowed by the Plan. A PCP
supervises, directs and gives initial care and basic medical services to you and is in charge of your
ongoing care.
Provider
A professional or Facility licensed by law that gives health care services within the scope of that license
and is approved by us. This includes any Provider that state law says we must cover when they give you
services that state law says we must cover. Providers that deliver Covered Services are described
throughout this Booklet. f you have a question about a Provider not described in this Booklet please call
the number on the back of your dentification Card.

138
QuaIified EarIy Intervention Service Provider
Means a person or agency, as defined by Colorado law in accordance with part C, who provides Early
ntervention Services and is listed on the registry of early intervention service providers.
Recovery
Recovery is money the Member, the Member's legal representative, or beneficiary receives whether by
settlement, verdict, judgment, order or by some other monetary award or determination, from another,
their insurer, or from any uninsured motorist, underinsured motorist, medical payments, personal injury
protection, or any other insurance coverage, to compensate the Member as a result of bodily injury or
illness to the Member. Regardless of how the Member, the Member's legal representative, or beneficiary
or any agreement may characterize the money received, it shall be subject to the Subrogation and
Reimbursement under the "General Policy Provisions section of this Booklet.
ReferraI
Please see the "How to Access Services and Obtain Approval of Benefits section for details.
RetaiI HeaIth CIinic
A Facility that gives limited basic health care services to Members on a "walk-in basis. These clinics are
often found in major pharmacies or retail stores. Medical services are typically given by Physician
Assistants and Nurse Practitioners.
Service Area
The geographical area where you can get Covered Services from an n-Network Provider.
SkiIIed Nursing FaciIity
A Facility operated alone or with a Hospital that cares for you after a Hospital stay when you have a
condition that needs more care than you can get at home. t must be licensed by the appropriate agency
and accredited by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of
Hospitals of the American Osteopathic Association, or otherwise approved by us. A Skilled Nursing
Facility gives the following:
1. npatient care and treatment for people who are recovering from an illness or injury;
2. Care supervised by a Doctor;
3. 24 hour per day nursing care supervised by a full-time registered nurse.
A Skilled Nursing Facility is not a place mainly for care of the aged, Custodial Care or domiciliary care,
treatment of alcohol or drug dependency; or a place for rest, educational, or similar services.
SpeciaI EnroIIment
A period of time in which eligible people or their dependents can enroll after the initial enrollment, typically
due to an event such as marriage, birth, adoption, etc. See the "Eligibility section for more details.
SpeciaIist (SpeciaIty Care Physician \ Provider or SCP)
A Specialist is a Doctor who focuses on a specific area of medicine or group of patients to diagnose,
manage, prevent, or treat certain types of symptoms and conditions. A non-Physician Specialist is a
Provider who has added training in a specific area of health care.

139
SpeciaIty Drugs
Drugs that typically need close supervision and checking of their effect on the patient by a medical
professional. These drugs often need special handling, such as temperature-controlled packaging and
overnight delivery, and are often not available at retail pharmacies. They may be administered in many
forms including, but not limited to, injectable, infused, oral and inhaled.
Subscriber
An employee or member of the Group who is eligible for and has enrolled in the Plan.
TranspIant Benefit Period
Please see the "Benefits/Coverage (What is Covered) section for details.
Urgent Care Center
A licensed health care Facility that is separate from a Hospital and whose main purpose is giving
immediate, short-term medical care, without an appointment, for urgent care.
UtiIization Review
A set of formal techniques to monitor or evaluate the clinical necessity, appropriateness, efficacy or
efficiency of, health care services, procedures or settings. Techniques include ambulatory review,
prospective review, second opinion, certification, concurrent review, Care Management, discharge
planning and/or retrospective review. Utilization Review also includes reviewing whether or not a
procedure or treatment is considered Experimental or nvestigational, and reviewing your medical
circumstances when such a review is needed to determine if an exclusion applies.





End of BookIet