2015 Ma 2000 SBC

1 of 15
AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2015 12/31/2015

u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P%a$ &"'e: PPO
&his is o$%" a su!!ar"( If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-844-404-6843.
)!'orta$t *uestio$s A$s+ers Wh" this Matters:
What is the overall
deductible?
For in-network providers
,2-000 individual / ,.-000 family
For out-of-network providers
,5-000 individual /
,10-000 family
Doesnt apply to In-network
preventive care and routine eye
exams.
ou must pay all the costs up to the deductible amount
before this plan begins to pay for covered services you
use. !heck your policy or plan document to see when the
deductible starts over "usually, but not always, #anuary
$st%. &ee the chart starting on page ' for how much you
pay for covered services after you meet the deductible.
Are there other
deductibles for
specic services?
es. For durable medical
e(uipment there is a ,250
deductible.
ou must pay all of the costs for these services up to the
speci)c deductible amount before this plan begins to pay
for these services.
!s there an out"of"
poc#et limit on m$
e%penses?
For in-network providers
,/-/00 individual&,13-200 family
For out-of-network providers
,10-000 individual /
,20-000 family
*he out-of-poc#et limit is the most you could pay during
a coverage period "usually one year% for your share of the
cost of covered services. *his limit helps you plan for
health care expenses.
What is not included
in the out"of"poc#et
limit?
+alance-+illed charges, ,ealth
!are this plan doesnt cover,
-remiums, .ut-of-network
deductibles, and .ut-of-
network pharmacy claims.
/ven though you pay these expenses, they dont count
toward the out-of-poc#et limit.
!s there an overall
annual limit on what
the plan pa$s?
0o.
*he chart starting on page ' describes any limits on what
the plan will pay for specifc covered services, such as
o1ice visits.
'uestions( !all 1-844-404-6843 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 2lossary. ou can view the 2lossary
at www.anthem.com or call 1-844-404-6843 to re(uest a copy.
2 of 15
)oes this plan use a
networ# of
providers?
es. For a list of in-networ#
providers, see
www.anthem.com or call $-344-
454-6347
If you use an in-network doctor or other health care
provider, this plan will pay some or all of the costs of
covered services. +e aware, your in-network doctor or
hospital may use an out-of-network provider for some
services. -lans use the term in-network, preferred, or
participating for providers in their networ#. &ee the
chart starting on page ' for how this plan pays di1erent
kinds of providers.
)o ! need a referral
to see a specialist?
0o.
ou can see the specialist you choose without permission
from this plan.
Are there services
this plan doesn*t
cover?
es.
&ome of the services this plan doesnt cover are listed on
page 6. &ee your policy or plan document for additional
information about e%cluded services.
+opa$ments are )xed dollar amounts "for example, 8$9% you pay for covered health care, usually when you
receive the service.
+oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed
amount for the service. For example, if the plans allowed amount for an overnight hospital stay is
8$,555, your coinsurance payment of '5: would be 8'55. *his may change if you havent met your
deductible.
*he amount the plan pays for covered services is based on the allowed amount. If an out-of-network
provider charges more than the allowed amount, you may have to pay the di1erence. For example, if an
out-of-network hospital charges 8$,955 for an overnight stay and the allowed amount is 8$,555, you may
have to pay the 8955 di1erence. "*his is called balance billin,.%
*his plan may encourage you to use in-network providers by charging you lower deductibles,
copa$ments and coinsurance amounts.
Co!!o$
Medica% Eve$t
ervices 0ou Ma" Need
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
4i!itatio$s 5 E6ce'tio$s
-rimary care visit to treat an
in;ury or illness
8'9
copay<visit
95:
coinsurance
============none============
3 of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
!f $ou visit a
health care
provider*s
o-ice or clinic
&pecialist visit
845
copay<visit
95:
coinsurance
============none============
.ther practitioner o1ice visit
!hiropractor
845
copay<visit
>cupuncturist
0ot covered
!hiropractor
95:
coinsurance
>cupuncturist
0ot covered
!hiropractic care is limited to
$' visits per calendar year
combined in and out of
network.
-reventive
care<screening<immuni?ation
0o cost share
95:
coinsurance
============none============
!f $ou have a
test
Diagnostic test "x-ray, blood
work%
5:
coinsurance
95:
coinsurance
============none============
Imaging "!*<-/* scans, @AIs%
5:
coinsurance
95:
coinsurance
============none============
. of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
!f $ou need
dru,s to treat
$our illness or
condition
@ore
information
about
prescription
dru, covera,e
is available at
www.express-
scripts.com
2eneric drugs "Aetail<75 dayB
@ail<C5 day%
8$5 Aetail<8'5
@ail
0ot !overed
@aintenance @eds are re(uired to be
)lled mail order after 7 )lls at retail
"penalty applies%. If pre-auth re(uired
D not obtained, drug may not be
covered. !ertain -reventive meds no
copay. If a generic e(uivalent is
available D brand is
prescribed<member will pay brand
name cost di1erence. -lan uses
preferred drug list to identify
coverage.
-referred brand drugs "Aetail<75 dayB
@ail<C5 day%
879 Aetail<83E.9
@ail
0ot !overed
0on-preferred brand "Aetail<75dayB
@ail<C5day%
865 Aetail<8$95
@ail
0ot !overed
&pecialty drugs
>ll &pecialty
meds process
through
>ccredo at the
mail order
costs.
0ot !overed
*he mail order cost will be based
on the medication tier "generic,
preferred, non-preferred%.
&pecialty meds can not be )lled
at retail pharmacies.
!f $ou have
outpatient
sur,er$
Facility fee "e.g., ambulatory
surgery center%
5:
coinsurance
95:
coinsurance
============none============
-hysician<surgeon fees
5:
coinsurance
95:
coinsurance
============none============
5 of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
!f $ou need
immediate
medical
attention
/mergency room services
8'55 copay <
visitF
professional
and other
services
sub;ect to
deductible
8'55 copay <
visitF
professional
and other
services
sub;ect to
deductible
8'55 copay is waived if
admitted for inpatient stay.
@embers may be balance
billed for out of network
services.
/mergency medical
transportation
5:
coinsurance
5:
coinsurance
services
Grgent care 8E9 copay 8E9 copay
services
!f $ou have a
hospital sta$
Facility fee "e.g., hospital room%
5:
coinsurance
95:
coinsurance
-recerti)cation is re(uired for
Inpatient hospital admission.
> 8955 penalty is applied if
an .ut of 0etwork admission
is not precerti)ed. -hysical
@edicine and Aehabilitation
limited to $55 days per
member per calendar year.
-hysician<surgeon fee
5:
coinsurance
95:
coinsurance
============none============
/ of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
!f $ou have
mental health.
behavioral
health. or
substance
abuse needs
@ental<+ehavioral health
outpatient services
@ental<+ehavi
oral ,ealth
.1ice Hisit
8'9
copay<visit
@ental<+ehavi
oral ,ealth
Facility Hisit
5:
coinsurance
@ental<+ehavi
oral,ealth
.1ice Hisit
95:
coinsurance
@ental<+ehavi
oral ,ealth
Facility
Hisit
95:
coinsurance
============none============
@ental<+ehavioral health
inpatient services
5:
coinsurance
95:
coinsurance
is not precerti)ed.
&ubstance use disorder
outpatient services
&ubstance
>buse .1ice
Hisit
8'9
copay<visit
&ubstance
>buse Facility
Hisit
5:
coinsurance
&ubstance
>buse .1ice
Hisit
95:
coinsurance
&ubstance
>buse Facility
Hisit
95:
coinsurance
============none============
7 of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
&ubstance use disorder
inpatient services
5:
coinsurance
95:
coinsurance
is not precerti)ed.
!f $ou are
pre,nant
-renatal and postnatal care
5:
coinsurance
95:
coinsurance
============none============
Delivery and all inpatient
services
5:
coinsurance
95:
coinsurance
============none============
8 of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
!f $ou need
help recoverin,
or have other
special health
needs
,ome health care
5:
coinsurance
95:
coinsurance
============none============
Aehabilitation services
845 copay for
outpatient
services. 5:
coinsurance
for inpatient
care.
95:
coinsurance
Iimited to 65 visits combined
physical therapy, speech
therapy and occupational
therapy. &ervices from In-
0etwork and .ut-of-0etwork
providers count toward your
limit.
,abilitation services
845 copay for
outpatient
services. 5:
coinsurance
for inpatient
care.
95:
coinsurance
>ll rehabilitation and
habilitation visits count toward
your rehabilitation visit limit.
&killed nursing care
5:
coinsurance
95:
coinsurance
Iimited to $55 inpatient
daysper member per calendar
year. -recerti)cation is
re(uired or 8955 penalty is
applied if an .ut of 0etwork
admission is not precerti)ed.
&ervices from In-0etwork and
.ut-of-0etwork providers
count toward your limit.
Durable medical e(uipment 8'95
Deductible
then '5:
coinsurance
8'95
Deductible
then '5:
coinsurance
8'95 deductible combined in
and out of network. @ember
may be balance billed for out
of network services.
9 of 15
Co!!o$
Medica% Eve$t
0our Cost )f
0ou 1se a$
)$2$et+or3
Provider
0our Cost )f
0ou 1se a$
Out2of2$et+or3
Provider
,ospice service
5:
coinsurance
95:
coinsurance
is not precerti)ed.
!f $our child
needs dental or
e$e care
/ye exam 0o cost share
95:
coinsurance
Iimited to one exam per
calendar year for $3 and
younger. Iimited to one exam
every ' years for $C and older.
2lasses 0ot !overed 0ot !overed ============none============
Dental check-up 0ot !overed 0ot !overed ============none============
E6c%uded ervices 5 Other Covered ervices:
ervices 0our P%a$ :oes NO& Cover /0his isn*t a complete list. +hec# $our polic$ or plan document for other
e%cluded services.1
J >cupuncture
J !osmetic surgery
J Dental care ">dult%
J Iong-term care
J -rivate-duty nursing
J Aoutine foot care
J Keight loss programs
10 of 15
Other Covered ervices /0his isn*t a complete list. +hec# $our polic$ or plan document for other covered
services and $our costs for these services.1
J +ariatric surgery
J !hiropractic care "Iimits apply%
J ,earing aids "Iimits apply%
J Infertility treatment "Iimits apply%
J @ost coverage provided outside
the Gnited &tates.
&ee www.+!+&.com<bluecardworld
wide
J Aoutine eye care ">dult - Iimits
apply%
0our ;ights to Co$ti$ue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and &tate laws may provide
protections that allow you to keep health coverage. >ny such rights may be limited in duration and will re(uire you
to pay a premium, which may be signi)cantly higher than the premium you pay while covered under the plan.
.ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at $-355-'93-97$3. ou may also contact
your state insurance department, the G.&. Department of Iabor, /mployee +ene)ts &ecurity >dministration at $-366-
444-7'E' or www.dol.gov<ebsa, or the G.&. Department of ,ealth and ,uman &ervices at $-3EE-'6E-'7'7 x6$969 or
www.cciio.cms.gov.
11 of 15
0our <rieva$ce a$d A''ea%s ;ights:
f you have a complaint or are dissatis)ed with a denial of coverage for claims under your plan, you may be able to
appeal or )le a ,rievance. For (uestions about your rights, this notice, or assistance, you can contactB
>nthem +lue !ross and +lue &hield
-... +ox 94$9C
Ios >ngeles, !> C5594-5$9C
For grievances and<or appeals regarding you prescription drug coverage, call the number listed on the back of
prescription member ID card or visit www.express-scripts.com.
>dditionally, a consumer assistance program can help you )le your appeal. !ontactB
0ew ,ampshire Department of Insurance
'$ &outh Fruit &t. &uite $4
!oncord, 0, 5775$
$-355-39'-74$6
www.nh.gov<insurance
consumersvcsLins.nh.gov
For /AI&> information contactB
Department of Iabors /mployee +ene)ts &ecurity >dministration
$-366-444-/+&> "7'E'%
www.dol.gov<ebsa<healthreform
12 of 15
:oes this Coverage Provide Mi$i!u! Esse$tia% Coverage=
*he >1ordable !are >ct re(uires most people to have health care coverage that (uali)es as Mminimum essential
coverage.N This plan or policy does provide minimum essential coverage.
:oes this Coverage Meet the Mi$i!u! >a%ue ta$dard=
*he >1ordable !are >ct establishes a minimum value standard of bene)ts of a health plan. *he minimum value
standard is 65: "actuarial value%. This health coverage does meet the minimum value standard for the
benefts it provides.
4a$guage Access ervices:
======================To see examples of how this plan might cover costs for a sample medical situation, see the next
page.===========
?avi$g a @a@"
"normal delivery%
Ma$agi$g t"'e 2 dia@etes
"routine maintenance of
a well-controlled condition%
13 of 15
Coverage E6a!'%es
Coverage for: Individual/Family | P%a$ &"'e: PPO
A@out these Coverage
E6a!'%es:
*hese examples show how this plan
might cover medical care in given
situations. Gse these examples to
see, in general, how much )nancial
protection a sample patient might
get if they are covered under
di1erent plans.
A!ou$t o+ed to 'roviders: $7,540
P%a$ 'a"s $5,70
Patie$t 'a"s $!,"70
a!'%e care costs:
,ospital charges "mother%
8',E5
5
Aoutine obstetric care
8',$5
5
,ospital charges "baby% 8C55
>nesthesia 8C55
Iaboratory tests 8955
-rescriptions 8'55
Aadiology 8'55
Haccines, other preventive 845
0otal
23.44
0
Patie$t 'a"s:
Deductibles 8'555
!opays 8'5
!oinsurance 85
Iimits or exclusions 8$95
0otal
25.13
0
A!ou$t o+ed to 'roviders: $5,400
P%a$ 'a"s $!,50
Patie$t 'a"s $!,#70
a!'%e care costs:
-rescriptions
8',C5
5
@edical /(uipment and
&upplies
8$,75
5
.1ice Hisits and -rocedures 8E55
/ducation 8755
Iaboratory tests 8$55
Haccines, other preventive 8$55
0otal
24.40
0
Patie$t 'a"s:
Deductibles
8','9
5
!opays 8745
!oinsurance 8'55
Iimits or exclusions 835
0otal
25.83
0

&his is
$ot a cost
esti!ator(
Dont use these
examples to estimate
your actual costs under
this plan. *he actual
care you receive will be
di1erent from these
examples, and the cost
of that care will also be
di1erent.
&ee the next page for
important information
about these examples.
*uestio$s a$d a$s+ers a@out the Coverage E6a!'%es:
What are so!e of the
assu!'tio$s @ehi$d the
Coverage E6a!'%es=
!osts dont include premiums.
&ample care costs are based on
national averages supplied by
the G.&. Department of ,ealth
and ,uman &ervices, and
arent speci)c to a particular
geographic area or health plan.
*he patients condition was not
an excluded or preexisting
condition.
>ll services and treatments
started and ended in the same
coverage period.
*here are no other medical
expenses for any member
covered under this plan.
.ut-of-pocket expenses are
based only on treating the
condition in the example.
*he patient received all care
from in-network providers. If
the patient had received care
from out-of-network providers,
costs would have been higher.
What does a Coverage E6a!'%e
sho+=
For each treatment situation, the
!overage /xample helps you see
how deductibles, copa$ments,
and coinsurance can add up. It
also helps you see what expenses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
:oes the Coverage E6a!'%e
'redict !" o+$ care $eeds=
6o. *reatments shown are ;ust
examples. *he care you would
receive for this condition could
be di1erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
:oes the Coverage E6a!'%e
'redict !" future e6'e$ses=
6o. !overage /xamples are not
cost estimators. ou cant use
the examples to estimate costs
for an actual condition. *hey are
for comparative purposes only.
our own costs will be di1erent
depending on the care you
receive, the prices your
providers charge, and the
reimbursement your health plan
allows.
Ca$ ) use Coverage E6a!'%es
to co!'are '%a$s=
7es. Khen you look at the
&ummary of +ene)ts and
!overage for other plans, youll
)nd the same !overage
/xamples. Khen you compare
plans, check the M-atient -aysN
box in each example. *he
smaller that number, the more
coverage the plan provides.
Are there other costs ) shou%d
co$sider +he$ co!'ari$g
'%a$s=
7es. >n important cost is the
premium you pay. 2enerally,
the lower your premium, the
more youll pay in out-of-pocket
costs, such as copa$ments,
deductibles, and coinsurance.
ou should also consider
contributions to accounts such
as health savings accounts
",&>s%, Oexible spending
arrangements "F&>s% or health
reimbursement accounts ",A>s%
that help you pay out-of-pocket
expenses.

2015 Ma 2000 SBC

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

2015 Ma 2000 SBC

Transféré par

Droits d'auteur :

Formats disponibles

1 of 15

AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2015 12/31/2015

Vous aimerez peut-être aussi