AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO 'his is on&# a s"mmar#( 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. )mpor%an% *"es%ions Ans+ers Wh# %his Ma%%ers: What is the overall deductible? For in-network providers ,1-000 individual / ,2-500 family For out-of-network providers ,5-000 individual / ,10-000 family Doesnt apply to in-network preventive care, routine eye exams or outpatient labsx-rays or ultrasounds. !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 porivders ,6-600 individual/,1-200 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. 0ven though you pay these expenses, they dont count toward the out-of-poc#et limit. &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 2 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO !s there an overall annual limit on what the plan pa$s? 2o. +he chart starting on page ( describes any limits on what the plan will pay for specifc covered services, such as o3ice visits. (oes this plan use a networ# of providers? !es. For a list of preferred providers, see www.anthem.com or call %-455-565-745( 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 di3erent kinds of providers. (o ! need a referral to see a specialist? 2o. !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 7. 'ee your policy or plan document for additional information about e%cluded services. *opa$ments are *xed dollar amounts #for example, 8%9& you pay for covered health care, usually when you receive the service. *oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for an overnight hospital stay is 8%,666, your coinsurance payment of :6; would be 8:66. +his may change if you havent met your deductible. +he amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the di3erence. For example, if an out-of-network hospital charges 8%,966 for an overnight stay and the allowed amount is 8%,666, you may have to pay the 8966 di3erence. #+his is called balance billin+.& +his plan may encourage you to use in-network providers by charging you lower deductibles, copa$ments and coinsurance amounts. &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !f $ou visit a health care provider)s o,ice or clinic .rimary care visit to treat an in<ury or illness 8:9 copayvisit 96; coinsurance ============none============ 'pecialist visit 856 copay visit 96; coinsurance ============none============ /ther practitioner o3ice visit "hiropractor 856 copayvisit >cupuncturist 2ot covered "hiropractor 96; coinsurance >cupuncturist 2ot covered "hiropractic care limited to %: visits per member per calendar year. .reventive carescreeningimmuni?ation 2o "ost 'hare 96; coinsurance ============none============ !f $ou have a test Diagnostic test #x-ray, blood work& 2o "ost 'hare 96; coinsurance "osts may vary by site of service. Imaging #"+.0+ scans, @AIs& 6; coinsurance 96; coinsurance ============none============ &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 5 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !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 1eneric drugs #Aetail(6 dayB @ailC6 day& 8%6 Aetail8:6 @ail 2ot "overed @aintenance @eds are re)uired to be *lled mail order after ( *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 prescribedmember will pay brand name cost di3erence. .lan uses preferred drug list to identify coverage. .referred brand drugs #Aetail(6 dayB @ailC6 day& 8(9 Aetail84E.9 @ail 2ot "overed 2on-preferred brand #Aetail(6dayB @ailC6day& 876 Aetail8%96 @ail 2ot "overed 'pecialty drugs >ll 'pecialty meds process through >ccredo at the mail order costs. 2ot "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& 6; coinsurance 96; coinsurance ============none============ .hysiciansurgeon fees 6; coinsurance 96; coinsurance ============none============ &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 5 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !f $ou need immediate medical attention 0mergency room services 8%96 copay visitF professional and other services sub<ect to deductible 8%96 copay visitF professional and other services sub<ect to deductible 8%96 copay is waived if admitted for inpatient stay. @embers may be balance billed for out of network services. 0mergency medical transportation 6; coinsurance 6; coinsurance @embers may be balance billed for out of network services Grgent care 896 copay 896 copay @embers may be balance billed for out of network services !f $ou have a hospital sta$ Facility fee #e.g., hospital room& 6; coinsurance 96; coinsurance .recerti*cation is re)uired for Inpatient hospital admission. > 8966 penalty is applied if an /ut of 2etwork admission is not precerti*ed. .hysical @edicine and Aehabilitation limited to %66 days per member per calendar year. .hysiciansurgeon fee 6; coinsurance 96; coinsurance ============none============ &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 6 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !f $ou have mental health- behavioral health- or substance abuse needs @ental,ehavioral health outpatient services @ental,ehavio ral -ealth /3ice Hisit 8:9 copayvisit @ental,ehavio ral -ealth Facility Hisit 6; coinsurance @ental,ehavi oral-ealth /3ice Hisit 96; coinsurance @ental,ehavi oral -ealth Facility Hisit 96; coinsurance ============none============ @ental,ehavioral health inpatient services 6; coinsurance 96; coinsurance .recerti*cation is re)uired for Inpatient hospital admission. > 8966 penalty is applied if an /ut of 2etwork admission is not precerti*ed. 'ubstance use disorder outpatient services 'ubstance >buse /3ice Hisit 8:9 copayvisit 'ubstance >buse Facility Hisit 6; coinsurance 'ubstance >buse /3ice Hisit 96; coinsurance 'ubstance >buse Facility Hisit 96; coinsurance ============none============ &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 6 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions 'ubstance use disorder inpatient services 6; coinsurance 96; coinsurance .recerti*cation is re)uired for Inpatient hospital admission. > 8966 penalty is applied if an /ut of 2etwork admission is not precerti*ed. !f $ou are pre+nant .renatal and postnatal care 6; coinsurance 96; coinsurance ============none============ Delivery and all inpatient services 6; coinsurance 96; coinsurance ============none============ &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 7 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !f $ou need help recoverin+ or have other special health needs -ome health care 6; coinsurance 96; coinsurance ============none============ Aehabilitation services 856 copay for outpatient services. 6; coinsurance for inpatient care. 96; coinsurance Iimited to 76 visits combined physical therapy, speech therapy and occupational therapy. 'ervices from In- 2etwork and /ut-of-2etwork providers count toward your limit. -abilitation services 856 copay for outpatient services. 6; coinsurance for inpatient care. 96; coinsurance >ll rehabilitation and habilitation visits count toward your rehabilitation visit limit. 'killed nursing care 6; coinsurance 96; coinsurance Iimited to %66 inpatient days per member per calendar year. .recerti*cation is re)uired or 8966 penalty is applied if an /ut of 2etwork admission is not precerti*ed.. Durable medical e)uipment 8:96 deductible then :6; coinsurance 8:96 deductible then :6; coinsurance 8:96 deductible combined in and out of network. @embers may be balance billed for out of network services. -ospice service 6; coinsurance 96; coinsurance .recerti*cation is re)uired for Inpatient hospital admission. > 8966 penalty is applied if an /ut of 2etwork admission is not precerti*ed. &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 8 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO Common Medi.a& Even% !ervi.es /o" Ma# Need /o"r Cos% )f /o" 0se an )n-ne%+or1 Provider /o"r Cos% )f /o" 0se an O"%-of-ne%+or1 Provider 2imi%a%ions 3 E4.ep%ions !f $our child needs dental or e$e care 0ye exam 2o cost share 96; coinsurance Iimited to one exam per year for %4 and younger. Iimited to one exam every : years for %C and older. 1lasses 2ot "overed 2ot "overed ============none============ Dental check-up 2ot "overed 2ot "overed ============none============ E4.&"ded !ervi.es 3 O%her Covered !ervi.es: !ervi.es /o"r P&an 9oes NO' Cover ./his isn)t a complete list. *hec# $our polic$ or plan document for other e%cluded services.0 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 O%her Covered !ervi.es ./his isn)t a complete list. *hec# $our polic$ or plan document for other covered services and $our costs for these services.0 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.,",'.combluecardworld wide J Aoutine eye care #>dult - Iimits apply& &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 10 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO /o"r :igh%s %o Con%in"e 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 %-466-:94-9(%4. !ou may also contact your state insurance department, the G.'. Department of Iabor, 0mployee ,ene*ts 'ecurity >dministration at %-477- 555-(:E: or www.dol.govebsa, or the G.'. Department of -ealth and -uman 'ervices at %-4EE-:7E-:(:( x7%979 or www.cciio.cms.gov. &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 11 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO /o"r ;rievan.e and Appea&s :igh%s: If 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 95%9C Ios >ngeles, "> C6695-6%9C For grievances andor appeals regarding you prescription drug coverage, call the number listed on the back of prescription member ID card or visit www.express-scripts.com. For 0AI'> information contactB Department of Iabors 0mployee ,ene*ts 'ecurity >dministration %-477-555-0,'> #(:E:& www.dol.govebsahealthreform >dditionally, a consumer assistance program can help you *le your appeal. "ontactB 2ew -ampshire Department of Insurance :% 'outh Fruit 'treet, 'uite %5 "oncord, 2- 6((6% #466& 49:-(5%7 www.nh.govinsurance consumerservicesLins.nh.gov &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. 12 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 !"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO 9oes %his Coverage Provide Minim"m Essen%ia& Coverage< +he >3ordable "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. 9oes %his Coverage Mee% %he Minim"m =a&"e !%andard< +he >3ordable "are >ct establishes a minimum value standard of bene*ts of a health plan. +he minimum value standard is 76; #actuarial value&. This health coverage does meet the minimum value standard for the benefts it provides. 2ang"age A..ess !ervi.es: ======================To see examples of how this plan might cover costs for a sample medical situation, see the next page.=========== &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. >aving a ?a?# #normal delivery& Managing %#pe 2 dia?e%es #routine maintenance of a well-controlled condition& 1 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 Coverage E4amp&es Coverage for: Individual/Family | P&an '#pe: PPO A?o"% %hese Coverage E4amp&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 di3erent plans. Amo"n% o+ed %o providers: $7,540 P&an pa#s $,!70 Pa%ien% pa#s $","70 !amp&e .are .os%s: -ospital charges #mother& 8:,E6 6 Aoutine obstetric care 8:,%6 6 -ospital charges #baby& 8C66 >nesthesia 8C66 Iaboratory tests 8966 .rescriptions 8:66 Aadiology 8:66 Haccines, other preventive 856 /otal 12-34 0 Pa%ien% pa#s: Deductibles 8%,66 6 "opays 8:6 "oinsurance 86 Iimits or exclusions 8%96 /otal 11-12 0 Amo"n% o+ed %o providers: $5,400 P&an pa#s $!,!#0 Pa%ien% pa#s $$,0$0 !amp&e .are .os%s: .rescriptions 8:,C6 6 @edical 0)uipment and 'upplies 8%,(6 6 /3ice Hisits and .rocedures 8E66 0ducation 8(66 Iaboratory tests 8%66 Haccines, other preventive 8%66 /otal 13-40 0 Pa%ien% pa#s: Deductibles 8%,:9 6 "opays 85C6 "oinsurance 8:66 Iimits or exclusions 846 /otal 14-04 0 &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy.
'his is no% a .os% es%ima%or( Dont use these examples to estimate your actual costs under this plan. +he actual care you receive will be di3erent from these examples, and the cost of that care will also be di3erent. 'ee the next page for important information about these examples. 15 of 16 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2015-12/1/2015 Coverage E4amp&es Coverage for: Individual/Family | P&an '#pe: PPO &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 1lossary. !ou can view the 1lossary at www.anthem.com or call 1-844-404-6843 to re)uest a copy. *"es%ions and ans+ers a?o"% %he Coverage E4amp&es: Wha% are some of %he ass"mp%ions ?ehind %he Coverage E4amp&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. Wha% does a Coverage E4amp&e sho+< For each treatment situation, the "overage 0xample 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. 9oes %he Coverage E4amp&e predi.% m# o+n .are needs< 5o. +reatments shown are <ust examples. +he care you would receive for this condition could be di3erent based on your doctors advice, your age, how serious your condition is, and many other factors. 9oes %he Coverage E4amp&e predi.% m# f"%"re e4penses< 5o. "overage 0xamples 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 di3erent depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can ) "se Coverage E4amp&es %o .ompare p&ans< 6es. Khen you look at the 'ummary of ,ene*ts and "overage for other plans, youll *nd the same "overage 0xamples. Khen you compare plans, check the M.atient .aysN box in each example. +he smaller that number, the more coverage the plan provides. Are %here o%her .os%s ) sho"&d .onsider +hen .omparing p&ans< 6es. >n important cost is the premium you pay. 1enerally, 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.