1 of 15

Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015

Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO

#%i! i! on"y a !ummary& 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 1-855-271-4549.
'm$oran (ue!ion! An!wer! )%y %i! Maer!:
What is the
overall
deductible?
For in-network
providers
*3+000 individual /
*,+000 family
Doesnt apply to in-
network preventive care
and routine eye eam.
!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
seci!c services?
!es. "25# deductible for
Durable )edical
*+uipment per member
per calendar year.
,rescription Drugs -%..
per person, per calendar
year, -(.. per family
per calendar year.
!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.
$s there an out%
of%oc&et limit
on m' e(enses?
!es. For in-network
providers
*,+000 individual /
*12+000 family
0he out-of-oc&et limit is the most you could pay during a coverage
period #usually one year& for your share of the cost of covered
services. 0his limit helps you plan for health care epenses.
What is not
included in the
out%of%oc&et
limit?
1alance-1illed charges,
2ealth "are this plan
doesnt cover,
,remiums, and 3ut-of-
network pharmacy
claims.
*ven though you pay these epenses, they dont count toward the
out-of-oc&et limit.
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
2 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
$s there an
overall annual
limit on what the
lan a's?
5o.
0he chart starting on page ( describes any limits on what the plan
will pay for specifc covered services, such as o6ice visits.
+oes this lan
use a networ& of
roviders?
!es. For a list of
referred roviders,
see www.anthem.com
or call %-788-9:%-;8;<
If you use an in-network doctor or other health care rovider, this
plan will pay some or all of the costs of covered services. 1e aware,
your in-network doctor or hospital may use an out-of-network
rovider for some services. ,lans use the term in-network,
referred, or participating for roviders in their networ&. 'ee the
chart starting on page ( for how this plan pays di6erent kinds of
roviders.
+o $ need a
referral to see a
secialist?
5o.
!ou can see the secialist you choose without permission from this
plan.
Are there
services this lan
doesn,t cover?
!es.
'ome of the services this plan doesnt cover are listed on page 8. 'ee
your policy or plan document for additional information about
e(cluded services.
-oa'ments are /ed dollar amounts #for eample, -%8& 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 eample, if the plans allowed amount for an overnight hospital stay is
-%,..., your coinsurance payment of 9.= would be -9... 0his may change if you havent met your
deductible.
0he amount the plan pays for covered services is based on the allowed amount. If an out-of-network
rovider charges more than the allowed amount, you may have to pay the di6erence. For eample, if an
out-of-network hospital charges -%,8.. for an overnight stay and the allowed amount is -%,..., you may
have to pay the -8.. di6erence. #0his is called balance billin..&
0his plan may encourage you to use in-networ& roviders by charging you lower deductibles,
coa'ments and coinsurance amounts.
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
3 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
$f 'ou visit a
health care
rovider,s
o/ice or clinic
,rimary care visit to treat an
in>ury or illness
-(.
copay/visit
5ot "overed ????????????none????????????
'pecialist visit
-8.
copay/visit
5ot "overed ????????????none????????????
3ther practitioner o6ice visit
"hiropractor
-8.
copay/visit
@cupuncturist
5ot covered
"hiropractor
5ot "overed
@cupuncturist
5ot covered
????????????none????????????
,reventive
care/screening/immuniAation
5o "ost
'hare
5ot "overed ????????????none????????????
$f 'ou have a
test
Diagnostic test #-ray, blood
work&
%.=
coinsurance
5ot "overed ????????????none????????????
Imaging #"0/,*0 scans, )BIs&
%.=
coinsurance
5ot "overed ????????????none????????????
$f 'ou need
dru.s to treat
'our illness or
condition
)ore
information
about
rescrition
dru. covera.e
is available at
www.epress-
scripts.com
4eneric drugs #Betail/(. dayC )ail/<.
day&
-%8 Betail/-(.
)ail
5ot "overed
If pre-auth re+uired D not obtained,
drug may not be covered. "ertain
,reventive meds no copay. If a generic
e+uivalent is available D brand is
prescribed/member will pay brand
name cost di6erence. ,lan uses
preferred drug list to identify coverage.
,referred brand drugs #Betail/(. dayC
)ail/<. day&
-(8 Betail/-7:.8
)ail
5ot "overed
5on-preferred brand #Betail/(.dayC
)ail/<.day&
-:. Betail/-%:8
)ail
5ot "overed
'pecialty drugs
@ll 'pecialty
meds process
through
@ccredo at
the mail order
costs.
5ot "overed
0he mail order cost will be
based on the medication tier
#generic, preferred, non-
preferred&. 'pecialty meds can
not be /lled at retail
pharmacies.
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
5 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
$f 'ou have
outatient
sur.er'
Facility fee #e.g., ambulatory
surgery center&
%.=
coinsurance
5ot "overed ????????????none????????????
,hysician/surgeon fees
%.=
coinsurance
5ot "overed ????????????none????????????
$f 'ou need
immediate
medical
attention
*mergency room services
-98.
copay/visitE
professional
and other
services %.=
coinsurance
-98.
copay/visitE
professional
and other
services %.=
coinsurance
-98. copay waived if
admitted. )ember may be
balance billed for out of
network services.
*mergency medical
transportation
%.=
coinsurance
%.=
coinsurance
)ember may be balance
billed for out of network
services.
Frgent care
-8.
copay/visit
5ot "overed ????????????none????????????
$f 'ou have a
hosital sta'
Facility fee #e.g., hospital room&
%.=
coinsurance
5ot "overed
,hysical )edicine and
Behabilitation limited to %..
days per member per
calendar year.
,hysician/surgeon fee
%.=
coinsurance
5ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
5 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
$f 'ou have
mental health0
behavioral
health0 or
substance
abuse needs
)ental/1ehavioral health
outpatient services
)ental/1ehavi
oral 2ealth
36ice Gisit
-(.
copay/visit
)ental/1ehavi
oral 2ealth
Facility
Gisit
%.=
coinsurance
)ental/1ehavi
oral2ealth
36ice
Gisit
5ot
"overed
)ental/1ehavi
oral 2ealth
Facility
Gisit
5ot
"overed
????????????none???????????? .
)ental/1ehavioral health
inpatient services
%.=
coinsurance
5ot "overed ????????????none????????????
'ubstance use disorder
outpatient services
'ubstance
@buse 36ice
Gisit
-(.
copay/visit
'ubstance
@buse
Facility Gisit
%.=
coinsurance
'ubstance
@buse 36ice
Gisit
5ot
"overed
'ubstance
@buse Facility
Gisit
5ot
"overed
????????????none???????????? .
'ubstance use disorder inpatient
services
%.=
coinsurance
5ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
, of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
$f 'ou are
re.nant
,renatal and postnatal care
%.=
coinsurance
5ot "overed ????????????none????????????.
Delivery and all inpatient services
%.=
coinsurance
5ot "overed ????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
6 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
$f 'ou need
hel recoverin.
or have other
secial health
needs
2ome health care
%.=
coinsurance
5ot "overed ????????????none????????????
Behabilitation services
-8.
copay/visit for
outpatient
services.
Inpatient
services %.=
coinsurance.
5ot "overed
Himited to I. visits per
member per calendar year for
physical therapy,
occupational therapy, and
speech therapy combined.
2abilitation services
-8.
copay/visit for
outpatient
services.
Inpatient
services %.=
coinsurance.
5ot "overed
@ll rehabilitation and
habilitation visits count
toward your rehabilitation
visit limit.
'killed nursing care
%.=
coinsurance
5ot "overed
Himited to %.. days per
calendar year..
Durable medical e+uipment
-98.
deductible
then 9.=
coinsurance
5ot "overed
'upplies are sub>ect to -98.
deductible per member per
year. 0)$ @ppliances are not
covered.
2ospice service
%.=
coinsurance
5ot "overed ????????????none????????????
$f 'our child
needs dental or
e'e care *ye eam 5o cost share 5ot "overed
3ne eam each calendar year
for members ages %7 years
and younger. 3ne eam every
two calendar years for
members %< years and older.
4lasses 5ot "overed 5ot "overed ?????????????none????????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
7 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
Common
Medi-a" Even
Servi-e! .ou May /eed
.our Co! 'f
.ou 0!e an
'n-newor1
Provider
.our Co! 'f
.ou 0!e an
Ou-of-newor1
Provider
2imiaion! 3 E4-e$ion!
Dental check-up 5ot "overed 5ot "overed ?????????????none????????????
E4-"uded Servi-e! 3 O%er Covered Servi-e!:
Servi-e! .our P"an 8oe! /O# Cover 12his isn,t a comlete list. -hec& 'our olic' or lan document for other
e(cluded services.3
J @cupuncture
J "osmetic surgery
J Dental care #@dult&
J 2earing aids
J Infertility treatment
J Hong-term care
J Boutine foot care
J Keight loss programs
O%er Covered Servi-e! 12his isn,t a comlete list. -hec& 'our olic' or lan document for other covered
services and 'our costs for these services.3
J 1ariatric surgery #Himitations )ay
@pply&
J "hiropractic care #Himitations
@pply&
J )ost coverage provided outside the
Fnited 'tates. 'ee
www.1"1'.com/bluecardworldwide
J ,rivate-duty nursing #covered
under 2ome 2ealth "are&
J Boutine eye care #@dult ?
Himitations )ay @pply&
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
9 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
.our :ig%! o Coninue 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 remium, which may be signi/cantly higher than the premium you pay while covered under the plan.
3ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at %-7..-987-8(%7. !ou may also contact
your state insurance department, the F.'. Department of Habor, *mployee 1ene/ts 'ecurity @dministration at %-7II-
;;;-(9:9 or www.dol.gov/ebsa, or the F.'. Department of 2ealth and 2uman 'ervices at %-7::-9I:-9(9( I%8I8 or
www.cciio.cms.gov.
.our ;rievan-e and A$$ea"! :ig%!:
If you have a complaint or are dissatis/ed with a denial of coverage for claims under your plan, you may be able to
aeal or /le a .rievance. For +uestions about your rights, this notice, or assistance, you can contactC
@nthem 1lue "ross 1lue 'hield
"linical @ppealsC ,.3. 1o %.88I7 @tlanta, 4@ (.(;7
3perational @ppealsC ,.3. 1o %.88I7 @tlanta, 4@ (.(;7
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.epress-scripts.com.
For *BI'@ information contactC
Department of Habors *mployee 1ene/ts 'ecurity @dministration
%-7II-;;;-*1'@ #(9:9&
www.dol.gov/ebsa/healthreform
@dditionally, a consumer assistance program can help you /le your appeal. "ontactC
5ew 2ampshire Department of Insurance
9% 'outh Fruit 'treet, 'uite %;
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
10 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
"oncord, 52 .((.%
#7..& 789-(;%I
www.nh.gov/insurance
consumerservicesLins.nh.gov
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
11 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P"an #y$e: EPO
8oe! %i! Coverage Provide Minimum E!!enia" Coverage<
0he @6ordable "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.
8oe! %i! Coverage Mee %e Minimum =a"ue Sandard<
0he @6ordable "are @ct establishes a minimum value standard of bene/ts of a health plan. 0he minimum value
standard is I.= #actuarial value&. This health coverage does meet the minimum value standard for the
benefts it provides.
2anguage A--e!! Servi-e!:
??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next
page.???????????
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
>aving a ?a?y
#normal delivery&
Managing y$e 2 dia?ee!
#routine maintenance of
a well-controlled condition&
12 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Coverage E4am$"e!
Coverage for: Individual/Family | P"an #y$e: EPO
A?ou %e!e Coverage
E4am$"e!:
0hese eamples show how this plan
might cover medical care in given
situations. Fse these eamples to
see, in general, how much /nancial
protection a sample patient might
get if they are covered under
di6erent plans.
Amoun owed o $rovider!: $7,54
P"an $ay! $!,"4
Paien $ay! $!,#
Sam$"e -are -o!!:
2ospital charges #mother&
-9,:.
.
Boutine obstetric care
-9,%.
.
2ospital charges #baby& -<..
@nesthesia -<..
Haboratory tests -8..
,rescriptions -9..
Badiology -9..
Gaccines, other preventive -;.
2otal
"7054
#
Paien $ay!:
Deductibles
-(,.9
.
"opays -.
"oinsurance -;(.
Himits or eclusions -%8.
2otal
"405#
#
Amoun owed o $rovider!: $5,4
P"an $ay! $!,$
Paien $ay! $$,!%
Sam$"e -are -o!!:
,rescriptions
-9,<.
.
)edical *+uipment and
'upplies
-%,(.
.
36ice Gisits and ,rocedures -:..
*ducation -(..
Haboratory tests -%..
Gaccines, other preventive -%..
2otal
"504#
#
Paien $ay!:
Deductibles -%8..
"opays -I..
"oinsurance -9..
Himits or eclusions -7.
2otal
"2048
#
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.

#%i! i!
no a -o!
e!imaor&
Dont use these
eamples to estimate
your actual costs under
this plan. 0he actual
care you receive will be
di6erent from these
eamples, and the cost
of that care will also be
di6erent.
'ee the net page for
important information
about these eamples.
13 of 15
Awane: Maine 3000 EPO Coverage Period: 01/01/2015 - 12/31/2015
Coverage E4am$"e!
Coverage for: Individual/Family | P"an #y$e: EPO
)uestions* "all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossary
at www.anthem.com or call 1-855-271-4549 to re+uest a copy.
(ue!ion! and an!wer! a?ou %e Coverage E4am$"e!:
)%a are !ome of %e
a!!um$ion! ?e%ind %e
Coverage E4am$"e!<
"osts dont include remiums.
'ample care costs are based on
national averages supplied by
the F.'. Department of 2ealth
and 2uman 'ervices, and
arent speci/c to a particular
geographic area or health plan.
0he patients condition was not
an ecluded or preeisting
condition.
@ll services and treatments
started and ended in the same
coverage period.
0here are no other medical
epenses for any member
covered under this plan.
3ut-of-pocket epenses are
based only on treating the
condition in the eample.
0he patient received all care
from in-network roviders. If
the patient had received care
from out-of-network roviders,
costs would have been higher.
)%a doe! a Coverage E4am$"e
!%ow<
For each treatment situation, the
"overage *ample helps you see
how deductibles, coa'ments,
and coinsurance can add up. It
also helps you see what epenses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
8oe! %e Coverage E4am$"e
$redi- my own -are need!<
6o. 0reatments shown are >ust
eamples. 0he care you would
receive for this condition could
be di6erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
8oe! %e Coverage E4am$"e
$redi- my fuure e4$en!e!<
6o. "overage *amples are not
cost estimators. !ou cant use
the eamples to estimate costs
for an actual condition. 0hey are
for comparative purposes only.
!our own costs will be di6erent
depending on the care you
receive, the prices your
roviders charge, and the
reimbursement your health plan
allows.
Can ' u!e Coverage E4am$"e!
o -om$are $"an!<
7es. Khen you look at the
'ummary of 1ene/ts and
"overage for other plans, youll
/nd the same "overage
*amples. Khen you compare
plans, check the M,atient ,aysN
bo in each eample. 0he
smaller that number, the more
coverage the plan provides.
Are %ere o%er -o!! ' !%ou"d
-on!ider w%en -om$aring
$"an!<
7es. @n important cost is the
remium you pay. 4enerally,
the lower your remium, the
more youll pay in out-of-pocket
costs, such as coa'ments,
deductibles, and coinsurance.
!ou should also consider
contributions to accounts such
as health savings accounts
#2'@s&, Oeible spending
arrangements #F'@s& or health
reimbursement accounts #2B@s&
that help you pay out-of-pocket
epenses.