1of 14 AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016 !"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 https://eoc.anthem.com/eocdps/f 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 ,1000individual / ,2.00family For out-of-network providers ,.000individual / ,10000family Doesn’t 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 thisplan 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. Fo r durable me dical e)uipment there is a ,2.0deductible. ! ou must pay all of the costs for these se rvices up t o the speci*c deductibleamount before this plan begins to pay for these services. Is there an out–of– pocet li!it on !" e#penses? For in-network porivders ,6600individual /,1200family For out-of-network providers ,10000individual / ,20000family +he out-of-pocet li!it 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 inc luded in the out–of–pocet li!it? ut-of-etwork deductible, premiums, penalties for non-compliance, balance- billed charges, and health care this plan doesn’t cover. ven though you pay these expenses, they don’t count toward the out-of-pocet li!it. $uestions% "all 1-844-404-6843 or visit us at&&& 'anthe!'co! If you aren’t clear about any of the underlined terms used in this form, see the /lossary . ! ou can view the /lossary at&&& 'anthe!'co!or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"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 completeterms in the policy or plan document at https://eoc.anthem.com/eocdps/f or by calling 1-844-404-6843.
)mpor%an% *"es%ions Ans+ers Wh# %his Ma%%ers:
What is the overalldeductible?
For in-network providers
,1000 individual /,2.00 family
For out-of-network providers
,.000 individual /,10000 family
Doesn’t apply to in-networkpreventive care, routine eyeexams or outpatientlabsx-rays or ultrasounds.
!ou must pay all the costs up to the deductible amountbefore this plan begins to pay for covered services you use."heck your policy or plan document to see when thedeductible starts over #usually, but not always, $anuary%st&. 'ee the chart starting on page ( for how much you payfor covered services after you meet the deductible.
Are there otherdeductibles forspecic services?
!es. For durable medicale)uipment there is a ,2.0 deductible.
!ou must pay all of the costs for these services up to thespeci*c deductible amount before this plan begins to payfor these services.
Is there an out–of–pocet li!it on !"e#penses?
For in-network porivders
,6600 individual /,1200 family
For out-of-network providers
,10000 individual /
,20000 family
+he out-of-pocet li!it is the most you could pay during acoverage period #usually one year& for your share of the costof covered services. +his limit helps you plan for health careexpenses.
What is not includedin the out–of–pocetli!it?
ut-of-etwork deductible,premiums, penalties fornon-compliance, balance-billed charges, and healthcare this plan doesn’t cover.
ven though you pay these expenses, they don’t counttoward the out-of-pocet li!it.
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO
Is there an overallannual li!it on &hatthe plan pa"s?
o.+he chart starting on page ( describes any limits on whatthe plan will pay for specifc covered services, such as o0ice
visits.
(oes this plan use anet&or ofproviders?
!es. For a list of preferredproviders, seewww.anthem.com or call
%-122-232-412(
If you use an in-network doctor or other health careprovider , this plan will pay some or all of the costs of
covered services. 5e aware, your in-network doctor orhospital may use an out-of-network provider for someservices. 6lans use the term in-network, preferred, orparticipating for providers in their net&or . 'ee the chartstarting on page ( for how this plan pays di0erent kinds ofproviders.
(o I need a referralto see a specialist?
o. !ou can see the specialist you choose without permissionfrom this plan.
Are there services
this plan doesn)tcover? !es.
'ome of the services this plan doesn’t cover are listed on
page 4. 'ee your policy or plan document for additionalinformation about e#cluded services.
• *opa"!ents are *xed dollar amounts #for example, 7%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 allo&ed
a!ount for the service. For example, if the plan’s allo&ed a!ount for an overnight hospital stay is7%,333, your coinsurance payment of 93: would be 7933. +his may change if you haven’t met yourdeductible.
•
+he amount the plan pays for covered services is based on the allo&ed a!ount. If an out-of-network provider charges more than the allo&ed a!ount, you may have to pay the di0erence. For example, if anout-of-network hospital charges 7%,833 for an overnight stay and the allo&ed a!ount is 7%,333, you mayhave to pay the 7833 di0erence. #+his is called balance billin+.&
• +his plan may encourage you to use in-network providers by charging you lower deductibles,
copa"!ents and coinsurance amounts.
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
"hiropractic care limited to%9 visits per member percalendar year.
6reventivecarescreeningimmuni=ation
o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
If "ou have a
test
Diagnostic test #x-ray, bloodwork&
o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
Imaging #"+6+ scans, >?Is& o "harge 83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
If "ou needdru+s to treat "our illness orcondition
>oreinformation
aboutprescriptiondru+ covera+e is available atwww.medco.com
/eneric drugs #?etail(3 day@>ailA3 day&
7%8 ?etail7(3>ail
ot "overed>aintenance >eds are re)uired to be*lled mail order after ( *lls at retail#penalty applies&. If pre-auth re)uired Bnot obtained, drug may not be covered."ertain 6reventive meds no copay. If ageneric e)uivalent is available B brand isprescribedmember will pay brand namecost di0erence. 6lan uses preferred druglist to identify coverage.
6referred brand drugs #?etail(3 day@>ailA3 day&
7(8 ?etail71C.8>ail
ot "overed
on-preferred brand #?etail(3day@>ailA3day&
743 ?etail7%83>ail
ot "overed
'pecialty drugs
ll 'pecialty
meds processthrough
ccredo at themail order
costs.
ot "overed
+he mail order cost will be
based on the medication tier#generic, preferred, non-preferred&. 'pecialty meds cannot be *lled at retailpharmacies.
If "ou haveoutpatientsur+er"
Facility fee #e.g., ambulatorysurgery center&
o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
6hysiciansurgeon fees o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
7%83 copay is waived ifadmitted for inpatient stay.>embers may be balancebilled for out of networkservices.
mergency medicaltransportation
o "harge o "harge>embers may be balancebilled for out of networkservices
rgent care 783 copay 783 copay
>embers may be balance
billed for out of networkservices
If "ou have ahospital sta"
Facility fee #e.g., hospital room& o "harge83:coinsurance
6recerti*cation is re)uiredfor Inpatient hospitaladmission. 7833 penalty isapplied if an ut of etworkadmission is not precerti*ed.
6hysiciansurgeon fee o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO
CommonMedia& Even%
!ervies o" Ma# Need
o"r Cos% )f o" se an)n-ne%+orProvider
o"r Cos% )f o" se an
O"%-of-ne%+orProvider
3imi%a%ions E5ep%ions
If "ou have!ental healthbehavioralhealth orsubstanceabuse needs
>ental5ehavioral healthoutpatient services
798 copayvisit83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
>ental5ehavioral healthinpatient services
o "harge83:coinsurance
6recerti*cation is re)uiredfor Inpatient hospitaladmission. 7833 penalty isapplied if an ut of etworkadmission is not precerti*ed.
'ubstance use disorderoutpatient services
798 copay visit83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
'ubstance use disorder
inpatient services o "harge
83:
coinsurance
6recerti*cation is re)uiredfor Inpatient hospital
admission. 7833 penalty isapplied if an ut of etworkadmission is not precerti*ed.
If "ou arepre+nant
6renatal and postnatal care o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
Delivery and all inpatientservices
o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO
CommonMedia& Even%
!ervies o" Ma# Need
o"r Cos% )f o" se an)n-ne%+orProvider
o"r Cos% )f o" se an
O"%-of-ne%+orProvider
3imi%a%ions E5ep%ions
If "ou needhelp recoverin+or have otherspecial healthneeds
Gome health care o "harge83:coinsurance
<<<<<<<<<<<<none<<<<<<<<<<<<
?ehabilitation services
723 copay foroutpatientservices. ocharge forinpatient care
83:coinsurance
Inpatient physical medicinerehabilitation is limited to%33 days per member percalendar year. Himited to 43
visits combined physicaltherapy, speech therapy andoccupational therapy. lltherapy limits are combinedin and out of network.
Gabilitation services
723 copay foroutpatientservices. ocharge forinpatient care
83:coinsurance
ll rehabilitation andhabilitation visits counttoward your rehabilitation visitlimit.
'killed nursing care o "harge83:coinsurance
Himited to %33 inpatient daysper member per calendar
year. 6recerti*cation isre)uired or 7833 penalty isapplied.
Durable medical e)uipment7983deductible then93:coinsurance
7983deductiblethen 93:coinsurance
7983 deductible combined inand out of network. >embersmay be balance billed for outof network services.
Gospice service o "harge83:coinsurance
6recerti*cation is re)uiredfor Inpatient hospitaladmission. 7833 penalty isapplied if an ut of etworkadmission is not precerti*ed.
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO
o"r 9igh%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 pre!iu!, 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 %-133-981-8(%1. !ou may also contact
your state insurance department, the .'. Department of Habor, mployee 5ene*ts 'ecurity dministration at %-144-222-(9C9 or www.dol.govebsa, or the .'. Department of Gealth and Guman 'ervices at %-1CC-94C-9(9( x4%848 orwww.cciio.cms.gov.
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
!"mmar# of $enefi%s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P&an '#pe: PPO
o"r ;rievane and Appea&s 9igh%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 contact@
nthem 5lue "ross and 5lue 'hield
6.. 5ox 82%8AHos ngeles, " A3382-3%8A
For grievances andor appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.express-scripts.com.
For ?I' information contact@
Department of Habor’s mployee 5ene*ts 'ecurity dministration%-144-222-5' #(9C9&
www.dol.govebsahealthreform
dditionally, a consumer assistance program can help you *le your appeal. "ontact@
ew Gampshire Department of Insurance9% 'outh Fruit 'treet, 'uite %2"oncord, G 3((3%#133& 189-(2%4www.nh.govinsuranceconsumerservicesKins.nh.gov
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
+he 0ordable "are ct establishes a minimum value standard of bene*ts of a health plan. +he minimum value
standard is 43: #actuarial value&. This health coverage does meet the minimum value standard for the
benets it provides.
3ang"age Aess !ervies:
<<<<<<<<<<<<<<<<<<<<<<To see examples o how this plan might cover costs or a sample medical situation, see the next
page.–––––––––––<<<<<<<<<<<
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
Coverage E5amp&es
Coverage for: Individual/Family | P&an '#pe: PPO
A?o"% %hese CoverageE5amp&es:
+hese examples show how this planmight cover medical care in givensituations. se these examples tosee, in general, how much *nancialprotection a sample patient mightget if they are covered underdi0erent plans.
Amo"n% o+ed %o providers: $7,540
P&an pa#s $,!70
Pa%ien% pa#s $","70
!amp&e are os%s:
Gospital charges #mother&79,C3
3
?outine obstetric care79,%3
3Gospital charges #baby& 7A33
nesthesia 7A33
Haboratory tests 7833
6rescriptions 7933
?adiology 7933
Naccines, other preventive 723
/otal24
0
Pa%ien% pa#s:
Deductibles7%,33
3"opays 793
"oinsurance 73
Himits or exclusions 7%83
/otal112
0
Amo"n% o+ed %o providers: $5,400
P&an pa#s $!,#00
Pa%ien% pa#s $#,#00
!amp&e are os%s:
6rescriptions79,A3
3>edical )uipment and
'upplies
7%,(3
30ice Nisits and 6rocedures 7C33
ducation 7(33
Haboratory tests 7%33
Naccines, other preventive 7%33
/otal40
0
Pa%ien% pa#s:
Deductibles7%,98
3"opays 74C3
"oinsurance 7933
Himits or exclusions 713
/otal0
0
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
'his isno% a os%es%ima%or(
Don’t use theseexamples to estimate
your actual costs underthis plan. +he actualcare you receive will bedi0erent from theseexamples, and the costof that care will also bedi0erent.
AWANE: MA Comprehensive PPO Coverage Period: 01/01/2016-12/1/2016
Coverage E5amp&es
Coverage for: Individual/Family | P&an '#pe: PPO
$uestions% "all 1-844-404-6843 or visit us at &&&'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the /lossary. !ou can view the /lossaryat &&&'anthe!'co! or call 1-844-404-6843 to re)uest a copy.
*"es%ions and ans+ers a?o"% %he Coverage E5amp&es:
Wha% are some of %heass"mp%ions ?ehind %heCoverage E5amp&es<
• "osts don’t include pre!iu!s.
• 'ample care costs are based onnational averages supplied bythe .'. Department of Gealthand Guman 'ervices, andaren’t speci*c to a particulargeographic area or health plan.
• +he patient’s condition was notan excluded or preexisting
condition.• ll services and treatments
started and ended in the samecoverage period.
• +here are no other medicalexpenses for any membercovered under this plan.
• ut-of-pocket expenses arebased only on treating thecondition in the example.
• +he patient received all carefrom in-network providers. Ifthe patient had received carefrom out-of-network providers,costs would have been higher.
Wha% does a Coverage E5amp&esho+<
For each treatment situation, the
"overage xample helps you seehow deductibles, copa"!ents,and coinsurance can add up. Italso helps you see what expensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.
7oes %he Coverage E5amp&e
predi% m# o+n are needs< 5o' +reatments shown are ;ust
examples. +he care you wouldreceive for this condition couldbe di0erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.
cost estimators. !ou can’t usethe examples to estimate costsfor an actual condition. +hey arefor comparative purposes only.
!our own costs will be di0erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.
Can ) "se Coverage E5amp&es
%o ompare p&ans<
es' Jhen you look at the
'ummary of 5ene*ts and"overage for other plans, you’ll*nd the same "overagexamples. Jhen you compareplans, check the L6atient 6aysMbox in each example. +hesmaller that number, the morecoverage the plan provides.
Are %here o%her os%s ) sho"&donsider +hen omparingp&ans<
es' n important cost is the
pre!iu! you pay. /enerally,the lower your pre!iu!, themore you’ll pay in out-of-pocket
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