7/21/2019 2016 AWANE NH 1500 http://slidepdf.com/reader/full/2016-awane-nh-1500 1/14 1 of 14 Awane: New Hampshire 1500 EPO 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 ($pe: EPO (his is on'$ a s#mmar$) If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-855-271-4549 . *mpor&an& +#es&ions Answers ,h$ &his -a&&ers: What is the overall deductible? For in-network providers, .2000 Individual / .4000 Family Doesn’t apply to in- network preventive care and routine eye exams. 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 $st%. &ee the chart starting on page ' for how much you pay for covered services after you meet the deductible. Are there other deductibles for specic services? es. .250 deductible for Durable (edical )*uipment per member per calendar year. ou must pay all of the costs for these services up to the speci+c deductible amount before this plan begins to pay for these services. Is there an out ofpoc!et li"it on "# e$penses? es. For in-network providers .6!50individual .1200 family he out-of-poc!et 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 included in the outofpoc!et li"it? alance-illed charges, /ealth !are this plan doesn’t cover, 0remiums, and 1ut-of- network pharmacy claims. )ven though you pay these expenses, they don’t count toward the out-of-poc!et li"it. Is there an overall annual li"it on %hat 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. &uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co" If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossary at %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO 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 ($pe: EPO
(his is on'$ a s#mmar$) If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-855-271-4549.
*mpor&an& +#es&ions Answers ,h$ &his -a&&ers:
What is theoveralldeductible?
For in-networkproviders,
.2000 Individual / .4000Family
Doesn’t apply to in-network preventive careand 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 orplan document to see when the deductible starts over "usually, butnot always, #anuary $st%. &ee the chart starting on page ' for howmuch you pay for covered services after you meet the deductible.
Are there otherdeductibles for
specic services?
es. .250 deductible forDurable (edical
)*uipment per memberper calendar year.
ou must pay all of the costs for these services up to the speci+c
deductible amount before this plan begins to pay for these services.
Is there an outofpoc!et li"iton "# e$penses?
es. For in-networkproviders
.6!50 individual
.1200 family
he out-of-poc!et li"it is the most you could pay during a coverageperiod "usually one year% for your share of the cost of coveredservices. his limit helps you plan for health care expenses.
What is notincluded in the
outofpoc!etli"it?
alance-illed charges,/ealth !are this plandoesn’t cover,
0remiums, and 1ut-of-network pharmacyclaims.
)ven though you pay these expenses, they don’t count toward the
out-of-poc!et li"it.
Is there anoverall annualli"it on %hat theplan pa#s?
2o.he chart starting on page ' describes any limits on what the planwill pay for specifc covered services, such as o3ice visits.
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO 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 ($pe: EPO
)oes this planuse a net%or! ofproviders?
es. For a list of in-net%or! providers, seewww.anthem.com or call$-566-'7$-8689.
If you use an in-network doctor or other health care provider , this plan will pay some or all of the costs of covered services. e aware,
your in-network doctor or hospital may use an out-of-networkprovider for some services. 0lans use the term in-network,preferred, or participating for providers in their net%or! . &ee the
chart starting on page ' for how this plan pays di3erent kinds ofproviders.
)o I need areferral to see aspecialist?
2o. ou can see the specialist you choose without permission from thisplan.
Are thereservices this plandoesn*t cover?
es.&ome of the services this plan doesn’t cover are listed on page 6. &ee
your policy or plan document for additional information aboute$cluded services.
•
+opa#"ents are +xed dollar amounts "for example, :$6% you pay for covered health care, usually when youreceive the service.
• +oinsurance is your share of the costs of a covered service, calculated as a percent of the allo%ed
a"ount for the service. For example, if the plan’s allo%ed a"ount for an overnight hospital stay is:$,;;;, your coinsurance payment of ';< would be :';;. 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 di3erence. For example, if anout-of-network hospital charges :$,6;; for an overnight stay and the allo%ed a"ount is :$,;;;, you mayhave to pay the :6;; di3erence. "his is called balance billin,.%
• his plan may encourage you to use in-network providers by charging you lower deductibles,
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
2ot !overedDeductible waived when labservices performed in o3iceor independent lab. !ostsmay vary by site of service.
Imaging "!0) scans, (CIs%;<coinsurance
2ot !overed?????????????none????????????
If #ou needdru,s to treat #our illness orcondition
(oreinformationaboutprescriptiondru, covera,e is available atwww.medco.com
4eneric drugs "Cetail>; day (ail9;day%
:$6 Cetail:>;(ail
2ot !overed(aintenance (eds are re*uired to be+lled mail order after > +lls at retail"penalty applies%. If pre-auth re*uired Enot obtained, drug may not be covered.
!ertain 0reventive meds no copay. If ageneric e*uivalent is available E brand isprescribedmember will pay brand namecost di3erence. 0lan uses preferred druglist to identify coverage.
0referred brand drugs "Cetail>; day(ail9; day%
:8; Cetail:$;;(ail 2ot !overed
2on-preferred brand "Cetail>;day(ail9;day%
:7; Cetail:$76(ail
2ot !overed
&pecialty drugs
@ll &pecialtymeds process
through @ccredo at the
mail ordercosts.
2ot !overed
he mail order cost will bebased on the medication tier"generic, preferred, non-preferred%. &pecialty medscan not be +lled at retailpharmacies.
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
:'6; copay waived ifadmitted. (ember may bebalance billed for out ofnetwork services.
)mergency medicaltransportation
;<coinsurance
;<coinsurance
(ember may be balancebilled for out of networkservices.
rgent care :6; copayvisit 2ot !overed ????????????none????????????
If #ou have ahospital sta#
Facility fee "e.g., hospital room%;<coinsurance
2ot !overed
0hysical (edicine andCehabilitation limited to $;;days per member percalendar year.
0hysiciansurgeon fee;<coinsurance
2ot !overed?????????????none????????????
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2016 12/!1/2016
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
Common
-edia' Even&"ervies o# -a$ Need
o#r Cos& *f o# 3se an*nne&worProvider
o#r Cos& *f o# 3se an
O#&ofne&worProvider
imi&a&ions E7ep&ions
If #ou have"ental health.behavioralhealth. orsubstanceabuse needs
(entalehavioral healthoutpatient services
(entalehavi
oral /ealth13ice Gisit
:>; copayvisit
(entalehavioral /ealth
Facility Gisit
;<coinsurance
(entalehavioral/ealth
13ice Gisit
2ot!overed
(entalehavioral /ealth
Facility
Gisit 2ot!overed
?????????????none????????????
(entalehavioral healthinpatient services
;<coinsurance
2ot !overed ????????????none????????????
&ubstance use disorderoutpatient services
&ubstance @buse 13ice
Gisit:>; copayvisit
&ubstance @buse Facility
Gisit;<coinsurance
&ubstance @buse 13ice
Gisit 2ot
!overed
&ubstance @buse Facility
Gisit 2ot!overed
?????????????none????????????
&ubstance use disorder inpatientservices
;<coinsurance
2ot !overed ????????????none????????????
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO 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 ($pe: EPO
Common
-edia' Even&"ervies o# -a$ Need
o#r Cos& *f o# 3se an*nne&worProvider
o#r Cos& *f o# 3se an
O#&ofne&worProvider
imi&a&ions E7ep&ions
If #ou arepre,nant
0renatal and postnatal care;<coinsurance
2ot !overed?????????????none????????????
Delivery and all inpatient services;<coinsurance
2ot !overed?????????????none????????????
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Himited to ; visits permember per calendar yearfor physical therapy,occupational therapy, andspeech therapy combined.
/abilitation services
:6; copayvisitfor outpatient
services.Inpatientservicessub=ect todeductible.
2ot !overed
@ll rehabilitation and
habilitation visits counttoward your rehabilitation
visit limit.
&killed nursing care;<coinsurance
2ot !overedHimited to $;; days percalendar year.
Durable medical e*uipment
:'6;deductiblethen ';<
coinsurance
2ot !overed
&upplies are sub=ect to :'6;deductible per member per
year. (# @ppliances are
not covered./ospice service
;<coinsurance
2ot !overed?????????????none????????????
If #our childneeds dental or e#e care
)ye exam 2o !ost &hare 2ot !overed 1ne exam each calendar year for members ages $5 years and younger. 1neexam every two calendar
years for members $9 yearsand older.
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2016 12/!1/2016
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPO
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 pre"iu", which may be signi+cantly higher than the premium you pay while covered under the plan.
1ther limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at $-5;;-'65-6>$5. ou may also contact
your state insurance department, the .&. Department of Habor, )mployee ene+ts &ecurity @dministration at $-5-888->'7' or www.dol.govebsa, or the .&. Department of /ealth and /uman &ervices at $-577-'7-'>'> x$66 orwww.cciio.cms.gov.
o#r <rievane and Appea's ;igh&s:
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2016 12/!1/2016
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPOIf you have a complaint or are dissatis+ed with a denial of coverage for claims under your plan, you may be able to appeal or +le a ,rievance. For *uestions about your rights, this notice, or assistance, you can contact
For grievances andor appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.express-scripts.com.
For )CI&@ information contact
Department of Habor’s )mployee ene+ts &ecurity @dministration$-5-888-)&@ ">'7'%www.dol.govebsahealthreform
@dditionally, a consumer assistance program can help you +le your appeal. !ontact2ew /ampshire Department of Insurance'$ &outh Fruit &treet, &uite $8!oncord, 2/ ;>>;$"5;;% 56'->8$www.nh.govinsuranceconsumerservicesLins.nh.gov
9oes &his Coverage Provide -inim#m Essen&ia' Coverage=
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2016 12/!1/2016
"#mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P'an ($pe: EPOhe @3ordable !are @ct re*uires most people to have health care coverage that *uali+es as Mminimum essential
coverage.N This plan or policy does provide minimum essential coverage.
he @3ordable !are @ct establishes a minimum value standard of bene+ts of a health plan. he minimum value
standard is ;< "actuarial value%. This health coverage does meet the minimum value standard for the
benets it provides.
ang#age Aess "ervies:
??????????????????????To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.–––––––––––???????????
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2016 12/!1/2016
Coverage E7amp'es
Coverage for: Individual/Family | P'an ($pe: EPO
A?o#& &hese CoverageE7amp'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 underdi3erent plans.
Amo#n& owed &o providers: $7,54
P'an pa$s $5,!7
Pa&ien& pa$s $",#7
"amp'e are os&s:
/ospital charges "mother%:',7;
;
Coutine obstetric care:',$;
;
/ospital charges "baby% :9;; @nesthesia :9;;
Haboratory tests :6;;
0rescriptions :';;
Cadiology :';;
Gaccines, other preventive :8;
0otal7.54
3
Pa&ien& pa$s:
Deductibles :',;;;
!opays :';
!oinsurance :;
Himits or exclusions :$6;
0otal2.17
3
Amo#n& owed &o providers: $5,4
P'an pa$s $",4#
Pa&ien& pa$s $",
"amp'e are os&s:
0rescriptions:',9;
;(edical )*uipment and
&upplies
:$,>;
;13ice Gisits and 0rocedures :7;;
)ducation :>;;
Haboratory tests :$;;
Gaccines, other preventive :$;;
0otal5.43
3
Pa&ien& pa$s:
Deductibles:','6
;!opays :8;
!oinsurance :';;
Himits or exclusions :5;
0otal2.99
3
&uestions' !all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryat %%%(anthe"(co" or call 1-855-271-4549 to re*uest a copy.
(his isno& a os&es&ima&or)
Don’t use theseexamples to estimate
your actual costs underthis plan. he actualcare you receive will bedi3erent from theseexamples, and the costof that care will also bedi3erent.
+#es&ions and answers a?o#& &he Coverage E7amp'es:
,ha& are some of &heass#mp&ions ?ehind &heCoverage E7amp'es=
• !osts don’t include pre"iu"s.
• &le care costs are based onnational averages supplied bythe .&. Department of /ealthand /uman &ervices, andaren’t speci+c to a particulargeographic area or health plan.
• he patient’s condition was notan excluded or preexisting
condition.• @ll services and treatments
started and ended in the samecoverage period.
• here are no other medicalexpenses for any membercovered under this plan.
• 1ut-of-pocket expenses arebased only on treating thecondition in the example.
• he patient received all carefrom in-network providers. Ifthe patient had received carefrom out-of-network providers,costs would have been higher.
,ha& does a Coverage E7amp'eshow=
For each treatment situation, the
!overage )xample helps you seehow deductibles, copa#"ents,and coinsurance can add up. Italso helps you see what expensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.
9oes &he Coverage E7amp'e
predi& m$ own are needs= o( reatments shown are =ust
examples. he care you wouldreceive for this condition couldbe di3erent 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 di3erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.
Can * #se Coverage E7amp'es
&o ompare p'ans=
es( Khen you look at the
&ummary of ene+ts and!overage for other plans, you’ll+nd the same !overage)xamples. Khen you compareplans, check the M0atient 0aysNbox in each example. hesmaller that number, the morecoverage the plan provides.
Are &here o&her os&s * sho#'donsider when omparingp'ans=
es( @n important cost is the
pre"iu" you pay. 4enerally,the lower your pre"iu", themore you’ll pay in out-of-pocket
