Solution PPO Plans

Summary of Features

Small Group EmployeeElect

Solution 5000 PPO

MCASB2931C (7/09)

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Solution 5000 PPO: Combines a modest premium PPO plan with a high deductible, providing predictable copays for office visits and prescription drugs along with coverage for preventive care and physical exams

It’s just the right amount of coverage for you.

• Yougetupto$5,000,000incoveredbenefitsoveryourlifetime.

• Youchoosefromover53,000doctorsandspecialists,andfromover400hospitals.

• Yousavemoneybecausewe’venegotiatedlowerrateswithourin-networkdoctors.

• YougetemergencycarecoveredwhiletravelingacrosstheU.S.andthroughouttheworld,24/7.

Great Ways to Save!

AnthemBlueCrossisworkinghardtohelpyousavemoneyonhealthcarecosts.Oneoftheeasiestandmostconvenientwaystosaveisbyorderingmaintenancemedicationsthroughourmail-orderpharmacy.Yourmedicationsaredeliveredrighttoyourdoor,andwithourlowermail-orderpharmacybenefits,youcansaveasmuchas$80ormoreperyearonprescriptioncosts!Andnow,yourplanoffersgenericmedicationsata$10copay,savingyouevenmore.

You can save over 66 percent on pharmacy costs using mail order!

Ourmail-orderservicepharmacyisaprovenmoneysaver.Geta90-daymail-ordersupplyforthesamecostasa30-dayretailsupplyforgenerics!Gowithbrandformularyorbrandnonformularymedicationsandgeta90-daysupplyforthesamecostasa60-dayretailsupply.Mailorderslashesprescriptioncostsbygivingyougreatersuppliesofmaintenancemedicationsforaslittleasone-thirdthecost.

Anthem 360° Health®: Optimize Your Health

360°Healthoffersyouvaluabletools,resourcesandsupporttohelpyoutolivehealthier,startingtoday.Andit’sallavailablethroughonecentralizedresource.Whetheryouarehealthyandwanttostaythatwayoryouneedhelpmanagingachroniccondition,360°Healthisheretohelpyoureachyourpersonalhealthgoals.

Access Tools and Resources

Atanthem.com/ca,360°Healthbringstogether:

• Onlineresources(likehelpfuldecision-makingtoolsandvaluablehealthinformation).

• Interactivehealthprograms.

• Personalguidance.

• Discountsonhealth-relatedproducts.

•MyHealth@Anthem,yourpersonalonlineresourceformemberhealthandwellnessinformation.Ourtrustedsitehasinteractivetoolsthathelpyoucheckyourhealthstatusandlearnwhatyoucandotoimproveit.

Get Guidance

Sometimesyouneedexpertinformationandsupportfromatrustedsource.Weprovideprogramstoaddressyourconcernsandgiveyoutheassistanceyouneedinreachingyourhealthgoals.

Solid protection,practical solution

* Member pays full cost of drug at negotiated rates until brand-name deductible is met. Costs may vary for brand name drugs if generic equivalent is available.

Manage a Condition

OurConditionCareprogramscanhelpyoubettermanagechronicconditionsincludingasthma,diabetes,heartfailure,coronaryarterydiseaseandchronicobstructivepulmonarydisease.Visitanthem.com/catodaytolearnmoreabouthow360°Healthcanhelpyoulivebettertodayandinthefuture.

We’re dedicated to improving your health.

WithAnthem,you’llhavepeaceofmindknowingthatyou’recoveredbyoneofthemosttrustednamesinhealthcarecoverage,andthatyou’regettingmorevalueinsomanyways.Westillhavethesamecommitmenttoyouthatwe’vehadtoallCaliforniansoverthelast70years—todeliverhigh-quality,affordablehealthcoverageandhelpyoubeashealthyasyoucanbe.AsthehealthcareplanmoreCaliforniansdependon,welookforwardtoservingyourhealthcareneeds.

Haveaquestion?JustcallSmallGroupCustomerServiceat800-627-8797andwe’llbehappytohelp.

Comprehensive coverage you can trust. Modest premiums with predictable office visit copays. Preventive care and physical exam coverage and valuable hospital coverage. That’s what makes our Solution 5000 PPO Plan a practical, cost-effective solution.

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You’re free to go to health care providers outside

of the Anthem Blue Cross network, but you’ll save

a substantial amount by choosing from our 53,000

doctors and 400 hospitals. Staying in the Anthem

Blue Cross network will help you get maximum

value from your health care benefits — and from

your health care dollar.

Powerful savings from Anthem

With Anthem health coverage, you save in three significant ways:

1.Ourin-networkdoctorsandhospitalschargeyoulower,AnthemBlueCross-negotiatedfees.

2.TheBlueCard®programgivesyouaccesstoin-networkprovidersatdiscountedratesallacrossthecountry.

3.Youpayonlyaportionofthefeesforyoureligiblecoveredexpenses(seeexamplebelow)andwepaytherest,afteryourdeductible.

Thisisanexampleonly.Yoursavingsmayvarybasedonyourplanandservicesreceived.

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Small Group Solution 5000 PPO PlanAll amounts listed are the member’s responsibility to pay after deductible(s), unless otherwise noted. In-network negotiated fees can result in 30 to 40% savings compared to providers’ usual fees.

CORE FEATURES IN NETWORK Receive Negotiated Savings

OUT OF NETWORK Pay Higher Costs

Annual Deductible $5,000 per member for all medical services except office visits, annual physical exam and prescription drugs; two-member maximum, in network and out of network combined. Annual deductible applies toward annual in-network out-of-pocket maximum

Maximum Lifetime Covered ChargesPaid by Anthem Blue Cross In network and out of network combined

$5,000,000

Annual Out-of-Pocket Maximum1 $7,500 per member, two-member maximum Once Anthem Blue Cross payments reach $15,000 per member, member pays nothing for covered expenses for the remainder of the year except charges over the allowed amounts

Office Visits Not subject to annual deductible

$40 copay for unlimited visits 50% of negotiated fee plus 100% of excess charges

Other Professional ServicesIncludes maternity, diagnostic lab and X-ray

40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Hospital Inpatient Facility Services Pre-service Review required

40% of negotiated fee after annual deductible All charges in excess of $650 per day after annual deductible

Hospital Inpatient Professional Services Includes lab, physician, anesthesia

40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Outpatient Facility Services Pre-service Review required for certain surgical services and diagnostic procedures

40% of negotiated fee after annual deductible All charges in excess of $380 per day after annual deductible

Ambulatory Surgical Centers Pre-service Review required

40% of negotiated fee after annual deductible All charges in excess of $380 per day after annual deductible

Prescription Drugs3

Amounts shown are for a 30-day retail supply; mail-order service available

Annual $250 brand-name prescription drug deductible per member applies to brand-name drugs in network and out of network combined

Generic: $10 copay

Brand2:$250 brand-name prescription drug deductible applies$35 copay for Formulary$50 copay for Non-FormularySelf-injectable (except insulin): 30% of negotiated fee up to $100 per fill (subject to brand-name prescription drug deductible, if applicable)

50% of drug limited fee schedule plus 100% of excess charges if filled within California. $250 brand-name deductible applies.

Annual Preventive Care OptionsPhysical Exam (Ages 7 - Adult)Maximum Anthem Blue Cross payment of $500 for members covered more than 6 months or $250 if covered 6 months or less; not subject to annual deductible; in network and out of network combined. HealthyCheckSM Screenings do not apply.

$40 copay per office visit plus 40% of negotiated fee for all other covered services

50% of negotiated fee plus 100% of excess charges

1 Services that do not apply to the annual out-of-pocket maximum include but are not limited to: deductible and copay paid under the pharmacy benefit; copay paid for acupuncture/acupressure; copay for mental or nervous disorders and substance abuse (except for treatment of severe mental illness and serious emotional disturbances of a child); copay for not obtaining pre-service review; $500 copay for infertility services; non-covered services.

2 Copays listed apply when generic equivalent is not available. If a member selects a brand-name drug when a generic-equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for a generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug. The additional amount paid does not apply to the member’s brand-name deductible.3 Infertility Drugs: Infertility drug lifetime maximum Anthem Blue Cross payment is $1,500 in network and out of network combined. Classified specialty drugs must be obtained through the Specialty Pharmacy Program and are subject to the terms of the program.

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1 Age and frequency limitations apply.2 Does not apply to coverage of severe mental illness and serious emotional disturbances of a child, except pre-service review. 3 Classified specialty drugs must be obtained through the mail-order Specialty Pharmacy Program and are subject to the terms of the program. Limited to 30-day supply.

This is an overview of coverage. A comprehensive description of coverage, benefits and limitations is contained in the Certificate. Review the Exclusions and Limitations prior to applying for coverage.

ADDITIONAL FEATURES IN NETWORK Receive Negotiated Savings

OUT OF NETWORK Pay Higher Costs

Well Baby Immunizations and Adult Screening Tests1 Well-Baby Immunizations (Children through age 6) Includes regular check-ups and immunizations

Adult Preventive Services (Ages 7 - Adult) Includes annual Pap, breast exam and mammogram for women, and Prostate Specific Antigen study for men, and colorectal cancer screenings.

$40 copay for office visit (not subject to deductible) plus 40% of negotiated fee for all other covered services after annual deductible

50% of negotiated fee plus 100% of excess charges after annual deductible

Emergency Care$100 Emergency Room copay for each visit - waived if admitted

40% of negotiated fee after annual deductible 40% of customary and reasonable charges plus 100% of excess after annual deductible

Ambulance 40% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Skilled Nursing Facility100 days per year, in network and out of network combined Pre-service Review required

40% of negotiated fee after annual deductible All charges in excess of $150 per day after annual deductible

Home Health Care100 four-hour visits per year, in network and out of network combined Pre-service Review required

40% of negotiated fee after annual deductible All charges in excess of $75 per visit after annual deductible

Physical/Occupational Therapy, Chiropractic Care24 visits per year, in network and out of network combined

40% of negotiated fee after annual deductible All charges in excess of $25 per visit after annual deductible

Acupuncture/Acupressure24 visits per year, in network and out of network combined

All of the negotiated fee in excess of $30 per visit after annual deductible All charges in excess of $30 per visit after annual deductible

Mental Health/Inpatient2

Includes chemical dependency; 30 days per year, in network and out of network combined

Pre-service Review required

All of the negotiated fee in excess of $175 per day after annual deductible All charges in excess of $175 per day after annual deductible

Mental Health/Outpatient Professional Services2

Includes chemical dependency. One visit per day, 20 visits per year, in network and out of network combinedPre-service Review required after the 12th outpatient professional visit

All of the negotiated fee in excess of $25 per visit after annual deductible All charges in excess of $25 per visit after annual deductible

Infusion Therapy3

Includes chemotherapyPre-service Review required

40% of negotiated fee after annual deductible All charges in excess of $50 per day for all infusion therapy expenses except drugs; all charges in excess of the average wholesale price for all infusion therapy drugs; all charges in excess of the combined maximum Anthem Blue Cross payment of $500 per day; after annual deductible

Infertility Services3

Maximum lifetime Anthem Blue Cross payment $2,000, in network and out of network combined

$500 copay plus 40% of the balance of negotiated fee after annual deductible $500 copay plus 50% of the balance of negotiated fee plus 100% of excess charges after annual deductible

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Exclusions and Limitations

Followingisanabbreviatedlistofexclusionsandlimitations;pleaseseetheCertificateforcomprehensivedetails.

•AnyamountsinexcessofmaximumsstatedintheCertificate

•Servicesorsuppliesthatarenotmedicallynecessary

•Servicesreceivedbeforeyoureffectivedate

•Servicesreceivedafteryourcoverageends

•Anyconditionsforwhichbenefitscanberecoveredunderanyworkers’compensationlaworsimilarlaw

•Servicesyoureceiveforwhichyouarenotlegallyobligatedtopay

•Servicesforwhichnochargeismadetoyouintheabsenceofinsurancecoverage

•ServicesnotlistedascoveredintheCertificate

•Servicesfromrelatives

•VisioncareexceptasspecificallystatedintheCertificate

•Eyesurgeryperformedsolelyforthepurposeofcorrectingrefractivedefects

•Hearingaids.RoutinehearingtestsexceptasspecificallystatedintheCertificate

•Sexchanges

•DentalandorthodonticservicesexceptasspecificallystatedintheCertificate

•Cosmeticsurgery

•RoutinephysicalexaminationsexceptasspecificallystatedintheCertificate

•Treatmentofmentalornervousdisordersandsubstanceabuse(includingnicotineuse)orpsychologicaltesting,exceptasspecificallystatedintheCertificate

•Custodialcare

•Experimentalorinvestigationalservices

•Servicesprovidedbyalocal,stateorfederalgovernmentagency,unlessyouhavetopayforthem

•Diagnosticadmissions

•Telephoneorfacsimilemachineconsultations

•Personalcomfortitems

•Nutritionalcounseling

•Healthclubmemberships

•Commercialweightlossprograms,unlessapprovedbyus

•Medicalsuppliesandequipment/durablemedicalequipment,exceptasspecificallystatedintheCertificate

•Specialtydrugs,exceptasspecificallystatedintheCertificate

•AnyservicestotheextentyouareentitledtoreceiveMedicarebenefitsforthoseserviceswithoutpaymentofadditionalpremiumforMedicarecoverage

•Foodordietarysupplements,exceptasspecificallystatedintheCertificateorasrequiredbylaw

•Genetictestingfornon-medicalreasonsorwhenthereisnomedicalindicationornofamilyhistoryofgeneticabnormality

•Outdoortreatmentprograms

•Replacementofprostheticsanddurablemedicalequipmentwhenlostorstolen

•AnyservicesorsuppliesprovidedtoanypersonnotcoveredundertheAgreementinconnectionwithasurrogatepregnancy

•ImmunizationssolelyfortraveloutsidetheUnitedStates

•Servicesorsuppliesrelatedtoapre-existingcondition

•EducationalservicesexceptasspecificallyprovidedorarrangedbyAnthemBlueCross

•Infertilityservices(includingsterilizationreversal)exceptasspecificallystatedintheCertificate

•Careortreatmentprovidedinanon-contractinghospital

•PrivatedutynursingexceptasspecificallystatedintheCertificate

•Servicesprimarilyforweightreductionexceptmedicallynecessarytreatmentofmorbidobesity

•Outpatientdrugs,medicationsorothersubstancesdispensedoradministeredinanyoutpatientsetting

•Contraceptivedevicesunlessyourphysiciandeterminesthatoralcontraceptivedrugsarenotmedicallyappropriatelaw

General Provisions

Member Privacy: OurcompleteNotice of Privacy Practicesprovidesacomprehensiveoverviewofthepoliciesandpracticesweenforcetopreserveourmembers’privacyrightsandcontroluseoftheirhealthcareinformation,including:therighttoauthorizereleaseofinformation;therighttolimitaccesstomedicalinformation;protectionoforal,writtenandelectronicinformation;useofdata;andinformationsharedwithemployers.Thisnoticecanbedownloadedfromourwebsiteatanthem.com/caorobtained

bycallingSmallGroupCustomerServiceat800-627-8797.

Utilization Review: TheAnthemBlueCrossUtilizationReviewProgramhelpsmembersreceivecoverageforappropriatetreatmentintheappropriatesetting.Fourreviewprocessesareincluded:1)Pre-serviceReviewassessesmedicalnecessitybeforeservicesareprovided;2)AdmissionReviewdeterminesatthetimeofadmissionifthestayorsurgeryisMedicallyNecessaryintheeventPre-serviceReviewisnotconducted;3)ContinuedStayReviewdeterminesifacontinuedstayisMedicallyNecessary;4)RetrospectiveReviewdeterminesifthestayorsurgerywasMedicallyNecessaryaftercarehasbeenprovidedifnoneofthefirstthreereviewswereperformed.UtilizationReviewisnotthepracticeofmedicineortheprovisionofmedicalcaretoyou.Onlyyourdoctorcanprovideyouwithmedicaladviceandmedicalcare.

Grievances: Allcomplaintsanddisputesrelatingtoamember’scoveragemustberesolvedinaccordancewithAnthemBlueCrossLifeandHealthInsuranceCompany’sgrievanceprocedure.Youcanreportyourgrievancebyphoneorinwriting;seeyourAnthemBlueCrossLifeandHealthInsuranceCompanyIDcardfortheappropriatecontactinformation.AllgrievancesreceivedbyAnthemBlueCrossLifeandHealthInsuranceCompanythatcannotberesolvedbyphone(whenappropriate)tothemutualsatisfactionofthememberandAnthemBlueCrossLifeandHealthInsuranceCompanywillbeacknowledgedinwriting,togetherwithadescriptionofhowAnthemBlueCrossLifeandHealthInsuranceCompanyproposestoresolvethegrievance.Grievancesthatcannotberesolvedbytheseproceduresshallberesolvedasindicatedthroughbindingarbitration,oriftheplanyouarecoveredunderissubjecttotheEmployeeRetirementIncomeSecurityActof1974(ERISA),incompliancewithERISArules.IfthegroupissubjecttoERISA,andamemberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sproposedresolutionofagrievance,themembermaysubmitanappealbyphoneorinwritingbycontactingthephonenumberoraddressprintedontheletterheadoftheAnthemBlueCrossLifeandHealthInsuranceCompanyresponseletter.

ForthepurposesofERISA,thereisonelevelofappeal.Forurgentcarerequestsforbenefits,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin72hoursfromthedatetheappealisreceived.Forpre-servicerequestsforbenefits,thememberwillreceivearesponsewithin30calendardaysfromthedatetheappealisreceived.Forpost-serviceclaims,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin60calendardaysfromthedatetheappealisreceived.

IfthememberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sdecisionontheappeal,themembermayelecttohavethedisputesettledthroughalternativeresolutionoptions,suchasvoluntarybindingarbitration.

Department of Insurance: Overseeingtheindustryandprotectingthestate’sinsuranceconsumersistheresponsibilityoftheCaliforniaDepartmentofInsurance(CDI).TheCDIregulates,investigatesandauditsinsurancebusinesstoensurethatcompaniesremainsolventandmeettheirobligationstoinsurancepolicyholders.Ifyouhaveaproblemregardingyourcoverage,pleasecontactAnthemBlueCrossfirsttoresolvetheissue.Ifcontactsbetweenyou(thecomplainant)andAnthemBlueCross(theInsurer)havefailedtoproduceasatisfactorysolutiontotheproblem,youmaywishtocontacttheCDI.TheycanbereachedbywritingtotheCaliforniaDepartmentofInsurance,ConsumerServicesDivision,300SouthSpringSt.-SouthTower,LosAngeles,CA90013.TheCDIalsohasatoll-freephonenumber800-927-HELP(4357)thatyoumaycallforassistance.

Binding Arbitration: IftheplanissubjecttoERISA,anydisputeinvolvinganadversebenefitdecisionmustberesolvedunderERISAclaimsprocedurerules,andisnotsubjecttomandatorybindingarbitration.MembersmaypursuevoluntarybindingarbitrationaftertheyhavecompletedanappealunderERISArules.Ifthememberhasanotherdisputethatdoesnotinvolveanadversebenefitdecision,orifthegroupdoesnotprovideaplanthatissubjecttoERISA,thenthememberandAnthemBlueCrossagreetobeboundbythearbitrationprovisionscontainedintheenrollmentformandCertificate.

Medicare: UnderTEFRA/DEFRA,Medicareistheprimarycoverageforgroupsoflessthan20employees.AnthemBlueCrosscoverageisconsideredprimarycoverageforgroupsof20ormoreemployees.ThisAnthemBlueCrosscoverageisnotasupplementtoMedicare,butprovidesbenefitsaccordingtothenon-duplicationofMedicareclause.

IfMedicareisamember’sprimaryhealthplan,AnthemBlueCrosswillnotprovidebenefitsthatduplicateanybenefitsyouareentitledtoreceiveunderMedicare.ThismeansthatwhenMedicareistheprimaryhealthcoverage,benefitsareprovidedinaccordancewiththebenefitsoftheplan,lessanyamountpaidbyMedicare.IfyouareentitledtoPartAandBofMedicare,youwillbeeligiblefornon-duplicateMedicarecoverage,withsupplementalcoordinationofbenefits.However,ifyouarerequiredtopaytheSocialSecurityAdministration

anadditionalpremiumforanypartofMedicare,thentheabovepolicywillonlyapplyifyouareenrolledinthatpartofMedicare.Note:Medicare-eligibleemployees/dependentsenrolledinplanswhereMedicareisprimarymayobtainanIndividualAnthemBlueCrossMedicareSupplementplanwiththepre-existingconditionexclusionwaived.

Specialty Pharmacy Program: Specialtymedicationsareusuallydispensedasaninjectabledrug,butmaybeavailableinotherforms,suchasapillorinhalant.Theyareusedtotreatcomplexconditions.Prescriptionsforaspecialtypharmacydrugarecoveredonlywhenorderedthroughthespecialtypharmacyprogram,unlessyouaregivenanexceptionfromthespecialtydrugprogram(seeyourCertificatefordetails).Thespecialtypharmacyprogramwilldeliveryourmedicationtoyoubymailorcommoncarrier(youcannotpickupyourmedication).

Youmayhavetopaythefullcostofaspecialtypharmacydrug,ifitisnotobtainedfromthespecialtypharmacyprogram.

Specialtydrugsarelimitedtoa30-daysupplyforeachfill.

Coordination of Benefits: Thebenefitsofamember’splanmaybereducedifthememberhasothergrouphealth,dental,drugorvisioncoverage,sothatbenefitsandservicesthememberreceivesfromallgroupcoveragesdonotexceed100percentofthecoveredexpense.

Third-Party Liability: Ifamemberisinjured,theresponsiblepartymaybelegallyobligatedtopayformedicalexpensesrelatedtothatinjury.AnthemBlueCrossmayrecoverbenefitspaidformedicalexpensesifthememberrecoversdamagesfromalegallyliablethirdparty.Examplesofthird-partyliabilitysituationsincludecaraccidentsandwork-relatedinjuries.

Voiding Coverage for False and Misleading Information: Falseormisleadinginformationorfailuretosubmitanyrequiredenrollmentmaterialsmayformthebasisforvoidingcoveragefromthedateaplanwasissuedorretroactivelyadjustingthepremiumtowhatitwouldhavebeenifthecorrectinformationhadbeenfurnished.Nobenefitswillbepaidforanyclaimsubmittedifcoverageismadevoid.Premiumsalreadypaidforthetimeperiodforwhichcoveragewasrescindedwillberefunded,minusanyclaimspaid.

Incurred Medical Care Ratio: Asrequiredbylaw,weareadvisingyouthatAnthemBlueCrossanditsaffiliatedcompanies’incurredmedicalcareratiofor2008was83.4percent.Thisratiowascalculatedafterproviderdiscountswereapplied.

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AGENT Guide

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Anthem Blue Cross is an NCQA Accredited health plan.Goods and services available through discount programs are not benefits of coverage. Anthem Blue Cross does not endorse or recommend any goods or services provided at a discount by these vendors or practitioners. These programs may be changed or withdrawn at any time without notice by the offering vendor or practitioner.

Solution 5000 PPO Plan is offered by Anthem Blue Cross Life and Health insurance Company.

Health care plans provided by Anthem Blue Cross. insurance plans provided by Anthem Blue Cross Life and Health insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. independent licensees of the Blue Cross Association. ® ANTHeM and 360° HeALTH are registered trademarks. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. The WebMd website is owned and operated by WebMd Health Corp. WebMd Health is solely responsible for its website and is not affiliated with Anthem Blue Cross or any affiliate of Anthem Blue Cross.

anthem.com/ca