Awane: New Hampshire 1500 EPO: This Is Only A Summary

Awane: New Hampshire 1500 EPO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO
This is only a summary. 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. Important Questions Answers For in-network providers, What is the overall deductible? $1,500 Individual / $3,750 Family Doesnt apply to innetwork preventive care and routine eye exams. Yes. $250 deductible for Durable Medical Equipment per member per calendar year. Yes. For in-network providers $6,350 individual / $12,700 family Premiums, balancebilled charges, penalties for non compliance, pharmacy claims and health care this plan doesnt cover. No. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services? Is there an out ofpocket limit on my expenses? What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays?
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
Even though you pay these expenses, they dont count toward the out-of-pocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Questions: Call 1-855-271-4549 or visit us at www.anthem.com 1 of 14 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-855-271-4549 to request a copy.
Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO 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. Be aware, Yes. For a list of inDoes this plan your in-network doctor or hospital may use an out-of-network network providers, use a network of provider for some services. Plans use the term in-network, see www.anthem.com or providers? preferred, or participating for providers in their network. See the call 1-855-271-4549. chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesnt cover? No. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 5. See your policy or plan document for additional information about excluded services.
Yes.
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you
receive the service. Coinsurance 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 $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible. The 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 difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care Your Cost If You Use an In-network Provider $30 copay/visit Your Cost If You Use an Out-of-network Provider Not Covered
Services You May Need Primary care visit to treat an injury or illness
Limitations & Exceptions none

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider Specialist visit providers office or clinic Other practitioner office visit Preventive care/screening/immunization If you have a test $50 copay/visit $50 copay/visit No Charge
Diagnostic test (x-ray, blood work) No Charge Imaging (CT/PET scans, MRIs) No Charge
$10 Retail/$20 Mail
$35 Retail/$87.5 Mail $60 Retail/$150 Mail
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Not Covered none Not Covered none Not Covered none Deductible waived when lab Not Covered services performed in office or independent lab. Not Covered none Not Covered Not Covered Not Covered
Maintenance Meds are required to be filled mail order after 3 fills at retail (penalty applies). If pre-auth required & not obtained, drug may not be covered. Certain Preventive meds no copay. If a generic equivalent is available & brand is prescribed/member will pay brand name cost difference. Plan uses preferred drug list to identify coverage.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medco.com If you have outpatient surgery
Generic drugs (Retail/30 day: Mail/90

day) Preferred brand drugs (Retail/30 day: Mail/90 day)
Non-preferred brand (Retail/30day: Mail/90day)
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
All Specialty meds process through Not Covered Accredo at the mail order costs. $75 copay/visit for ambulatory surgical center; Not Covered other providers No Charge
The mail order cost will be based on the medication tier (generic, preferred, nonpreferred). Specialty meds can not be filled at retail pharmacies.
none

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider Physician/surgeon fees No Charge $250 copay /visit; professional and other services subject to deductible No Charge $50 copay/visit No Charge No Charge
If you need immediate medical attention
Emergency room services
Emergency medical transportation Urgent care
If you have a hospital stay
Facility fee (e.g., hospital room) Physician/surgeon fee
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Deductible waived when Not Covered performed in an ambulatory surgical center. $250 copay/visit; Copay waived if admitted. professional Member may be balance and other billed for out of network services services. subject to deductible Member may be balance No Charge billed for out of network services. Not Covered none Failure to precertify may Not Covered result in a penalty of $500. Not Covered none

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider $30 copay/visit or Mental/Behavioral health consultation; outpatient services other services subject to If you have deductible mental health, Mental/Behavioral health inpatient No Charge behavioral services health, or $30 copay/visit substance or consultation; abuse needs Substance use disorder outpatient other services services subject to deductible Substance use disorder inpatient No Charge services If you are pregnant Prenatal and postnatal care Delivery and all inpatient services No Charge No Charge
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider
Not Covered
none Failure to precertify may result in a penalty of $500. none Failure to precertify may result in a penalty of $500. none none
Not Covered
Not Covered
Not Covered Not Covered Not Covered

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider Home health care No Charge $50 copay/visit for outpatient services. Inpatient services subject to deductible. $50 copay/visit for outpatient services. Inpatient services subject to deductible. No Charge
Rehabilitation services
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Not Covered none Inpatient rehabilitation limited to 60 days per calendar year. Outpatient services limited to 60 visits per member per calendar Not Covered year for physical therapy, occupational therapy, and speech therapy combined. Limits are combined in and out-of- network. All rehabilitation and habilitation visits count toward your rehabilitation visit limit. Limited to 100 days per calendar year. Failure to precertify may result in a penalty of $500. Supplies are subject to $250 deductible per member per year. TMJ Appliances are not covered. none
If you need help recovering or have other Habilitation services special health needs
Not Covered
Skilled nursing care
Not Covered
Durable medical equipment Hospice service
20% coinsurance No Charge
Not Covered Not Covered

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need In-network Medical Event Provider
Eye exam If your child needs dental or eye care Glasses Dental check-up
No Charge
Not Covered Not Covered
Coverage Period: 01/01/2014 - 12/31/2014 Coverage for: Individual/Family | Plan Type: EPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider One exam each calendar year for members ages 18 years and younger. One Not Covered exam every two calendar years for members 19 years and older. Not Covered none Not Covered none
Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Hearing aids Long-term care Routine foot care Weight loss programs
Non-emergency care when traveling Infertility treatment outside the U.S.
Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery (Limitations May Coverage provided outside the Apply) United States. See Private-duty nursing (covered under Home Health Care)

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Chiropractic care
www.BCBS.com/bluecardworldwide Routine eye care (Adult Limitations May Apply)
Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-258-5318. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
Coverage Period: 01/01/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross Blue Shield Clinical Appeals: P.O. Box 105568 Atlanta, GA 30348 Operational Appeals: P.O. Box 105568 Atlanta, GA 30348 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.express-scripts.com. For ERISA information contact: Department of Labors Employee Benefits Security Administration 1-866-444-EBSA (3272) www.dol.gov/ebsa/healthreform Additionally, a consumer assistance program can help you file your appeal. Contact: New Hampshire Department of Insurance 21 South Fruit Street, Suite 14 Concord, NH 03301 (800) 852-3416 www.nh.gov/insurance consumerservices@ins.nh.gov

Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Coverage Examples
About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.
Having a baby
(normal delivery)
Managing type 2 diabetes

(routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,820 Patient pays $1,580 Sample care costs: $2,70 0 $2,10 0 $900 $900 $500 $200 $200 $40 $7,54 0 $1,50 0 $0 $0 $150 $1,65 0 Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1,48 0 $0 $20 $80 $1,58 0 $2,90 0 $1,30 0 $700 $300 $100 $100 $5,40 0
This is not a cost Amount owed to providers: $7,540 estimator. Plan pays $5,890
Patient pays $1,650 Dont use these examples to estimate Sample care costs: your actual costs under Hospital (mother) this plan.charges The actual care you receive will be Routine obstetric care different from these examples, and the cost Hospital charges (baby) of that care will also be Anesthesia different. Laboratory tests Prescriptions See the next page for Radiology important information Vaccines, other preventive about these examples. Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total

Coverage Examples
Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?
Costs dont include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and arent specific to a particular geographic area or health plan. The patients condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.
What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, 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.
No. Coverage Examples are not

cost estimators. You cant use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.
Does the Coverage Example predict my own care needs?
Can I use Coverage Examples to compare plans?
No. Treatments shown are just

examples. The care you would receive for this condition could be different based on your doctors advice, your age, how serious your condition is, and many other factors.
Yes. When you look at the

Summary of Benefits and Coverage for other plans, youll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides.
Does the Coverage Example predict my future expenses?
Are there other costs I should consider when comparing plans?
Yes. An important cost is the
premium you pay. Generally, the lower your premium, the more youll pay in out-of-pocket
costs, such as copayments, deductibles, and coinsurance. You should also consider
contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

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Awane: New Hampshire 1500 EPO