Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO #%i" i" onl a "ummar& If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-634-8638. 'm$or!an! (ue"!ion" An"wer" )% !%i" Ma!!er": What is the overall deductible? For in-network providers *2+000 individual / *,+000 family Doesnt apply to in-network preventive care and 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 or plan document to see when the deductible starts over "usually, but not always, #anuary $st%. &ee the chart starting on page ' for how much you pay for covered services after you meet the deductible. Are there other deductibles for specic services? (o. ou dont have to meet deductibles for speci)c services, but see the chart starting on page ' for other costs for services this plan covers. !s there an out"of" poc#et limit on m$ e%penses? es. In-(etwork *roviders *5+0-0 Individual + *10+1,0 Family ,his plan has a separate -ut of *ocket .aximum of *1+2.0 Individual/*2+5/0 per family for in and out of network prescription drugs ,he out-of-poc#et limit 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 out"of"poc#et limit? /alance-/illed charges, 0ealth !are this plan doesnt cover, and *remiums 1ven though you pay these expenses, they dont count toward the out-of-poc#et limit. !s there an overall annual limit on what the plan pa$s? (o. ,he chart starting on page ' describes any limits on what the plan will pay for specifc covered services, such as o2ice visits. &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. 2 of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO *oes this plan use a networ# of providers? es. For a list of preferred providers, see www.anthem.com or call $-566-576-'$88. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. /e aware, your in-network doctor or hospital may use an out-of-network provider for some services. *lans use the term in-network, preferred, or participating for providers in their networ#. &ee the chart starting on page ' for how this plan pays di2erent kinds of providers. *o ! need a referral to see a specialist? es. ,his plan will pay some or all of the costs to see a specialist for covered services but only if you have the plans permission before you see the specialist from this plan. Are there services this plan doesn+t cover? es. &ome of the services this plan doesnt cover are listed on page 9. &ee your policy or plan document for additional information about e%cluded services. ,opa$ments are )xed dollar amounts "for example, :$9% you pay for covered health care, usually when you receive the service. ,oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for an overnight hospital stay is :$,666, your coinsurance payment of 86; would be :866. ,his may change if you havent met your deductible. ,he 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 di2erence. For example, if an out-of-network hospital charges :$,966 for an overnight stay and the allowed amount is :$,666, you may have to pay the :966 di2erence. ",his is called balance billin-.% ,his plan may encourage you to use in-networ# providers by charging you lower deductibles, copa$ments and coinsurance amounts. &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. 3 of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO Common Medi0al 1ven! Servi0e" 2ou Ma 3eed 2our Co"! 'f 2ou 4"e an 'n5ne!wor6 Provider 7imi!a!ion" 8 190e$!ion" !f $ou visit a health care provider+s o.ice or clinic *rimary care visit to treat an in<ury or illness :'6 copay +visit ============none============ &pecialist visit :96 copay +visit ============none============ -ther practitioner o2ice visit !hiropractor :96 copay+visit >cupuncturist (ot covered ============none============ *reventive care+screening+immuni?ation (o cost share ============none============ !f $ou have a test Diagnostic test "x-ray, blood work% (o cost share for labs in o2ice or independent lab@ other services 6; coinsurance Deductible waived when lab services performed in o2ice or independent lab. !osts may vary by site of service. Imaging "!,+*1, scans, .AIs% 6; coinsurance ============none============ !f $ou need dru-s to treat $our illness or condition 3eneric drugs "Aetail+'6 dayB .ail+C6 day% :$9 Aetail+:'6 .ail .aintenance .eds are re4uired to be )lled mail order after ' )lls at retail "penalty applies%. If pre-auth re4uired D not obtained, drug may not be covered. !ertain *reventive meds no copay. If a generic e4uivalent is available D brand is prescribed+member will pay brand name cost di2erence. *lan uses preferred drug list to identify coverage. *referred brand drugs "Aetail+'6 dayB .ail+C6 day% :'9 Aetail+:57.9 .ail (on-preferred brand "Aetail+'6dayB .ail+C6day% :76 Aetail+:$79 .ail &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. / of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO Common Medi0al 1ven! Servi0e" 2ou Ma 3eed 2our Co"! 'f 2ou 4"e an 'n5ne!wor6 Provider 7imi!a!ion" 8 190e$!ion" .ore information about prescription &pecialty drugs >ll &pecialty meds process through >ccredo at the mail order costs. ,he mail order cost will be based on the medication tier "generic, preferred, non-preferred%. &pecialty meds can not be )lled at retail pharmacies. !f $ou have outpatient sur-er$ Facility fee "e.g., ambulatory surgery center% :79+copay visit ,his copay applies to free standing ambulatory surgical center only@ other providers sub<ect to deductible. ============none============ *hysician+surgeon fees 6; coinsurance Deductible waived if services are provided at a free standing ambulatory surgical center. !f $ou need immediate medical attention 1mergency room services :896 copay +visit@ professional and other services sub<ect to deductible. :896 copay is waived if admitted for inpatient stay. .embers may be balance billed for out of network services. 1mergency medical transportation 6; coinsurance .embers may be balance billed for out of network services. &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. 5 of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO Common Medi0al 1ven! Servi0e" 2ou Ma 3eed 2our Co"! 'f 2ou 4"e an 'n5ne!wor6 Provider 7imi!a!ion" 8 190e$!ion" Ergent care :96 copay +visit@ professional and other services sub<ect to deductible ============none============ !f $ou have a hospital sta$ Facility fee "e.g., hospital room% 6; coinsurance Inpatient physical medicine rehabilitation is limited to F6 days per member per calendar year. *hysician+surgeon fee 6; coinsurance ============none============ !f $ou have mental health/ behavioral health/ or substance abuse needs .ental+/ehavioral health outpatient services .ental+/ehavioral 0ealth -2ice Gisit :'6 copay+visit .ental+/ehavioral 0ealth Facility Gisit 6; coinsurance ============none============ .ental+/ehavioral health inpatient services 6; coinsurance ============none============ &ubstance use disorder outpatient services &ubstance >buse -2ice Gisit :'6 copay+visit &ubstance >buse Facility Gisit 6; coinsurance ============none============ &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. , of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO Common Medi0al 1ven! Servi0e" 2ou Ma 3eed 2our Co"! 'f 2ou 4"e an 'n5ne!wor6 Provider 7imi!a!ion" 8 190e$!ion" &ubstance use disorder inpatient services 6; coinsurance ============none============ !f $ou are pre-nant *renatal and postnatal care 6; coinsurance -2ice visits not sub<ect to deductible Delivery and all inpatient services 6; coinsurance ============none============ !f $ou need help recoverin- or have other special health needs 0ome health care 6; coinsurance ============none============ Aehabilitation services :96 copay+visit for outpatient visit@ inpatient services sub<ect to deductible. -utpatient limited to 86 visits each therapy physical therapy, speech therapy and occupational therapy. 0abilitation services :96 copay+visit for outpatient visit@ inpatient services sub<ect to deductible. >ll rehabilitation and habilitation visits count toward your rehabilitation visit limit. &killed nursing care 6; coinsurance Himited to $66 days per calendar year Durable medical e4uipment 6; coinsurance ============none============ 0ospice service 6; coinsurance ============none============ !f $our child needs dental or e$e care 1ye exam (o cost share -ne vision exam every 8 years. 3lasses (ot !overed ============none============ Dental check-up (ot !overed ============none============ &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. . of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO 190luded Servi0e" 8 O!%er Covered Servi0e": Servi0e" 2our Plan :oe" 3O# Cover 01his isn+t a complete list. ,hec# $our polic$ or plan document for other e%cluded services.2 I >cupuncture I !osmetic surgery I Dental care ">dult% I Hong-term care I *rivate-duty nursing I Aoutine foot care I Jeight loss programs O!%er Covered Servi0e" 01his isn+t a complete list. ,hec# $our polic$ or plan document for other covered services and $our costs for these services.2 I /ariatric surgery "Himitations may apply% I !hiropractic care I 0earing aids "Himitations may apply% I Infertility treatment "Himitations may apply% I .ost coverage provided outside the Enited &tates. &ee www./!/&.com+bluecardworld wide I Aoutine eye care ">dult - Himitations may apply% 2our ;ig%!" !o Con!inue 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 re4uire you to pay a premium, 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 $-566-895-9'$5. ou may also contact your state insurance department, the E.&. Department of Habor, 1mployee /ene)ts &ecurity >dministration at $-5FF- KKK-'878 or www.dol.gov+ebsa, or the E.&. Department of 0ealth and 0uman &ervices at $-577-8F7-8'8' xF$9F9 or www.cciio.cms.gov. &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. - of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO 2our <rievan0e and A$$eal" ;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 appeal or )le a -rievance. For 4uestions about your rights, this notice, or assistance, you can contactB >nthem /lue !ross D /lue &hield *.-. /ox 9$5 (orth 0aven, !onnecticut 6FK7'-69$5 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 1AI&> information contactB Department of Habors 1mployee /ene)ts &ecurity >dministration $-5FF-KKK-1/&> "'878% www.dol.gov+ebsa+healthreform >dditionally, a consumer assistance program can help you )le your appeal. !ontactB (ew 0ampshire Department of Insurance 8$ &outh Fruit &treet, &uite $K !oncord, (0 6''6$ "566% 598-'K$F www.nh.gov+insurance consumerservicesLins.nh.gov &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. = of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO :oe" !%i" Coverage Provide Minimum 1""en!ial Coverage> ,he >2ordable !are >ct re4uires most people to have health care coverage that 4uali)es as Mminimum essential coverage.N This plan or policy does provide minimum essential coverage. :oe" !%i" Coverage Mee! !%e Minimum ?alue S!andard> ,he >2ordable !are >ct establishes a minimum value standard of bene)ts of a health plan. ,he minimum value standard is F6; "actuarial value%. This health coverage does meet the minimum value standard for the benefts it provides. 7anguage A00e"" Servi0e": ======================To see examples of how this plan might cover costs for a sample medical situation, see the next page.=========== &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. Having a @a@ "normal delivery% Managing !$e 2 dia@e!e" "routine maintenance of a well-controlled condition% 10 of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Coverage 19am$le" Coverage for: Individual / Family| Plan #$e: HMO A@ou! !%e"e Coverage 19am$le": ,hese examples show how this plan might cover medical care in given situations. Ese these examples to see, in general, how much )nancial protection a sample patient might get if they are covered under di2erent plans. Amoun! owed !o $rovider": $7,5! Plan $a" $5,"7! Pa!ien! $a" $#,$7! Sam$le 0are 0o"!": 0ospital charges "mother% :8,76 6 Aoutine obstetric care :8,$6 6 0ospital charges "baby% :C66 >nesthesia :C66 Haboratory tests :966 *rescriptions :866 Aadiology :866 Gaccines, other preventive :K6 1otal 3(/44 0 Pa!ien! $a": Deductibles :8,66 6 !opays :86 !oinsurance :6 Himits or exclusions :$96 1otal 3)/1( 0 Amoun! owed !o $rovider": $5,!! Plan $a" $#,7%! Pa!ien! $a" $#,&#! Sam$le 0are 0o"!": *rescriptions :8,C6 6 .edical 14uipment and &upplies :$,'6 6 -2ice Gisits and *rocedures :766 1ducation :'66 Haboratory tests :$66 Gaccines, other preventive :$66 1otal 34/40 0 Pa!ien! $a": Deductibles :8,66 6 !opays :9K6 !oinsurance :6 Himits or exclusions :56 1otal 3)/6) 0 &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy.
#%i" i" no! a 0o"! e"!ima!or& Dont use these examples to estimate your actual costs under this plan. ,he actual care you receive will be di2erent from these examples, and the cost of that care will also be di2erent. &ee the next page for important information about these examples. 11 of 13 Awane: Sanel 2000 HMO Blue Coverage Period: 01/01/2015 12/31/2015 Coverage 19am$le" Coverage for: Individual / Family| Plan #$e: HMO &uestions' !all 1-800-8(0-31)) or visit us at www.anthem.com If you arent clear about any of the underlined terms used in this form, see the 3lossary. ou can view the 3lossary at www.anhem.com or call 1-800-8(0-31)) to re4uest a copy. (ue"!ion" and an"wer" a@ou! !%e Coverage 19am$le": )%a! are "ome of !%e a""um$!ion" @e%ind !%e Coverage 19am$le"> !osts dont include premiums. &le care costs are based on national averages supplied by the E.&. Department of 0ealth and 0uman &ervices, and arent speci)c to a particular geographic area or health plan. ,he patients condition was not an excluded or preexisting condition. >ll services and treatments started and ended in the same coverage period. ,here are no other medical expenses for any member covered under this plan. -ut-of-pocket expenses are based only on treating the condition in the example. ,he patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. )%a! doe" a Coverage 19am$le "%ow> For each treatment situation, the !overage 1xample helps you see how deductibles, copa$ments, 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. :oe" !%e Coverage 19am$le $redi0! m own 0are need"> 5o. ,reatments shown are <ust examples. ,he care you would receive for this condition could be di2erent based on your doctors advice, your age, how serious your condition is, and many other factors. :oe" !%e Coverage 19am$le $redi0! m fu!ure e9$en"e"> 5o. !overage 1xamples are not cost estimators. ou cant use the examples to estimate costs for an actual condition. ,hey are for comparative purposes only. our own costs will be di2erent depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can ' u"e Coverage 19am$le" !o 0om$are $lan"> 6es. Jhen you look at the &ummary of /ene)ts and !overage for other plans, youll )nd the same !overage 1xamples. Jhen you compare plans, check the M*atient *aysN box in each example. ,he smaller that number, the more coverage the plan provides. Are !%ere o!%er 0o"!" ' "%ould 0on"ider w%en 0om$aring $lan"> 6es. >n important cost is the premium you pay. 3enerally, the lower your premium, the more youll pay in out-of-pocket costs, such as copa$ments, deductibles, and coinsurance. ou should also consider contributions to accounts such as health savings accounts "0&>s%, Oexible spending arrangements "F&>s% or health reimbursement accounts "0A>s% that help you pay out-of-pocket expenses.