2015 Ma Choice Ppo SBC

1 of 15
AWANE: Massachusetts Choice PPO Coverage Period: 01/01/2015-12/31/2015

u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| P%a$ &"'e: PPO
&his is o$%" a su!!ar"( If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-844-404-6843.
)!'orta$t *uestio$s A$s+ers Wh" this Matters:
What is the overall
deductible?
For in-network providers
,500 individual / ,1-250 family
For out-of-network providers
,5-000 individual /
,10-000 family
Doesnt 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 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, $anuary
%st&. 'ee the chart starting on page ( for how much you pay
for covered services after you meet the deductible.
Are there other
deductibles for
specic services?
!es. For durable medical
e)uipment there is a ,250
deductible.
!ou must pay all of the costs for these services up to the
speci*c deductible amount before this plan begins to pay
for these services.
!s there an out"of"
poc#et limit on m$
e%penses?
For in-network providers
,2-000 individual /
,5-000 family
For out-of-network providers
,10-000 individual /
,20-000 family
+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,
-ealth "are this plan doesnt
cover, .remiums, /ut-of-
network deductibles, and
/ut-of-network pharmacy
claims.
0ven though you pay these expenses, they dont count
toward the out-of-poc#et limit.
&uestions' "all 1-844-404-6843 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. !ou can view the 1lossary
at www.anthem.com or call 1-844-404-6843 to re)uest a copy.
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!s there an overall
annual limit on what
the plan pa$s?
2o.
+he chart starting on page ( describes any limits on what
the plan will pay for specifc covered services, such as o3ice
visits.
(oes this plan use a
networ# of
providers?
!es. For a list of preferred
providers, see
www.anthem.com or call
%-455-565-745(
If you use an in-network doctor or other health care
provider, this plan will pay some or all of the costs of
covered services. ,e aware, your in-network doctor or
hospital may use an out-of-network provider for some
services. .lans use the term in-network, preferred, or
participating for providers in their networ#. 'ee the chart
starting on page ( for how this plan pays di3erent kinds of
providers.
(o ! need a referral
to see a specialist?
2o.
!ou can see the specialist you choose without permission
from this plan.
Are there services
this plan doesn)t
cover?
!es.
'ome of the services this plan doesnt cover are listed on
page 7. 'ee your policy or plan document for additional
information about e%cluded services.
*opa$ments are *xed dollar amounts #for example, 8%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
8%,666, your coinsurance payment of :6; would be 8:66. +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 di3erence. For example, if an
out-of-network hospital charges 8%,966 for an overnight stay and the allowed amount is 8%,666, you may
have to pay the 8966 di3erence. #+his is called balance billin+.&
+his plan may encourage you to use in-network providers by charging you lower deductibles,
copa$ments and coinsurance amounts.
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Co!!o$
Medica% Eve$t
ervices .ou Ma" Need
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
1i!itatio$s 2 E3ce'tio$s
!f $ou visit a
health care
provider)s
o,ice or clinic
.rimary care visit to treat an
in<ury or illness
8(6 copayvisit
96;
coinsurance
============none============
'pecialist visit
896 copay
visit
96;
coinsurance
============none============
/ther practitioner o3ice visit
"hiropractor
896 copayvisit
>cupuncturist
2ot covered
"hiropractor
96;
coinsurance
>cupuncturist
2ot covered
"hiropractic limited to %:
visits per member per
calendar year.
.reventive
carescreeningimmuni?ation
2o "ost 'hare
96;
coinsurance
============none============
!f $ou have a
test
Diagnostic test #x-ray, blood
work&
2o "ost 'hare
96;
coinsurance
"osts may vary by site of
service.
Imaging #"+.0+ scans, @AIs&
%6;
coinsurance
96;
coinsurance
============none============
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
!f $ou need
dru+s to treat
$our illness or
condition
@ore
information
about
prescription
dru+ covera+e
is available at
www.express-
scripts.com
1eneric drugs #Aetail(6 dayB
@ailC6 day&
8%6 Aetail8:6
@ail
2ot "overed
@aintenance @eds are re)uired to be
*lled mail order after ( *lls at retail
#penalty applies&. If pre-auth re)uired D
not obtained, drug may not be covered.
"ertain .reventive meds no copay. If a
generic e)uivalent is available D brand
is prescribedmember will pay brand
name cost di3erence. .lan uses
preferred drug list to identify coverage.
.referred brand drugs #Aetail(6 dayB
@ailC6 day&
8(9 Aetail84E.9
@ail
2ot "overed
2on-preferred brand #Aetail(6dayB
@ailC6day&
876 Aetail8%96
@ail
2ot "overed
'pecialty drugs
>ll 'pecialty
meds process
through
>ccredo at the
mail order
costs.
2ot "overed
+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&
%6;
coinsurance
96;
coinsurance
============none============
.hysiciansurgeon fees
%6;
coinsurance
96;
coinsurance
============none============
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
!f $ou need
immediate
medical
attention
0mergency room services
8%96
copayvisitF
professional
and other
services
%6; coinsuran
ce
8%96 copay
visitF
professional
and other
services
%6; coinsuranc
e
8%96 copay is waived if
admitted for inpatient stay.
@embers may be balance
billed for out of network
services.
0mergency medical
transportation
%6;
coinsurance
%6;
coinsurance
services
Grgent care 896 copay 896 copay
services
!f $ou have a
hospital sta$
Facility fee #e.g., hospital room&
%6;
coinsurance
96;
coinsurance
.recerti*cation is re)uired
for Inpatient hospital
admission. > 8966 penalty is
applied if an /ut of 2etwork
admission is not precerti*ed.
.hysical @edicine and
Aehabilitation limited to %66
days per member per
calendar year.
.hysiciansurgeon fee
%6;
coinsurance
96;
coinsurance
============none============
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
!f $ou have
mental health-
behavioral
health- or
substance
abuse needs
@ental,ehavioral health
outpatient services
@ental,ehavi
oral -ealth
/3ice Hisit
8(6 copayvisit
@ental,ehavi
oral -ealth
Facility
Hisit
%6;
coinsurance
@ental,ehavio
ral
-ealth /3ice
Hisit
96;
coinsurance
@ental,ehavio
ral -ealth
Facility
Hisit
96;
coinsurance
============none============
@ental,ehavioral health
inpatient services
%6;
coinsurance
96;
coinsurance
'ubstance use disorder
outpatient services
'ubstance
>buse /3ice
Hisit
8(6 copayvisit
'ubstance
>buse Facility
Hisit
%6;
coinsurance
'ubstance
>buse /3ice
Hisit
96;
coinsurance
'ubstance
>buse Facility
Hisit
96;
coinsurance
============none============
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
'ubstance use disorder
inpatient services
%6;
coinsurance
96;
coinsurance
!f $ou are
pre+nant
.renatal and postnatal care
%6; coinsuran
ce
96;
coinsurance
============none============
Delivery and all inpatient
services
%6;
coinsurance
96;
coinsurance
============none============
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
!f $ou need
help recoverin+
or have other
special health
needs
-ome health care
%6;
coinsurance
96;
coinsurance
============none============
Aehabilitation services
896 copay for
outpatient
servicesF. %6;
coinsurance
for inpatient
care
96;
coinsurance
Iimited to 76 visits combined
physical therapy, speech
therapy and occupational
therapy. 'ervices from In-
2etwork and /ut-of-2etwork
providers count toward your
limit.
-abilitation services
896 copay for
outpatient
servicesF %6;
coinsurance
for inpatient
care
96;
coinsurance
>ll rehabilitation and
habilitation visits count
toward your rehabilitation visit
limit.
'killed nursing care
%6;
coinsurance
96;
coinsurance
Iimited to %66 inpatient days
per member per calendar
year. .recerti*cation is
re)uired or 8966 penalty is
'ervices from In-2etwork and
/ut-of-2etwork providers
count toward your limit.
Durable medical e)uipment 8:96
deductible
then :6;
coinsurance
8:96
deductible then
:6;
coinsurance
8:96 deductible combined in
and out of network. @embers
may be balance billed for out
of network services.
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Co!!o$
Medica% Eve$t
.our Cost )f
.ou /se a$
)$-$et+or0
Provider
.our Cost )f
.ou /se a$
Out-of-$et+or0
Provider
-ospice service
%6;
coinsurance
96;
coinsurance
!f $our child
needs dental or
e$e care
0ye exam 2o cost share
96;
coinsurance
Iimited to one exam per year
for %4 and younger. Iimited
to one exam every : years for
%C and older
1lasses 2ot "overed 2ot "overed ============none============
Dental check-up 2ot "overed 2ot "overed ============none============
E3c%uded ervices 2 Other Covered ervices:
ervices .our P%a$ 9oes NO& Cover ./his isn)t a complete list. *hec# $our polic$ or plan document for other
e%cluded services.0
J >cupuncture
J "osmetic surgery
J Dental care #>dult&
J Iong-term care
J .rivate-duty nursing
J Aoutine foot care
J Keight loss programs
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Other Covered ervices ./his isn)t a complete list. *hec# $our polic$ or plan document for other covered
services and $our costs for these services.0
J ,ariatric surgery
J "hiropractic care #Iimits apply&
J -earing aids #Iimits apply&
J Infertility treatment #Iimits apply&
J @ost coverage provided outside
the Gnited 'tates.
'ee www.,",'.combluecardworld
wide
J Aoutine eye care #>dult - Iimits
apply&
.our :ights to Co$ti$ue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provide
protections that allow you to keep health coverage. >ny such rights may be limited in duration and will re)uire you
to pay a premium, which may be signi*cantly higher than the premium you pay while covered under the plan.
/ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at %-466-:94-9(%4. !ou may also contact
your state insurance department, the G.'. Department of Iabor, 0mployee ,ene*ts 'ecurity >dministration at %-477-
555-(:E: or www.dol.govebsa, or the G.'. Department of -ealth and -uman 'ervices at %-4EE-:7E-:(:( x7%979 or
www.cciio.cms.gov.
11 of 15
.our ;rieva$ce a$d A''ea%s :ights:
If you have a complaint or are dissatis*ed with a denial of coverage for claims under your plan, you may be able to
appeal or *le a +rievance. For )uestions about your rights, this notice, or assistance, you can contactB
>nthem ,lue "ross and ,lue 'hield
../. ,ox 95%9C
Ios >ngeles, "> C6695-6%9C
For grievances andor appeals regarding you prescription drug coverage, call the number listed on the back of
prescription member ID card or visit www.express-scripts.com.
For 0AI'> information contactB
Department of Iabors 0mployee ,ene*ts 'ecurity >dministration
%-477-555-0,'> #(:E:&
www.dol.govebsahealthreform
>dditionally, a consumer assistance program can help you *le your appeal. "ontactB
2ew -ampshire Department of Insurance
:% 'outh Fruit 't. 'uite %5
"oncord, 2- 6((6%
%.466.49:.(5%7
www.nh.govinsurance
consumersvcsLins.nh.gov
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9oes this Coverage Provide Mi$i!u! Esse$tia% Coverage<
+he >3ordable "are >ct re)uires most people to have health care coverage that )uali*es as Mminimum essential
coverage.N This plan or policy does provide minimum essential coverage.
9oes this Coverage Meet the Mi$i!u! =a%ue ta$dard<
+he >3ordable "are >ct establishes a minimum value standard of bene*ts of a health plan. +he minimum value
standard is 76; #actuarial value&. This health coverage does meet the minimum value standard for the
benefts it provides.
1a$guage Access ervices:
======================To see examples of how this plan might cover costs for a sample medical situation, see the next
page.===========
>avi$g a ?a?"
#normal delivery&
Ma$agi$g t"'e 2 dia?etes
#routine maintenance of
a well-controlled condition&
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Coverage E3a!'%es
Coverage for: Individual/Family| P%a$ &"'e: PPO
A?out these Coverage
E3a!'%es:
+hese examples show how this plan
might cover medical care in given
situations. Gse these examples to
see, in general, how much *nancial
protection a sample patient might
get if they are covered under
di3erent plans.
A!ou$t o+ed to 'roviders: $7,540
P%a$ 'a"s $,!0
Patie$t 'a"s $",!#0
a!'%e care costs:
-ospital charges #mother&
8:,E6
6
Aoutine obstetric care
8:,%6
6
-ospital charges #baby& 8C66
>nesthesia 8C66
Iaboratory tests 8966
.rescriptions 8:66
Aadiology 8:66
Haccines, other preventive 856
/otal
12-34
0
Patie$t 'a"s:
Deductibles 8966
"opays 8:6
"oinsurance 87%6
Iimits or exclusions 8%96
/otal
11-48
0
A!ou$t o+ed to 'roviders: $5,400
P%a$ 'a"s $$,740
Patie$t 'a"s $",0
a!'%e care costs:
.rescriptions
8:,C6
6
@edical 0)uipment and
'upplies
8%,(6
6
/3ice Hisits and .rocedures 8E66
0ducation 8(66
Iaboratory tests 8%66
Haccines, other preventive 8%66
/otal
13-40
0
Patie$t 'a"s:
Deductibles 8E96
"opays 87(6
"oinsurance 8:66
Iimits or exclusions 846
/otal
11-66
0

&his is
$ot a cost
esti!ator(
Dont use these
examples to estimate
your actual costs under
this plan. +he actual
care you receive will be
di3erent from these
examples, and the cost
of that care will also be
di3erent.
'ee the next page for
important information
about these examples.
*uestio$s a$d a$s+ers a?out the Coverage E3a!'%es:
What are so!e of the
assu!'tio$s ?ehi$d the
Coverage E3a!'%es<
"osts dont include premiums.
'ample care costs are based on
national averages supplied by
the G.'. Department of -ealth
and -uman '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.
What does a Coverage E3a!'%e
sho+<
For each treatment situation, the
"overage 0xample helps you see
how deductibles, copa$ments,
and coinsurance can add up. It
also helps you see what expenses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
9oes the Coverage E3a!'%e
'redict !" o+$ care $eeds<
5o. +reatments shown are <ust
examples. +he care you would
receive for this condition could
be di3erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
9oes the Coverage E3a!'%e
'redict !" future e3'e$ses<
5o. "overage 0xamples 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 di3erent
depending on the care you
receive, the prices your
providers charge, and the
reimbursement your health plan
allows.
Ca$ ) use Coverage E3a!'%es
to co!'are '%a$s<
6es. Khen you look at the
'ummary of ,ene*ts and
"overage for other plans, youll
*nd the same "overage
0xamples. Khen you compare
plans, check the M.atient .aysN
box in each example. +he
smaller that number, the more
coverage the plan provides.
Are there other costs ) shou%d
co$sider +he$ co!'ari$g
'%a$s<
6es. >n important cost is the
premium you pay. 1enerally,
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
#-'>s&, Oexible spending
arrangements #F'>s& or health
reimbursement accounts #-A>s&
that help you pay out-of-pocket
expenses.

2015 Ma Choice Ppo SBC

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AWANE: Massachusetts Choice PPO Coverage Period: 01/01/2015-12/31/2015

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