2016 awane ct gold plus sbc

7/21/2019 2016 AWANE CT GOLD PLUS SBC

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AWANE: CT GOLD PLAN PLUS Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO

Questions: Call 1-844-404-6843 or visit us at www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com or call 1-844-404-6843 to request a copy.

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 plandocument at https://eoc.anthem.com/eocdps/fi or by calling 1-844-404-6843.

Important Questions Answers Why this Matters:

What is the overalldeductible?

For in-network providers$2,500 individual / $5,000 family

For out-of-network providers

$5,000 individual / $10,000 family

Doesn’t apply to in-networkpreventive care, routine eye exams oroutpatient labs/x-rays or ultrasounds.

You must pay all the costs up to the deductible amount before this plan beginsto 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 thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.

Are there other deductiblesfor specific services?

No. 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.

Is there an out – of – pocketlimit on my expenses?

For in-network porivders

$5,000 individual /$10,000 family

For out-of-network providers

$10,000 individual / $20,000 family

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 helpsyou plan for health care expenses.

What is not included in theout – of – pocket limit?

Out-of-Network deductible,premiums, penalties fornon-compliance, balance-billedcharges, and health care this plandoesn’t cover.

Even though you pay these expenses, they don’t count toward the out-of- pocket limit.

Is there an overall annuallimit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.

Does this plan use anetwork of providers?

Yes. For a list of preferred providers,see www.anthem.com or call

1-844-404-6843

If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctoror hospital may use an out-of-network provider for some services. Plans usethe term in-network, preferred, or participating for providers in theirnetwork . See the chart starting on page 2 for how this plan pays different kindsof providers.

https://eoc.anthem.com/eocdps/fi






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Do I need a referral to see aspecialist?

No. You can see the specialist you choose without permission from this plan.

Are there services this plandoesn’t cover?

Yes.Some of the services this plan doesn’t cover are listed on page 6. See yourpolicy or plan document for additional information about excluded services.

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, ifthe plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven’t 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 andthe 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.

CommonMedical Event

Services You May Need

Your Cost If You Use anIn-networkProvider

Your Cost If You Use an

Out-of-networkProvider

Limitations & Exceptions

If you visit a healthcare provider’s office

or clinic

Primary care visit to treat an injury or illness $15 copay/visit 30% coinsurance –––––––––––– none ––––––––––––

Specialist visit $45 copay /visit 30% coinsurance –––––––––––– none ––––––––––––

Other practitioner office visit $15 copay /visit 30% coinsuranceChiropractic care limited to 20 visitsper member per calendar year.

Preventive care/screening/immunization No Charge 30% coinsurance –––––––––––– none ––––––––––––

If you have a test

Diagnostic test (x-ray, blood work)$15 copay/visit lab$45 copay/visit x-ray

30% coinsurance –––––––––––– none ––––––––––––

Imaging (CT/PET scans, MRIs)$75copay/procedure

30% coinsurance –––––––––––– none ––––––––––––



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CommonMedical Event






If you need drugs totreat your illness orcondition

More informationabout prescription

drug coverage is

available at www.medco.com

Generic drugs (Retail/30 day: Mail/90 day) $10 Retail/$35 Mail Not Covered

Maintenance Meds are required to be filled mail order

after 3 fills at retail (penalty applies). If pre-authrequired & not obtained, drug may not be covered.Certain Preventive meds no copay. If a genericequivalent is available & brand is prescribed/member will pay brand name cost difference. Plan usespreferred drug list to identify coverage.

Preferred brand drugs (Retail/30 day: Mail/90 day)

$35 Retail/$87.5 Mail Not Covered

Non-preferred brand (Retail/30day: Mail/90day) $60 Retail/$150 Mail Not Covered

Specialty drugs

All Specialty medsprocess through

Accredo at the mailorder costs.

Not Covered

The mail order cost will be based on themedication tier (generic, preferred, non-preferred). Specialty meds can not be

filled at retail pharmacies.

If you have

outpatient surgery

Facility fee (e.g., ambulatory surgery center) $250 copay/visit 30% coinsurance –––––––––––– none ––––––––––––

Physician/surgeon fees No Charge 30% coinsurance –––––––––––– none ––––––––––––

If you needimmediate medicalattention

Emergency room services $150 copay/visit $150 copay/visitMembers may be balance billed for outof network services

Emergency medical transportation 100% 100%Members may be balance billed for outof network services

Urgent care $45 copay/visit 30% CoinsuranceMembers may be balance billed for outof network services

If you have a

hospital stay

Facility fee (e.g., hospital room) $500 copay/visit 30% coinsurance

Precertification is required forInpatient hospital admission. A $500penalty is applied if an Out of Network

admission is not precertified.Physician/surgeon fee No Charge 30% coinsurance –––––––––––– none ––––––––––––



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CommonMedical Event






If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral health outpatient

services $15 copay/visit 30% coinsurance –––––––––––– none ––––––––––––

Mental/Behavioral health inpatientservices

$500 copay/visit 30% coinsurance

Precertification is required forInpatient hospital admission. A $500penalty is applied if an Out of Networkadmission is not precertified.

Substance use disorder outpatient services $15 copay /visit 30% coinsurance –––––––––––– none ––––––––––––

Substance use disorder inpatient services $500 copay/visit 30% coinsurance

Precertification is required forInpatient hospital admission. A $500penalty is applied if an Out of Networkadmission is not precertified.

If you are pregnantPrenatal and postnatal care No Charge 30% coinsurance –––––––––––– none ––––––––––––

Delivery and all inpatient services $500 copay/visit 30% coinsurance –––––––––––– none ––––––––––––



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CommonMedical Event






If you need helprecovering or haveother special healthneeds

Home health care $15 copay/visit 30% coinsurance Limited to 100 per calendar year.

Rehabilitation services

$45 copay foroutpatient services.$500 copay/visit forinpatient care

30% coinsurance

Inpatient physical medicinerehabilitation is limited to 90 days permember per calendar year. Limited to40 visits combined physical therapy,speech therapy and occupationaltherapy. All therapy limits arecombined in and out of network.

Habilitation services

$45 copay foroutpatient services.$500 copay/visit for

inpatient care

30% coinsurance All rehabilitation and habilitation visitscount toward your rehabilitation visit

limit.

Skilled nursing care $500 copay/visit 30% coinsuranceLimited to 90 inpatient days permember per calendar year.

Durable medical equipment 100% 30% coinsurance –––––––––––– none ––––––––––––

Hospice service No Charge 30% coinsurance –––––––––––– none ––––––––––––

If your child needsdental or eye care

Eye exam No Charge 30% coinsuranceLimited to one exam per year for 18and younger. Limited to one examevery 2 years for 19 and older.

Glasses Not Covered Not Covered –––––––––––– none ––––––––––––

Dental check-up Not Covered Not Covered –––––––––––– none ––––––––––––



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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture

• Cosmetic surgery

• Dental care (Adult)

• Long-term care

• Non-emergency care when traveling outside

the U.S.

• Routine foot care

• Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

• Bariatric surgery

• Chiropractic care (Limits apply)

• Infertility treatment (Limits apply)

• Coverage provided outside the United States.See www.BCBS.com/bluecardworldwide

• Hearing aids (Limitations apply)

• Routine eye care (Adult - Limitations 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 healthcoverage. 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, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov .

http://www.bcbs.com/bluecardworldwide



http://www.dol.gov/ebsa



http://www.cciio.cms.gov/








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Your Grievance and Appeals Rights:

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. Forquestions about your rights, this notice, or assistance, you can contact:

Anthem Blue Cross and Blue ShieldP.O. Box 54159Los Angeles, CA 90054-0159

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 Labor’s 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 Insurance21 South Fruit Street, Suite 14Concord, NH 03301(800) 852-3416 www.nh.gov/insurance [email protected]

http://www.express-scripts.com/


http://www.dol.gov/ebsa/healthreform


http://www.nh.gov/insurance


mailto:[email protected]

mailto:[email protected]






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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. ––––––––––– –––––––––––



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AWANE: CT GOLD PLAN PLUS Coverage Period: 01/01/2016-12/31/2016 Coverage Examples Coverage for: Individual/Family | Plan Type: PPO


Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these CoverageExamples:

These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

Amount owed to providers: $7,540 Plan pays $4,370 Patient pays $3,170

Sample care costs:Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:Deductibles $2,500

Copays $520

Coinsurance $0Limits or exclusions $150

Total $3,170

Amount owed to providers: $5,400 Plan pays $2,590 Patient pays $2,810

Sample care costs:Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100 Vaccines, other preventive $100

Total $5,400

Patient pays:Deductibles $2,500

Copays $230

Coinsurance $0

Limits or exclusions $80

Total $2,810

This isnot a costestimator.

Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.

See the next page forimportant information aboutthese examples.



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AWANE: CT GOLD PLAN PLUS Coverage Period: 01/01/2016-12/31/2016 Coverage Examples Coverage for: Individual/Family | Plan Type: PPO


Questions and answers about the Coverage Examples:

What are some of theassumptions behind the

Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren’t specific to aparticular geographic area or health plan.

The patient’s condition was not anexcluded or preexisting condition.

All services and treatments started andended in the same coverage period.

There are no other medical expenses forany member covered under this plan.

Out-of-pocket expenses are based onlyon treating the condition in the example.

The patient received all care from in-network providers. If the patient hadreceived care from out-of-network providers, costs would have been higher.

What does a Coverage Exampleshow?

For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.

Does the Coverage Examplepredict my own care needs?

No. Treatments shown are just examples. The care you would receive for thiscondition could be different based on yourdoctor’s advice, your age, how serious yourcondition is, and many other factors.

Does the Coverage Examplepredict my future expenses?

No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices your providers charge, and the reimbursementyour health plan allows.

Can I use Coverage Examplesto compare plans?

Yes. When you look at the Summary ofBenefits and Coverage for other plans,you’ll find the same Coverage Examples. When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider when comparingplans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments,deductibles, and coinsurance. Youshould 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-pocketexpenses.

2016 awane ct gold plus sbc

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