2016 awane me core epo

7/21/2019 2016 AWANE ME CORE EPO

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Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016

Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO

$&i" i" on#y a "ummary' If you want more detail about your coverage and costs, you can get the complete

terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-855-271-4549.

(m%or!an! )ue"!ion" An"wer" *&y !&i" Ma!!er":

What is theoveralldeductible?

For in-networkproviders

+5,00 individual /+11,.00 family

Doesn’t apply to in-network preventive careand routine eye eam.

!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 orplan document to see when the deductible starts over #usually, butnot always, $anuary %st&. 'ee the chart starting on page ( for howmuch you pay for covered services after you meet the deductible.

Are there otherdeductibles forspecic services?

!es. $250 deductible forDurable )edical*+uipment per memberper calendar year.

rescription Drugs %per person, per calendar

year, ( per familyper calendar year.

!ou must pay all of the costs for these services up to the specicdeductible amount before this plan begins to pay for these services.

s there a! out"of"poc#et liito! % e&pe!ses?

!es. For in-networkproviders

+6,350 individual /+12,00 family

0he out-of-poc#et liit is the most you could pay during a coverageperiod #usually one year& for your share of the cost of coveredservices. 0his limit helps you plan for health care epenses.

What is !oti!cluded i! theout"of"poc#etliit?

1alance-1illed charges,2ealth "are this plandoesn’t cover,remiums, and 3ut-of-network pharmacyclaims.

*ven though you pay these epenses, they don’t count toward theout-of-poc#et liit.

'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.

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

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



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s there a!overall a!!ualliit o! )hat thepla! pa%s?

5o.0he chart starting on page ( describes any limits on what the planwill pay for specifc covered services, such as o6ice visits.

+oes this pla!use a !et)or# ofproviders?

!es. For a list ofpreferred providers,see www.anthem.comor call %-788-9:%-;8;<

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. 1e aware, your in-network doctor or hospital may use an out-of-networkprovider for some services. lans use the term in-network,preferred, or participating for providers in their !et)or# . 'ee thechart starting on page ( for how this plan pays di6erent kinds ofproviders.

+o !eed areferral to see aspecialist?

5o. !ou can see the specialist you choose without permission from thisplan.

Are thereservices this pla!does!,t cover?

!es. 'ome of the services this plan doesn’t cover are listed on page 8. 'ee your policy or plan document for additional information aboute&cluded services.

• opa%e!ts are ed dollar amounts #for eample, %8& you pay for covered health care, usually when you

receive the service.

• oi!sura!ce is your share of the costs of a covered service, calculated as a percent of the allo)ed

aou!t for the service. For eample, if the plan’s allo)ed aou!t for an overnight hospital stay is%,, your coi!sura!ce payment of 9= would be 9. 0his may change if you haven’t met yourdeductible.

• 0he amount the plan pays for covered services is based on the allo)ed aou!t. If an out-of-network

provider charges more than the allo)ed aou!t, you may have to pay the di6erence. For eample, if anout-of-network hospital charges %,8 for an overnight stay and the allo)ed aou!t is %,, you mayhave to pay the 8 di6erence. #0his is called bala!ce billi!..&

• 0his plan may encourage you to use i!-!et)or# providers by charging you lower deductibles,

copa%e!ts and coi!sura!ce amounts.




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Common

Media# Even!Servie" ou May eed

our Co"! (f ou "e an(n-ne!wor4Provider

our Co"! (f ou "e an

Ou!-of-ne!wor4Provider

imi!a!ion" E7e%!ion"

f %ou visit ahealth careprovider,so/ice or cli!ic

rimary care visit to treat anin>ury or illness

;copay/visit

5ot "overed ????????????none????????????

'pecialist visit@copay/visit

5ot "overed ????????????none????????????

3ther practitioner o6ice visit

"hiropractor@copay/visit

Acupuncturist5ot covered

"hiropractor5ot "overed

Acupuncturist5ot covered

????????????none????????????

reventive

care/screening/immuniBation

5o "ost

'hare5ot "overed ????????????none????????????

f %ou have atest

Diagnostic test #-ray, bloodwork&

=coinsurance

5ot "overed ????????????none????????????

Imaging #"0/*0 scans, )CIs&=coinsurance

5ot "overed ????????????none????????????

f %ou !eeddru.s to treat %our ill!ess orco!ditio!

)oreinformationaboutprescriptio!dru. covera.e is available atwww.medco.com

4eneric drugs #Cetail/( day )ail/<

day&

9 Cetail/;)ail

5ot "overedIf pre-auth re+uired E not obtained,drug may not be covered. "ertainreventive meds no copay. If a generice+uivalent is available E brand isprescribed/member will pay brandname cost di6erence. lan uses

preferred drug list to identifycoverage.

referred brand drugs #Cetail/( day)ail/< day&

; Cetail/%)ail

5ot "overed

5on-preferred brand #Cetail/(day)ail/<day&

: Cetail/9%)ail 5ot "overed

'pecialty drugs

All 'pecialtymeds process

through Accredo at

the mail ordercosts.

5ot "overed

0he mail order cost will bebased on the medication tier#generic, preferred, non-preferred&. 'pecialty meds cannot be lled at retailpharmacies.

Facility fee #e.g., ambulatorysurgery center&

=coinsurance

5ot "overed ????????????none????????????




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Common






f %ou haveoutpatie!tsur.er%

hysician/surgeon fees=

coinsurance5ot "overed ????????????none????????????

f %ou !eediediateedicalatte!tio!

*mergency room services

98 copay/visitprofessionaland otherservicessub>ect todeductible

98copay/visitprofessionaland otherservicessub>ect todeductible

98 "opay waived ifadmitted. )ember may bebalance billed for out ofnetwork services.

*mergency medical

transportation

=

coinsurance

=

coinsurance

)ember may be balance

billed for out of networkservices.

Grgent care8copay/visit

5ot "overed ????????????none????????????

f %ou have ahospital sta%

Facility fee #e.g., hospital room&=coinsurance

5ot "overed

hysical )edicine andCehabilitation limited to %days per member percalendar year.

hysician/surgeon fee=coinsurance

5ot "overed ????????????none????????????




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Common






f %ou havee!tal healthbehavioralhealth orsubsta!ceabuse !eeds

)ental/1ehavioral healthoutpatient services

)ental/1ehavi

oral 2ealth36ice Hisit

;copay/visit

)ental/1ehavioral 2ealth

Facility Hisit

=

coinsurance

)ental/1ehavioral2ealth

36ice Hisit

5ot"overed

)ental/1ehavioral 2ealth

Facility Hisit

5ot"overed

????????????none????????????.

)ental/1ehavioral healthinpatient services

=coinsurance

5ot "overed ????????????none????????????

'ubstance use disorderoutpatient services

'ubstance Abuse 36ice

Hisit;copay/visit

'ubstance Abuse

Facility Hisit=coinsurance

'ubstance Abuse 36ice

Hisit 5ot"overed

'ubstance Abuse Facility

Hisit 5ot"overed

????????????none????????????.

'ubstance use disorder inpatientservices

=coinsurance

5ot "overed ????????????none????????????




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Common






f %ou arepre.!a!t

renatal and postnatal care=coinsurance

5ot "overed ????????????none????????????.

Delivery and all inpatient services=coinsurance

5ot "overed ????????????none????????????




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Common






f %ou !eed

help recoveri!.or have otherspecial health!eeds

2ome health care=coinsurance

5ot "overed ????????????none????????????

Cehabilitation services

@copay/visit foroutpatientservices.Inpatientservicessub>ect todeductible.

5ot "overed

imited to @ visits permember per calendar yearfor physical therapy,occupational therapy, andspeech therapy combined.

2abilitation services

@

copay/visit foroutpatientservices.Inpatientservicessub>ect todeductible.

5ot "overed

All rehabilitation andhabilitation visits counttoward your rehabilitation

visit limit.

'killed nursing care=coinsurance

5ot "overedimited to % days percalendar year.

Durable medical e+uipment

98

deductiblethen 9=coinsurance

5ot "overed

'upplies are sub>ect to 98

deductible per member per year. 0)$ Appliances are notcovered.

2ospice service=coinsurance

5ot "overed ????????????none????????????




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Common






f %our child!eeds de!tal or e%e care

*ye eam 5o cost share 5ot "overed

3ne eam each calendar year for members ages %7 years and younger. 3neeam every two calendar

years for members %< yearsand older.

4lasses 5ot "overed 5ot "overed ?????????????none????????????

Dental check-up 5ot "overed 5ot "overed ?????????????none????????????

E7#uded Servie" O!&er Covered Servie":

Servie" our P#an 9oe" O$ Cover his is!,t a coplete list* hec# %our polic% or pla! docue!t for othere&cluded services*3

J Acupuncture

J "osmetic surgery

J Dental care #Adult&

J 2earing aids

J Infertility treatment

J ong-term care

J Coutine foot care

J Keight loss programs

O!&er Covered Servie" his is!,t a coplete list* hec# %our polic% or pla! docue!t for other coveredservices a!d %our costs for these services*3

J 1ariatric surgery #imitations )ay Apply&

J "hiropractic care #imitations Apply&

J )ost coverage provided outside theGnited 'tates. 'eewww.1"1'.com/bluecardworldwide

J rivate-duty nursing #coveredunder 2ome 2ealth "are&

J Coutine eye care #Adult ?imitations )ay Apply&


http://www.bcbs.com/bluecardworldwide

http://www.bcbs.com/bluecardworldwide



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our ig&!" !o Con!inue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provideprotections that allow you to keep health coverage. Any such rights may be limited in duration and will re+uire you

to pay a preiu, which may be signicantly higher than the premium you pay while covered under the plan.

3ther limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at %-7-987-8(%7. !ou may also contact your state insurance department, the G.'. Department of abor, *mployee 1enets 'ecurity Administration at %-7@@-;;;-(9:9 or www.dol.gov/ebsa, or the G.'. Department of 2ealth and 2uman 'ervices at %-7::-9@:-9(9( @%8@8 orwww.cciio.cms.gov.

our ;rievane and A%%ea#" ig&!":


http://www.dol.gov/ebsa

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

http://www.dol.gov/ebsa

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



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Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPOIf you have a complaint or are dissatised with a denial of coverage for claims under your plan, you may be able to appeal or le a .rieva!ce. For +uestions about your rights, this notice, or assistance, you can contact

Anthem 1lue "ross 1lue 'hield"linical Appeals .3. 1o %88@7 Atlanta, 4A ((;73perational Appeals .3. 1o %88@7 Atlanta, 4A ((;7

For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.epress-scripts.com.

For *CI'A information contact

Department of abor’s *mployee 1enets 'ecurity Administration%-7@@-;;;-*1'A #(9:9&www.dol.gov/ebsa/healthreform

Additionally, a consumer assistance program can help you le your appeal. "ontact

5ew 2ampshire Department of Insurance9% 'outh Fruit 'treet, 'uite %;"oncord, 52 ((%#7& 789-(;%@www.nh.gov/insuranceconsumerservicesLins.nh.gov


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

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



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9oe" !&i" Coverage Provide Minimum E""en!ia# Coverage<

0he A6ordable "are Act re+uires most people to have health care coverage that +ualies as Mminimum essential

coverage.N This plan or policy does provide minimum essential coverage.

9oe" !&i" Coverage Mee! !&e Minimum =a#ue S!andard<

0he A6ordable "are Act establishes a minimum value standard of benets of a health plan. 0he minimum value

standard is @= #actuarial value&. This health coverage does meet the minimum value standard for the

benets it provides.

anguage Ae"" Servie":

??????????????????????To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.–––––––––––???????????




>aving a ?a?y#normal delivery&

Managing !y%e 2 dia?e!e"#routine maintenance of

a well-controlled condition&

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Awane: Maine COE EPO Coverage Period: 01/01/2016 - 12/31/2016

Coverage E7am%#e"

Coverage for: Individual/Family | P#an $y%e: EPO

A?ou! !&e"e CoverageE7am%#e":

0hese eamples show how this planmight cover medical care in givensituations. Gse these eamples tosee, in general, how much nancialprotection a sample patient mightget if they are covered underdi6erent plans.

Amoun! owed !o %rovider": $7,54

P#an %ay" $!,47

Pa!ien! %ay" $",7

Sam%#e are o"!":

2ospital charges #mother&9,:

Coutine obstetric care9,%

2ospital charges #baby& <

Anesthesia <

aboratory tests 8

rescriptions 9

Cadiology 9

Haccines, other preventive ;

otal$754

0

Pa!ien! %ay":

Deductibles8,<

"opays 9

"oinsurance

imits or eclusions %8

otal$07

0

Amoun! owed !o %rovider": $5,4

P#an %ay" $#7

Pa!ien! %ay" $4,5

Sam%#e are o"!":

rescriptions9,<

)edical *+uipment and

'upplies

%,(

36ice Hisits and rocedures :

*ducation (

aboratory tests %

Haccines, other preventive %

otal$540

0

Pa!ien! %ay":

Deductibles

;,98

"opays

"oinsurance 9

imits or eclusions 7

otal$45

0


$&i" i"no! a o"!e"!ima!or'

Don’t use theseeamples to estimate

your actual costs underthis plan. 0he actualcare you receive will bedi6erent from theseeamples, and the costof that care will also bedi6erent.

'ee the net page forimportant information



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Awane: Maine COE EPO Coverage Period: 01/01/2016 - 12/31/2016

Coverage E7am%#e"

Coverage for: Individual/Family | P#an $y%e: EPO




)ue"!ion" and an"wer" a?ou! !&e Coverage E7am%#e":

*&a! are "ome of !&ea""um%!ion" ?e&ind !&eCoverage E7am%#e"<

• "osts don’t include preius.

• 'ample care costs are based onnational averages supplied bythe G.'. Department of 2ealthand 2uman 'ervices, andaren’t specic to a particulargeographic area or health plan.

• 0he patient’s condition was notan ecluded or preeistingcondition.

• All services and treatmentsstarted and ended in the samecoverage period.

• 0here are no other medicalepenses for any membercovered under this plan.

• 3ut-of-pocket epenses arebased only on treating thecondition in the eample.

• 0he patient received all care

from in-network providers. Ifthe patient had received carefrom out-of-network providers,costs would have been higher.

*&a! doe" a Coverage E7am%#e"&ow<

For each treatment situation, the"overage *ample helps you see

how deductibles, copa%e!ts,and coi!sura!ce can add up. Italso helps you see what epensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.

9oe" !&e Coverage E7am%#e%redi! my own are need"<

6o* 0reatments shown are >ust

eamples. 0he care you wouldreceive for this condition couldbe di6erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.

9oe" !&e Coverage E7am%#e%redi! my fu!ure e7%en"e"<

6o* "overage *amples are !ot

cost estimators. !ou can’t usethe eamples to estimate costsfor an actual condition. 0hey arefor comparative purposes only.

!our own costs will be di6erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.

Can ( u"e Coverage E7am%#e"!o om%are %#an"<

es* Khen you look at the

'ummary of 1enets and"overage for other plans, you’llnd the same "overage*amples. Khen you compareplans, check the Matient aysNbo in each eample. 0hesmaller that number, the morecoverage the plan provides.

Are !&ere o!&er o"!" ( "&ou#don"ider w&en om%aring%#an"<

es* An important cost is the

preiu you pay. 4enerally,the lower your preiu, themore you’ll pay in out-of-pocketcosts, such as copa%e!ts,



deductibles, and coi!sura!ce. !ou should also considercontributions to accounts such

as health savings accounts#2'As&, Oeible spendingarrangements #F'As& or health

reimbursement accounts #2CAs&that help you pay out-of-pocketepenses.

2016 awane me core epo

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