2016 awane me ind

7/24/2019 2016 AWANE ME IND

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Awane: Maine Industry EPO Coverage Period: 01/01/2016 - 12/1/2016

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

%'is is on$y a su""ary( 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.

I"&ortant )uestions Answers *'y t'is Matters:

What is theoveralldeductible?

For in-networkproviders

+1,000 individual / +,000family

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 for

specic services?

!es. +20 deductible forDurable )edical*+uipment per memberper 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.

Is there an outofpoc!et li"iton "# e$penses?

!es. For in-networkproviders

+,000 individual / +.,000family

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

What is notincluded in the

outofpoc!etli"it?

alance-illed charges,ealth "are this plandoesn’t cover,

0remiums, and 1ut-of-network pharmacyclaims.

*ven though you pay these epenses, they don’t count toward the

out-of-poc!et li"it.

Is there anoverall annualli"it on %hat theplan pa#s?

2o.he chart starting on page ( describes any limits on what the planwill pay for specifc covered services, such as o3ice visits.

&uestions' "all 1-855-271-4549 or visit us at %%%(anthe"(co"If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat %%%(anthe"(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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)oes this planuse a net%or! ofproviders?

!es. For a list of in-network providers, seewww.anthem.com or call%-566-(7%-8689.

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-networkprovider for some services. 0lans use the term in-network,preferred, or participating for providers in their net%or! . 'ee the

chart starting on page ( for how this plan pays di3erent kinds ofproviders.

)o I need areferral to see aspecialist?

2o. !ou can see the specialist you choose without permission from thisplan.

Are thereservices this plandoesn*t cover?

!es.'ome of the services this plan doesn’t cover are listed on page 6. 'ee

your policy or plan document for additional information aboute$cluded services.

•

+opa#"ents are ed dollar amounts #for eample, :%6& you pay for covered health care, usually when youreceive the service.

• +oinsurance is your share of the costs of a covered service, calculated as a percent of the allo%ed

a"ount for the service. For eample, if the plan’s allo%ed a"ount for an overnight hospital stay is:%,;;;, your coinsurance payment of (;< would be :(;;. his may change if you haven’t met yourdeductible.

• he amount the plan pays for covered services is based on the allo%ed a"ount. If an out-of-network

provider charges more than the allo%ed a"ount, you may have to pay the di3erence. For eample, if anout-of-network hospital charges :%,6;; for an overnight stay and the allo%ed a"ount is :%,;;;, you mayhave to pay the :6;; di3erence. #his is called balance billin,.&

• his plan may encourage you to use in-network providers by charging you lower deductibles,

copa#"ents and coinsurance amounts.

Co""on

Media$ Event!ervies ou May eed

our Cost If ou se anIn-networ3Provider

our Cost If ou se an

Out-of-networ3Provider

4i"itations 5 Ee&tions

0rimary care visit to treat anin=ury or illness

:>; copay/ visit

2ot "overed?????????????none????????????


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• +opa#"ents are ed dollar amounts #for eample, :%6& you pay for covered health care, usually when you

receive the service.


a"ount for the service. For eample, if the plan’s allo%ed a"ount for an overnight hospital stay is:%,;;;, your coinsurance payment of (;< would be :(;;. his may change if you haven’t met your

deductible.• he amount the plan pays for covered services is based on the allo%ed a"ount. If an out-of-network




If #ou visit ahealth careprovider*soice or clinic

'pecialist visit:6; copay/

visit2ot "overed

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

1ther practitioner o3ice visit

"hiropractor:6; copay/visit

@cupuncturist2ot covered

"hiropractor2ot "overed

@cupuncturist2ot covered

"hiropractic care is limitedto %( visits per member percalendar year.

0reventivecare/screening/immuniAation

2o "ost 'hare 2ot "overed?????????????none????????????

If #ou have atest

Diagnostic test #-ray, bloodwork&

(;<coinsurance

2ot "overed?????????????none????????????

Imaging #"/0* scans, )BIs& (;<coinsurance 2ot "overed ?????????????none????????????

If #ou needdru,s to treat #our illness orcondition

4eneric drugs #Betail/>; dayC )ail/9;day&

:%6 Betail/:>;)ail

2ot "overedIf pre-auth re+uired not obtained,drug may not be covered. "ertain0reventive meds no copay. If ageneric e+uivalent is available brand is prescribed/member will paybrand name cost di3erence. 0lan usespreferred drug list to identifycoverage.

0referred brand drugs #Betail/>; dayC)ail/9; day&

:>6 Betail/:57.6)ail

2ot "overed

2on-preferred brand #Betail/>;dayC)ail/9;day&

:7; Betail/:%76)ail

2ot "overed


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)oreinformationaboutprescription

'pecialty drugs

@ll 'pecialtymeds process

through @ccredo at the

mail ordercosts.

2ot "overed

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

If #ou haveoutpatientsur,er#

Facility fee #e.g., ambulatorysurgery center&

(;<coinsurance

2ot "overed?????????????none????????????

0hysician/surgeon fees(;<coinsurance

2ot "overed?????????????none????????????


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If #ou needi""ediate"edicalattention

*mergency room services

:(6;copay/visitE

professionaland otherservices (;<coinsurance

:(6;copay/visitE

professionaland otherservices (;<coinsurance

:(6; "opay waived if

admitted. )ember may bebalance billed for out ofnetwork services.

*mergency medicaltransportation

(;<coinsurance

(;<coinsurance

)ember may be balancebilled for out of networkservices.

rgent care:6; copay/

visit2ot "overed

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

If #ou have ahospital sta#

Facility fee #e.g., hospital room& (;<coinsurance

2ot "overed

0hysical )edicine and

Behabilitation limited to %;;days per member percalendar year.

0hysician/surgeon fee(;<coinsurance

2ot "overed?????????????none????????????


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If #ou have"ental health.

behavioralhealth. orsubstanceabuse needs

)ental/ehavioral healthoutpatient services

)ental/ehavioral ealth13ice Gisit

:>; copay/visit

)ental/ehavioral ealth

Facility Gisit

(;<coinsurance

)ental/ehavioralealth

13ice Gisit 2ot"overed

)ental/ehavioral ealth

Facility Gisit

2ot"overed

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

)ental/ehavioral healthinpatient services

(;<coinsurance

2ot "overed ????????????none????????????


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'ubstance use disorderoutpatient services

'ubstance @buse 13ice

Gisit:>; copay/visit

'ubstance @buse Facility

Gisit(;<coinsurance

'ubstance @buse 13ice

Gisit 2ot"overed

'ubstance @buse Facility

Gisit 2ot"overed

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

'ubstance use disorder inpatientservices

(;<coinsurance

2ot "overed ????????????none????????????

If #ou arepre,nant

0renatal and postnatal care(;<coinsurance

2ot "overed?????????????none????????????

Delivery and all inpatient services(;<coinsurance

2ot "overed?????????????none????????????


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If #ou needhelp recoverin,

or have otherspecial healthneeds

ome health care(;<coinsurance

2ot "overed?????????????none????????????

Behabilitation services

:6; copay/visitfor outpatientservices.Inpatientservices (;<coinsurance.

2ot "overed

Himited to ; visits permember per calendar yearfor physical therapy,occupational therapy, andspeech therapy combined.

abilitation services

:6; copay/visitfor outpatientservices.Inpatient

services (;<coinsurance.

2ot "overed

@ll rehabilitation andhabilitation visits counttoward your rehabilitation

visit limit.

'killed nursing care(;<coinsurance

2ot "overedHimited to %;; days percalendar year.

Durable medical e+uipment :(6;deductiblethen (;<coinsurance

2ot "overed 'upplies are sub=ect to :(6;deductible per member per

year. )$ @ppliances arenot covered.


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ospice service(;<coinsurance

2ot "overed?????????????none????????????

If #our childneeds dental or e#e care

*ye eam 2o cost share 2ot "overed

1ne eam per calendar yearfor members %5 years and

younger.1ne eam every ( calendar

years for members %9 yearsand older.

4lasses 2ot "overed 2ot "overed?????????????none????????????

Dental check-up 2ot "overed 2ot "overed?????????????none????????????


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E$uded !ervies 5 Ot'er Covered !ervies:

!ervies our P$an 9oes O% Cover /0his isn*t a co"plete list( +hec! #our polic# or plan docu"ent for other

e$cluded services(

J @cupuncture

J "osmetic surgery

J Dental care #@dult&

J earing aids

J Infertility treatment

J Hong-term care

J Boutine foot care

J Keight loss programs

Ot'er Covered !ervies /0his isn*t a co"plete list( +hec! #our polic# or plan docu"ent for other coveredservices and #our costs for these services(

J ariatric surgery #Himitations )ay @pply&

J "hiropractic care #Himitations @pply&

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

J 0rivate-duty nursing #coveredunder ome ealth "are&

J Boutine eye care #@dult ?Himitations )ay @pply&

our ig'ts to Continue 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 pre"iu", which may be signicantly higher than the premium you pay while covered under the plan.

1ther limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at %-5;;-(65-6>%5. !ou may also contact your state insurance department, the .'. Department of Habor, *mployee enets 'ecurity @dministration at %-5-


http://www.bcbs.com/bluecardworldwide

http://www.bcbs.com/bluecardworldwide

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!u""ary of #enefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P$an %y&e: EPO888->(7( or www.dol.gov/ebsa, or the .'. Department of ealth and uman 'ervices at %-577-(7-(>(> %66 orwww.cciio.cms.gov.

our ;rievane and A&&ea$s ig'ts:

If 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 ,rievance. For +uestions about your rights, this notice, or assistance, you can contactC

@nthem lue "ross lue 'hield"linical @ppealsC 0.1. o %;665 @tlanta, 4@ >;>851perational @ppealsC 0.1. o %;665 @tlanta, 4@ >;>85

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 *BI'@ information contactC

Department of Habor’s *mployee enets 'ecurity @dministration%-5-888-*'@ #>(7(&www.dol.gov/ebsa/healthreform

@dditionally, a consumer assistance program can help you le your appeal. "ontactC2ew ampshire Department of Insurance(% 'outh Fruit 'treet, 'uite %8"oncord, 2 ;>>;%#5;;& 56(->8%www.nh.gov/insurance

consumerservicesLins.nh.gov


http://www.dol.gov/ebsa

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

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

http://www.nh.gov/insurance

mailto:[email protected]

http://www.dol.gov/ebsa

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

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

http://www.nh.gov/insurance

mailto:[email protected]

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9oes t'is Coverage Provide Mini"u" Essentia$ Coverage<

he @3ordable "are @ct 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.

9oes t'is Coverage Meet t'e Mini"u" =a$ue !tandard<

he @3ordable "are @ct establishes a minimum value standard of benets of a health plan. he minimum value

standard is ;< #actuarial value&. This health coverage does meet the minimum value standard for the

benets it provides.

4anguage Aess !ervies:

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


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>aving a ?a?y#normal delivery&

Managing ty&e 2 dia?etes#routine maintenance of

a well-controlled condition&

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Coverage Ea"&$es

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

A?out t'ese CoverageEa"&$es:

hese eamples show how this planmight cover medical care in givensituations. se these eamples tosee, in general, how much nancialprotection a sample patient mightget if they are covered underdi3erent plans.

A"ount owed to &roviders: $7,54

P$an &ays $5,!"

Patient &ays $",4"

!a"&$e are osts:

ospital charges #mother&:(,7;

;

Boutine obstetric care:(,%;

;ospital charges #baby& :9;;

@nesthesia :9;;

Haboratory tests :6;;

0rescriptions :(;;

Badiology :(;;

Gaccines, other preventive :8;

0otal7.54

3

Patient &ays:

Deductibles:%,;;

;"opays :(;

"oinsurance:%,(6

;Himits or eclusions :%6;

0otal2.42

3


%'is isnot a ostesti"ator(

Don’t use theseeamples to estimate

your actual costs underthis plan. he actualcare you receive will bedi3erent from theseeamples, and the costof that care will also bedi3erent.

'ee the net page forimportant information

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Coverage Ea"&$es


A"ount owed to &roviders: $5,4

P$an &ays $#,!5 Patient &ays $4,44

!a"&$e are osts:

0rescriptions:(,9;

;)edical *+uipment and'upplies

:%,>;;

13ice Gisits and 0rocedures :7;;

*ducation :>;;Haboratory tests :%;;

Gaccines, other preventive :%;;

0otal5.43

3

Patient &ays:

Deductibles:%,(6

;"opays :7%;

"oinsurance :(%;Himits or eclusions :5;

0otal2.25

3


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Coverage Ea"&$es



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)uestions and answers a?out t'e Coverage Ea"&$es:

*'at are so"e of t'eassu"&tions ?e'ind t'eCoverage Ea"&$es<

• "osts don’t include pre"iu"s.

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

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

• @ll services and treatmentsstarted and ended in the samecoverage period.

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

• 1ut-of-pocket epenses arebased only on treating thecondition in the eample.

• he patient received all care

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

*'at does a Coverage Ea"&$es'ow<

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

how deductibles, copa#"ents,and coinsurance 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.

9oes t'e Coverage Ea"&$e&redit "y own are needs<

o( reatments shown are =ust

eamples. he care you wouldreceive for this condition couldbe di3erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.

9oes t'e Coverage Ea"&$e&redit "y future e&enses<

o( "overage *amples are not

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

!our own costs will be di3erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.

Can I use Coverage Ea"&$esto o"&are &$ans<

es( Khen you look at the

'ummary of enets and"overage for other plans, you’llnd the same "overage*amples. Khen you compareplans, check the M0atient 0aysNbo in each eample. hesmaller that number, the morecoverage the plan provides.

Are t'ere ot'er osts I s'ou$donsider w'en o"&aring&$ans<

es( @n important cost is the

pre"iu" you pay. 4enerally,the lower your pre"iu", themore you’ll pay in out-of-pocketcosts, such as copa#"ents,

7/24/2019 2016 AWANE ME IND


deductibles, and coinsurance. !ou should also considercontributions to accounts such

as health savings accounts#'@s&, Oeible spendingarrangements #F'@s& or health

reimbursement accounts #B@s&that help you pay out-of-pocketepenses.

2016 awane me ind

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