nh risk 7s

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Awane: New Hampshire Risk EPO Coverage Period: 01/01/2014 - 12/31/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |Plan Type: EPO

This is only a summary. If you want more detail about your coverage and costs, you can get the completeterms in the policy or plan document at www.anthem.com or by calling 1-855-271-4549.

Important Questions Answers Why this Matters:

What is theoveralldeductible?

For in-network providers

$1,500individual /$3,000 family

Doesnt apply to in-network preventive careand routine eye exams.

You must pay all the costs up to the deductible amount before thisplan begins to pay for covered services you use. Check your policy orplan document to see when the deductible starts over (usually, butnot always, January 1st). See the chart starting on page 2 for howmuch you pay for covered services after you meet the deductible.

Are there otherdeductibles forspecific services?

Yes. $250 deductible forDurable MedicalEquipment per memberper calendar year.

You must pay all of the costs for these services up to the specificdeductible amount before this plan begins to pay for these services.

Is there an outofpocket limiton my expenses?

For in-network providers

$4,500individual /$9,000 family

The out-of-pocket limit is the most you could pay during a coverageperiod (usually one year) for your share of the cost of coveredservices. This limit helps you plan for health care expenses.

What is notincluded in theoutofpocketlimit?

Premiums, balance-billed charges, penaltiesfor non compliance,pharmacy claims andhealth care this plan

doesnt cover.

Even though you pay these expenses, they dont count toward theout-of-pocket limit.

Is there anoverall annuallimiton what theplan pays?

No.The chart starting on page 2 describes any limits on what the plan willpay for specific covered services, such as office visits.

Questions: Call 1-855-271-4549 or visit us at www.anthem.comIf you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com or call 1-855-271-4549 to request a copy.

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Does this planuse a network ofproviders?

Yes. For a list ofpreferred providers,see www.anthem.comor call 1-855-271-4549

If you use an in-network doctor or other health care provider, thisplan will pay some or all of the costs of covered services. Be aware,your in-network doctor or hospital may use an out-of-networkprovider for some services. Plans use the term in-network,preferred, or participatingfor providers in their network. See thechart starting on page 2 for how this plan pays different kinds ofproviders.

Do I need areferral to see aspecialist?

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

Are thereservices this plandoesnt cover?

Yes.Some of the services thisplan doesnt cover are listed on page 7. Seeyour policy or plan document for additional information aboutexcluded services.

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when youreceive the service.

Coinsurance isyourshare of the costs of a covered service, calculated as a percent of the allowed

amountfor the service. For example, if the plans allowed amount for an overnight hospital stay is $1,000,your coinsurance payment of 20% would be $200. This may change if you havent met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network

providercharges more than the allowed amount, you may have to pay the difference. For example, if anout-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you mayhave to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use in-networkprovidersby charging you lower deductibles,

copayments and coinsurance amounts.

Common

Medical EventServices You May Need

Your Cost IfYou Use anIn-networkProvider

Your Cost IfYou Use an

Out-of-networkProvider

Limitations & Exceptions

If you visit ahealth care

Primary care visit to treat aninjury or illness

$30copay/visit

Not Covered none


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Common






providersoffice or clinic

Specialist visit$50copay/visit

Not Covered none

Other practitioner office visit$50copay/visit

Not Coverednone

Preventivecare/screening/immunization

No Charge Not Covered none

If you have a

test

Diagnostic test (x-ray, blood work)

No Charge forlabs in officeorindependentlab; other

services 20%coinsurance

Not CoveredDeductible waived when labservices performed in office orindependent lab.

Imaging (CT/PET scans, MRIs)20%coinsurance

Not Covered none

If you needdrugs to treatyour illness orcondition

More informationaboutprescriptiondrug coverageis available atwww.medco.com

Generic drugs (Retail/30 day: Mail/90day)

$10 Retail/$20Mail

Not Covered$100 Deductible/Person $300Deductible/Family. Maintenance Meds arerequired to be filled mail order after 3 fills atretail (penalty applies). If pre-auth required &not obtained, drug may not be covered.Certain Preventive meds no copay. If ageneric equivalent is available & brand isprescribed/member will pay brand name costdifference. Plan uses preferred drug list toidentify coverage.

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

$35 Retail/$87.5Mail

Not Covered

Non-preferred brand (Retail/30day:

Mail/90day)

$60 Retail/$150

Mail

Not Covered

Specialty drugs

All Specialtymeds process

throughAccredo at the

mail ordercosts.

Not Covered

The mail order cost will be basedon the medication tier (generic,preferred, non-preferred).Specialty meds can not be filledat retail pharmacies.


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Common






If you haveoutpatientsurgery

Facility fee (e.g., ambulatorysurgery center)

$75copay/visit forambulatorysurgicalcenter; otherproviders 20%coinsurance

Not Covered none

Physician/surgeon fees

No Chargeambulatorysurgicalcenter; other

providers 20%coinsurance

Not CoveredDeductible waived whenperformed in an ambulatorysurgical center.

If you needimmediatemedicalattention

Emergency room services

$250copay/visit;professionaland otherservices 20%coinsurance

$250copay/visit;professionaland otherservices 20%coinsurance

Copay waived if admitted.Member may be balance billedfor out of network services.

Emergency medicaltransportation

20%coinsurance

20%coinsurance

Member may be balance billedfor out of network services.

Urgent care $50 copay/visit

Not Covered none

If you have ahospital stay

Facility fee (e.g., hospital room)20%coinsurance

Not CoveredFailure to precertify may resultin a penalty of $500.

Physician/surgeon fee20%coinsurance

Not Covered none


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Common






If you havemental health,behavioralhealth, orsubstance

abuse needs

Mental/Behavioral healthoutpatient services

$30copay/visit orconsultation;other services20%coinsurance

Not Covered none

Mental/Behavioral health inpatientservices

20%coinsurance


Substance use disorder outpatientservices

$30copay/visit or

consultation;other services20%coinsurance

Not Covered none

Substance use disorder inpatientservices

20%coinsurance


If you arepregnant

Prenatal and postnatal care20%coinsurance

Not Coverednone

Delivery and all inpatient services20%

coinsuranceNot Covered none


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Common






If you needhelp recoveringor have otherspecial healthneeds

Home health care20%coinsurance

Not Covered none

Rehabilitation services

$50copay/visit foroutpatientservices.Inpatientservices 20%coinsurance.

Not Covered

Inpatient rehabilitation limitedto 60 days per calendar year.Outpatient services limited to60 visits per member percalendar year for physicaltherapy, occupational therapy,and speech therapy combined.Limits are combined in andout-of- network.

Habilitation services

$50copay/visit foroutpatientservices.Inpatientservices 20%coinsurance.

Not CoveredAll rehabilitation andhabilitation visits count towardyour rehabilitation visit limit.

Skilled nursing care20%coinsurance

Not Covered

Limited to 100 days percalendar year. Failure toprecertify may result in a

penalty of $500.

Durable medical equipment20%coinsurance

Not Covered

Supplies are subject to $250deductible per member peryear. TMJ Appliances are notcovered.

Hospice service20%coinsurance

Not Covered none


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Common






If your childneeds dental oreye care

Eye exam No Charge Not Covered

One exam per calendar yearfor members 18 years andyounger.One exam every 2 calendaryears for members 19 yearsand older.

Glasses Not Covered Not Covered none

Dental check-up Not Covered Not Covered none

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover(This isnt a complete list. Check your policy or plan document for otherexcluded services.)

Acupuncture

Cosmetic surgery

Dental care (Adult)

Hearing aids

Long-term care

Non-emergency care when traveling

outside the U.S.

Routine foot care

Weight loss programs

Infertility treatment

Other Covered Services(This isnt a complete list. Check your policy or plan document for other coveredservices and your costs for these services.)

Bariatric surgery (Limitations MayApply)

Chiropractic care

Coverage provided outside theUnited States. Seewww.BCBS.com/bluecardworldwide

Routine eye care (Adult LimitationsMay Apply)

Private-duty nursing (coveredunder Home Health Care)

http://www.bcbs.com/bluecardworldwidehttp://www.bcbs.com/bluecardworldwide

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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 health coverage. 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 contactyour state insurance department, the U.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 and Human Services at 1-877-267-2323 x61565 orwww.cciio.cms.gov.

Your Grievance and Appeals Rights:

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

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Awane: New Hampshire Risk EPO Coverage Period: 01/01/2014 - 12/31/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |Plan Type: EPOIf you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able toappeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact:

Anthem Blue Cross Blue ShieldClinical Appeals: P.O. Box 105568 Atlanta, GA 30348Operational Appeals: P.O. Box 105568 Atlanta, GA 30348

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

For ERISA information contact:

Department of Labors Employee Benefits Security Administration1-866-444-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) 852-3416www.nh.gov/[email protected]

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.

http://www.express-scripts.com/mailto:[email protected]://www.express-scripts.com/mailto:[email protected]

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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 nextpage.


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Having a baby(normal delivery)

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

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Awane: New Hampshire Risk EPO Coverage Period: 01/01/2014 - 12/31/2014Coverage Examples

Coverage for: Individual/Family |Plan Type: EPO

About these CoverageExamples:

These examples show how this planmight cover medical care in givensituations. Use these examples tosee, in general, how much financialprotection a sample patient mightget if they are covered underdifferent plans.

Amount owed to providers: $7,540

Plan pays $4,820

Patient pays $2,720

Sample care costs:

Hospital charges (mother)$2,70

0

Routine obstetric care$2,10

0Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total$7,54

0

Patient pays:

Deductibles$1,52

0

Copays $0

Coinsurance$1,05

0

Limits or exclusions $150

Total$2,72

0


This isnot a costestimator.

Dont use theseexamples to estimateyour actual costs underthis plan. The actualcare you receive will bedifferent from theseexamples, and the costof that care will also bedifferent.

See the next page forimportant information

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Amount owed to providers: $5,400

Plan pays $3,360

Patient pays $2,040

Sample care costs:

Prescriptions$2,90

0Medical Equipment andSupplies

$1,300

Office Visits and Procedures $700

Education $300Laboratory tests $100

Vaccines, other preventive $100

Total$5,40

0

Patient pays:

Deductibles$1,36

0

Copays $400

Coinsurance $200Limits or exclusions $80

Total$2,04

0


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