solution ppo plans

Solution PPO Plans

Summary of features

Small Group EmployeeElect

Solution 3500 PPO

MCASB2930C (7/09)

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Solution 3500 PPO: Combines a modest premium PPO plan with a high deductible, providing predictable copays for office visits and prescription drugs along with coverage for preventive care and physical exams. It’s just the right amount of coverage for you.

• Yougetupto$5,000,000incoveredbenefitsoveryourlifetime.

• Youchoosefromover53,000doctorsandspecialists,andfromover400hospitals.

• Yousavemoneybecausewe’venegotiatedlowerrateswithourin-networkdoctors.

• YougetemergencycarecoveredwhiletravelingacrosstheU.S.andthroughouttheworld,24/7.

Great Ways to Save!

AnthemBlueCrossisworkinghardtohelpyousavemoneyonhealthcarecosts.Oneoftheeasiestandmostconvenientwaystosaveisbyorderingmaintenancemedicationsthroughourmail-orderpharmacy.Yourmedicationsaredeliveredrighttoyourdoor,andwithourlowermail-orderpharmacybenefits,youcansaveasmuchas$80ormoreperyearonprescriptioncosts!Andnow,yourplanoffersgenericmedicationsata$10copay,savingyouevenmore.

Anthem 360° Health®: Optimize Your Health

360°Healthoffersyouvaluabletools,resourcesandsupporttohelpyoutolivehealthier,startingtoday.Andit’sallavailablethroughonecentralizedresource.Whetheryouarehealthyandwanttostaythatwayoryouneedhelpmanagingachroniccondition,360°Healthisheretohelpyoureachyourpersonalhealthgoals.

Access Tools and Resources

Atanthem.com/ca,360°Healthbringstogether:

• Onlineresources(likehelpfuldecision-makingtoolsandvaluablehealthinformation).

• Interactivehealthprograms.

• Personalguidance.

• Discountsonhealth-relatedproducts.

•MyHealth@Anthem,yourpersonalonlineresourceformemberhealthandwellnessinformation.Ourtrustedsitehasinteractivetoolsthathelpyoucheckyourhealthstatusandlearnwhatyoucandotoimproveit.

Get Guidance

Sometimesyouneedexpertinformationandsupportfromatrustedsource.Weprovideprogramstoaddressyourconcernsandgiveyoutheassistanceyouneedinreachingyourhealthgoals.

Manage a Condition

OurConditionCareprogramscanhelpyoubettermanagechronicconditionsincludingasthma,diabetes,heartfailure,coronaryarterydiseaseandchronicobstructivepulmonarydisease.Visitanthem.com/catodaytolearnmoreabouthow360°Healthcanhelpyoulivebettertodayandinthefuture.

Solid protection,practical solution

We’re dedicated to improving your health.

WithAnthem,you’llhavepeaceofmindknowingthatyou’recoveredbyoneofthemosttrustednamesinhealthcarecoverage,andthatyou’regettingmorevalueinsomanyways.Westillhavethesamecommitmenttoyouthatwe’vehadtoallCaliforniansoverthelast70years—todeliverhigh-quality,affordablehealthcoverageandhelpyoubeashealthyasyoucanbe.AsthehealthcareplanmoreCaliforniansdependon,welookforwardtoservingyourhealthcareneeds.

Haveaquestion?JustcallSmallGroupCustomerServiceat800-627-8797andwe’llbehappytohelp.

Comprehensive coverage you can trust. Modest premiums with predictable office visit copays. Preventive care, physical exam coverage and valuable hospital coverage. That’s what makes our Solution 3500 PPO a practical, cost-effective solution.

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You’re free to go to health care providers

outside of the Anthem Blue Cross network,

but you’ll save a substantial amount by

choosing from our 53,000 doctors and 400

hospitals. Staying in the Anthem Blue Cross

network will help you get maximum value

from your health care benefits — and from

your health care dollar.

Powerful savings from Anthem

With Anthem health coverage, you save in three significant ways:

1.Ourin-networkdoctorsandhospitalschargeyoulower,AnthemBlueCross-negotiatedfees.

2.TheBlueCard®programgivesyouaccesstoin-networkprovidersatdiscountedratesallacrossthecountry.

3.Youpayonlyaportionofthefeesforyoureligiblecoveredexpenses(seeexamplebelow)andwepaytherest,afteryourdeductible.

Thisisonlyanexample.Yoursavingsmayvarybasedonyourplanandservicesreceived.

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1 Services that do not apply to the annual out-of-pocket maximum include but are not limited to: deductible and copay paid under the pharmacy benefit; copay paid for acupuncture/acupressure; copay for mental or nervous disorders and substance abuse (except for treatment of severe mental illness and serious emotional disturbances of a child); copay for not obtaining pre-service review; $500 copay for infertility services; non-covered services.

2 Copays listed apply when generic equivalent is not available. If a member selects a brand-name drug when a generic-equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for a generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug. The additional amount paid does not apply to the member’s brand name deductible.

3 Infertility Drugs: Infertility drug lifetime maximum Anthem Blue Cross payment is $1,500 in network and out of network combined. Classified specialty drugs must be obtained through the Specialty Pharmacy Program and are subject to the terms of the program.

Small Group Solution 3500 PPO PlanAll amounts listed are the member’s responsibility to pay after deductible(s), unless otherwise noted. In-network negotiated fees can result in 30 to 40% savings compared to providers’ usual fees.

CORE FEATURES IN NETWORK Receive Negotiated Savings

OUT OF NETWORK Pay Higher Costs

Annual Deductible $3,500 per member for all medical services except office visits and annual physical exam, and prescription drugs; two-member maximum, in network and out of network combined. Annual deductible for in-network services applies toward annual in-network out-of-pocket maximum

Maximum Lifetime Covered ChargesPaid by Anthem Blue Cross In network and out of network combined

$5,000,000

Annual Out-of-pocket Maximum1 $5,000 per member, two-member maximum Once Anthem Blue Cross payments reach $10,000 per member, members pay nothing for covered expenses for the remainder of the year except charges over the allowed amounts

Office Visits Not subject to annual deductible

$35 copay per visit 50% of negotiated fee plus 100% of excess charges

Other Professional ServicesIncludes maternity, diagnostic lab and X-ray

35% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Hospital Inpatient Facility Services Pre-service review required

35% of negotiated fee after annual deductible All charges in excess of $650 per day after annual deductible

Hospital Inpatient Professional Services Includes lab, physician, anesthesia

35% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Outpatient Facility Services Pre-service Review required for certain surgical services and diagnostic procedures


Ambulatory Surgical Centers Pre-service Review required


Prescription Drugs3

Amounts shown are for a 30-day retail supply; mail-order service available

Annual $250 brand-name prescription drug deductible per member applies to brand-name drugs in network and out of network combined

Generic: $10 copay

Brand2:

$250 brand-name prescription drug deductible applies

$35 copay for Formulary

$50 copay for Non-Formulary

Self-injectable (except insulin): 30% of negotiated fee up to $100 per fill (subject to brand-name prescription drug deductible, if applicable)

50% of drug limited fee schedule plus 100% of excess charges if filled within California. $250 brand-name deductible applies.

Annual Preventive Care OptionsPhysical Exam (Ages 7 - Adult)Maximum Anthem Blue Cross payment of $500 for members covered more than 6 months or $250 if covered 6 months or less; not subject to annual deductible; in network and out of network combined

$35 copay per office visit plus 35% of negotiated fee for all other covered services

50% of negotiated fee plus 100% of excess charges

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This is an overview of coverage. A comprehensive description of coverage, benefits and limitations is contained in the Certificate. Review the Exclusions and Limitations prior to applying for coverage.

ADDITIONAL FEATURES IN NETWORK Receive Negotiated Savings

OUT OF NETWORK Pay Higher Costs

Well Baby Immunizations and Adult Screening Tests1 Well-Baby Immunizations (Children through age 6) Includes regular check-ups and immunizations

Adult Preventive Services (Ages 7 - Adult) Includes annual Pap, breast exam and mammogram for women, and Prostate Specific Antigen study for men; and colorectal cancer screenings.

$35 copay per office visit (not subject to deductible) plus 35% of negotiated fee for all other covered services after annual deductible

50% of negotiated fee plus 100% of excess charges, after annual deductible

Emergency Care$100 Emergency Room copay for each visit - waived if admitted

35% of negotiated fee after annual deductible 35% of customary and reasonable charges plus 100% of excess after annual deductible

Ambulance 35% of negotiated fee after annual deductible 50% of negotiated fee plus 100% of excess charges after annual deductible

Skilled Nursing Facility100 days per year, in network and out of network combined Pre-service Review required


Home Health Care100 four-hour visits per year, in network and out of network combined Pre-service Review required

35% of negotiated fee after annual deductible All charges in excess of $75 per visit after annual deductible

Physical/Occupational Therapy, Chiropractic Care24 visits per year, in network and out of network combined

35% of negotiated fee after annual deductible All charges in excess of $25 per visit after annual deductible

Acupuncture/Acupressure24 visits per year, in network and out of network combined

All of the negotiated fee in excess of $30 per visit after annual deductible All charges in excess of $30 per visit after annual deductible

Mental Health/Inpatient2

Includes chemical dependency 30 days per year, in network and out of network combined. Pre-service Review required

All of the negotiated fee in excess of $175 per day after annual deductible All charges in excess of $175 per day after annual deductible

Mental Health/Outpatient Professional Services2

Includes chemical dependency. One visit per day, 20 visits per year, in network and out of network combined. Pre-service Review required after the 12th visit

All of the negotiated fee in excess of $25 per visit after annual deductible All charges in excess of $25 per visit after annual deductible

Infusion Therapy3

Includes chemotherapyPre-service Review required

35% of negotiated fee after annual deductible All charges in excess of $50 per day for all infusion therapy expenses except drugs; all charges in excess of the average wholesale price for all infusion therapy drugs; all charges in excess of the combined maximum Anthem Blue Cross payment of $500 per day; after annual deductible

Infertility Services3

Maximum lifetime Anthem Blue Cross payment $2,000, in network and out of network combined

$500 copay plus 35% of the balance of negotiated fee after annual deductible $500 copay plus 50% of the balance of negotiated fee plus 100% of excess charges after annual deductible

1 Age and frequency limitations apply.2 Does not apply to coverage of severe mental illness and serious emotional disturbances of a child, except pre-service review.3 Classified specialty drugs must be obtained through the mail-order Specialty Pharmacy Program and are subject to the terms of the program. Limited to 30-day supply.

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Exclusions and Limitations

Followingisanabbreviatedlistofexclusionsandlimitations;pleaseseetheCertificateforcomprehensivedetails.

•AnyamountsinexcessofmaximumsstatedintheCertificate

•Servicesorsuppliesthatarenotmedicallynecessary

•Servicesreceivedbeforeyoureffectivedate

•Servicesreceivedafteryourcoverageends

•Anyconditionsforwhichbenefitscanberecoveredunderanyworkers’compensationlaworsimilarlaw

•Servicesyoureceiveforwhichyouarenotlegallyobligatedtopay

•Servicesforwhichnochargeismadetoyouintheabsenceofinsurancecoverage

•ServicesnotlistedascoveredintheCertificate

•Servicesfromrelatives

•VisioncareexceptasspecificallystatedintheCertificate

•Eyesurgeryperformedsolelyforthepurposeofcorrectingrefractivedefects

•Hearingaids.RoutinehearingtestsexceptasspecificallystatedintheCertificate

•Sexchanges

•DentalandorthodonticservicesexceptasspecificallystatedintheCertificate

•Cosmeticsurgery

•RoutinephysicalexaminationsexceptasspecificallystatedintheCertificate

•Treatmentofmentalornervousdisordersandsubstanceabuse(includingnicotineuse)orpsychologicaltesting,exceptasspecificallystatedintheCertificate

•Custodialcare

•Experimentalorinvestigationalservices

•Servicesprovidedbyalocal,stateorfederalgovernmentagency,unlessyouhavetopayforthem

•Diagnosticadmissions

•Telephoneorfacsimilemachineconsultations

•Personalcomfortitems

•Nutritionalcounseling

•Healthclubmemberships

•Commercialweightlossprograms

•Medicalsuppliesandequipment/durablemedicalequipmentexceptasspecificallystatedintheCertificate

•Specialtydrugs,exceptasspecificallystatedintheCertificate

•AnyservicestotheextentyouareentitledtoreceiveMedicarebenefitsforthoseserviceswithoutpaymentofadditionalpremiumforMedicarecoverage

•Foodordietarysupplements,exceptasspecificallystatedintheCertificateorasrequiredbylaw

•Genetictestingfornon-medicalreasonsorwhenthereisnomedicalindicationornofamilyhistoryofgeneticabnormality

•Outdoortreatmentprograms

•Replacementofprostheticsanddurablemedicalequipmentwhenlostorstolen

•AnyservicesorsuppliesprovidedtoanypersonnotcoveredundertheAgreementinconnectionwithasurrogatepregnancy

•ImmunizationssolelyfortraveloutsidetheUnitedStates

•Servicesorsuppliesrelatedtoapre-existingcondition

•EducationalservicesexceptasspecificallyprovidedorarrangedbyAnthemBlueCross

•Infertilityservices(includingsterilizationreversal)exceptasspecificallystatedintheCertificate

•Careortreatmentprovidedinanon-contractinghospital

•PrivatedutynursingexceptasspecificallystatedintheCertificate

•Servicesprimarilyforweightreductionexceptmedicallynecessarytreatmentofmorbidobesity

•Outpatientdrugs,medicationsorothersubstancesdispensedoradministeredinanyoutpatientsetting

•Contraceptivedevicesunlessyourphysiciandeterminesthatoralcontraceptivedrugsarenotmedicallyappropriate

General Provisions

Member Privacy: OurcompleteNotice of Privacy Practicesprovidesacomprehensiveoverviewofthepoliciesandpracticesweenforcetopreserveourmembers’privacyrightsandcontroluseoftheirhealthcareinformation,including:therighttoauthorizereleaseofinformation;therighttolimitaccesstomedicalinformation;protectionoforal,writtenandelectronicinformation;useofdata;andinformationsharedwithemployers.Thisnoticecanbedownloadedfromourwebsiteatanthem.com/caorobtainedbycallingSmallGroupCustomerServiceat800-627-8797.

Utilization Review: TheAnthemBlueCrossUtilizationReviewProgramhelpsmembersreceivecoverageforappropriatetreatmentintheappropriatesetting.Fourreviewprocessesareincluded:1)Pre-serviceReviewassessesmedicalnecessitybeforeservicesareprovided;2)AdmissionReviewdeterminesatthetimeofadmissionifthestayorsurgeryisMedicallyNecessaryintheeventPre-serviceReviewisnotconducted;3)ContinuedStayReviewdeterminesifacontinuedstayisMedicallyNecessary;4)RetrospectiveReviewdeterminesifthestayorsurgerywasMedicallyNecessaryaftercarehasbeenprovidedifnoneofthefirstthreereviewswereperformed.UtilizationReviewisnotthepracticeofmedicineortheprovisionofmedicalcaretoyou.Onlyyourdoctorcanprovideyouwithmedicaladviceandmedicalcare.

Grievances: Allcomplaintsanddisputesrelatingtoamember’scoveragemustberesolvedinaccordancewithAnthemBlueCrossLifeandHealthInsuranceCompany’sgrievanceprocedure.Youcanreportyourgrievancebyphoneorinwriting;seeyourAnthemBlueCrossLifeandHealthInsuranceCompanyIDcardfortheappropriatecontactinformation.AllgrievancesreceivedbyAnthemBlueCrossLifeandHealthInsuranceCompanythatcannotberesolvedbyphone(whenappropriate)tothemutualsatisfactionofthememberandAnthemBlueCrossLifeandHealthInsuranceCompanywillbeacknowledgedinwriting,togetherwithadescriptionofhowAnthemBlueCrossLifeandHealthInsuranceCompanyproposestoresolvethegrievance.Grievancesthatcannotberesolvedbytheseproceduresshallberesolvedasindicatedthroughbindingarbitration,oriftheplanyouarecoveredunderissubjecttotheEmployeeRetirementIncomeSecurityActof1974(ERISA),incompliancewithERISArules.IfthegroupissubjecttoERISA,andamemberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sproposedresolutionofagrievance,themembermaysubmitanappealbyphoneorinwritingbycontactingthephonenumberoraddressprintedontheletterheadoftheAnthemBlueCrossLifeandHealthInsuranceCompanyresponseletter.

ForthepurposesofERISA,thereisonelevelofappeal.Forurgentcarerequestsforbenefits,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin72hoursfromthedatetheappealisreceived.Forpre-servicerequestsforbenefits,thememberwillreceivearesponsewithin30calendardaysfromthedatetheappealisreceived.Forpost-serviceclaims,AnthemBlueCrossLifeandHealthInsuranceCompanywillrespondwithin60calendardaysfromthedatetheappealisreceived.

IfthememberdisagreeswithAnthemBlueCrossLifeandHealthInsuranceCompany’sdecisionontheappeal,themembermayelecttohavethedisputesettledthroughalternativeresolutionoptions,suchasvoluntarybindingarbitration.

Department of Insurance: Overseeingtheindustryandprotectingthestate’sinsuranceconsumersistheresponsibilityoftheCaliforniaDepartmentofInsurance(CDI).TheCDIregulates,investigatesandauditsinsurancebusinesstoensurethatcompaniesremainsolventandmeettheirobligationstoinsurancepolicyholders.Ifyouhaveaproblemregardingyourcoverage,includingcomplaintsregardingtheabilitytoaccessneededhealthcareinatimelymanner,pleasecontactAnthemBlueCrossfirsttoresolvetheissue.Ifcontactsbetweenyou(thecomplainant)andAnthemBlueCross(theInsurer)havefailedtoproduceasatisfactorysolutiontotheproblem,youmaywishtocontacttheCDI.TheycanbereachedbywritingtotheCaliforniaDepartmentofInsurance,ConsumerServicesDivision,300SouthSpringSt.-SouthTower,LosAngeles,CA90013.TheCDIalsohasatoll-freephonenumber800-927-HELP(4357)thatyoumaycallforassistance.

Binding Arbitration: IftheplanissubjecttoERISA,anydisputeinvolvinganadversebenefitdecisionmustberesolvedunderERISAclaimsprocedurerules,andisnotsubjecttomandatorybindingarbitration.MembersmaypursuevoluntarybindingarbitrationaftertheyhavecompletedanappealunderERISArules.Ifthememberhasanotherdisputethatdoesnotinvolveanadversebenefitdecision,orifthegroupdoesnotprovideaplanthatissubjecttoERISA,thenthememberandAnthemBlueCrossagreetobeboundbythearbitrationprovisionscontainedintheenrollmentformandCertificate.

Medicare: UnderTEFRA/DEFRA,Medicareistheprimarycoverageforgroupsoflessthan20employees.AnthemBlueCrosscoverageisconsideredprimarycoverageforgroupsof20ormoreemployees.ThisAnthemBlueCrosscoverageisnotasupplementtoMedicare,butprovidesbenefitsaccordingtothenon-duplicationofMedicareclause.

IfMedicareisamember’sprimaryhealthplan,AnthemBlueCrosswillnotprovidebenefitsthatduplicateanybenefitsyouareentitledtoreceiveunderMedicare.ThismeansthatwhenMedicareistheprimaryhealthcoverage,benefitsareprovidedinaccordancewiththebenefitsoftheplan,lessanyamountpaidbyMedicare.IfyouareentitledtoPartAandBofMedicare,youwill

beeligiblefornon-duplicateMedicarecoverage,withsupplementalcoordinationofbenefits.However,ifyouarerequiredtopaytheSocialSecurityAdministrationanadditionalpremiumforanypartofMedicare,thentheabovepolicywillonlyapplyifyouareenrolledinthatpartofMedicare.Note:Medicare-eligibleemployees/dependentsenrolledinplanswhereMedicareisprimarymayobtainanIndividualAnthemBlueCrossMedicareSupplementplanwiththepre-existingconditionexclusionwaived.

Specialty Pharmacy Program: Specialtymedicationsareusuallydispensedasaninjectabledrug,butmaybeavailableinotherforms,suchasapillorinhalant.Theyareusedtotreatcomplexconditions.Prescriptionsforaspecialtypharmacydrugarecoveredonlywhenorderedthroughthespecialtypharmacyprogram,unlessyouaregivenanexceptionfromthespecialtydrugprogram(seeyourCertificatefordetails).Thespecialtypharmacyprogramwilldeliveryourmedicationtoyoubymailorcommoncarrier(youcannotpickupyourmedication).

Youmayhavetopaythefullcostofaspecialtypharmacydrug,ifitisnotobtainedfromthespecialtypharmacyprogram.

Specialtydrugsarelimitedtoa30-daysupplyforeachfill.

Coordination of Benefits: Thebenefitsofamember’splanmaybereducedifthememberhasothergrouphealth,dental,drugorvisioncoverage,sothatbenefitsandservicesthememberreceivesfromallgroupcoveragesdonotexceed100percentofthecoveredexpense.

Third-party Liability: Ifamemberisinjured,theresponsiblepartymaybelegallyobligatedtopayformedicalexpensesrelatedtothatinjury.AnthemBlueCrossmayrecoverbenefitspaidformedicalexpensesifthememberrecoversdamagesfromalegallyliablethirdparty.Examplesofthird-partyliabilitysituationsincludecaraccidentsandwork-relatedinjuries.

Voiding Coverage for False and Misleading Information: Falseormisleadinginformationorfailuretosubmitanyrequiredenrollmentmaterialsmayformthebasisforvoidingcoveragefromthedateaplanwasissuedorretroactivelyadjustingthepremiumtowhatitwouldhavebeenifthecorrectinformationhadbeenfurnished.Nobenefitswillbepaidforanyclaimsubmittedifcoverageismadevoid.Premiumsalreadypaidforthetimeperiodforwhichcoveragewasrescindedwillberefunded,minusanyclaimspaid.

Incurred Medical Care Ratio: Asrequiredbylaw,weareadvisingyouthatAnthemBlueCrossanditsaffiliatedcompanies’incurredmedicalcareratiofor2008was83.4percent.Thisratiowascalculatedafterproviderdiscountswereapplied.

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AGENT Guide

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Anthem Blue Cross and its branded affilate, Anthem Blue Cross Life and Health insurance Company, are NCQA Accredited health plans. Goods and services available through discount programs are not benefits of coverage. Anthem Blue Cross does not endorse or recommend any goods or services provided at a discount by these vendors or practitioners. These programs may be changed or withdrawn at any time without notice by the offering vendor or practitioner.

Solution 3500 PPO Plan is offered by Anthem Blue Cross Life and Health insurance Company.

Health care plans provided by Anthem Blue Cross. insurance plans provided by Anthem Blue Cross Life and Health insurance Company. Anthem Blue Cross is the trade name of Blue Cross of California. independent licensees of the Blue Cross Association. ® ANTHeM and 360° HeALTH are registered trademarks. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. The WebMd website is owned and operated by WebMd Health Corp. WebMd Health is solely responsible for its website and is not affiliated with Anthem Blue Cross or any affiliate of Anthem Blue Cross.

anthem.com/ca

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