Your Plan: Anthem Preferred DirectAccess gpaf Your Network: BlueCare

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1 Your Plan: Anthem Preferred DirectAccess gpaf Your Network: BlueCare This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal contract of coverage. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. Covered Medical Benefits Deductible See notes below to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Retail Prescription Drug Coverage section. Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. Your copays, coinsurance and deductibles count toward your out-of-pocket limit. If Pediatric Vision and/or Dental services are covered under this plan, these services count towards your out of pocket limit. For prescription drug, all cost shares count towards your plan's annual out-of-pocket limit. Doctor Home and Services Preventive care In-network preventive care is not subject to deductible, if your plan has a deductible. Member: $3,000 For Family: $6,000 Member: $5,500 For Family: $11,000 Member: $6,000 For Family: $12,000 Member: $11,000 For Family: $22,000 Primary care visit to treat an injury or illness Specialist care visit $45 copay Prenatal and post-natal visit Covered in Full Other practitioner visits: Retail health clinic Chiropractor services Limited to 20 visits across outpatient and other professional visits. Other services in an office: Allergy testing Chemo/radiation therapy Hemodialysis Prescription drugs Page 1 of 7

2 Covered Medical Benefits Diagnostic Services Lab: X-ray: $45 copay $45 copay Advanced diagnostic imaging (for example, MRI/PET/CAT scans): If your plan has a copay on Advanced diagnostic imaging, your combined copay responsibility for this benefit will not exceed $375 per benefit period. $75 copay $75 copay Emergency and Urgent Care Emergency room facility services $150 copay Same as in-network Emergency room doctor and other services Same as in-network Ambulance (air and ground) Same as in-network Urgent care $45 copay Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit Facility visit: Facility fees Doctor and other services Page 2 of 7

3 Covered Medical Benefits Outpatient Surgery Facility fee: Hospital Freestanding surgical center $250 copay $250 copay Doctor and other services Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fee (for example, room & board) $500 copay per day up to 3 days Doctor and other services Recovery & Rehabilitation Home health care Limited to 100 visits; limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health. 25% coinsurance Rehabilitation services (for example, physical/speech/occupational therapy): Limited to 40 combined visits for Physical, Occupational and Speech Therapy. Visit limits are combined across outpatient and other professional visits. Cardiac rehabilitation $45 copay Skilled nursing care (in a facility) Limited to 90 combined days for Rehab and Skilled Nursing Facility. $500 copay per day up to 3 days Durable medical equipment & prosthetics 5 5 Page 3 of 7

4 Covered Prescription Drug Benefits Retail Prescription Drug Coverage This plan includes Home Delivery (Mail Order). Home Delivery copays are 2.5 times retail copays for 90 day supply. Drug tier 1 Drug tier 2 $35 copay Drug tier 3 $40 copay Drug tier 4 25% coinsurance Drug tier 4 per-prescription maximum cost share (in-network only) $250 Page 4 of 7

5 Covered Vision Benefits This is a brief outline of your in-network coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, and out-of-network coverage (If applicable), see the combined Evidence of Coverage/Disclosure Form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/certificate, the Evidence of Coverage/Disclosure form/certificate will prevail. In-network Pediatric Vision benefit cost shares accumulate to the Medical plan out-of-pocket limit and are not subject to the Medical plan deductible, if plan includes a deductible. Adult Vision services are covered. (See below and your Evidence of Coverage for details.) Children's Vision Essential Health Benefits Vision exam (once every calendar year) Frames (once every calendar year) Lenses (once every calendar year) Elective contact lenses (once every calendar year) Adult Vision Vision exam (once every calendar year) $20 copay Frames (once every other calendar year) $0 copay, $130 frame allowance Lenses (once every other calendar year) $20 copay Elective contact lenses (once every other calendar year) $0 copay, $80 allowance Page 5 of 7

6 Covered Dental Benefits This is a brief outline of your in-network coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, and out-of-network coverage (If applicable), see the combined Evidence of Coverage/Disclosure Form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/certificate, the Evidence of Coverage/Disclosure form/certificate will prevail. Dental services are not subject to Plan deductible if Plan includes a Medical deductible. Dental services may be subject to a separate dental deductible. Children's Dental Essential Health Benefits are covered. Children's Dental Essential Health Benefits Diagnostic and preventive Basic services 4 Major services 5 Deductible $50 Annual Out-of-Pocket limit $300 Your plan also includes the following Healthy Support features Healthy Lifestyles Online Quarterly Health Webinars Gym membership reimbursement Healthy Lifestyles incentives Tobacco free certification with incentives Online well-being health improvement program focused on physical, social and emotional behaviors, including healthy eating, exercise and weight management One hour health education seminars delivered via the web Members are rewarded for regular visits to their gym Members track rewards online for participating in Healthy Lifestyles By certifying online, members are rewarded for being tobacco free Up to $400 / year Up to $150 / year in gift cards $50 / year gift card Page 6 of 7

7 Notes: In-network inpatient hospital and outpatient surgery (facility) services are subject to a deductible. If your plan includes a hospital stay copay and you are readmitted within 72 hours of a prior admission for the same diagnosis, your hospital stay copay for your readmission is waived. If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived. If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. If you elect a medical plan that does not include qualified Pediatric/Children s Dental coverage you will be enrolled in a separate Children s Dental plan, unless notification is received that you have enrolled in coverage elsewhere. If your plan includes out of network benefit and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. When rendered by an out-of-network provider, home health services are subject to a $50 deductible. For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Life and Disability products underwritten by Anthem Life Insurance Company. Page 7 of 7