Your Plan: Anthem Silver Blue Access Choice 5000/20%/6600 Your Network: Blue Access Choice

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1 Your Plan: Anthem Silver Blue Access Choice 5000/20%/6600 Your Network: Blue Access Choice This summary of benefits is a brief outline of coverage, designed to help y ou 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 cov erage will prevail. Covered Medical Benefits Overall Deductible This is an embedded plan. See notes section at the end of the document to understand how your 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. See notes section at the end of the document for additional information regarding your out of pocket maximum. Member: $5,000 For Family: $10,000 Member: $6,600 For Family: $13,200 Member: $10,000 For Family: $20,000 Member: $13,200 For Family: $26,400 For prescription drug, all cost shares count towards your plan's annual out-of-pocket limit. Doctor Home and Office Services Preventive care In-network preventive care is not subject to, if your plan has a. Additionally, immunizations for children prior to their 6th birthday have no cost share for in and out of network charges. Covered in full Primary care visit to treat an injury or illness $40 copay Specialist care visit $60 copay Prenatal and post-natal care Page 1 of 11

2 Covered Medical Benefits Doctor Home and Office Services (continued) Other practitioner visits: Retail health clinic $40 copay On-line visit $40 copay Chiropractor services Limited to 26 visits per benefit period (does not include manipulation by a professional provider other than a chiropractor). OON NOT covered. $40 copay Not Covered Other services in an office: Allergy testing $40 copay Chemo/radiation therapy Hemodialysis Prescription drugs Page 2 of 11

3 Covered Medical Benefits Diagnostic Services Lab: Freestanding/Reference Labs Covered in Full 30% coinsurance after Office (Office cost share applies only when Freestanding /Reference lab is not used) Outpatient hospital X-ray: Office Freestanding radiology center Outpatient hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding radiology center Outpatient hospital Page 3 of 11

4 Covered Medical Benefits Emergency and Urgent Care Urgent care (office setting) $60 copay Emergency room facility services $250 copay and 20% coinsurance Same as In Network Emergency room doctor and other services Ambulance (air and ground) Same as In Network Same as In Network Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit $40 copay Facility visit: Facility fees Doctor services Outpatient Surgery Facility fee: Freestanding surgical center Hospital Doctor services: Freestanding surgical center Hospital Page 4 of 11

5 Covered Medical Benefits Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fee (for example, room & board) Doctor and other services Recovery & Rehabilitation Home health care Limited to 100 visits; limit does not apply to separate Physical, Occupational or Speech Therapy limits, when performed as part of Home Health. Limit does not include I.V. therapy. Limit is combined in-network and out-of-network. $40 copay Rehabilitation services (for example, physical/speech/occupational therapy): Office $40 copay Outpatient hospital Physical and Occupational Therapy limited to 20 visits each per benefit period across all outpatient settings; combined In and Out of Network. Speech Therapy is unlimited. Cardiac rehabilitation Office $60 copay Outpatient hospital Limited to 36 visits across outpatient and other professional visits. Limit is combined innetwork and out-of-network. Skilled nursing care (in a facility) Limited to 150 combined days per benefit period for Physical Medicine, Rehab and Skilled Nursing Facility. Limit is combined in-network and out-of-network. Durable medical equipment & prosthetics Page 5 of 11

6 Covered Prescription Drug Benefits Retail Prescription Drug Coverage This plan uses a Anthem National Drug List. Drugs not on the list are not covered. Home Delivery copays are 2.5 times retail copays and select drugs are available for up to a 90 day supply. Deductible Your prescription drug applies to Tiers 2,3, and 4 only,and is combined innetwork and out-of-network if your plan includes out-of-network coverage. Prescription Deductible (Member) : $500 Prescription Deductible (Family) : $1,000 Drug tier 1 - Typically Generic $15 copay 50% coinsurance Drug tier 2 - Typically Preferred / Formulary Brand $35 copay after Drug tier 3 - Typically Non-preferred/Non-formulary and Specialty Drugs $70 copay after Drug tier 4 - Typically Specialty Drugs 25% coinsurance after Drug tier 4 per-prescription maximum cost share $250 None Page 6 of 11

7 Covered Vision Benefits This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, 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. Children s vision services count towards your out of pocket limit. For children through age 18, there is a selection of frames and contact lenses that are covered under this plan. Review the formal contract of coverage or contact your vision provider for more information. For covered services with a reimbursement amount, you will have no cost share up to that amount. All costs beyond the reimbursement amount are subject to balance billing. Children's Vision Essential Health Benefits Vision exam $0 copay $30 reimbursement Frames $0 copay $45 reimbursement Lenses Single $0 copay $25 reimbursement Bifocal $0 copay $40 reimbursement Trifocal $0 copay $55 reimbursement Elective Contact Lenses $0 copay $60 reimbursement Non-Elective Contact Lenses Covered in full $210 reimbursement Page 7 of 11

8 Covered Vision Benefits Adult Vision Essential Health Benefits Vision exam Not covered Not covered Frames Not covered Not covered Lenses Single Not covered Not covered Bifocal Not covered Not covered Trifocal Not covered Not covered Elective Contact Lenses Not covered Not covered Non-Elective Contact Lenses Not covered Not covered Page 8 of 11

9 Covered Dental Benefits This is a brief outline of your dental coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, 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. Children s dental services count towards your out of pocket limit. Children's Dental Essential Health Benefits Diagnostic and preventive 10% coinsurance after 10% coinsurance after Basic services Major services Medically Necessary Orthodontia services Cosmetic Orthodontia services Not covered Not covered Deductible (Applies to all services) Combined with Medical Combined with Medical Out-of-Pocket Limit Combined with Medical Combined with Medical Adult Dental Essential Health Benefits Diagnostic and preventive Not covered Not covered Basic services Not covered Not covered Major services Not covered Not covered Deductible Not covered Not covered Out-of-Pocket Limit Not covered Not covered Page 9 of 11

10 Notes: Deductible(s) apply to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the does not apply to Emergency Room Services where a copayment and percentage (%) coinsurance applies and may not apply to some Behavioral Health services where coinsurance applies. This plan has an embedded which has a single and family ; the single is embedded in the family. The family can be met by any combination of amounts from any/all covered family members but one member is required to meet the single. 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 your plan includes out of network benefits and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. Your copays, coinsurance and count toward your out of pocket amount. All medical and prescription drug s, copayments and coinsurance apply toward the out of pocket maximum (excluding preventive services that meet the requirement of federal and state law received in network and Non Network Human Organ and Tissue Transplant (HOTT) Services ). Benefit period refers to calendar year. Primary Care Physician (PCP) is a professional provider who is a practitioner who specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other professional provider as allowed by the plan. Specialty (SCP) is a professional provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. Emergency Room Charges for both in-network & out of network share the same in-network cost shares. Out-of-Network s may also bill you for any charges over the Plan s Maximum Allowed Amount. If admitted to the hospital the copayment is waived. Wigs and scalp hair prosthetics - Covered 1 per benefit period after cancer treatment. Limit is combined in-network and out-of-network. The copayment for a single chiropractic service will not be more than 50% of the total cost of that service. Covered in Full (CIF) means you will not have to pay, copayment and/or coinsurance cost shares up to the maximum allowable amount. Your cost share for a Live Health OnLine web visit will be equal to your PCP cost share but will not exceed $49. Covered accidental dental services are covered up to $3000 per accident. In-network and out-of-network s, copayments, coinsurance and out-of-pocket maximum amounts are separate and do not accumulate toward each other. Page 10 of 11

11 No Copayment or Coinsurance applies to certain diabetic and asthmatic supplies when you get them from an In-Network Pharmacy. These supplies are not covered if you get them from an Out-of-Network Pharmacy. Diabetic test strips are covered subject to applicable Prescription Drug Copayment / Coinsurance. Covered 4th Tier specialty drugs obtained through home delivery are limited to a 30 day supply. Covered dependents are covered through the end of the month in which the child attains age 26. A Specialist copayment is applicable to care provided by Specialists, excluding Physical Therapy in the Office setting, General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or other Network as allowed by Plan. Covered private duty visits rendered in the home are limited to 82 visits per benefit period and 164 visits per lifetime. Covered in network Hospice services are covered in full and are subject to any applicable. If you select a brand drug when a generic equivalent is available, you will be responsible for the generic copay plus the cost difference between the generic and brand drug. If the physician indicates no substitutions for your prescription, you will only be responsible for the Tier 1, 2 or 3 brand drug copays. For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. In Missouri, (excluding 30 counties in the Kansas City area) Anthem Blue Cross and Blue Shield is the trade name of RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees 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. I have reviewed the above summary of benefits and understand that it is intended to be an abbreviated outline of coverage. The Group s benefits and exclusions are set forth in their entirety in the Certificate of Coverage. I understand that in the event of a conflict between the Certificate of Coverage and this description, the terms of the Certificate of Coverage will prevail. Authorized group signature (if applicable) Date Underwriting signature (if applicable) Date Page 11 of 11

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