Your Plan: Anthem Premier Guided Access gvja Your Network: HMO Blue New England 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 Overall 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 the calendar year. 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 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: $2,000 For Family: $4,000 Member: $2,000 For Family: $4,000 Member: For Family: Non- Covered Member: For Family: Non- Covered Primary care visit to treat an injury or illness $15 copay Specialist care visit $35 copay Maternity: Post-natal visits Prenatal visits are covered in full. Other practitioner visits: Retail health clinic Chiropractor services $10 copay $15 copay Other services in an office: Allergy testing Chemo/radiation therapy Hemodialysis Prescription drugs $10 copay 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 1 of 6
Covered Medical Benefits Diagnostic Services Lab: Freestanding lab X-ray: Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Freestanding radiology center Emergency and Urgent Care Emergency room facility services $150 copay + 0% coinsurance Same as in-network Emergency room doctor and other services Same as in-network Ambulance (air and ground) Same as in-network Urgent care (office setting) $35 copay Same as in-network Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit $15 copay Facility visit: Facility fees Doctor and other services 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 2 of 6
Covered Medical Benefits Outpatient Surgery Facility fee: Hospital Freestanding ambulatory surgical center $125 copay Doctor and other services Hospital Freestanding ambulatory surgical center Covered In full 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 $15 copay Rehabilitation services (for example, physical/speech/occupational therapy): Limited to 20 visits each for Physical, Occupational and Speech Therapy. Visit limits are combined across outpatient and other professional visits. $15 copay Cardiac rehabilitation $35 copay Skilled nursing care (in a facility) Limited to 100 days. Durable medical equipment & prosthetics 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 3 of 6
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 $5 copay Drug tier 2 $30 copay Drug tier 3 Greater of 25% coinsurance - $60 copay Drug tier 3 per-prescription maximum cost share (in-network only) $250 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 4 of 6
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 your 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) Available only if the contact lenses benefit is not used. Elective contact lenses (once every calendar year) Contacts are available only if the eyeglass lense benefit is not used. Adult Vision Vision exam (once every calendar year) $20 copay Frames (once every other calendar year) $0 copay, $130 frame allowance Lenses (once every calendar year) Available only if the contact lenses benefit is not used. $20 copay Elective contact lenses (once every calendar year) Contacts are available only if the eyeglass lense benefit is not used. $0 copay, $80 allowance 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 5 of 6
Notes: Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary Care Physician for select covered services. All medical services subject to a coinsurance are also subject to the annual medical deductible with exception of facility emergency room charge, non-surgical charges (diagnostic lab/x-ray, supplies, etc.) rendered in a free standing surgical facility. 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. If your plan includes a Site of Service benefit option, you can save money on in-network lab tests and outpatient surgery. The cost listed for ambulatory surgery applies to Site of Service locations visit anthem.com/siteofservicenh or view your SBC for plan details. To view your prescription formulary list log on to www.anthem.com/health insurance/customer care/forms library For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. Exclusions and Limitations: The services listed below are not covered by this plan. Complete details on exclusions and limitations are stated in the Subscriber Certificate. Any service that is not medically necessary Any service required by a third party (court ordered services are covered if all of the other terms of the plan are met) Cosmetic surgery Custodial or convalescent care Educational testing and therapy Experimental and/or investigational services except as required by law for clinical trials Hospitalization for conditions that are not covered Human organ transplants other than those listed in the Subscriber Certificate as Covered Services Mental health services which do not usually result in favorable modification through therapy Miscellaneous devices, materials, and supplies, including, but not limited to, dentures and support devices for the feet and corrective shoes Permanent dental restoration, most oral surgery (general anesthesia, hospital or surgical day care facility charges for dental procedures are covered for certain individuals only to the extent required by law) Personal comfort items Radial keratotomy or other surgery to correct vision Routine podiatry Services covered by government programs to the extent permitted by law Services for workrelated illness or injury Sex changes Services, treatments, procedures or programs for weight or appetite control, weight loss, weight management or control of obesity, except for diabetes education, nutrition counseling, and medically necessary surgical and non surgical services to treat diseases and ailments caused by or resulting from obesity or morbid obesity Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. 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. 12Q3 NH-HNE-T2bP1-R-NA-O-1-1-2014 Page 6 of 6