anthem_med_ppo 250_plan summary_2015_9292015_34134_pm

7/17/2019 Anthem_MED_PPO 250_Plan Summary_2015_9292015_34134_PM

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Y

Modiied Classic PPO

is uary o Beneits is a brie oerie o your plan's beneits only e beneits listed are or bot in state and out o stateebers tere ay be dierences in beneits dependin on ere you reside For ore detailed inoration about te beneits inyour plan please reer to your Certiicate o nsurance or idence o Coerae (OC) ic eplains te ull rane o coered

serices as ell as any eclusions and liitations or your planI g , mm f , w. vw h fm w f f v v. v Sv hv mxmm v / m . Th m f v/ w f h v w g mg h f v / , g f whh h m.m f v h mxmm. mxmm h m fm . f m, , m, x f h .

ubject to Utilization eie

planation o Maiu Alloed Aountxmm w m h mm h f v v v fm g Ngv. I h m w h v v m wh , m .

v—Th h v h g mm f v v. m f h ffw h v hg & h mxmm w m.

N v— mg , mm m : hm f h, g wh hv, fm fm h v, hg. m f h ff w h v hg &h mxmm w m.

Emg Ng v Ng H, mm h m v. m m f m x f h m v.

h g N h Hh v, mm f ff w h v x & hg, w & g .

Calendar year deductible or all proiders $250/mm; $750/fm

Additional deductible or non-Ante Blue Cross PPO ospital orresidential treatent center i utilization reie not obtained

$500/m

Deductible or eerency roo serices $150/v

Annual Out-o-Pocket Maius £ v & h Hh v $2,250/mm; $4,500/fm£ N v $6,500/mm; $13,000/fm

Th fwg f mxmm: v x. f f mxmm m f m g g , h v mm fm w g q f m g v x f h m f h . Th mm m f v x.

Lietie Maiu m

Coered erices PPO Per Meber Copay on-PPO Per Meber Copay†

Preentie Care ericesvv Sv g*, h xm, vvg V V vv fwm v f h g h HhR Sv m.*Th xhv. Th f vv Sv q f w.

N

30%

Pysician Medical erices£ ff & hm v $20/v

‡30%

£ H & g f v 10% 30%

£ Sg & g ; hg h 10% 30%

£ g m m v

10% 30%

Diabetes ducation Proras ‡

NTINE N NEXT GE




£ Th mm & h fm h , h mgm f h & fmgm g

$20/v

30%

£ Pysical erapy Pysical Medicine Occupationalerapy

10% 30%

£ Ciropractic erices $20/v

30%

peec erapy10% 30%

Acupuncture£ Sv f h m f ,

$20/v

30%

Dianostic -ray Lab£ h g x & 10% 30%

Adanced ain 10% 30%

8 Urent Care

$20/v

30%

erency Care£ Emg m v &

10% 10%

£ h v 10% 10%

ospital Medical erices £ Smv v m, m v &

10% 30%

£ m , g v &

10% 30%

killed ursin Facility £ Smv m, v &

10% 30%

elated Outpatient Medical erices upplies£ G m , v &

10% I mg wh

h f: 10%;Nmg: 30%

£ f, g & h f & §

20% 20%

£ g §

20% 20%

Abulatory urical Centers £ g, v & 10% 30%

Prenancy Maternity Care£ h ff v $20/v‡

30%

£ g f v 10% 30%

Nm v, , m f g & Rf h h & H Sv ff h h vg.Mental or erous Disorders and ubstance Abuse£ I f

10% 30%

£ I h v 10% 30%

£ f 10% 30%

£ h ff v

$20/v ‡

30%

Durable Medical uipent £ R h f E

10% 30%

NTINE N NEXT GE




oe ealt Care £ Sv & fm hm hh g

10% 30%

oe nusion erapy £ I m, v & ; gv

g & v v m h; mqm; v

10% 30%

eodialysis£ hm v & 10% 30%

ospice Care£ I v; fm vm v N

30%

Bariatric urery [] [] £ I v v wh m

g f wgh , f m

10% N vƒ

£ Tv x f h, f g

N

N vƒ

Oran issue ransplants [] [] £ I v v wh vgv

g

10% N vƒ

£ T v x f h, f

N

N vƒ

£ h, m $30,000

Prostetic Deices£ vg f h; h v

mh f g; g m; f m ; hf f g wh q

f g; & h h & f mm wh

10% 30%

f h m h w h wh h mm v v. If h h v h v , h mm h m f wh wh f, f . m f , hg whh x v x.I h f v, vg m f, g h mm hm . Th f v h mm f f w. Th m h q m g f v h ,v f h m w h . If h mm h h qm, w w h f m hqm.

Th Smm f f h m wh f qm, g v f h f hh fm w. w v g f h w hh fm w fm h .S. m f Hh Hm Sv, m f I Rv Sv, w m q m hg h mm f f. Th f mm h v f h f m f I h f m f gHh .

† Th g f mg v fm Nhm v h h m.

Th h v f. f v fm ff .., X, , g, f .

Th v m h w h wh h mm v v.

Ex: If v fm f Ex E f f f S Sf f f, h v w v m h w f.

†† v h f m ; v vw m vg h v.



Exclusions and Limitations

Not Medically Necessary. Sv pp h , f

Exerimental or Inestigatie. A p vv p B, f b bf b h h q p vv, h b q p vw, b h Cf

Outside te United tates. Sv pp fh b b pv h S, h v pp fh wh

rime or Nuclear Energy. C h f (1) h b' f p f, j f f v; (2) f , whh h f w, wh v f vb f h f j f h f

Not oered. Sv v bf h b' ffv Sv v f hb' v , p pf v h Cf

Excess mounts. A f v p bf

Work-Related. f bf v b v, h bj, hw, w' p, p' b w p w, whh h b h bf f h p f b whh bf b v f h p w' p, w w pv h bf f h p f h , bj h f v b Cf b C S 4903, pf v hCf

Goernment Treatment. A v h b v h w pvb , f v , p wh p h p pq b f w w v p f h v f h b q p f h h v h b f f

erices o Relaties. Pf v v f p v h b' h wh h b b b , p pf v h Cf

Voluntary ayment. Sv f whh h b h b p, f whh hw b h b f v h hh p v, p vv v hb h hp Sh hp h fw:1 b w b v h;2 10% f b b p h p ;3 h f f h h f p fp ;4 p p wh b p; 5 wh f p hv h hp' h

Not eciically Listed. Sv pf h p v v

riate ontracts. Sv pp pv p pv bw h b pv, f whh b p phb, pf S 1802(42 SC 1395) f X f h S S A

Inatient Diagnostic Tests. p b h wh hp p f whh hv b pf f p b

Mental or Nerous Disorders. A , , v b b, hbv h , p pf v h C f

Nicotine Use. S p f b f h p ff wh Ah S p pf v h C Cf

Ortodontia. B, h h pp h v

Dental erices or ulies. F , f , p pfbw " " b pvv f ; , pp, pp, p p; h h, jwb , b :1 , , p f h; 2 Sv pv h pp h fw:1 Sv whh w q b w v; 2 Sv pf v h b;3 v pp h h f hp h /

Hearing ids or Tests. h , p pf v hCf

Otometric erices or ulies. p v, hp f, pf v h Cf , p pf v h Cf

Outatient Occuational Teray. p p hp, p b h hh ,hp, h f hp pv, pf v h Cf

Outatient eec Teray. p ph hp, p pf v hCf

osmetic urgery. C h v pf f bf hp ( ) f h b pv pp h pp v (h , pf f b vp b, , j f h pp f pv b f p pp), pf fw C b v b f ph ph

ommercial Weigt Loss rograms. h p, whh h p pv, pf v h h ,b , wh p (h h, J C, A h )

f p h pp f bb v , bhv f p f h f v b v S f b b v b hCf

terilization Reersal.

Inertility Treatment. A v pp fh wh h f f, , b , , , f , v f, v fp f

urrogate Moter erices. F v pp pv p v h p wh p (, b , h b f h b hw f f p)

Ortoedic soes and soe inserts. h pp hp fw p f b, h h h p, hp h f p b, pf h C/Cf

ir onditioners. A pf, hf

ustodial are or Rest ures. p b h wh hp p f v h ph hp Sv pv b h, h f h, h f Sv pv b f , p pf v h Cf

linical Trials - Sv pp wh , p pf v h Cf C

Healt lu Memersis. h b bhp, qp, h f phf p , h h f v, qp f fvp ph f, v f b h pp hh p

ersonal Items. A pp f f, h bf

Education or ounseling. v , p pf v h Cf h pp f h f v b v

ood or Dietary ulements. / pp, p pv h q b w h , b , h f pp h b ph v h , whh b w q h wpp p b ph

Teleone and acsimile Macine onsultations. C pv b ph fh

Routine Exams or Tests. ph whh ,j , h q b p v h, p pf v h Cf

cuuncture. Ap , p pf v h Cf Ap p, p hh b pp p pf f h b b p p

Eye urgery or Reractie Deects. A p f h pp f fv f f h h h (p) / C

q f h ysical Teray or ysical Medicine. Sv f ph f ph hp ph, p wh pv v p f pf v hCf

Outatient rescrition Drugs and Medications. p pp , p pf v h C f A pp, vh p pp C, hh b

ecialty armacy Drugs. Sp ph h b b f h pph p, b, whh b f ph, v b h p bw hv p h f f h p ph b f ph hh hv b b f h p ph p

ontracetie Deices. Cpv v pb f bh p pf v h Cf

Diaetic ulies. Pp pp b pp p pf v h Cf

riate Duty Nursing Pv v

Liestyle rograms. P ' f whh b ,, h w pp hb p ppvb

Varicose Vein Treatment. f v v v (p v) b h ( hp h ) wh v f pp

Wigs.

Tird arty Liaility — Ah B C f h Cp b f bf p f h b v f b h p

oordination o eneits — h bf f h p b f h b h h phh v h h v v f p v 100% f h v p

®

anthem_med_ppo 250_plan summary_2015_9292015_34134_pm

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