hsa sms prem

7/28/2019 Hsa Sms Prem

1/17

MOBR80011SPL (9/10)

Our plans fit your plans

Lumenos HSA PlusSmartSense Plus

Premier Plus

Individual and Family Health Care Planfor Missou


2/17

Our plans fit the

way you live.In a world thats constantly changing, one things for certain:its important to have health care coverage you can dependon -- coverage designed to help fit your budget, and your wayof life.

For over 70 years, Anthem Blue Cross and Blue Shield hasprovided health care coverage and security to our Missourineighbors. And now, were pleased to offer these sameIndividual health care plans with added benefits and featureof the Patient Protection and Affordable Health Care Act.

Youre in charge of your health and budget, and our Individu

health care plans help keep it that way. We still offer a widerange of coverage options as unique as you are. And if youhave any questions, were here to help.

Sounds like a plan.

Experience you can rely onAnthem is committed to helping simplify your life and improvinyour health. Thats why we offer:

One of the largest provider networks in Missouri. Withmore than 10,500 doctors and specialists and over 125hospitals throughout the state, chances are your doctor is in

one of our networks. A choice of plans to help fit your budget and lifestyle. No

matter where you are in life, weve got a plan designed to hefit your health coverage needs, as well as your budget.

Optional dental and life insurance. To enhance your health, walso offer dental and term life coverage and make it easy toenroll.

Coverage that travels with you. No matter where life takes yoyour health coverage goes with you. And network providers ithe BlueCard program across the country will help make iteasy to get access to the care you need.

ConditionCare to provide one-on-one help from trained

professionals in managing chronic conditions like asthma,diabetes, coronary artery disease, chronic obstructivepulmonary disease and heart failure.

Future Moms, a program designed to help you have a healthpregnancy. While not maternity coverage, Future Momsprovides educational materials, certain screenings and 24/7phone access to registered nurses.

Why do you need health

care coverage?These days, a single day in the hospital can costthousands of dollars. The financial risk you take

without health coverage just isnt worth it. Not

only does health care coverage help you stay

healthy, it also gives you added security, because

you know youre protected against the high cost of

unexpected medical bills.

1


3/17

Cost-Sharing: The costs of medical care today can bestaggering. Health care coverage from Anthem can helpprotect you against these high costs. With most health care

coverage, you pay a monthly premium, then you share someof the cost of covered medical care with the company thatprovides your health care coverage. The level of cost-sharingyou choose directly impacts your premium amount. The moreyou are willing to share in the costs, the lower your premium.With Anthem, you can choose your level of protection and thelevel of cost-sharing that works best for your health care needsand budget.

Deductible is the amount you have to pay each calendaryear for covered services before your health care plan startspaying. For some services, the plan will even begin to paybefore the deductible is met. Usually, the higher a plans

deductible, the lower the premium. In some cases, you mayalso have a separate deductible for certain services such asprescription drugs.

Coinsurance is the percentage of the cost of coveredservices that you will be responsible for, after your annualdeductible is met. With some plans, you have a choice ofcoinsurance levels. Much like your deductible, selecting ahigher coinsurance typically lowers your monthly premiumbecause it increases your share of the cost.

Copayment is a specific dollar amount you have to pay forcertain covered services.

Out-Of-Pocket Maximum is the most that you would payin a calendar year for deductible and coinsurance for networkcovered services. Once you reach this maximum, the plan pays

at 100% for most covered services for the rest of the calendaryear.

Prescription Drugs are medications that must beauthorized for use by your doctor. Anthem offers varyinglevels of prescription drug coverage. Depending on the plan,you may have coverage for generic drugs or generic andbrand name drugs.

Generic Drugs are prescription drugs that typicallyhave been in use for some time and can be manufacturedand distributed by numerous companies, so their cost isusually much lower. Generic drugs must, by law, contain thesame active ingredients as their brand name equivalent and

have the same clinical benefit.

Brand Name Drugs are prescription drugs that aremanufactured and marketed under a registered name. Theyare usually patented and may be exclusively offered bycertain manufacturers.

Tiers represent a cost level within the generic and brandname prescription drug categories. The prescription drugcoverage under your health care plan will differ for each ofthese tiers. Not all products have this tiering.

Tier 1: Generally includes generic drugs and a few lower costbrand name drugs.

Tier 2: Generally includes higher cost generic and brandname drugs.

Tier 3 and 4: Highest cost brand name drugs.

Formulary is a list of prescription drugs our health careplans cover. They include generic and preferred brand namedrugs that have been rigorously reviewed and selected bya committee of practicing doctors and clinical pharmacistsfor their quality and effectiveness. Weve negotiated lowerprices on these formulary drugs, so youll save when yourdoctor prescribes medication from our formularies. Therecan be different formularies for different health care plans.Formulary lists can be found at anthem.com.

Health Savings Account (HSA) is a special bankaccount that can be set up by a member enrolled in aqualified HSA-compatible high-deductible health plan.Contributions to this account can be made with certaintax advantages and funds from the account can be usedfor qualified health care expenses. See the insert from ourpreferred banking partner for more details and consultyour tax advisor.

Network Discounts: With Anthem, you haveaccess to some of the largest provider networks inthe state. These network (or participating) providershave agreed to accept lower costs for their coveredservices to Anthem members similar to volumediscounts. These negotiated costs help reduce theoverall cost of covered medical services, including yourshare of those costs.

This is true whether you are paying the entire cost forcovered services (such as while you are meeting yourdeductible), or whether we are sharing the cost. Withover 10,500 doctors and more than 125 hospitals,chances are your provider already participates. Just

visit a network provider to take advantage of thesavings.

With our PPO plans, you can always choose to receiveservices outside the network, but your share of thecost will be greater.

Some definitions so were all on the same page


4/17

Lumenos HSA PlusIs this the right plan for you?

Prescription Drug CoverageLumenos HSA Plus not only puts you in charge of yourhealth care dollars, it can help you use those dollars fogeneric and brand name prescription drugs in the waythat best suits you.

Once your deductible is met, there is a coinsurance,if applicable, for covered prescription drugs. But evenwhile you are meeting your deductible, you benefit fromlower negotiated rates on prescription drugs at networkpharmacies nationwide. Theres no need to have adifferent deductible or copayment for prescriptions; it al

works as one.

And since you decide how to spend it, your Health SavingsAccount dollars can be used to pay for prescriptiondrugs -- either while you are meeting your deductible, oafterward for those drugs not covered, like most over-thecounter medications.

How to Customize yourLumenos HSA Plus PlanChoose your deductible: You can usually lower youpremium by choosing a higher deductible. Simply choosethe deductible and premium combination that works bestfor you. Remember, any covered member can contributeto some or all of the policy deductible and out-of-pocketmaximum, whether the policy covers one member or awhole houseful.

Use your Health Savings Account the wayyou want: Your HSA, if you choose to open one, isfunded by you. So, it is yours to use for qualified healthcare expenses covered by the plan, or those not covere

at all, like contact lenses. Your HSA is also yours to keeif you ever leave the plan; you wont lose those dollars itheyre not used. In fact, the carryover from year to yeacan help you save for future financial needs. See theenclosed insert from our preferred banking partner formore information.

Other Optional Coverage: You can add moreprotection for you and your family by purchasingoptional dental benefits or life insurance. See your BeneGuide and the dental and life information in the back ofthis brochure for more details.

Lumenos HSA Plus Plan HighlightsThis plan offers traditional health coverage benefits thatcan be paired with a Health Savings Account (HSA) formore flexibility and potential tax advantages. Simpleplan designs make using them that much easier.

Features:

Preventive care benefits that help you focus onstaying healthy.

Anthem 360 Health

MyHealth@Anthem: Health assessments,resource centers, and health calculators so you seeprogress and stay motivated.

24/7 NurseLineSM: Health information from aregistered nurse whenever you need it.

MyHealth Coach: Personal help with a wide rangeof health needs, primarily high blood pressure, highcholesterol, low back pain, musculoskeletal issues

like arthritis, and certain types of cancer. Healthy Lifestyles Programs: Our proven

Tobacco-Free and Healthy Weight programs helpyou adopt new habits for a healthy lifestyle withpersonalized support and educational resources.

SpecialOffers@AnthemSM: Members-only discountshelp you stretch your health account even furtherwith savings on services and products that promotea healthy lifestyle.

You should know: Maternity benefits are not available with this plan.

Your Lumenos HSA Plus plan has a policy-leveldeductible and out-of-pocket maximum. Onceany combination of covered members on thepolicy meet these amounts, the plan pays 100%of covered expenses. Its that simple.

While Lumenos HSA Plus is compatible with aHealth Savings Account, your health care planworks with or without it. You may set up the HSAnow, later, or not at all. It's your choice.

Lumenos HSA Plus health plans were designed to giveyou more control over your health care costs. They helpyou focus on getting healthy and staying that way.

3


5/17

Benefit Guide forMissou

Benefits

Calendar Year Deductible

IndividualNETWORK:

NON-NETWORK:

Family

NETWORK:

NON-NETWORK:

Network Coinsurance Options

Calendar Year Out-of-PocketMaximum

IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:

How family deductibles and familyout-of-pocket maximums work

Plan Lifetime Maximum

Covered Services

Doctors Office Visits

Professional and DiagnosticServices(X-ray, lab, anesthesia, surgeon, etc.)

Inpatient Services(overnight hospital/facility stays)

Outpatient Services(without overnight hospital/facility stays)

Emergency Room Services

Preventive Care Services

Maternity

Optional Coverage(at additional cost)

Prescription Drug Coverage

Retail Drugs (and Mail Order

Drugs when available)

Optional Drug Coverage(when available)

Other Covered Benefitsinclude but are not limited to:

IMPORTANT: This Benefit Guide is intendedto be a brief outline of coverage and is notintended to be a legal contract. The entireprovisions of benefits, limitations andexclusions are contained in the Contract/Certificate of Coverage. In the event of aconflict between the Contract/Certificateof Coverage and this Benefit Guide, theterms of the Contract/Certificate ofCoverage will prevail.

Lumenos HSA Plus

Your Choices

$1,500 $1,500 $1,750 $2,500 $3,500 $5

$1,500 $1,500 $1,750 $2,500 $3,500 $5

$3,000 $3,000 $3,500 $5,000 $7,000 $11

$3,000 $3,000 $3,500 $5,000 $7,000 $11

0% 40% 20% 0% 0%

Add Your Chosen Deductible to the Amount Below

$0 $2,500 $3,250 $0 $0

$1,500 $6,500 $8,250 $2,500 $3,500 $5

$0 $5,000 $6,500 $0 $0

$3,000 $13,000 $16,500 $5,000 $7,000 $11

For family coverage, either one or more members must meet the family deductible before any covered services that are subject to deductible will be pby the plan. The family out-of-pocket maximum can be met by either one or more members. Once the maximum is met, no additional coinsurance will brequired for the family for the remainder of the calendar year.

Unlimited

Your Share of Costs(after deductible, unless waived or not subject to deductible)

NETWORK: 40%, 20% or 0% Coinsurance1

NON-NETWORK: 50%, 40% or 30% Coinsurance1









Covers all nationally recommended preventive care services, including well-child care, immunizations, PSA screenings, Pap tests, mammograms, and m

NETWORK: 0% Coinsurance; not subject to deductible


Not Covered

Dental, Life

Lumenos HSA Plus



Not Available

Ambulance, Chiropractic, Durable Medical Equipment, Home Health Care, Hospice Care, Mental Health, Organ Transplants, Rehabilitation Facilities, SkiNursing Care, Substance Abuse, Therapy Services, Urgent Care

1Coinsurance is designated by the plan you choose.

NOTE: Network and non-network deductibles are separate and do not accumulate towards each other. Network and non-network out-of-pocket maximare also separate and do not accumulate towards each other.


6/17

SmartSensePlus Is this the right plan for you?

Prescription Drug CoverageSmartSense Plus includes coverage for generic andselect brand name drugs.

For an additional cost, you can upgrade the SmartSensePlus prescription benefit to expand the coverage for mobrand name drugs. There is a separate deductible forthe brand name drugs when you choose the prescriptiondrug upgrade.

See your Benefit Guide for more details.

How to Customize yourSmartSense Plus PlanWith SmartSense Plus, you have some choice andflexibility to change the plan to better meet your needs.SmartSense offers a choice of:

Deductible: You can usually lower your premium bychoosing a higher deductible. Simply choose the deductiband premium combination that works best for you.

Prescription Drug Benefit: You can customize youplan by selecting the optional prescription drug upgradeas described above.

Dental Coverage and Life Insurance: Addprotection for your smile and your wallet. See your BeneGuide and the dental and life information in the back ofthis brochure for more details.

SmartSense Plus was designed to offer affordable, solidprotection without a lot of bells and whistles that maynot be important to you.

SmartSense Plus Plan Highlights

SmartSense Plus offers affordable price options,solid protection that covers essentials and evensome immediate benefits before the deductible.

Features: Immediate coverage with predictable

copayments for the first three Doctors OfficeVisits, per plan member, each calendar year.

Preventive care benefits that help you focus onstaying healthy

Choice of prescription drug coverage options.

5

You should know: Maternity benefits are not available with

this plan. After the first three Doctors Office Visits, all

other visits apply to your deductible.

Generic and select brand name drugs arealso available before the deductible, with acopayment or coinsurance.


7/17

Benefit Guide forMissou

Benefits


IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:



IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:



Covered Services

Doctors Office Visits






Maternity

Optional Coverage(at additional cost)


Retail Drugs (and Mail OrderDrugs when available)

Optional Drug Coverage

(when available)


IMPORTANT: This Benefit Guide is intendedto be a brief outline of coverage and is notintended to be a legal contract. The entireprovisions of benefits, limitations andexclusions are contained in the Contract/Certificate of Coverage. In the event of aconflict between the Contract/Certificateof Coverage and this Benefit Guide, the

terms of the Contract/Certificate ofCoverage will prevail.

SmartSensePlus

Your Choices

$500 $1,000 $1,500 $2,500 $3,500 $5,000 $

$500 $1,000 $1,500 $2,500 $3,500 $5,000 $

$1,000 $2,000 $3,000 $5,000 $7,000 $10,000 $

$1,000 $2,000 $3,000 $5,000 $7,000 $10,000 $

30% 30% 30% 30% 30% 30%


$5,000 $5,000 $5,000 $5,000 $5,000 $5,000

$7,500 $7,500 $7,500 $7,500 $7,500 $7,500

$10,000 $10,000 $10,000 $10,000 $10,000 $10,000 $

$15,000 $15,000 $15,000 $15,000 $15,000 $15,000 $

Each family member has an individual deductible and out-of-pocket maximum. The family deductible and out-of-pocket maximum can be satisfied by 2more members. No one person can contribute more than their individual deductible or out-of-pocket maximum.

Unlimited

Your Share of Costs(after deductible, unless waived or not subject to deductible)

NETWORK: Office Visit Copayment for first 3 visits: $35 Copayment,deductible waived, for first 3 visits per person per calendar year for primary care physician/spe

Other office services are subject to deductible and coinsurance. Office Visit Coinsurance for 4+ visits and Other Services: 30% Coinsurance

NON-NETWORK: 50% Coinsurance

NETWORK: 30% Coinsurance









NETWORK: 0% Coinsurance; not subject to deductible


Not Covered

Dental, Life

SmartSense Plus

Standard Drug Coverage:NETWORK: For Drugs on Formulary: Greater of$15 Copayment or 40% CoinsuranceFor Drugs Not on Formulary: Member is responsible for entire cost after applied Anthem negotiated discount.

NON-NETWORK: For Drugs on Formulary: Greater of$15 Copayment or 40% Coinsurance Member is also responsible for difference between Anthem allowable amount and actual cost of drug.For Drugs Not on Formulary: Member is responsible for entire cost.

Upgrade Drug Coverage:

Separate $250 per person deductible for Tiers 2, 3 and 4. If Generic drug is available, member is responsible for the difference in allowable charge betwbrand and generic, plus copayment or coinsurance.NETWORK: Tier 1 Drugs: Retail (30 day supply): $15 Copayment; Mail Order (90 day supply): $30 Copayment Brand Name Drugs (Tiers 2, 3, and 4): Greater of$30 Copayment or 40% Coinsurance for both Retail (30 day supply) or Mail Order (90 day supply) Tiers 2, 3 and 4: $4,000 annual Prescription Drug out-of-pocket maximum per person

NON-NETWORK:50% Coinsurance(minimum $60) per prescription. Mail Order and Specialty Drugs not covered.

Ambulance, Chiropractic, Durable Medical Equipment, Home Health Care, Hospice Care, Mental Health, Organ Transplants, Rehabilitation Facilities, SkiNursing Care, Substance Abuse, Therapy Services, Urgent Care



8/17

Prescription Drug CoveragePremier Plus offers broad prescription drug coverage,including benefits for generic and brand name drugs.There is a separate deductible for brand name drugs.

You also have the choice to upgrade your prescriptiondrug coverage to remove the separate deductible andhave more predictable cost-sharing amounts.

For an additional cost, you can choose to eliminate theseparate prescription drug deductible. See your BenefitGuide for more details.

How to Customize yourPremier Plus PlanWith Premier Plus, you have some choice and flexibility tchange the plan to better meet your needs. Premier offea choice of:

Deductible: You can usually lower your premiumby choosing a higher deductible. Simply choose thedeductible and premium combination that works bestfor you.

Coinsurance: At certain deductible levels, you have achoice of a percentage coinsurance or, for most care, nocoinsurance at all and coverage at 100% after satisfyingyour deductible. The zero coinsurance option will increasyour levels of coverage but also your premium if youchoose it.

Doctors Office Copayment: You can lower yourmonthly premium cost by choosing to remove the doctooffice copayment and instead apply those visits to your

policy deductible. After your deductible is met, you woulpay a coinsurance amount for doctor visits if you choosethis option.

Other Optional Coverage: You add more protectiofor you and your family by purchasing optional maternitybenefits, dental, and life insurance. See your Benefit Guidand the dental and life information in the back of thisbrochure for more details.

Premier Plus Is this the right plan for you?

Premier Plus Plan HighlightsPremier Plus offers robust benefits for bothroutine and unexpected medical care. The lowest

levels of coinsurance across all deductibles givesPremier added value over other plans we offer.

Features: Premier Plus offers an unlimited number

of Doctors Office Visits, with predictablecopayment, before the deductible.

Offers a choice of prescription drug coverageoptions.

Annual vision screening exam with copayment.

Preventive care benefits that help you focus on

staying healthy.

You should know: Maternity benefits are available with this plan at

an additional cost.

Premier Plus has our highest level of benefitsavailable, so the premiums are typically morethan our other plans.

Premier Plus health plans offer the highest level ofbenefits we offer for a variety of services. Great forfamilies or for individuals looking for richer benefits,Premier Plus offers the most benefits before thedeductible of any plan we offer and richer coverage aswell for prescription drugs.

7


9/17

Benefit Guide forMisso

Benefits


IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:



IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:



Covered ServicesDoctors Office Visits






MaternityOptional Coverage(at additional cost)


Retail Drugs (and Mail OrderDrugs when available)

Optional Drug Coverage(when available)


IMPORTANT: This Benefit Guide is intendedto be a brief outline of coverage and is notintended to be a legal contract. The entireprovisions of benefits, limitations andexclusions are contained in the Contract/Certificate of Coverage. In the event of aconflict between the Contract/Certificateof Coverage and this Benefit Guide, theterms of the Contract/Certificate ofCoverage will prevail.

Premier Plus

Your Choices

$500 $1,000 $1,500 $2,500 $3,500 $5,000

$500 $1,000 $1,500 $2,500 $3,500 $5,000

$1,000 $2,000 $3,000 $5,000 $7,000 $10,000

$1,000 $2,000 $3,000 $5,000 $7,000 $10,0000%

or 20%0%

or 20% 20%0%

or 20% 0% 0%


$0or $3,000

$0or $3,000 $3,000

$0or $3,000 $0 $0

$7,500 $7,500 $7,500 $7,500 $7,500 $7,500

$0or $6,000

$0or $6,000 $6,000

$0or $6,000 $0 $0

$15,000 $15,000 $15,000 $15,000 $15,000 $15,000

Each family member has an individual deductible and out-of-pocket maximum. The family deductible and out-of-pocket maximum can be satisfied by more members. No one person can contribute more than their individual deductible or out-of-pocket maximum.

Unlimited

Your Share of Costs(after deductible, unless waived or not subject to deductible)NETWORK: Office Visits: $30 Copayment,deductible waived, for primary care physician; $40 Copayment,deductible waived, for specialist;No-Office-Visit-Copayment-Option: (available on $1500/20% and $2500/0%) Office visits 20% or 0% Coinsurance 1

Other Services: 20% or 0% Coinsurance1

NON-NETWORK: 40% or 30% Coinsurance1

NETWORK: 20% or 0% Coinsurance1









NETWORK: 0% Coinsurance; not subject to deductibleNON-NETWORK: 40% or 30% Coinsurance1

Not Covered (see Optional Coverage below)

Dental, Life, Maternity (optional maternity rider available for purchase with $2,500 individual / $5,000 family or greater deductible; subject to 18-montwaiting period and $3,000 professional services / delivery copayment).

Premier Plus

Standard Drug Coverage:Separate $250 per person deductible for Tiers 2, 3 and 4. If Generic drug is available, member is responsible for the difference in allowable charge betbrand and generic, plus copayment or coinsurance.

NETWORK: Tier 1 Drugs: Retail (30 day supply): $15 Copayment; Mail Order (90 day supply): $30 Copayment Brand Name Drugs (Tiers 2, 3, and 4): Greater of$30 Copayment, or 40% Coinsurance for both Retail (30 day supply) or Mail Order (90 day supply) Tiers 2, 3 and 4: $4,000 annual Prescription Drug out-of-pocket maximum per person

NON-NETWORK:

50% Coinsurance (minimum $60) per prescription. Mail Order and Specialty Drugs not covered.Upgrade Drug Coverage::Retail Drugs (30 day supply):Tier 1 ($15 Copayment)/Tier 2 ($30 Copayment)/Tier 3 ($60 Copayment)/Tier 4 (25% Coinsurance; separate $2,500 aPrescription Drug out-of-pocket maximum)Mail Order Drugs (90 day supply): Tier 1 ($30 Copayment)/Tier 2 ($75 Copayment)/Tier 3 ($150 Copayment)/Tier 4 (25% Coinsurance; separate $2,500 aPrescription Drug out-of-pocket maximum)

NON-NETWORK:(30 day supply only): 50% Coinsurance (minimum $60) per perscription. Mail Order and Specialty Drugs not covered.

Ambulance, Chiropractic, Durable Medical Equipment, Home Health Care, Hospice Care, Mental Health, Organ Transplants, Rehabilitation Facilities, SkNursing Care, Substance Abuse, Therapy Services, Urgent Care, Vision Exam

1Coinsurance is designated by the plan you choose.



10/17

9

Save money and time by

using our dental network8IJMFPVSEFOUBM110QMBOTBMMPXZPVUPHPUPBOZ

dentist, you may save the most money when youDIPPTFPOFPGUIFEFOUJTUTJOPVS110QSPWJEFS

network. Even better, when you visit a network dentist,you have no deductible or coinsurance to pay for anycovered diagnostic or preventive service. And networkdentists file claims so there is no paperwork for you todo when you receive services.

9

Give yourselfevery advantageGood health anda bright smile.Regular dental check-ups and cleanings are important to

your overall health. Thats why we give you the option of

adding dental to your health coverage or even purchasing

a dental plan on its own.

Weve got you coveredTo help keep your smile bright and healthy, weve put togetherdental products that offer a broad range of benefits. And then wemade it affordable.

t %JBHOPTUJDBOEQSFWFOUJWFTFSWJDFTDPWFSFEXIFOusing a network dentist

t 3PVUJOFDIFDLVQTBOEDMFBOJOHTt 9SBZTBOEGMVPSJEFBQQMJDBUJPOTt 'JMMJOHTTQBDFNBJOUBJOFSTBOETFBMBOUT

t 4DBMJOHSPPUQMBOOJOHSPPUDBOBMTDSPXOTBOEEFOUVSFTcovered in some dental plans.

Plus, Anthem dental members automatically have access toUIF*OUFSOBUJPOBM&NFSHFODZ%FOUBM1SPHSBNBENJOJTUFSFECZ%F$BSF%FOUBM8JUIUIJTQSPHSBNZPVNBZSFDFJWFFNFSHFODZdental care from our listing of credentialed dentists whiletraveling or working nearly anywhere in the world

Additional Savings8JUI"OUIFNEFOUBMQMBOTZPVBMTPHFUEJTDPVOUTPOOPOcovered dental services like teeth whitening and orthodontia,and provider discounts after you meet your annual maximum.

Please contact your agent or visit us online at anthem.com to geadditional details on Anthems dental plans, get a quote or enrol

5IJTJTPOMZBTVNNBSZPG"OUIFNEFOUBMCFOFGJUT'PSDPNQMFUFCFOFGJUEFUBJMTQMFBTFSFGFSUPZPVS*OEJWJEVBM%FOUBM1PMJDZ

5IF*OUFSOBUJPOBM&NFSHFODZ%FOUBM1SPHSBNJTBENJOJTUFSFECZ%F$BSF

%FOUBM%F$BSF%FOUBMJTBOJOEFQFOEFOUDPNQBOZPGGFSJOHEFOUBM

BENJOJTUSBUJWFTFSWJDFTUP"OUIFN#MVF$SPTTBOE#MVF4IJFMEQMBOT


11/17

Optional Term Life InsuranceYou can add Anthem Blue Preferred Term Life Insurance to yourhealth coverage. Its easy. There are no medical exams or extraforms to fill out. Simply use your application to apply for coverage.

Additional informationSave time with automaticpremium paymentsHate writing checks? After your initial payment, our ElectronicFund Transfer (EFT) program will automatically withdraw funds

from your bank account each month to pay for your health planpremium. Youll not only save on postage, you wont have toworry about a lapse in coverage because you forgot to mail inyour payment. To sign up, just fill out the billing section of theenrollment application.

Ready to choose a plan?Call us. Contact your Anthem Blue Cross andBlue Shield agent.

Ask questions. If you arent sure about how a plaworks or have additional questions, your agent willbe happy to help.

Fill out an application. We'll process it as soon awe receive it!

Term Life Monthly Rates

Age $15,000 $25,000 $50,000

1-18 $1.50 $2.50 N/A

19-29 $2.85 $4.75 $9.50

30-39 $3.30 $5.50 $11.00

40-49 $7.50 $12.50 $25.00

50-59 $20.85 $34.75 $69.50

60-64 $29.40 $49.00 $98.00


12/17


13/17

Setting up a Health Savings Account

Our Lumenos HSA plans are a nice way to save on premiums. But thats just the tipof the savings iceberg. To realize your plans full financial power, consider openinga health savings account to go with your Lumenos plan. The portability and taxsavings of an HSA account can add up fast.

Weve joined with Affiliated Computer Services (ACS) and The Bank of New YorkMellon (BNY Mellon) to integrate their HSA accounts with our Lumenos HSA plans.Setting up your account with BNY Mellon is easy. Plus, it comes with built-inadvantages and conveniences:

A single customer service contact for the health plan and your HSA

A single online health site to access your plan benefit information andaccount details

Several payment and deposit options, including special checks andautomatic fund transfers

Competitive interest rates and investment opportunities for the fundsin your account

Of course, if youd rather use another financial institution for your account,thats fine too.

Stay focused on your fitness.

YOURE ONLY ONE CHECKMARK AWAY

Simply make the selection on yourapplication form. Well take care ofsetting up your account. Well also takecare of sending you a Welcome Kit to getyou started. All you have to take careof is your health. Which is, after all, themost important thing.

CENTFLY16001MS (8/10)

Let ACS|BNY Mellonhandle the finances.


14/17

ACS|BNY Mellon is an independent corporate entity that provides banking administration on behalf of Anthem Health PlansInc., d/b/a Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: AnthemInsurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in theKansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMOMissouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwrittenHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwritbenefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross and Blue Shield of Wisconsin (BCBSWi)underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare)underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POSpolicies. Life and disability products underwritten by Anthem Life Insurance Company. Independent licensees of theBlue 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 the registered marks of the Blue Cross and Blue Shield Association.

Interest and investments

Youll earn interest on your HSA funds and have the chance to invest your funds as longas you keep a minimum $1,500 HSA balance. Investment options include a number of

mutual families. Once youre ready to invest, just call the ACS|BNY Mellon HSA Solution

Contact Center at 866-686-4798 Monday through Friday from 8 a.m. to 8 p.m. (Eastern

Time) for a prospectus with more details.

Debit cards and checkbooks

Use your MasterCard debit card or your HSA checkbook (provided by BNY Mellon) to pay

your health care provider or pharmacy directly for eligible medical expenses, or to get

cash from your account.

Deposits to your account

To contribute to your HSA, simply send a check and deposit slip to the address printed

on your HSA checkbook. Or you can set up an electronic funds transfer between yourbank and BNY Mellon for regular account contributions.

Account activity statement

Each month, youll receive a statement from BNY Mellon that shows all of your account

activity. For an additional fee of $0.75 per month, you can receive a paper statement.

Please go to Anthem.com or call your dedicated Customer Service to learn how to

elect this option. Youll also receive IRS 1099 and IRS 5498 forms from BNY Mellon

near tax time to help with tax preparation.

ACS| BNY Mellon HSA fee and rate schedule

A Deposit Agreement and a

Disclosures and Fee Sheet

will be in your HSA Welcome

Kit. Please refer to those

documents for the complete

terms and conditions related

to your account.

As good as these options may

sound, you should still talk to

your tax advisor when trying to

maximize financial benefits for

your personal situation.

Administrative fees

One time account set-up $15

Banking fees

Monthly account fee $2.95

Debit card transactions no charge

Check writing no charge

ATM transactions $1

Card replacement $5

Check reorder $10

Non-sufficient funds $25

Stop check service $25

Duplicate check $5

Periodic paper statement $0.75

This is what the IRS requiresif you want to open aHealth Savings Account:

You must be covered by an HSA-

compatible high deductible health

plan (such as the Lumenos HSA plan).

You must be a U.S. resident, andnot a resident of Puerto Rico or

American Samoa.

You cannot be covered by any

other medical plan that is not an

HSA-compatible high deductible

health plan.

You cannot be enrolled in Medicare.

You cannot be claimed as a dependent

on another individual's tax return.

If you are a veteran, you may nothave received veteran's benefits

within the last three months.

You cannot be active military.

HSA Welcome Kit

If you make the selection on yourapplication form, your Health Savings

Account will automatically be set up

once youre approved for the

Lumenos HSA plan, and youll soon

receive an HSA Welcome Kit. In it,

youll find all of the banking

documentation and instructions

for using your account. A seperate

application for your account is only

required if you choose a financial

institution other than BNY Mellon.

A closer look


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Who Can Apply?ou can apply for coverage for yourself or with your family. You muste under the age of 65, reside in the Missouri service area, be a legalesident of the U.S. and be qualified under the Contract on the effectiveate, according to our medical underwriting guidelines. Family healthoverage includes you, your spouse or domestic partner and anyependent children. Children are covered to the end of the month in

which they turn age 26.

Whats A Pre-Existing Condition?or applicants age nineteen (19) and older, our plans cover pre-existingonditions after youve been enrolled in the plan for 12 months. Are-existing condition is any condition that was diagnosed or treated

within 12 months prior to the effective date of coverage or producedymptoms within 12 months prior to the effective date of coveragehat would have caused an ordinarily prudent person to seek medicaliagnosis or treatment. The pre-existing condition limitation does notpply to applicants under the age nineteen (19).

or Premier Plus, a pre-existing condition also includes a pregnancyxisting on your effective date, if maternity-related benefits areurchased.

you apply for coverage within 63 days of terminating your membershipwith another creditable health care plan, you can use your prior

overage for credit toward the 12-month waiting period. Anthem Blueross and Blue Shield will credit the time you were enrolled on therevious plan.

Access to the Medical Information Bureau (MIB)nformation regarding your insurability will be treated as confidential.nthem Blue Cross and Blue Shield or its reinsurers may, however,

make a brief report thereon to the MIB, a not-for-profit membershiprganization of insurance companies, which operates an informationxchange on behalf of its Members. If you apply to another MIB Memberompany for life or health insurance coverage, or a claim for benefitss submitted to such a company, MIB, upon request, will supply suchompany with the information in its file.

pon receipt of a request from you, MIB will arrange disclosure of anynformation it may have in your file. Please contact MIB at 866-692-6901TTY 866-346-3642). If you question the accuracy of information in MIBsle, you may contact MIB and seek a correction in accordance with therocedures set forth in the federal Fair Credit Reporting Act.

he address of MIBs Information Office is:0 Braintree Hill Park, Suite 400raintree, MA 02184-8734

nformation for consumers about MIB may be obtained on its websitet www.mib.com. Anthem Blue Cross and Blue Shield, or its reinsurers,

may also release information in its file to other insurance companies to

whom you may apply for life or health insurance, or to whom a claimbenefits may be submitted.

Utilization Management and Case ManagementOur Utilization Management (UM) services offer a structured prograthat monitors and evaluates member care and services. The UM clinteam, which is made up of health care professionals who hold activprofessional licenses and certificates, perform the prior authorizatconcurrent and retrospective review processes explained below. ThUM team follows criteria to assist in decisions regarding requests fhealth care and other covered benefits, and complies with specifictimeframes to ensure requests are handled in a timely manner. Ourcase management services help you to better understand and manyour health conditions.

Prospective Review / Pre-Admission Review

Prospective review (also known as pre-service or pre-admissionreview) is the process of reviewing a request for a medical proced

or service before it takes place. The review occurs to ensure that: the procedure is medically necessary and 2) the procedure meetsyour health care plans specific guidelines prior to being performeRequests for prospective review may include but are not limited to

inpatient hospitalizations

outpatient procedures

diagnostic procedures

therapy services

durable medical equipment

Prospective review is required for all elective inpatient admissionsand certain outpatient services. The review process evaluates med

necessity and the best level of care and assigns expected length ofif needed.

Concurrent Review

Concurrent review is an ongoing evaluation of a members hospital as well as ongoing extensions of services that may be needed (suchas acute care facilities, skilled nursing facilities, acute rehabilitatiofacilities, and home health care services). The review includesphysicians, member-assigned health care professionals(or member authorized representative) and takes place by telephonelectronically and/or onsite.

Concurrent review uses pre-set decision criteria in order to approvemedical care (deemed to be medically necessary) and assign the rilevel of care for continued medical treatment. Review decisions are

based on the medical information obtained at the time of the reviewConcurrent review also helps to coordinate care with behavioral heprograms.

Retrospective Review

The retrospective review process consists of obtaining information determine medical necessity as it relates to services provided withapproval or notice ahead of time (e.g. without pre-service notificatioRelevant clinical information is required for the retrospective reviewprocess. Review decisions are based only on the medical informatiothe doctor or other provider had at the time the member receivedmedical care.

OCD80000MTP (9/10)

Before choosing a health care plan, please review the

ollowing information, along with the other materials

nclosed.

SmartSense Plus, Premier Plus, CoreShareSM

, and LumenosHSA Plus

Missouri Coverage DetailsThings you need to know before you buy...


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Case Management

ase managers are licensed healthcare professionals who work withou to help you understand your benefits and support your health careeeds. The case manager works with you and your doctor to help youetter understand and manage your health conditions.

What Our Individual Health Care Plans Do Not Coverhe following Exclusions and Limitations will help you understand whatour health care plan does not include before you enroll. These are justome of the plans limitations and exclusions. Check your Contract orertificate of Coverage for a complete listing of benefits, exclusions and

maximum payment levels.

Medical Exclusions And Limitationsur plans do not provide benefits for:

Services, supplies or charges having to do with pre-existing conditions(see Whats A Pre-Existing Condition?)

Charges incurred prior to the effective date of coverage or after the

termination date of coverage

Private duty nursing

Maternity services (unless you purchase the optional maternitycoverage offered on Premier Plus plans)

Experimental or investigative treatment

Dental, except as spelled out in your contract

Charges greater than the maximum allowable amount (chargesexceeding the amount Anthem recognizes for services)

Benefits covered by Medicare or a governmental program

Care provided by a member of your family

Educational services

Comfort and/or convenience items

Treatment thats primarily intended to improve your appearance

Weight loss programs or treatment of obesity

Hearing aids, except as explained in your Contract

Eyeglasses or contact lenses

Radial keratotomy or keratomileusis or excimer laser photo

Sclerotherapy

Routine foot care

Artificial insemination, fertilization, infertility drugs or sterilization reversal

Sex transformation surgery

Custodial care

Artificial and mechanical hearts

Specialty drugs purchased at non-network pharmacies

Over-the-counter drugs, devices or products

TMJ and Craniomandibular Joint Disorders

Workers compensation

Services we determine arent medically necessary

he SmartSense Plus, CoreShare and Lumenos HSA Plusplans do notrovide coverage for vision, except as spelled out in your Contract.

The SmartSense Plus, Premier Plus, CoreShare and Lumenos HSA Pplans also limit the following outpatient services to 20 visits combinetwork and non-network:

Physical therapy

Occupational therapy

Other limitations of these plans include:

Home health care services limited to 60 visits

Optional maternity rider offered on Premier Plusis subject to an 18-month waiting period

Pre-existing conditions are subject to a 12 month waiting periodfor applicants age nineteen (19) and older

Our Appeal Rights And Confidentiality Policy

If we deny a claim or request for benefits completely or partially, we winotify you in writing. The notice will explain why we denied the claim/request and describe the appeals process. You can appeal decisionsthat deny or reduce benefits. We encourage you to file appeals rightaway when you first get an initial decision from us, but we require that

you file within six months of getting one. You should send additionalinformation that supports your appeal and state all the reasons why yofeel the appeal request should be granted. We will review your appealand let you know our decision in writing within 30 days of receiving youfirst appeal. If you are denied coverage based on medical necessity orexperimental/ investigative exclusions, you can request that a board-eligible or board-certified specialist review your appeal. If we denycoverage for reasons other than medical necessity or experimental/investigative reasons, you can also appeal. Please call customer serviceor check your Contract or Certificate of Coverage for more informationon our internal appeal and external review processes.

Unless our notice of decision includes a different address, sendrequests for a review of appeal to:

Anthem Blue Cross and Blue Shield

Appeals CoordinatorP.O. Box 33200Louisville, Kentucky 40232-3200

If we uphold our decision throughout the appeals process, you canrequest a review by the Missouri Department of Insurance. In additito the appeals processes we just described, Anthem has adopteda confidentiality policy in Missouri. This policy includes guidelinesregarding the protection of confidential member information anda members right to access and change information in Anthemspossession. The policy clearly points out when a member needs tosign a release before Anthem can disclose information to a membeprovider, spouse or other family members.

We Want You To Be SatisfiedIf you arent satisfied with your coverage, you can cancel it within 30days after you receive your Contract or Certificate of Coverage or haaccess to it online, whichever is earlier. If you havent submitted anclaims, youll get a full refund of the premium you paid when coverais cancelled within the first 30 days. You can view your Contract orCertificate of Coverage online or receive a paper copy of it upon reqas outlined in your initial membership letter.

This document is only a summary and is not a part of the Contract orCertificate of Coverage. If you are approved for coverage, the Contract orCertificate of Coverage you receive will include all the details of your plan.

2 SmartSense Plus, Premier Plus, CoreShareSM and Lumenos HSA Plus


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n 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 Allia

fe Insurance Company (HALIC), and HMO Missouri, Inc. RIT and cer tain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by

issouri, Inc. RIT and cer tain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross

lue Shield Association ANTHEM is a registered trademark of Anthem Insurance Companies Inc The Blue Cross and Blue Shield names and symbols are registered m

3 SmartSense Plus, Premier Plus, CoreShareSM and Lumenos HSA Plus

n the event of a conflict between the information in this document and yourontract or Certificate of Coverage, the terms of your Contract or Certificate ofoverage will prevail. Read your Contract or Certificate of Coverage carefully.nthem has the right to rescind, cancel, terminate or reform your coverageased on provisions described in the Contract or Certificate of Coverage.

his summary of benefits complies with federal and state requirements,ncluding applicable provisions of the recently enacted federal health careeform laws. As we receive additional guidance and clarification on the newealth care reform laws from the U.S. Department of Health and Humanervices, Department of Labor and Internal Revenue Service, we may beequired to make additional changes to this summary of benefits.

Selecting health coverageis an important decision.

To assist you, we supply the following for the plans underconsideration: Brochure, Benefit Guide, Coverage Details

and Enrollment Application. If you did not receive one ormore of these materials, please contact your Anthem BlueCross and Blue Shield agent to request them.

hsa sms prem

Documents