2015 NH 1500 EPO SBC

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Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2015 - 12/31/2015!mmar" of #enefi$s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%an &"pe: EPO

&his is on%" a s!mmar"' If you want more detail about your coverage and costs, you can get the completeterms in the policy or plan document atwww.anthem.comor by calling 1-855-271-4549.

(mpor$an$ )!es$ions Answers *h" $his +a$$ers:

What is theoveralldeductible?

For in-networkproviders,

,1500 Individual/,3.50Family

Doesnt apply to in-network preventive careand routine eye exams.

ou must pay all the costs up to the deductible amount before thisplan begins to pay for covered services you use. !heck your policy orplan document to see when the deductible starts over "usually, butnot always, #anuary $st%. &ee the chart starting on page 'for howmuch you pay for covered services after you meet the deductible.

Are there otherdeductibles for

seci!c services?

es. ,250deductible forDurable (edical)*uipment per memberper calendar year.

ou must pay all of the costs for these services up to the speci+cdeductibleamount before this plan begins to pay for these services.

"s there an out#of#oc$et limiton m% e&enses?

es. For in-networkproviders

,350individual ,12.00family

he out-of-oc$et limit is the most you could pay during a coverageperiod "usually one year% for your share of the cost of coveredservices. his limit helps you plan for health care expenses.

What is notincluded in the

out#of#oc$etlimit?

alance-illed charges,/ealth !are this plandoesnt cover,

0remiums, and 1ut-of-network pharmacyclaims.

)ven though you pay these expenses, they dont count toward the

out-of-oc$et limit.

"s there anoverall annuallimiton what thelan a%s?

2o.he chart starting on page 'describes any limits on what the planwill pay for specifccovered services, such as o3ice visits.

'uestions(!all 1-855-271-4549or visit us atwww.anthem.comIf you arent clear about any of the underlined terms used in this form, see the 4lossary. ou can view the 4lossaryatwww.anthem.comor call 1-855-271-4549to re*uest a copy.

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)oes this lanuse a networ$ ofroviders?

es. For a list of in-networ$ roviders, seewww.anthem.com or call$-566-'7$-8689.

If you use an in-network doctor or other health care rovider, thisplan will pay some or all of the costs of covered services. e aware,

your in-network doctor or hospital may use an out-of-networkroviderfor some services. 0lans use the term in-network,referred, or participatingfor rovidersin their networ$. &ee the

chart starting on page 'for how this plan pays di3erent kinds ofroviders.

)o " need areferral to see asecialist?

2o.ou can see the secialistyou choose without permission from thisplan.

Are thereservices this landoesn*t cover?

es.&ome of the services thisplan doesnt cover are listed on page 6. &ee

your policy or plan document for additional information aboute&cluded services.

+oa%mentsare +xed dollar amounts "for example, :$6% you pay for covered health care, usually when youreceive the service.

+oinsuranceisyour share of the costs of a covered service, calculated as a percent of the allowed

amountfor the service. For example, if the plans allowed amountfor an overnight hospital stay is:$,;;;, your coinsurancepayment of ';< would be :';;. his may change if you havent met yourdeductible.

he amount the plan pays for covered services is based on the allowed amount. If an out-of-network

rovidercharges more than the allowed amount, you may have to pay the di3erence. For example, if anout-of-network hospital charges :$,6;; for an overnight stay and the allowed amountis :$,;;;, you mayhave to pay the :6;; di3erence. "his is called balance billin,.%

his plan may encourage you to use in-network rovidersby charging you lower deductibles,

coa%mentsand coinsuranceamounts.

Common

+edia% Even$ervies o! +a" Need

o!r Cos$ (fo! se an(n-ne$worProvider

o!r Cos$ (fo! se an

O!$-of-ne$worProvider

4imi$a$ions E6ep$ions

0rimary care visit to treat anin=ury or illness

:>; copayvisit 2ot !overed?????????????none????????????


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Common



o!r Cos$ (fo! se an



"f %ou visit ahealth carerovider*soice or clinic

&pecialist visit :6; copayvisit 2ot !overed?????????????none????????????

1ther practitioner o3ice visit

!hiropractor:6; copayvisit

@cupuncturist2ot covered

!hiropractor2ot !overed

@cupuncturist2ot covered

?????????????none????????????

0reventivecarescreeningimmuniAation

2o !ost &hare 2ot !overed?????????????none????????????

"f %ou have atest

Diagnostic test "x-ray, bloodwork%

2o cost sharefor labs in

o3ice orindependentlabB otherservices ;;day(ail9;day%

:7; Cetail:$76(ail

2ot !overed

&pecialty drugs

@ll &pecialtymeds process

through@ccredo at the

mail ordercosts.

2ot !overed

he mail order cost will bebased on the medication tier"generic, preferred, non-preferred%. &pecialty medscan not be +lled at retailpharmacies.


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Common



o!r Cos$ (fo! se an



"f %ou haveoutatientsur,er%

Facility fee "e.g., ambulatorysurgery center%

:76 copayvisitfor ambulatorysurgicalcenterB othersites of service; x$66 orwww.cciio.cms.gov.

o!r

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Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2015 - 12/31/2015!mmar" of #enefi$s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%an &"pe: EPOIf you have a complaint or are dissatis+ed with a denial of coverage for claims under your plan, you may be able to aealor +le a ,rievance. For *uestions about your rights, this notice, or assistance, you can contact

@nthem lue !ross lue &hield!linical @ppeals 0.1. ox $;665 @tlanta, 4@ >;>851perational @ppeals 0.1. ox $;665 @tlanta, 4@ >;>85

For grievances andor appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.express-scripts.com.

For )CI&@ information contact

Department of Habors )mployee ene+ts &ecurity @dministration$-5-888-)&@ ">'7'%www.dol.govebsahealthreform

@dditionally, a consumer assistance program can help you +le your appeal. !ontact2ew /ampshire Department of Insurance'$ &outh Fruit &treet, &uite $8!oncord, 2/ ;>>;$"5;;% 56'->8$www.nh.govinsuranceconsumerservicesLins.nh.gov

9oes $his Coverage Provide +inim!m Essen$ia% Coverage=

http://www.express-scripts.com/http://www.nh.gov/insurancemailto:[email protected]://www.express-scripts.com/http://www.nh.gov/insurancemailto:[email protected]

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Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2015 - 12/31/2015!mmar" of #enefi$s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%an &"pe: EPOhe @3ordable !are @ct re*uires most people to have health care coverage that *uali+es as Mminimum essential

coverage.N This plan or policy does provide minimum essential coverage.

9oes $his Coverage +ee$ $he +inim!m >a%!e $andard=

he @3ordable !are @ct establishes a minimum value standard of bene+ts of a health plan. he minimum value

standard is ;< "actuarial value%. This health coverage does meet the minimum value standard for the

benets it provides.

4ang!age Aess ervies:

??????????????????????To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.???????????


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Having a ?a?""normal delivery%

+anaging $"pe 2 dia?e$es"routine maintenance of

a well-controlled condition%

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Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2015 - 12/31/2015Coverage E6amp%es

Coverage for: Individual/Family |P%an &"pe: EPO

A?o!$ $hese CoverageE6amp%es:

hese examples show how this planmight cover medical care in givensituations. se these examples tosee, in general, how much +nancialprotection a sample patient mightget if they are covered underdi3erent plans.

Amo!n$ owed $o providers:$7,54

P%an pa"s$5,!7

Pa$ien$ pa"s$",#7

amp%e are os$s:

/ospital charges "mother%:',7;

;

Coutine obstetric care:',$;

;/ospital charges "baby% :9;;

@nesthesia :9;;

Haboratory tests :6;;

0rescriptions :';;

Cadiology :';;

Gaccines, other preventive :8;

0otal754

3

Pa$ien$ pa"s:

Deductibles:$,6;

;!opays :';

!oinsurance :;

Himits or exclusions :$6;

0otal17

3

Amo!n$ owed $o providers:$5,4

P%an pa"s$","

Pa$ien$ pa"s$4,%

amp%e are os$s:

0rescriptions:',9;

;(edical )*uipment and

&upplies

:$,>;

;13ice Gisits and 0rocedures :7;;

)ducation :>;;

Haboratory tests :$;;

Gaccines, other preventive :$;;

0otal543

3

Pa$ien$ pa"s:

Deductibles:$,76

;!opays :69;

!oinsurance :';;

Himits or exclusions :5;

0otal22

3


&his isno$ a os$es$ima$or'

Dont use theseexamples to estimate

your actual costs underthis plan. he actualcare you receive will bedi3erent from theseexamples, and the costof that care will also bedi3erent.

&ee the next page forimportant information

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Awane: New Hampshire 1500 EPO Coverage Period: 01/01/2015 - 12/31/2015Coverage E6amp%es

Coverage for: Individual/Family |P%an &"pe: EPO


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)!es$ions and answers a?o!$ $he Coverage E6amp%es:

*ha$ are some of $heass!mp$ions ?ehind $heCoverage E6amp%es=

!osts dont include remiums.

&ample care costs are based onnational averages supplied bythe .&. Department of /ealthand /uman &ervices, andarent speci+c to a particulargeographic area or health plan.

he patientscondition was notan excluded or preexisting

condition. @ll services and treatments

started and ended in the samecoverage period.

here are no other medicalexpenses for any membercovered under this plan.

1ut-of-pocket expenses arebased only on treating thecondition in the example.

he patient received all carefrom in-network roviders. Ifthe patient had received carefrom out-of-network roviders,costs would have been higher.

*ha$ does a Coverage E6amp%eshow=

For each treatment situation, the

!overage )xample helps you seehow deductibles, coa%ments,and coinsurancecan add up. Italso helps you see what expensesmight be left up to you to paybecause the service or treatmentisnt covered or payment is limited.

9oes $he Coverage E6amp%e

predi$ m" own are needs=o.reatments shown are =ust

examples. he care you wouldreceive for this condition couldbe di3erent based on yourdoctors advice, your age, howserious your condition is, andmany other factors.

9oes $he Coverage E6amp%epredi$ m" f!$!re e6penses=

o.!overage )xamples are notcost estimators. ou cant usethe examples to estimate costsfor an actual condition. hey arefor comparative purposes only.

our own costs will be di3erentdepending on the care youreceive, the prices yourroviders charge, and thereimbursement your health planallows.

Can ( !se Coverage E6amp%es

$o ompare p%ans=

6es.Khen you look at the&ummary of ene+ts and!overage for other plans, youll+nd the same !overage)xamples. Khen you compareplans, check the M0atient 0aysNbox in each example. hesmaller that number, the morecoverage the planprovides.

Are $here o$her os$s ( sho!%donsider when omparingp%ans=

6es.@n important cost is theremiumyou pay. 4enerally,the lower your remium, themore youll pay in out-of-pocket

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costs, such as coa%ments,deductibles, and coinsurance.

ou should also consider

contributions to accounts suchas health savings accounts"/&@s%, Oexible spendingarrangements "F&@s% or health

reimbursement accounts "/C@s%that help you pay out-of-pocketexpenses.

Documents

2015 NH 1500 EPO SBC