2015 NH Comp EPO SBC

8/11/2019 2015 NH Comp EPO SBC

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Awane: New Hampshire Comprehensive 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

,1000individual / ,2500family

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

!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 specicdeductibleamount 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 /,1200family

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 epenses.

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 epenses, 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 ofreferred roviders,see www.anthem.com orcall %-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 5. 'ee

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

+oa%mentsare ed dollar amounts #for eample, :%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 eample, 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 eample, 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-2etwork 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

:>; copay/visit 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; copay/visit 2ot "overed ????????????none????????????

1ther practitioner o3ice visit

"hiropractor:6; copay/visit

@cupuncturist2ot covered

"hiropractor2ot "overed

@cupuncturist2ot covered

"hiropractic care is limitedto %( visits per member percalendar year.

0reventivecare/screening/immuniAation

2o "ost 'hare 2ot "overed ????????????none????????????

"f %ou have atest

Diagnostic test #-ray, bloodwork&

2o cost sharefor labs ino3ice or

independentlabB otherservices ; lls at retail#penalty applies&. If pre-auth re+uired Enot obtained, drug may not be covered."ertain 0reventive meds no copay. If ageneric e+uivalent is available E brand isprescribed/member will pay brand namecost di3erence. 0lan uses preferred druglist to identify coverage.

0referred brand drugs#Cetail/>; day)ail/9; day&

:>6 Cetail/:57.6)ail

2ot "overed

2on-preferred brand #Cetail/>;day)ail/9;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 copay/visitfor ambulatorysurgicalcenterB othersites of service;(7(&www.dol.gov/ebsa/healthreform

@dditionally, a consumer assistance program can help you le your appeal. "ontact

http://www.dol.gov/ebsahttp://www.cciio.cms.gov/http://www.express-scripts.com/http://www.dol.gov/ebsahttp://www.cciio.cms.gov/http://www.express-scripts.com/


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Awane: New Hampshire Comprehensive 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: EPO2ew ampshire Department of Insurance(% 'outh Fruit 'treet, 'uite %8"oncord, 2 ;>>;%#5;;& 56(->8%www.nh.gov/insuranceconsumerservicesLins.nh.gov

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

he @3ordable "are @ct re+uires most people to have health care coverage that +ualies as Mminimum essentialcoverage.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 benets 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:

mailto:[email protected]:[email protected]


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??????????????????????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 Comprehensive 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 eamples show how this planmight cover medical care in givensituations. se these eamples 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$!,"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:%,;;

;"opays :(;

"oinsurance :;

Himits or eclusions :%6;

0otal117

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:%,(6

;"opays :9;

"oinsurance :(;;

Himits or eclusions :5;

0otal222

3


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

Dont use theseeamples to estimate

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

'ee the net page forimportant information


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Awane: New Hampshire Comprehensive 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 specic to a particulargeographic area or health plan.

he patientscondition was notan ecluded or preeisting

condition. @ll services and treatments

started and ended in the samecoverage period.

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

1ut-of-pocket epenses arebased only on treating thecondition in the eample.

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 *ample helps you seehow deductibles, coa%ments,and coinsurancecan add up. Italso helps you see what epensesmight 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

eamples. 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 *amples are notcost estimators. !ou cant usethe eamples 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=

es.Khen you look at the'ummary of enets and"overage for other plans, youllnd the same "overage*amples. Khen you compareplans, check the M0atient 0aysNbo in each eample. hesmaller that number, the morecoverage the planprovides.

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

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


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Documents

2015 NH Comp EPO SBC