2016 AWANE MA RISK

7/24/2019 2016 AWANE MA RISK

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AWANE: Massachusetts Risk PPO Coverage Period: 01/01/201!12/"1/201

#u$$ar% of &e'efits a'd Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family| P(a' )%*e: PPO

)his is o'(% a su$$ar%+ If you want more detail about your coverage and costs, you can get the completeterms in the policy or plan document at https://eoc.anthem.com/eocdps/f or by calling 1-844-404-6843.

,$*orta't -uestio's A's.ers Wh% this Matters:

What is the overalldeductible?

For in-network providers

2000 individual /000 family

For out-of-network providers


Doesn’t apply to in-networkpreventive care, routine eyeexams or outpatientlabsx-rays or ultrasounds.

!ou must pay all the costs up to the deductible amountbefore this plan begins to pay for covered services you use."heck your policy or plan document to see when thedeductible starts over #usually, but not always, $anuary%st&. 'ee the chart starting on page ( for how much you payfor covered services after you meet the deductible.

Are there otherdeductibles forspecic services?

!es. For durable medicale)uipment there is a 250 deductible.

!ou must pay all of the costs for these services up to thespeci*c deductible amount before this plan begins to payfor these services.

Is there an out–of–pocet li!it on !"e#penses?

For in-network providers

00 individual /1"200 family

For out-of-network providers


+he out-of-pocet li!it is the most you could pay during acoverage period #usually one year& for your share of the costof covered services. +his limit helps you plan for health careexpenses.

What is not includedin the out–of–pocetli!it?

remiums, penalties fornon-compliance, balance-billed charges, and healthcare this plan doesn’t cover.

ven though you pay these expenses, they don’t counttoward the out-of-pocet li!it.

Is there an overallannual li!it on $hatthe plan pa"s?

o.+he chart starting on page ( describes any limits on whatthe plan will pay for specifc covered services, such as o/ice

visits.

%uestions& "all 1-844-404-6843 or visit us at $$$'anthe!'co!If you aren’t clear about any of the underlined terms used in this form, see the 0lossary. !ou can view the 0lossaryat $$$'anthe!'co! or call 1-844-404-6843 to re)uest a copy.

https://eoc.anthem.com/eocdps/fi

https://eoc.anthem.com/eocdps/fi

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(oes this plan use anet$or ofproviders?

!es. For a list of preferredproviders, seewww.anthem.com or call

%-122-232-412(

If you use an in-network doctor or other health careprovider , this plan will pay some or all of the costs ofcovered services. 5e aware, your in-network doctor orhospital may use an out-of-network provider for someservices. lans use the term in-network, preferred, or

participating for providers in their net$or . 'ee the chartstarting on page ( for how this plan pays di/erent kinds ofproviders.

(o I need a referralto see a specialist?

o. !ou can see the specialist you choose without permissionfrom this plan.

Are there servicesthis plan doesn)tcover?

!es.'ome of the services this plan doesn’t cover are listed onpage 4. 'ee your policy or plan document for additionalinformation about e#cluded services.

•

*opa"!ents are *xed dollar amounts #for example, 6%7& you pay for covered health care, usually when youreceive the service.

• *oinsurance is your share of the costs of a covered service, calculated as a percent of the allo$ed

a!ount for the service. For example, if the plan’s allo$ed a!ount for an overnight hospital stay is6%,333, your coinsurance payment of 839 would be 6833. +his may change if you haven’t met yourdeductible.

• +he amount the plan pays for covered services is based on the allo$ed a!ount. If an out-of-network

provider charges more than the allo$ed a!ount, you may have to pay the di/erence. For example, if anout-of-network hospital charges 6%,733 for an overnight stay and the allo$ed a!ount is 6%,333, you mayhave to pay the 6733 di/erence. #+his is called balance billin+.&

• +his plan may encourage you to use in-network providers by charging you lower deductibles,

copa"!ents and coinsurance amounts.


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Co$$o'Medica( Eve't

#ervices ou Ma% Need

our Cost ,f ou 3se a','!'et.orkProvider

our Cost ,f ou 3se a'

Out!of!'et.orkProvider

4i$itatio's E6ce*tio's

If "ou visit ahealth careprovider)so,ice or clinic

rimary care visit to treat anin:ury or illness

623 copayvisit739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

'pecialist visit 6<3 copay visit739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

=ther practitioner o/ice visit 6<3 copay visit739coinsurance

"hiropractic limited to %8 visits per member percalendar year.

reventivecarescreeningimmuni>ation

o "harge739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

If "ou have a

test

Diagnostic test #x-ray, bloodwork&

o "harge739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

Imaging #"++ scans, ?@Is& (39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

If "ou needdru+s to treat "our illness orcondition

?oreinformation

aboutprescriptiondru+ covera+e is available atwww.medco.com

0eneric drugs #@etail(3 dayA?ailB3 day&

683 @etail623?ail

ot "overed100 (eductible./erson 300(eductible.a!il" ?aintenance ?eds are re)uired to be *lledmail order after ( *lls at retail #penaltyapplies&. If pre-auth re)uired C not obtained,drug may not be covered. "ertain reventivemeds no copay. If a generic e)uivalent isavailable C brand is prescribedmember willpay brand name cost di/erence. lan usespreferred drug list to identify coverage.

referred brand drugs #@etail(3 dayA?ailB3 day&

623 @etail613?ail

ot "overed

on-preferred brand #@etail(3dayA?ailB3day&

643 @etail6%13?ail

ot "overed

'pecialty drugs

ll 'pecialtymeds process

through ccredo at the

mail ordercosts.

ot "overed

+he mail order cost will bebased on the medication tier#generic, preferred, non-preferred&. 'pecialty meds cannot be *lled at retailpharmacies.

If "ou haveoutpatientsur+er"

Facility fee #e.g., ambulatorysurgery center&

(39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

hysiciansurgeon fees(39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;


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Co$$o'Medica( Eve't






If "ou needi!!ediate!edicalattention

mergency room services

6%73 copay visitEprofessionaland otherservices(39 coinsurance

6%73 copay visitEprofessionaland otherservices(39 coinsurance

6%73 copay is waived ifadmitted for inpatient stay.?embers may be balancebilled for out of networkservices.

mergency medicaltransportation

(39coinsurance

(39coinsurance

?embers may be balancebilled for out of networkservices.

rgent care 673 copay 673 copay

?embers may be balance

billed for out of networkservices.

If "ou have ahospital sta"

Facility fee #e.g., hospital room&(39coinsurance

739coinsurance

recerti*cation is re)uiredfor Inpatient hospitaladmission. 6733 penalty isapplied if an =ut of etworkadmission is not precerti*ed.

hysiciansurgeon fee(39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;


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Co$$o'Medica( Eve't






If "ou have!ental healthbehavioralhealth orsubstanceabuse needs

?ental5ehavioral healthoutpatient services

623 copay visit739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

?ental5ehavioral healthinpatient services

(39coinsurance

739coinsurance


'ubstance use disorderoutpatient services

623 copayvisit739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

'ubstance use disorder

inpatient services

(39

coinsurance

739

coinsurance

recerti*cation is re)uiredfor Inpatient hospital

admission. 6733 penalty isapplied if an =ut of etworkadmission is not precerti*ed.

If "ou arepre+nant

renatal and postnatal care(39 coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

Delivery and all inpatientservices

(39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;


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Co$$o'Medica( Eve't






If "ou needhelp recoverin+or have otherspecial healthneeds

Gome health care(39coinsurance

739coinsurance

;;;;;;;;;;;;none;;;;;;;;;;;;

@ehabilitation services

6<3 copay foroutpatientservicesE (39coinsurancefor inpatientcare

739coinsurance

Inpatient physical medicinerehabilitation is limited to%33 days per calendar year.Himited to 43 visits permember per calendar yearcombined physical therapy,speech therapy andoccupational therapy. lltherapy limits are combined

in and out of network.

Gabilitation services

6<3 copay foroutpatientservicesE (39coinsurancefor inpatientcare

739coinsurance

ll rehabilitation andhabilitation visits counttoward your rehabilitation visitlimit.

'killed nursing care(39coinsurance

739coinsurance

Himited to %33 inpatient daysper member per calendar

year. recerti*cation is

re)uired

Durable medical e)uipment

6873deductible then839coinsurance

6873deductiblethen 839coinsurance

6873 deductible combined inand out of network. ?embersmay be balance billed for outof network services.

Gospice service(39coinsurance

739coinsurance



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Co$$o'Medica( Eve't






If "our childneeds dental or e"e care

ye exam o "harge739coinsurance

Himited to one exam per yearfor %1 and younger. Himitedto one exam every 8 years for%B and older.

0lasses ot "overed ot "overed ;;;;;;;;;;;;none;;;;;;;;;;;;

Dental check-up ot "overed ot "overed ;;;;;;;;;;;;none;;;;;;;;;;;;

E6c(uded #ervices Other Covered #ervices:

#ervices our P(a' 8oes NO) Cover 2his isn)t a co!plete list' *hec "our polic" or plan docu!ent for othere#cluded services'

cupuncture

"osmetic surgery

Dental care #dult&

Hong-term care

on-emergency care when traveling

outside the .'.

rivate-duty nursing

@outine foot care

Jeight loss programs

Other Covered #ervices 2his isn)t a co!plete list' *hec "our polic" or plan docu!ent for other coveredservices and "our costs for these services'

5ariatric surgery

"hiropractic care

Infertility treatment #Himits apply&

"overage provided outside thenited 'tates.'ee www.5"5'.combluecardworldwide

Gearing ids #Himitations apply&

@outine eye care #dult -Himitations apply&


http://www.bcbs.com/bluecardworldwide




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our Rights to Co'ti'ue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provide

protections that allow you to keep health coverage. ny such rights may be limited in duration and will re)uire you

to pay a pre!iu!, which may be signi*cantly higher than the premium you pay while covered under the plan.

=ther limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at %-133-871-7(%1. !ou may also contact

your state insurance department, the .'. Department of Habor, mployee 5ene*ts 'ecurity dministration at %-144-222-(8<8 or www.dol.govebsa, or the .'. Department of Gealth and Guman 'ervices at %-1<<-84<-8(8( x4%747 orwww.cciio.cms.gov.


http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

http://www.dol.gov/ebsa

http://www.cciio.cms.gov/

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our ;rieva'ce a'd A**ea(s Rights:

If you have a complaint or are dissatis*ed with a denial of coverage for claims under your plan, you may be able to appeal or *le a +rievance. For )uestions about your rights, this notice, or assistance, you can contactA

nthem 5lue "ross and 5lue 'hield.=. 5ox 72%7BHos ngeles, " B3372-3%7B

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.

dditionally, a consumer assistance program can help you *le your appeal. "ontactA

ew Gampshire Department of Insurance

8% 'outh Fruit 't. 'uite %2"oncord, G 3((3%%-133-178-(2%4www.nh.govinsuranceconsumersvcsKins.nh.gov

For @I' information contactA

Department of Habor’s mployee 5ene*ts 'ecurity dministration%-144-222-5' #(8<8&www.dol.govebsahealthreform


http://www.express-scripts.com/

http://www.nh.gov/insurance

mailto:[email protected]

http://www.dol.gov/ebsa/healthreform

http://www.express-scripts.com/

http://www.nh.gov/insurance

mailto:[email protected]

http://www.dol.gov/ebsa/healthreform

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8oes this Coverage Provide Mi'i$u$ Esse'tia( Coverage<

+he /ordable "are ct re)uires most people to have health care coverage that )uali*es as Lminimum essential

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

8oes this Coverage Meet the Mi'i$u$ =a(ue #ta'dard<

+he /ordable "are ct establishes a minimum value standard of bene*ts of a health plan. +he minimum value

standard is 439 #actuarial value&. This health coverage does meet the minimum value standard for the

benets it provides.

4a'guage Access #ervices:

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


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>avi'g a ?a?%#normal delivery&

Ma'agi'g t%*e 2 dia?etes#routine maintenance of

a well-controlled condition&

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Coverage E6a$*(es

Coverage for: Individual/Family| P(a' )%*e: PPO

A?out these CoverageE6a$*(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 underdi/erent plans.

A$ou't o.ed to *roviders: $7,540

P(a' *a%s $4,000

Patie't *a%s $,540

#a$*(e care costs:

Gospital charges #mother&68,<3

3

@outine obstetric care68,%3

3Gospital charges #baby& 6B33

nesthesia 6B33

Haboratory tests 6733

rescriptions 6833

@adiology 6833

Naccines, other preventive 623

otal54

0

Patie't *a%s:

Deductibles68,33

3"opays 683

"oinsurance6%,(<

3Himits or exclusions 6%73

otal34

0


)his is'ot a costesti$ator+

Don’t use theseexamples to estimate

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

'ee the next page forimportant information

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Coverage E6a$*(es


A$ou't o.ed to *roviders: $5,400

P(a' *a%s $!,!"0 Patie't *a%s $,#40

#a$*(e care costs:

rescriptions68,B3

3?edical )uipment and'upplies

6%,(33

=/ice Nisits and rocedures 6<33

ducation 6(33

Haboratory tests 6%33 Naccines, other preventive 6%33

otal40

0

Patie't *a%s:

Deductibles68,87

3"opays 64%3

"oinsurance 6833

Himits or exclusions 613

otal314

0


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Coverage E6a$*(es



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-uestio's a'd a's.ers a?out the Coverage E6a$*(es:

What are so$e of theassu$*tio's ?ehi'd theCoverage E6a$*(es<

• "osts don’t include pre!iu!s.

• 'ample care costs are based onnational averages supplied bythe .'. Department of Gealthand Guman 'ervices, andaren’t speci*c to a particulargeographic area or health plan.

• +he patient’s condition 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.

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

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

What does a Coverage E6a$*(esho.<

For each treatment situation, the

"overage xample helps you seehow deductibles, copa"!ents,and coinsurance can add up. Italso helps you see what expensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.

8oes the Coverage E6a$*(e

*redict $% o.' care 'eeds< 7o' +reatments shown are :ust

examples. +he care you wouldreceive for this condition couldbe di/erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.

8oes the Coverage E6a$*(e*redict $% future e6*e'ses<

7o' "overage xamples are not

cost estimators. !ou can’t usethe examples to estimate costsfor an actual condition. +hey arefor comparative purposes only.

!our own costs will be di/erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.

Ca' , use Coverage E6a$*(es

to co$*are *(a's<

es' Jhen you look at the

'ummary of 5ene*ts and"overage for other plans, you’ll*nd the same "overagexamples. Jhen you compareplans, check the Latient aysMbox in each example. +hesmaller that number, the morecoverage the plan provides.

Are there other costs , shou(dco'sider .he' co$*ari'g*(a's<

es' n important cost is the

pre!iu! you pay. 0enerally,the lower your pre!iu!, themore you’ll pay in out-of-pocket

7/24/2019 2016 AWANE MA RISK


costs, such as copa"!ents,deductibles, and coinsurance.

!ou should also considercontributions to accounts suchas health savings accounts#G's&, Oexible spendingarrangements #F's& or health

reimbursement accounts #G@s&that help you pay out-of-pocketexpenses.

Documents

2016 AWANE MA RISK