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2016 AWANE ME CORE EPO
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7/21/2019 2016 AWANE ME CORE EPO
http://slidepdf.com/reader/full/2016-awane-me-core-epo 1/15
1 of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
$&i" i" on#y a "ummary' If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-855-271-4549.
(m%or!an! )ue"!ion" An"wer" *&y !&i" Ma!!er":
What is theoveralldeductible?
For in-networkproviders
+5,00 individual /+11,.00 family
Doesn’t apply to in-network preventive careand routine eye eam.
!ou must pay all the costs up to the deductible amount before this plan 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 forspecic services?
!es. $250 deductible forDurable )edical*+uipment per memberper calendar year.
rescription Drugs %per person, per calendar
year, ( per familyper calendar year.
!ou must pay all of the costs for these services up to the specicdeductible amount before this plan begins to pay for these services.
s there a! out"of"poc#et liito! % e&pe!ses?
!es. For in-networkproviders
+6,350 individual /+12,00 family
0he out-of-poc#et liit is the most you could pay during a coverageperiod #usually one year& for your share of the cost of coveredservices. 0his limit helps you plan for health care epenses.
What is !oti!cluded i! theout"of"poc#etliit?
1alance-1illed charges,2ealth "are this plandoesn’t cover,remiums, and 3ut-of-network pharmacyclaims.
*ven though you pay these epenses, they don’t count toward theout-of-poc#et liit.
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
s there a!overall a!!ualliit o! )hat thepla! pa%s?
5o.0he chart starting on page ( describes any limits on what the planwill pay for specifc covered services, such as o6ice visits.
+oes this pla!use a !et)or# ofproviders?
!es. For a list ofpreferred providers,see www.anthem.comor call %-788-9:%-;8;<
If you use an in-network doctor or other health care provider , this
plan will pay some or all of the costs of covered services. 1e aware, your in-network doctor or hospital may use an out-of-networkprovider for some services. lans use the term in-network,preferred, or participating for providers in their !et)or# . 'ee thechart starting on page ( for how this plan pays di6erent kinds ofproviders.
+o !eed areferral to see aspecialist?
5o. !ou can see the specialist you choose without permission from thisplan.
Are thereservices this pla!does!,t cover?
!es. 'ome of the services this plan doesn’t cover are listed on page 8. 'ee your policy or plan document for additional information aboute&cluded services.
• opa%e!ts are ed dollar amounts #for eample, %8& you pay for covered health care, usually when you
receive the service.
• oi!sura!ce is your share of the costs of a covered service, calculated as a percent of the allo)ed
aou!t for the service. For eample, if the plan’s allo)ed aou!t for an overnight hospital stay is%,, your coi!sura!ce payment of 9= would be 9. 0his may change if you haven’t met yourdeductible.
• 0he amount the plan pays for covered services is based on the allo)ed aou!t. If an out-of-network
provider charges more than the allo)ed aou!t, you may have to pay the di6erence. For eample, if anout-of-network hospital charges %,8 for an overnight stay and the allo)ed aou!t is %,, you mayhave to pay the 8 di6erence. #0his is called bala!ce billi!..&
• 0his plan may encourage you to use i!-!et)or# providers by charging you lower deductibles,
copa%e!ts and coi!sura!ce amounts.
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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3 of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %ou visit ahealth careprovider,so/ice or cli!ic
rimary care visit to treat anin>ury or illness
;copay/visit
5ot "overed ????????????none????????????
'pecialist visit@copay/visit
5ot "overed ????????????none????????????
3ther practitioner o6ice visit
"hiropractor@copay/visit
Acupuncturist5ot covered
"hiropractor5ot "overed
Acupuncturist5ot covered
????????????none????????????
reventive
care/screening/immuniBation
5o "ost
'hare5ot "overed ????????????none????????????
f %ou have atest
Diagnostic test #-ray, bloodwork&
=coinsurance
5ot "overed ????????????none????????????
Imaging #"0/*0 scans, )CIs&=coinsurance
5ot "overed ????????????none????????????
f %ou !eeddru.s to treat %our ill!ess orco!ditio!
)oreinformationaboutprescriptio!dru. covera.e is available atwww.medco.com
4eneric drugs #Cetail/( day )ail/<
day&
9 Cetail/;)ail
5ot "overedIf pre-auth re+uired E not obtained,drug may not be covered. "ertainreventive meds no copay. If a generice+uivalent is available E brand isprescribed/member will pay brandname cost di6erence. lan uses
preferred drug list to identifycoverage.
referred brand drugs #Cetail/( day)ail/< day&
; Cetail/%)ail
5ot "overed
5on-preferred brand #Cetail/(day)ail/<day&
: Cetail/9%)ail 5ot "overed
'pecialty drugs
All 'pecialtymeds process
through Accredo at
the mail ordercosts.
5ot "overed
0he mail order cost will bebased on the medication tier#generic, preferred, non-preferred&. 'pecialty meds cannot be lled at retailpharmacies.
Facility fee #e.g., ambulatorysurgery center&
=coinsurance
5ot "overed ????????????none????????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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8 of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %ou haveoutpatie!tsur.er%
hysician/surgeon fees=
coinsurance5ot "overed ????????????none????????????
f %ou !eediediateedicalatte!tio!
*mergency room services
98 copay/visitprofessionaland otherservicessub>ect todeductible
98copay/visitprofessionaland otherservicessub>ect todeductible
98 "opay waived ifadmitted. )ember may bebalance billed for out ofnetwork services.
*mergency medical
transportation
=
coinsurance
=
coinsurance
)ember may be balance
billed for out of networkservices.
Grgent care8copay/visit
5ot "overed ????????????none????????????
f %ou have ahospital sta%
Facility fee #e.g., hospital room&=coinsurance
5ot "overed
hysical )edicine andCehabilitation limited to %days per member percalendar year.
hysician/surgeon fee=coinsurance
5ot "overed ????????????none????????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %ou havee!tal healthbehavioralhealth orsubsta!ceabuse !eeds
)ental/1ehavioral healthoutpatient services
)ental/1ehavi
oral 2ealth36ice Hisit
;copay/visit
)ental/1ehavioral 2ealth
Facility Hisit
=
coinsurance
)ental/1ehavioral2ealth
36ice Hisit
5ot"overed
)ental/1ehavioral 2ealth
Facility Hisit
5ot"overed
????????????none????????????.
)ental/1ehavioral healthinpatient services
=coinsurance
5ot "overed ????????????none????????????
'ubstance use disorderoutpatient services
'ubstance Abuse 36ice
Hisit;copay/visit
'ubstance Abuse
Facility Hisit=coinsurance
'ubstance Abuse 36ice
Hisit 5ot"overed
'ubstance Abuse Facility
Hisit 5ot"overed
????????????none????????????.
'ubstance use disorder inpatientservices
=coinsurance
5ot "overed ????????????none????????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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6 of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %ou arepre.!a!t
renatal and postnatal care=coinsurance
5ot "overed ????????????none????????????.
Delivery and all inpatient services=coinsurance
5ot "overed ????????????none????????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %ou !eed
help recoveri!.or have otherspecial health!eeds
2ome health care=coinsurance
5ot "overed ????????????none????????????
Cehabilitation services
@copay/visit foroutpatientservices.Inpatientservicessub>ect todeductible.
5ot "overed
imited to @ visits permember per calendar yearfor physical therapy,occupational therapy, andspeech therapy combined.
2abilitation services
@
copay/visit foroutpatientservices.Inpatientservicessub>ect todeductible.
5ot "overed
All rehabilitation andhabilitation visits counttoward your rehabilitation
visit limit.
'killed nursing care=coinsurance
5ot "overedimited to % days percalendar year.
Durable medical e+uipment
98
deductiblethen 9=coinsurance
5ot "overed
'upplies are sub>ect to 98
deductible per member per year. 0)$ Appliances are notcovered.
2ospice service=coinsurance
5ot "overed ????????????none????????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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. of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
Common
Media# Even!Servie" ou May eed
our Co"! (f ou "e an(n-ne!wor4Provider
our Co"! (f ou "e an
Ou!-of-ne!wor4Provider
imi!a!ion" E7e%!ion"
f %our child!eeds de!tal or e%e care
*ye eam 5o cost share 5ot "overed
3ne eam each calendar year for members ages %7 years and younger. 3neeam every two calendar
years for members %< yearsand older.
4lasses 5ot "overed 5ot "overed ?????????????none????????????
Dental check-up 5ot "overed 5ot "overed ?????????????none????????????
E7#uded Servie" O!&er Covered Servie":
Servie" our P#an 9oe" O$ Cover his is!,t a coplete list* hec# %our polic% or pla! docue!t for othere&cluded services*3
J Acupuncture
J "osmetic surgery
J Dental care #Adult&
J 2earing aids
J Infertility treatment
J ong-term care
J Coutine foot care
J Keight loss programs
O!&er Covered Servie" his is!,t a coplete list* hec# %our polic% or pla! docue!t for other coveredservices a!d %our costs for these services*3
J 1ariatric surgery #imitations )ay Apply&
J "hiropractic care #imitations Apply&
J )ost coverage provided outside theGnited 'tates. 'eewww.1"1'.com/bluecardworldwide
J rivate-duty nursing #coveredunder 2ome 2ealth "are&
J Coutine eye care #Adult ?imitations )ay Apply&
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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of 15
Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
our ig&!" !o Con!inue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and 'tate laws may provideprotections that allow you to keep health coverage. Any such rights may be limited in duration and will re+uire you
to pay a preiu, which may be signicantly higher than the premium you pay while covered under the plan.
3ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at %-7-987-8(%7. !ou may also contact your state insurance department, the G.'. Department of abor, *mployee 1enets 'ecurity Administration at %-7@@-;;;-(9:9 or www.dol.gov/ebsa, or the G.'. Department of 2ealth and 2uman 'ervices at %-7::-9@:-9(9( @%8@8 orwww.cciio.cms.gov.
our ;rievane and A%%ea#" ig&!":
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPOIf you have a complaint or are dissatised with a denial of coverage for claims under your plan, you may be able to appeal or le a .rieva!ce. For +uestions about your rights, this notice, or assistance, you can contact
Anthem 1lue "ross 1lue 'hield"linical Appeals .3. 1o %88@7 Atlanta, 4A ((;73perational Appeals .3. 1o %88@7 Atlanta, 4A ((;7
For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back ofprescription member ID card or visit www.epress-scripts.com.
For *CI'A information contact
Department of abor’s *mployee 1enets 'ecurity Administration%-7@@-;;;-*1'A #(9:9&www.dol.gov/ebsa/healthreform
Additionally, a consumer assistance program can help you le your appeal. "ontact
5ew 2ampshire Department of Insurance9% 'outh Fruit 'treet, 'uite %;"oncord, 52 ((%#7& 789-(;%@www.nh.gov/insuranceconsumerservicesLins.nh.gov
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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Awane: Maine Core EPO Coverage Period: 01/01/2016 - 12/31/2016
Summary of enefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P#an $y%e: EPO
9oe" !&i" Coverage Provide Minimum E""en!ia# Coverage<
0he A6ordable "are Act re+uires most people to have health care coverage that +ualies as Mminimum essential
coverage.N This plan or policy does provide minimum essential coverage.
9oe" !&i" Coverage Mee! !&e Minimum =a#ue S!andard<
0he A6ordable "are Act establishes a minimum value standard of benets of a health plan. 0he minimum value
standard is @= #actuarial value&. This health coverage does meet the minimum value standard for the
benets it provides.
anguage Ae"" Servie":
??????????????????????To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.–––––––––––???????????
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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>aving a ?a?y#normal delivery&
Managing !y%e 2 dia?e!e"#routine maintenance of
a well-controlled condition&
12 of 15
Awane: Maine COE EPO Coverage Period: 01/01/2016 - 12/31/2016
Coverage E7am%#e"
Coverage for: Individual/Family | P#an $y%e: EPO
A?ou! !&e"e CoverageE7am%#e":
0hese eamples show how this planmight cover medical care in givensituations. Gse these eamples tosee, in general, how much nancialprotection a sample patient mightget if they are covered underdi6erent plans.
Amoun! owed !o %rovider": $7,54
P#an %ay" $!,47
Pa!ien! %ay" $",7
Sam%#e are o"!":
2ospital charges #mother&9,:
Coutine obstetric care9,%
2ospital charges #baby& <
Anesthesia <
aboratory tests 8
rescriptions 9
Cadiology 9
Haccines, other preventive ;
otal$754
0
Pa!ien! %ay":
Deductibles8,<
"opays 9
"oinsurance
imits or eclusions %8
otal$07
0
Amoun! owed !o %rovider": $5,4
P#an %ay" $#7
Pa!ien! %ay" $4,5
Sam%#e are o"!":
rescriptions9,<
)edical *+uipment and
'upplies
%,(
36ice Hisits and rocedures :
*ducation (
aboratory tests %
Haccines, other preventive %
otal$540
0
Pa!ien! %ay":
Deductibles
;,98
"opays
"oinsurance 9
imits or eclusions 7
otal$45
0
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
$&i" i"no! a o"!e"!ima!or'
Don’t use theseeamples to estimate
your actual costs underthis plan. 0he actualcare you receive will bedi6erent from theseeamples, and the costof that care will also bedi6erent.
'ee the net page forimportant information
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Awane: Maine COE EPO Coverage Period: 01/01/2016 - 12/31/2016
Coverage E7am%#e"
Coverage for: Individual/Family | P#an $y%e: EPO
'uestio!s( "all 1-855-271-4549 or visit us at )))*a!the*coIf you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat )))*a!the*co or call 1-855-271-4549 to re+uest a copy.
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)ue"!ion" and an"wer" a?ou! !&e Coverage E7am%#e":
*&a! are "ome of !&ea""um%!ion" ?e&ind !&eCoverage E7am%#e"<
• "osts don’t include preius.
• 'ample care costs are based onnational averages supplied bythe G.'. Department of 2ealthand 2uman 'ervices, andaren’t specic to a particulargeographic area or health plan.
• 0he patient’s condition was notan ecluded or preeistingcondition.
• All services and treatmentsstarted and ended in the samecoverage period.
• 0here are no other medicalepenses for any membercovered under this plan.
• 3ut-of-pocket epenses arebased only on treating thecondition in the eample.
• 0he patient received all care
from in-network providers. Ifthe patient had received carefrom out-of-network providers,costs would have been higher.
*&a! doe" a Coverage E7am%#e"&ow<
For each treatment situation, the"overage *ample helps you see
how deductibles, copa%e!ts,and coi!sura!ce can add up. Italso helps you see what epensesmight be left up to you to paybecause the service or treatmentisn’t covered or payment is limited.
9oe" !&e Coverage E7am%#e%redi! my own are need"<
6o* 0reatments shown are >ust
eamples. 0he care you wouldreceive for this condition couldbe di6erent based on yourdoctor’s advice, your age, howserious your condition is, andmany other factors.
9oe" !&e Coverage E7am%#e%redi! my fu!ure e7%en"e"<
6o* "overage *amples are !ot
cost estimators. !ou can’t usethe eamples to estimate costsfor an actual condition. 0hey arefor comparative purposes only.
!our own costs will be di6erentdepending on the care youreceive, the prices yourproviders charge, and thereimbursement your health planallows.
Can ( u"e Coverage E7am%#e"!o om%are %#an"<
es* Khen you look at the
'ummary of 1enets and"overage for other plans, you’llnd the same "overage*amples. Khen you compareplans, check the Matient aysNbo in each eample. 0hesmaller that number, the morecoverage the plan provides.
Are !&ere o!&er o"!" ( "&ou#don"ider w&en om%aring%#an"<
es* An important cost is the
preiu you pay. 4enerally,the lower your preiu, themore you’ll pay in out-of-pocketcosts, such as copa%e!ts,
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deductibles, and coi!sura!ce. !ou should also considercontributions to accounts such
as health savings accounts#2'As&, Oeible spendingarrangements #F'As& or health
reimbursement accounts #2CAs&that help you pay out-of-pocketepenses.