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This guide is for information purposes only. You must enroll in a plan for your benefits to start.
Choosing and using your planYour guide to open enrollment and making the most of your benefits
115324MUMENMUB Rev. 05/19
33591antD1R1.A.indd 1 7/10/19 6:26 PM
Capital Area Health Consortium
Choosing your plan
It’s time to choose your plan
Using your plan
Notes
33591antD1R1.A.indd 2 7/10/19 6:26 PM
2
Your trusted health partner Anthem is committed to being your trusted health care partner. We’re developing the technology, solutions, programs and services that give you greater access to care. We also work with doctors to make sure you get affordable, quality health care.
Save this guideYou’ll find tips on how to make the most of your benefits and save on health care costs throughout the year.
Choosing your plan
Choosing your plan Using your plan
Table of contents
It’s time to choose your plan
Let’s get started
3
This is the perfect time to think about your health — where you are right now and where you want to be tomorrow. It’s your opportunity to check out the benefits, programs and resources that can support your health and well-being all year long.
This guide will help you understand our plans. It’s also full of tips, tools and resources that can help you reach your health and wellness goals when you become a member. So keep it handy to make the most of your benefits throughout the year.
The basics explained .........................................................................4
Explore your plan options .................................................................5
Vision benefits ...................................................................................6
How to use your plan ........................................................................7
The legal stuff we’re required to tell you ................................... 39
Choosing your plan
Coinsurance: Once you’ve met your deductible, you and your health plan share the cost of covered health care services. The coinsurance is your share of the costs, usually a percent of the cost of care. Your plan details show what portion of the cost you’ll pay.
Copay: A flat fee you pay for covered services like doctor visits.
The basics explained
What you pay and what your plan pays
You pay your deductible
You and your plan share cost
Your plan pays the cost
Deductible reached
Out-of-pocket limit reached
This chart is only an example. Your actual cost share will depend on your plan, the service you get and the doctor you choose. Check your plan details to see your actual share of the cost.
What you pay
What we pay
Words that are helpful to knowWe can help you crack the code of health insurance lingo. Here are the meanings of some common terms:
Deductible: A set amount you pay each year for covered services before your plan starts to pay for covered health care costs.
Out-of-pocket limit: This is the most you have to pay out of your own pocket each year for covered services. This amount may include your deductible and your percentage of the costs, depending on your plan. And some plans may still have you pay a copay at the time of service.
Premium: The premium, also called a monthly payment, is what you pay for the plan. It’s the money that comes out of your paycheck. Think of it like a membership fee that’s separate from what you pay when you get care.
Before we dive into the plan details, it may be helpful to review some health benefit basics.
4
Choosing your plan
Explore your plan options
5
Let’s take a look at the plan your employer is offering.
PPO With a Preferred Provider Organization (PPO), you can go to almost any doctor or hospital and you’re covered — giving you more choices and flexibility. You get special rates for doctors in your plan, which lowers your out-of-pocket costs.
You can choose a primary care provider (PCP) from the plan for preventive care, like checkups and screenings.
You don’t need to have a PCP to see a specialist.
When you want to see a specialist, like an orthopedic doctor or a cardiologist, you don’t need to visit your PCP first to get a referral. This can save you time and a copay.
You’ll pay less if you use doctors who are part of the PPO.
You can see providers who aren’t part of the PPO, but you’ll pay more.
Once you pay your deductible, you’ll pay a percentage of the total cost (also called coinsurance) anytime you get care for a covered service. Your plan will cover the rest.
Choosing your plan
Vision benefits
1 Available in Australia, Austria, Brazil, Canada, Chile, China, Colombia, Ecuador, England, France, Germany, Hong Kong SAR, Italy, Japan, Mexico, New Zealand, Peru, Puerto Rico, U.S., Spain and Switzerland.
2 American Optometric Association website, Evidence-Based Clinical Practice Guideline, Comprehensive Adult Eye and Vision Examination 2015 (accessed February 2019): aoa.org.
Keep an eye on your health
Routine eye checkups go beyond making sure you can see clearly. They also can catch other health problems early, like diabetes, high blood pressure, high cholesterol and rheumatoid arthritis.2
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When you choose Blue View VisionSM, you’ll be covered for checkups and eye exams and you’ll get allowances for the glasses or contacts you rely on.
Blue View Vision gives you access to more than 38,000 eye doctors at more than 27,000 locations across the country so you can find eye care and eyewear close to home and work. Locations include retail stores like LensCrafters®, Target Optical® and most Pearle Vision® stores. You can order glasses and contacts online through Glasses.com, ContactsDirect or 1-800-CONTACTS.
Blue View Vision’s International Travel Solution helps you when traveling outside of the U.S.:
Find a trusted eye doctor in 20 countries and territories.1
Get 24/7 phone support with translation services in 160 languages.
If you lose or break your glasses, you can get temporary emergency glasses with adjustable lenses delivered within 24 hours in most locations at no additional cost.
Using your plan
Using your plan
7
How to use your plan
Once you’ve chosen a plan, explore how to make the most of your benefits. Here you’ll learn simple ways to make using your plan easy. Plus, you’ll discover tools and resources that can help you reach your health and wellness goals. With Anthem, supporting your healthiest self is all part of the plan!
Using your plan
How to use your plan
Use your ID card right from your phone Introducing the Sydney Health mobile app. With Sydney Health you can find everything you need to know about your benefits – all in one place. You’ll have a custom experience that’s based on your plan, your specific health care needs and lots more. And you can quickly access your digital ID card to show it to your doctor. You can even use Sydney Health to track your health goals, find care, compare costs, and manage your claims.
Have a question? Sydney Health acts like a personal health guide, answering your questions and connecting you to the right resources at the right time. And you can use the chatbot to get answers quickly. Sydney Health makes it easier to get things done, so you can spend more time focusing on your health. Get started by downloading the Sydney Health mobile app.
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Register for online tools and resources Accessing your health plan on your mobile phone or computer makes life so much easier. Register on the Sydney Health mobile app and anthem.com to get personalized information about your health plan and more. You can:
Quickly access your digital ID card.
Find a doctor and estimate your costs before you go.
View your claims, see what’s covered and what you may owe for care.
Get support managing your health conditions and tracking your goals.
Update your email and communication preferences.
9 Using your plan
How to use your plan
9
Find a doctor in your plan The right doctor can make all the difference — and choosing one in your plan can save you money, too. So you’ll be happy to know your plan includes lots of top-notch doctors. If you decide to get care from doctors outside the plan, it’ll cost you more and your care might not be covered at all.
It’s easy to find a doctor in your plan. Simply use the Find a Doctor tool on the Sydney Health mobile app or at anthem.com to search for doctors, hospitals, labs and other health care professionals.
Schedule a checkup Preventive care, like regular checkups and screenings, can help you avoid health problems down the road. Your plan covers these services at little or no extra cost when you see a doctor in your plan:
Yearly physicals
Well-child visits
Flu shot
Routine shots
Screenings and tests
Check your plan details on the Sydney Health mobile app or anthem.com to confirm what preventive care is covered.
Page 1 of 13
Anthem® BlueCross and BlueShield
Your Plan: Anthem Century Preferred PPO $15/$0/$0/$50 Rx $10/$20
Your Network: Century Preferred
This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail.
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section.
$0 person / $0 family
$200 person / $600 family
Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost- shares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum.
$6,600 person / $13,200 family
$1,200 person / $1,600 family
Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible.
Included are the preventive care services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits.
No charge
20% coinsurance after medical deductible is met
Doctor Home and Office Services
Primary Care Visit to treat an injury or illness All services performed in the office are included in the office copay.
$15 copay per visit
20% coinsurance after medical deductible is met
Specialist Care Visit All services performed in the office are included in the office copay.
$20 copay per visit
20% coinsurance after medical deductible is met
Routine Prenatal Care Initial visit subject to $20 copay
No charge
20% coinsurance after medical deductible is met
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Page 2 of 13
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Routine Postnatal Care
No charge
20% coinsurance after medical deductible is met
Other Practitioner Visits:
Retail Health Clinic
On-line Visit Live Health Online is the preferred telehealth solutions (www.livehealthonline.com)
Chiropractic Coverage is limited to 50 combined visits with pt,ot,st per benefit period. Limit is combined In-Network and Non-Network.
Acupuncture
$15 copay per visit
$15 copay per visit
No charge Not covered
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Not covered
Other Services in an Office:
Allergy Testing
Chemo/Radiation Therapy
Dialysis/Hemodialysis
Prescription Drugs For the drugs itself dispensed in the office through infusion/injection.
$20 copay per visit
No charge
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Diagnostic Services
Lab:
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Page 3 of 13
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Office All services performed in the office are included in the office copay.
Freestanding/Site-of-Service Lab
Outpatient Hospital
No charge No charge No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
X-Ray:
Office
All services performed in the office are included in the office copay. Breast ultrasound cannot exceed $20 copay.
Freestanding/Site-of-Service Radiology Center Breast ultrasound cannot exceed $20 copay.
Outpatient Hospital
No charge No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Advanced Diagnostic Imaging: Imaging services include MRI, MRA, CAT, CTA, PET, and SPECT scans.
Office All services performed in the office are included in the office copay.
Freestanding/Site-of-Service Radiology Center
Outpatient Hospital
No charge
No charge No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met 20% coinsurance after medical deductible is met
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Page 4 of 13
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Emergency and Urgent Care
Urgent Care
$25 copay per visit
Not Covered
Emergency Room Facility Services
Emergency Room Doctor and Other Services
$50 copay per visit No charge
Covered as In- Network
Covered as In- Network
Ambulance Transportation
No charge
Covered as In- Network
Outpatient Mental/Behavioral Health and Substance Abuse
Doctor Office Visit and Online Visit
Facility visit:
Facility Fees
Doctor Services
No charge
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Outpatient Surgery
Facility Fees:
Hospital
Freestanding Surgical Center
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
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Page 5 of 13
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Doctor and Other Services:
Hospital
Freestanding Surgical Center
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Hospital Stay (all Inpatient stays including Maternity, Mental/Behavioral Health, Substance Abuse, Infertility, Human Organ and Tissue Transplant services):
Facility fees (for example, room & board) Doctor and other services
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Recovery & Rehabilitation
Home Health Care Coverage is limited to 200 visits per benefit period. Limit is combined In-Network and Non-Network
No charge
$50 deductible then 20% coinsurance
Rehabilitation services (for example, physical/speech/occupational therapy):
Office
Coverage for rehabilitative and habilitative physical therapy, occupational
therapy, speech therapy and chiropractic care combined is limited to 50 visits per benefit period. Limit is combined across professional visits and outpatient
facilities. Limit is combined In –Network and Non-Network
Outpatient Hospital Coverage for rehabilitative and habilitative physical therapy, occupational therapy,
speech therapy, and chiropractic care combined is limited to 50 visits per benefit period. Limit is combined across professional visits and outpatient facilities.
Limit is combined In –Network and Non-Network
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
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Page 6 of 13
Covered Medical Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Cardiac rehabilitation
Office Coverage is limited to 36 visit(s) per episode. Limit is combined In- Network and Non-Network. Visit limits are combined both across outpatient and other professional visits.
Outpatient Hospital Coverage is limited to 36 visit(s) per episode. Limit is combined In- Network and Non-Network. Visit limits are combined both across outpatient and other professional visits.
No charge
No charge
20% coinsurance after medical deductible is met
20% coinsurance after medical deductible is met
Skilled Nursing Care (in a facility) Coverage is limited to 120 days per benefit period. Limit is combined In-Network and Non-Network.
No charge
20% coinsurance after medical deductible is met
Hospice 60 day maximum
$200 copay
20% coinsurance after medical deductible is met
Durable Medical Equipment Coverage for hearing aids is limited to 1 per ear every 2 years.
No charge
20% coinsurance after medical deductible is met
Prosthetic Devices Mandatory coverage of a wig if prescribed by a licensed oncologist for a patient who suffers hair loss as a result of chemotherapy.
No charge
20% coinsurance after medical deductible is met
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Page 7 of 13
Covered Prescription Drug Benefits
Cost if you use an In-Network Provider
Cost if you use a Non-Network Provider
Pharmacy Deductible
Not applicable
Not applicable
Pharmacy Out of Pocket
Combined with medical out of pocket maximum
Combined with medical out of pocket maximum
Prescription Drug Coverage National Drug List
Tier 1 - Typically Generic Covers up to a 34 day supply (retail pharmacy). Covers up to a 100 day supply (home delivery program). Covers up to 100 day supply (retail maintenance pharmacy).
$10 copay per prescription (retail only). $0 copay per prescription (home delivery only).
20% coinsurance(retail and home delivery)
Tier 2 – Typically Preferred Brand Covers up to a 34 day supply (retail pharmacy). Covers up to a 100 day supply (home delivery program). Covers up to 100 day supply (retail maintenance pharmacy).
$20 copay per prescription (retail only). $0 copay per prescription (home delivery only).
20% coinsurance(retail and home delivery)
Tier 3 - Typically Non-Preferred Brand Covers up to a 34 day supply (retail pharmacy). Covers up to a 100 day supply (home delivery program). Covers up to 100 day supply (retail maintenance pharmacy).
$20 copay per prescription (retail only). $0 copay per prescription (home delivery only).
20% coinsurance(retail and home delivery)
Tier 4 - Typically Specialty (brand and generic) Covers up to a 30 day supply (retail pharmacy). Covers up to a 30 day supply (home delivery program).
Not applicable
Not applicable
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Page 11 of 13
Notes:
The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum.
For additional information on this plan, please visit sbc.anthem.com to obtain a "Summary of Benefit Coverage".
If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network.
If your plan includes out of network benefits and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. When receiving care from providers out of network, members may be subject to balance billing in addition to any applicable copayments, coinsurance and/or deductible. This amount does not apply to the out of network out of pocket limit.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue 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 registered marks of the Blue Cross and Blue Shield Association.
Questions: or visit us at www.anthem.com CT/LG/Anthem Century Preferred PPO $10/$0/$0/$50 Rx $10/$20/ 07- 2019
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Get help in your language
Curious to know what all this says? We would be too. Here’s the English version: If you have any questions about this document, you have the right to get help and information in your language at no cost. To talk to an interpreter, call
Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card.
(TTY/TDD: 711)
.
Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք
անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար
զանգահարեք հետևյալ հեռախոսահամարով՝ :
Chinese(中文)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通 話
，請致電。
French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces
informations et à une aide dans votre langue. Pour parler à un interprète, appelez le .
Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak
enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele .
Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e
informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero .
Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로
무료 도움 및 정보를 얻을 권리가 있습니다. 통역사와 이야기하려면로 문의하십시오.
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Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer: .
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Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su
idioma, sin costos. Para hablar con un intérprete, llame al .
Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang
humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag,
tawagan ang .
Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và
thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi .
It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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co
vere
d b
efo
re y
ou
m
eet
yo
ur
ded
ucti
ble
?
Yes
. Y
ou w
ill n
ot
hav
e to
mee
t th
e ded
uct
ible
bef
ore
th
e p
lan
pay
s fo
r an
y se
rvic
es.
Are
th
ere
oth
er
ded
ucti
ble
s fo
r sp
ecif
ic s
erv
ices?
Yes
. $50 f
or
Out-
of-
Net
wo
rk
Pro
vid
ers
for
Ho
me
Hea
lth
C
are.
Th
ere
are
no
oth
er
spec
ific
ded
uct
ible
s.
Yo
u m
ust
pay
all
of
the
cost
s fo
r th
ese
serv
ices
up
to
th
e sp
ecif
ic d
educt
ible
am
oun
t b
efo
re
this
pla
n b
egin
s to
pay
fo
r th
ese
serv
ices
.
Wh
at
is t
he o
ut-
of-
po
ck
et
lim
it f
or
this
p
lan
?
$6,6
00/in
div
idual
or
$13
,200/2-
mem
ber
fam
ily
or
$13
,200/3+
m
emb
er f
amily
fo
r In
-Net
wo
rk
Pro
vid
ers.
$1,
200/in
div
idual
or
$1,
400/2-m
emb
er f
amily
or
$1,
600/3+
mem
ber
fam
ily
for
Out-
of-
Net
wo
rk P
rovid
ers.
Th
e o
ut-
of-
po
cket
lim
it is
the
mo
st y
ou c
ould
pay
in
a y
ear
for
cover
ed s
ervic
es. If
yo
u h
ave
oth
er f
amily
mem
ber
s in
th
is p
lan
, th
ey h
ave
to m
eet
thei
r o
wn
out-
of-
po
cket
lim
its
un
til th
e
over
all fa
mily
out-
of-
po
cket
lim
it h
as b
een
met
.
Wh
at
is n
ot
inclu
ded
in
th
e o
ut-
of-
po
ck
et
lim
it?
Pre
miu
ms,
bal
ance
-bill
ing
char
ges,
an
d h
ealt
h c
are
this
p
lan
do
esn
't c
over
.
Even
th
ough
yo
u p
ay t
hes
e ex
pen
ses,
th
ey d
on
’t c
oun
t to
war
d t
he
out-
of-
po
cket
lim
it.
Wil
l yo
u p
ay l
ess
if
yo
u u
se a
netw
ork
p
rovi
der?
Yes
, P
PO
. See
w
ww
.an
them
.co
m o
r ca
ll (
800)
922-6
621 f
or
a lis
t o
f n
etw
ork
Th
is p
lan
use
s a
pro
vid
er n
etw
ork
. Y
ou w
ill p
ay les
s if
yo
u u
se a
pro
vid
er in
th
e p
lan
’s
net
wo
rk. Y
ou w
ill p
ay t
he
mo
st if
you u
se a
n o
ut-
of-
net
wo
rk p
rovid
er, an
d y
ou m
igh
t re
ceiv
e
a b
ill f
rom
a p
rovid
er f
or
the
dif
fere
nce
bet
wee
n t
he
pro
vid
er’s
ch
arge
an
d w
hat
yo
ur
pla
n
20
* F
or
mo
re in
form
atio
n a
bo
ut
limit
atio
ns
and e
xcep
tio
ns,
see
pla
n o
r p
olicy
do
cum
ent
at h
ttp
s://eo
c.an
them
.co
m/
eocd
ps/
fi.
2 o
f 11
pro
vid
ers.
p
ays
(bal
ance
billin
g). B
e aw
are
your
net
wo
rk p
rovid
er m
igh
t use
an
out-
of-
net
wo
rk p
rovid
er
for
som
e se
rvic
es (
such
as
lab
wo
rk).
Ch
eck w
ith
yo
ur
pro
vid
er b
efo
re y
ou g
et s
ervic
es.
Do
yo
u n
eed
a r
efe
rral
to s
ee a
sp
ecia
list
? N
o.
Yo
u c
an s
ee t
he
spec
ialis
t yo
u c
ho
ose
wit
ho
ut
a re
ferr
al.
A
ll co
paym
en
t an
d c
oin
sura
nce c
ost
s sh
ow
n in
th
is c
har
t ar
e af
ter
your
ded
ucti
ble
has
bee
n m
et, if
a d
ed
ucti
ble
ap
plie
s.
Co
mm
on
Med
ical
Eve
nt
Serv
ices
Yo
u M
ay N
eed
Wh
at
Yo
u W
ill
Pay
Lim
itati
on
s, E
xcep
tio
ns,
& O
ther
Imp
ort
an
t In
form
ati
on
In
-Netw
ork
Pro
vid
er
(Yo
u w
ill
pay t
he l
east
)
Ou
t-o
f-N
etw
ork
P
rovi
der
(Yo
u w
ill
pay t
he m
ost
)
If y
ou
vis
it a
h
ealt
h c
are
p
rovi
der’
s o
ffic
e
or
cli
nic
Pri
mar
y ca
re v
isit
to
tre
at a
n
inju
ry o
r ill
nes
s $1
5 c
op
ay/vis
it
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
Sp
ecia
list
vis
it
$20 c
op
ay/vis
it
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
Pre
ven
tive
care
/sc
reen
ing/
im
mun
izat
ion
N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
Yo
u m
ay h
ave
to p
ay f
or
serv
ices
th
at
aren
't p
reven
tive.
Ask
yo
ur
pro
vid
er if
the
serv
ices
nee
ded
are
pre
ven
tive.
T
hen
ch
eck w
hat
yo
ur
pla
n w
ill p
ay
for.
If y
ou
have
a t
est
Dia
gno
stic
tes
t (x
-ray
, b
loo
d
wo
rk)
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
----
----
no
ne-
----
---
Imag
ing
(CT
/P
ET
sca
ns,
MR
Is)
N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
P
rio
r au
tho
riza
tio
n is
req
uir
ed.
If y
ou
need
dru
gs
to t
reat
yo
ur
illn
ess
or
co
nd
itio
n
Mo
re in
form
atio
n
abo
ut
pre
scri
pti
on
d
rug
co
vera
ge is
avai
lab
le a
t h
ttp
://w
ww
.an
the
m.c
om
/p
har
mac
yin
form
atio
n/
E
ssen
tial
Tie
r 1 -
Typ
ical
ly G
ener
ic
$10 C
op
ay/p
resc
rip
tio
n
(ret
ail)
an
d $
0 C
op
ay
(ho
me
del
iver
y)
20%
of
the
in-n
etw
ork
al
low
ance
, p
lus
the
dif
fere
nce
bet
wee
n
An
them
s p
aym
ent
and t
he
ph
arm
acis
t’s
actu
al c
har
ge
34-d
ay s
up
ply
fo
r R
etai
l 35-1
00-d
ay s
up
ply
fo
r M
ail O
rder
.
Tie
r 2 -
Typ
ical
ly P
refe
rred
/
No
n-
Pre
ferr
ed B
ran
d
$20 C
op
ay/p
resc
rip
tio
n
(ret
ail)
an
d $0
Co
pay
(h
om
e del
iver
y)
Tie
r 3 -
Typ
ical
ly N
on
-Pre
ferr
ed
/ S
pec
ialt
y D
rugs
$20 C
op
ay/p
resc
rip
tio
n
(ret
ail)
an
d $0
Co
pay
(h
om
e del
iver
y)
20%
of
the
in-n
etw
ork
al
low
ance
, p
lus
the
dif
fere
nce
bet
wee
n
An
them
s p
aym
ent
and t
he
ph
arm
acis
t’s
actu
al c
har
ge
Tie
r 4 -
Typ
ical
ly S
pec
ialt
y (b
ran
d a
nd g
ener
ic)
No
t ap
plic
able
N
ot
app
licab
le
21
* F
or
mo
re in
form
atio
n a
bo
ut
limit
atio
ns
and e
xcep
tio
ns,
see
pla
n o
r p
olicy
do
cum
ent
at h
ttp
s://eo
c.an
them
.co
m/
eocd
ps/
fi.
3 o
f 11
Co
mm
on
Med
ical
Eve
nt
Serv
ices
Yo
u M
ay N
eed
Wh
at
Yo
u W
ill
Pay
Lim
itati
on
s, E
xcep
tio
ns,
& O
ther
Imp
ort
an
t In
form
ati
on
In
-Netw
ork
Pro
vid
er
(Yo
u w
ill
pay t
he l
east
)
Ou
t-o
f-N
etw
ork
P
rovi
der
(Yo
u w
ill
pay t
he m
ost
)
If y
ou
have
o
utp
ati
en
t su
rgery
Fac
ility
fee
(e.
g., am
bula
tory
su
rger
y ce
nte
r)
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
Ph
ysic
ian
/su
rgeo
n f
ees
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
If y
ou
need
im
med
iate
m
ed
ical
att
en
tio
n
Em
erge
ncy
ro
om
car
e $5
0 c
op
ay/vis
it
$50 c
op
ay/vis
it
Co
pay
wai
ved
if
adm
itte
d.
Em
erge
ncy
med
ical
tr
ansp
ort
atio
n
No
ch
arge
C
over
ed a
s In
-Net
wo
rk
----
----
no
ne-
----
---
Urg
ent
care
$2
5/vis
it
No
t co
ver
ed
Out
of
net
wo
rk u
rgen
t ca
re p
aid a
s em
erge
ncy
ro
om
If y
ou
have
a
ho
spit
al
stay
Fac
ility
fee
(e.
g., h
osp
ital
ro
om
) N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
Fai
lure
to
ob
tain
pre
auth
ori
zati
on
m
ay r
esult
in
no
n c
over
age
or
reduce
d
ben
efit
s
Ph
ysic
ian
/su
rgeo
n f
ees
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
If y
ou
need
m
en
tal
healt
h,
beh
avi
ora
l h
ealt
h,
or
sub
stan
ce
ab
use
serv
ices
Outp
atie
nt
serv
ices
Off
ice
Vis
it N
o c
har
ge
O
ther
Outp
atie
nt
No
ch
arge
Off
ice
Vis
it
20%
co
insu
ran
ce a
fter
ded
uct
ible
O
ther
Outp
atie
nt
20%
co
insu
ran
ce a
fter
ded
uct
ible
----
----
no
ne-
----
---
Inp
atie
nt
serv
ices
N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
Fai
lure
to
ob
tain
pre
auth
ori
zati
on
m
ay r
esult
in
no
n c
over
age
or
reduce
d
ben
efit
s
If y
ou
are
p
reg
nan
t
Off
ice
vis
its
$20/vis
it f
irst
vis
it
20%
co
insu
ran
ce a
fter
ded
uct
ible
F
ailu
re t
o o
bta
in p
re a
uth
ori
zati
on
m
ay r
esult
in
no
n-c
over
age
or
reduce
d
ben
efit
s. M
ater
nit
y ca
re m
ay in
clude
test
s an
d s
ervic
es d
escr
ibed
els
ewh
ere
in t
he
SB
C (
i.e. ult
raso
un
d).
Ch
ildb
irth
/del
iver
y p
rofe
ssio
nal
se
rvic
es
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
Ch
ildb
irth
/del
iver
y fa
cilit
y se
rvic
es
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
If y
ou
need
help
re
co
veri
ng
or
have
o
ther
specia
l h
ealt
h n
eed
s
Ho
me
hea
lth
car
e N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
, H
om
e H
ealt
h
Car
e ded
uct
ible
ap
plie
s
Co
ver
age
is lim
ited
to
200 v
isit
s. P
rio
r au
tho
riza
tio
n is
requir
ed.
Reh
abili
tati
on
ser
vic
es
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
C
over
age
is lim
ited
to
50 v
isit
s p
er
mem
ber
per
cal
endar
yea
r fo
r
22
* F
or
mo
re in
form
atio
n a
bo
ut
limit
atio
ns
and e
xcep
tio
ns,
see
pla
n o
r p
olicy
do
cum
ent
at h
ttp
s://eo
c.an
them
.co
m/
eocd
ps/
fi.
4 o
f 11
Co
mm
on
Med
ical
Eve
nt
Serv
ices
Yo
u M
ay N
eed
Wh
at
Yo
u W
ill
Pay
Lim
itati
on
s, E
xcep
tio
ns,
& O
ther
Imp
ort
an
t In
form
ati
on
In
-Netw
ork
Pro
vid
er
(Yo
u w
ill
pay t
he l
east
)
Ou
t-o
f-N
etw
ork
P
rovi
der
(Yo
u w
ill
pay t
he m
ost
)
Hab
ilita
tio
n s
ervic
es
No
ch
arge
20%
co
insu
ran
ce a
fter
ded
uct
ible
C
hir
op
ract
or,
Sp
eech
, P
hys
ical
an
d
Occ
up
atio
nal
th
erap
y.
Skille
d n
urs
ing
care
N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
120 d
ays
limit
/b
enef
it p
erio
d.
Dura
ble
med
ical
equip
men
t N
o c
har
ge
20%
co
insu
ran
ce a
fter
ded
uct
ible
--
----
--n
on
e---
----
-
Ho
spic
e se
rvic
es
$200 C
op
ay
20%
co
insu
ran
ce a
fter
ded
uct
ible
P
rio
r au
tho
riza
tio
n is
requir
ed
If y
ou
r ch
ild
n
eed
s d
en
tal
or
eye c
are
Eye
exa
m(r
outi
ne
or
med
ical
) N
o c
har
ge if
pre
ven
tati
ve
Med
ical
$20 C
op
ay
20%
co
insu
ran
ce a
fter
ded
uct
ible
C
over
age
for
Eye
exa
ms
is lim
ited
to
o
ne
exam
ever
y 1 c
alen
dar
yea
rs.
Sep
arat
e V
isio
n p
lan
(gl
asse
s)
Ch
ildre
n’s
gla
sses
N
ot
cover
ed
No
t co
ver
ed
Ch
ildre
n’s
den
tal ch
eck-u
p
No
t co
ver
ed
No
t co
ver
ed
Exclu
ded
Serv
ices
& O
ther
Co
vere
d S
erv
ices:
Serv
ices
Yo
ur
Pla
n G
en
era
lly D
oes
NO
T C
ove
r (C
heck
yo
ur
po
licy o
r p
lan
do
cu
men
t fo
r m
ore
in
form
ati
on
an
d a
lis
t o
f an
y o
ther
exclu
ded
se
rvic
es.
)
Acu
pun
cture
Lo
ng
term
car
e
Ro
uti
ne
foo
t ca
re
Co
smet
ic s
urg
ery
Wei
ght
loss
pro
gram
s
Oth
er
Co
vere
d S
erv
ices
(Lim
itati
on
s m
ay a
pp
ly t
o t
hese
serv
ices.
Th
is i
sn’t
a c
om
ple
te l
ist.
Ple
ase
see y
ou
r p
lan
do
cu
men
t.)
Ch
iro
pra
ctic
car
e
Hea
rin
g ai
ds(
rest
rict
ion
s ap
ply
)
Bar
iatr
ic s
urg
ery
Ro
uti
ne
eye
care
(ad
ult
)
Mo
st c
over
age
pro
vid
ed o
uts
ide
the
Un
ited
Sta
tes.
See
ww
w.b
cbsg
lob
alco
re.c
om
Infe
rtili
ty t
reat
men
t
(Fo
r m
emb
ers
enro
lled
eff
ecti
ve 7
/1/1
9 o
r th
erea
fter
, co
vere
d s
ervi
ces
rela
ted
to
infe
rtili
ty m
ust
be
ren
der
ed a
t th
e C
ente
r fo
r A
dva
nce
d R
epro
du
ctiv
e Se
rvic
es.
Infe
rtili
ty s
ervi
ces
per
form
ed b
y an
y p
rovi
der
o
ther
th
an t
he
Cen
ter
for
Ad
van
ced
Rep
rod
uct
ive
Serv
ices
are
co
nsi
der
ed n
on
-co
vere
d s
ervi
ces.
)
23
* F
or
mo
re in
form
atio
n a
bo
ut
limit
atio
ns
and e
xcep
tio
ns,
see
pla
n o
r p
olicy
do
cum
ent
at h
ttp
s://eo
c.an
them
.co
m/
eocd
ps/
fi.
5 o
f 11
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e:
Th
ere
are
agen
cies
th
at c
an h
elp
if
you w
ant
to c
on
tin
ue
your
cover
age
afte
r it
en
ds.
Th
e co
nta
ct in
form
atio
n f
or
tho
se
agen
cies
is:
Co
nn
ecti
cut
Dep
artm
ent
of
Insu
ran
ce, 153 M
arket
Str
eet,
7th
Flo
or,
Har
tfo
rd, C
T 0
6103, (8
60)
297-3
000, (8
00)
203-3
447. D
epar
tmen
t o
f L
abo
r,
Em
plo
yee
Ben
efit
s Sec
uri
ty A
dm
inis
trat
ion
, (8
66)
444-E
BSA
(3272),
ww
w.d
ol.g
ov/eb
sa/h
ealt
hre
form
. O
ther
co
ver
age
op
tio
ns
may
be
avai
lab
le t
o y
ou t
oo
,
incl
udin
g b
uyi
ng
indiv
idual
in
sura
nce
co
ver
age
thro
ugh
th
e H
ealt
h I
nsu
ran
ce M
arket
pla
ce. F
or
mo
re in
form
atio
n a
bo
ut
the
Mar
ket
pla
ce, vis
it
ww
w.H
ealt
hC
are.
gov
or
call
1-8
00-3
18-2
596.
Yo
ur
Gri
eva
nce a
nd
Ap
peals
Rig
hts
: T
her
e ar
e ag
enci
es t
hat
can
hel
p if
you h
ave
a co
mp
lain
t ag
ain
st y
our
pla
n f
or
a den
ial o
f a
clai
m. T
his
co
mp
lain
t is
ca
lled a
gri
evan
ce o
r ap
pea
l. F
or
mo
re in
form
atio
n a
bo
ut
your
righ
ts, lo
ok a
t th
e ex
pla
nat
ion
of
ben
efit
s yo
u w
ill r
ecei
ve
for
that
med
ical
cla
im. Y
our
pla
n
do
cum
ents
als
o p
rovid
e co
mp
lete
in
form
atio
n t
o s
ub
mit
a c
laim
, ap
pea
l, o
r a
grie
van
ce f
or
any
reas
on
to
yo
ur
pla
n. F
or
mo
re in
form
atio
n a
bo
ut
your
righ
ts,
this
no
tice
, o
r as
sist
ance
, co
nta
ct:
AT
TN
: G
riev
ance
s an
d A
pp
eals
, P
.O. B
ox
1038, N
ort
h H
aven
, C
T 0
6473-4
201
Dep
artm
ent
of
Lab
or,
Em
plo
yee
Ben
efit
s Sec
uri
ty A
dm
inis
trat
ion
, (8
66)
444-E
BSA
(3272),
ww
w.d
ol.g
ov/eb
sa/h
ealt
hre
form
Co
nn
ecti
cut
Dep
artm
ent
of
Insu
ran
ce, 153 M
arket
Str
eet,
7th
Flo
or,
Har
tfo
rd, C
T 0
6103, (8
60)
297-3
000, (8
00)
203-3
447
Do
es
this
pla
n p
rovi
de M
inim
um
Ess
en
tial
Co
vera
ge?
Yes
If y
ou d
on
’t h
ave
Min
imum
Ess
enti
al C
over
age
for
a m
on
th, yo
u’ll
hav
e to
mak
e a
pay
men
t w
hen
yo
u f
ile y
our
tax
retu
rn u
nle
ss y
ou q
ual
ify
for
an e
xem
pti
on
fr
om
th
e re
quir
emen
t th
at y
ou h
ave
hea
lth
co
ver
age
for
that
mo
nth
. D
oes
this
pla
n m
eet
the M
inim
um
Valu
e S
tan
dard
s?
Yes
If y
our
pla
n d
oes
n’t
mee
t th
e M
inim
um
Val
ue
Sta
nd
ards,
yo
u m
ay b
e el
igib
le f
or
a p
rem
ium
tax
cre
dit
to
hel
p y
ou p
ay f
or
a p
lan
th
rough
th
e M
arket
pla
ce.
––––––––––––––––––––––
To
see
exam
ples
of ho
w thi
s pl
an m
ight
cov
er c
osts
for
a s
ampl
e m
edic
al s
itua
tion
, se
e th
e ne
xt se
ctio
n.––––––––––––––––––––––
24
Th
e p
lan
wo
uld
be
resp
on
sib
le f
or
the
oth
er c
ost
s o
f th
ese
EX
AM
PL
E c
over
ed s
ervic
es.
6 o
f 11
Ab
ou
t th
ese
Co
vera
ge E
xam
ple
s:
T
his
is
no
t a c
ost
est
imato
r. T
reat
men
ts s
ho
wn
are
just
exa
mp
les
of
ho
w t
his
pla
n m
igh
t co
ver
med
ical
car
e. Y
our
actu
al c
ost
s w
ill
be
dif
fere
nt
dep
endin
g o
n t
he
actu
al c
are
you r
ecei
ve,
th
e p
rice
s yo
ur
pro
vid
ers
char
ge, an
d m
any
oth
er f
acto
rs. F
ocu
s o
n t
he
cost
sh
arin
g am
oun
ts (
ded
uct
ible
s, c
op
aym
ents
an
d c
oin
sura
nce
) an
d e
xclu
ded
ser
vic
es u
nder
th
e p
lan
. U
se t
his
in
form
atio
n t
o c
om
par
e th
e p
ort
ion
of
cost
s yo
u m
igh
t p
ay u
nder
dif
fere
nt
hea
lth
pla
ns.
Ple
ase
no
te t
hes
e co
ver
age
exam
ple
s ar
e b
ased
on
sel
f-o
nly
co
ver
age.
Peg
is
Havin
g a
Bab
y
(9 m
on
ths
of
in-n
etw
ork
pre
-nat
al c
are
and a
h
osp
ital
del
iver
y)
M
an
ag
ing
Jo
e’s
typ
e 2
Dia
bete
s (a
yea
r o
f ro
uti
ne
in-n
etw
ork
car
e o
f a
wel
l-
con
tro
lled
co
ndit
ion
)
M
ia’s
Sim
ple
Fra
ctu
re
(in
-net
wo
rk e
mer
gen
cy r
oo
m v
isit
an
d f
ollo
w
up
car
e)
T
he p
lan
’s o
vera
ll d
ed
ucti
ble
$0
Th
e p
lan
’s o
vera
ll d
ed
ucti
ble
$0
Th
e p
lan
’s o
vera
ll d
ed
ucti
ble
$0
S
pecia
list
co
pay
men
t $50
Sp
ecia
list
co
pay
men
t $50
Sp
ecia
list
co
pay
men
t $50
H
osp
ital
(facil
ity)
cop
aym
ent
$500
Ho
spit
al
(facil
ity)
cop
aym
ent
$500
Ho
spit
al
(facil
ity)
cop
aym
ent
$500
O
ther
coin
sura
nce
0%
Oth
er
coin
sura
nce
0%
Oth
er
coin
sura
nce
0%
Th
is E
XA
MP
LE
eve
nt
inclu
des
serv
ices
lik
e:
S
pecia
list
off
ice
vis
its
(pre
nata
l ca
re)
Ch
ildb
irth
/D
eliv
ery
Pro
fess
ion
al S
ervic
es
Ch
ildb
irth
/D
eliv
ery
Fac
ility
Ser
vic
es
Dia
gn
ost
ic t
est
s (u
ltra
soun
ds a
nd b
lood
wor
k)
Sp
ecia
list
vis
it (
anes
thes
ia)
T
his
EX
AM
PL
E e
ven
t in
clu
des
serv
ices
lik
e:
P
rim
ary
care
ph
ysi
cia
n o
ffic
e vis
its
(inc
ludi
ng
dise
ase
educ
atio
n)
Dia
gn
ost
ic t
est
s (b
lood
wor
k)
Pre
scri
pti
on
dru
gs
D
ura
ble
med
ical
eq
uip
men
t (g
luco
se m
eter
)
T
his
EX
AM
PL
E e
ven
t in
clu
des
serv
ices
lik
e:
E
merg
en
cy r
oo
m c
are
(in
clud
ing
med
ical
sup
plie
s)
Dia
gn
ost
ic t
est
(x-r
ay)
Du
rab
le m
ed
ical
eq
uip
men
t (c
rutc
hes)
R
eh
ab
ilit
ati
on
serv
ices
(phy
sica
l th
erap
y)
To
tal
Exam
ple
Co
st
$12
,840
T
ota
l E
xam
ple
Co
st
$7,4
60
T
ota
l E
xam
ple
Co
st
$2,0
10
In t
his
exam
ple
, P
eg
wo
uld
pay:
In
th
is e
xam
ple
, Jo
e w
ou
ld p
ay:
In
th
is e
xam
ple
, M
ia w
ou
ld p
ay:
Co
st S
har
ing
Co
st S
har
ing
Co
st S
har
ing
Ded
ucti
ble
s $0
Ded
ucti
ble
s $0
Ded
ucti
ble
s $0
Co
paym
en
ts
$640
C
op
aym
en
ts
$1,9
85
C
op
aym
en
ts
$1,5
85
Co
insu
ran
ce
$0
C
oin
sura
nce
$0
C
oin
sura
nce
$37
Wha
t is
n’t co
vere
d
Wha
t is
n’t co
vere
d
Wha
t is
n’t co
vere
d
Lim
its
or
excl
usi
on
s $6
0
L
imit
s o
r ex
clusi
on
s $5
5
L
imit
s o
r ex
clusi
on
s $0
Th
e t
ota
l P
eg
wo
uld
pay i
s $700
T
he t
ota
l Jo
e w
ou
ld p
ay i
s $2,0
40
T
he t
ota
l M
ia w
ou
ld p
ay i
s $1,
622
25
Lan
gu
ag
e A
ccess
Serv
ices:
7 o
f 11
(T
TY
/T
DD
: 711
)
Alb
an
ian
(S
hq
ip):
Nës
e ken
i p
yetj
e n
ë lid
hje
me
kët
ë do
kum
ent,
ken
i të
dre
jtë
të m
errn
i fa
las
ndih
më
dh
e in
form
acio
n n
ë gj
uh
ën t
uaj
. P
ër t
ë ko
nta
ktu
ar m
e
një
për
kth
yes,
tel
efo
no
ni (8
00)
922-6
621
Am
hari
c (አአአአ
)አ ስ
ስስስ
ስስስ
ስስስስስ
ስስስ
ስስስስ
ስስስስ
ስስስ
ስስስስ
ስስ
ስስስ
ስስስ
ስስስ
ስስስስስ
ስስስ
ስስስስስ
ስስስስስስ
ስስስስስ
(800)
922-6
621 ስ
ስስስስ
.(800)
922-6
621
A
rmen
ian
(հայերեն
). Եթե
այս
փաստաթղթի
հետ
կապված հարցեր
ունեք
, դուք
իրավունք
ունեք
անվճար
ստանալ օգնություն
և
տեղեկատվություն
ձեր
լեզվով
: Թարգմանչի
հետ
խոսելու համար
զանգահարեք
հետևյալ հեռախոսահամարով՝
(800)
922-6
621:
(800)
922-6
621.
(
800)
922-6
621
(800)
922-6
621
Ch
inese
(中文
)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通話，請致電
(800)
922-6
621。
(800)
922-6
621.
Du
tch
(N
ed
erl
an
ds)
: B
ij vra
gen
over
dit
do
cum
ent
heb
t u r
ech
t o
p h
ulp
en
in
form
atie
in
uw
taa
l zo
nder
bijk
om
ende
ko
sten
. A
ls u
een
to
lk w
ilt s
pre
ken
,
bel
t u (
800)
922-6
621.
(800)
922-6
621
Fre
nch
(F
ran
çais
) :
Si vo
us
avez
des
ques
tio
ns
sur
ce d
ocu
men
t, v
ous
avez
la
po
ssib
ilité
d’a
ccéd
er g
ratu
item
ent
à ce
s in
form
atio
ns
et à
un
e ai
de
dan
s vo
tre
lan
gue.
Po
ur
par
ler
à un
in
terp
rète
, ap
pel
ez le
(800)
922-6
621.
26
Lan
gu
ag
e A
ccess
Serv
ices:
8 o
f 11
Germ
an
(D
eu
tsch
): W
enn
Sie
Fra
gen
zu d
iese
m D
okum
ent
hab
en, h
aben
Sie
An
spru
ch a
uf
ko
sten
frei
e H
ilfe
un
d I
nfo
rmat
ion
in
Ih
rer
Sp
rach
e. U
m m
it
ein
em D
olm
etsc
her
zu s
pre
chen
, b
itte
wäh
len
Sie
(800)
922-6
621.
Gre
ek
(Ε
λλη
νικά)
Αν
έχετ
ε τυ
χόν
απορίε
ς σχετ
ικά μ
ε το
παρόν
έγγρ
αφο, έχ
ετε
το δ
ικαίω
μα ν
α λ
άβετ
ε βοήθε
ια κ
αι πλη
ροφορίε
ς στη
γλώ
σσα σ
ας
δω
ρεά
ν. Γ
ια ν
α
μιλ
ήσετ
ε μ
ε κά
ποιο
ν διε
ρμ
ηνέ
α, τη
λεφω
νήστε
στο
(800)
922-6
621.
Gu
jara
ti (ગજુરાતી)
: જો આ
દસ્તાવેજ
અંગ
ેઆપને
કોઈપણ
પ્રશ્નો હોય
તો, કોઈપણ
ખર્ચ વગર આપની ભાષામાં મદદ
અને
માહહતી મેળવવાનો તમન
ેઅહિકાર છે
. દુભ
ાહષયા સાથે વાત
કરવા માટે, કોલ
કરો
(800)
922-6
621.
Hait
ian
Cre
ole
(K
reyò
l A
yis
yen
): S
i o
u g
en n
enp
òt
kes
yon
so
u d
okim
an s
a a,
ou g
en d
wa
po
u jw
enn
èd a
k e
nfò
mas
yon
nan
lan
g o
u g
rati
s. P
ou p
ale
ak y
on
en
tèp
rèt,
rel
e (8
00)
922-6
621.
(800)
922-6
621
H
mo
ng
(W
hit
e H
mo
ng
): Y
og
tias
ko
j m
uaj
lus
nug
dab
tsi
nts
ig t
xog
dai
m n
taw
v n
o, ko
j m
uaj
cai
tau
txa
is k
ev p
ab t
hia
b lus
qh
ia h
ais
ua
ko
j h
om
lus
yam
tsim
xam
tus
nqi.
Txh
awm
rau
th
am n
rog
tus
nee
g tx
hai
s lu
s, h
u x
ov t
oo
j ra
u (
800)
922-6
621.
Igb
o (
Igb
o):
Ọ bụr ụ n
a ị
nw
ere
ajụjụ
ọ bụla
gb
asar
a ak
wụkwọ a
, ị
nw
ere
ikik
e ịn
wet
a en
yem
aka
na
ozi
n'a
sụsụ
gị
na
akwụghị ụgw
ọ ọ
bụla
. K
a gị
na ọkọ
wa
okw
u k
wuo
okw
u, kpọọ (
800)
922-6
621.
Ilo
kan
o (I
lok
an
o):
Nu a
ddaa
n k
a it
i an
iam
an a
sal
udso
d p
angg
ep iti
day
toy
a do
kum
ento
, ad
da
kar
ben
gam
a m
akaa
la t
i tu
lon
g ken
im
po
rmas
yon
bab
aen
ti
len
guah
em n
ga a
wan
ti b
ayad
na.
Tap
no
mak
atun
gto
ng
ti m
aysa
nga
tag
ipat
arus,
aw
agan
ti (8
00)
922-6
621.
Ind
on
esi
an
(B
ah
asa
In
do
nesi
a):
Jik
a A
nda
mem
iliki p
erta
nya
an m
enge
nai
do
kum
en in
i, A
nda
mem
iliki h
ak u
ntu
k m
endap
atkan
ban
tuan
dan
in
form
asi
dal
am b
ahas
a A
nda
tan
pa
bia
ya. U
ntu
k b
erb
icar
a den
gan
in
terp
rete
r kam
i, h
ub
un
gi (
800)
922-6
621.
Itali
an
(It
ali
an
o):
In
cas
o d
i ev
entu
ali do
man
de
sul p
rese
nte
do
cum
ento
, h
a il
dir
itto
di ri
cever
e as
sist
enza
e in
form
azio
ni n
ella
sua
lingu
a se
nza
alc
un
co
sto
aggi
un
tivo
. P
er p
arla
re c
on
un
in
terp
rete
, ch
iam
i il
num
ero
(800)
922-6
621
(800)
922-6
621
27
Lan
gu
ag
e A
ccess
Serv
ices:
9 o
f 11
(800)
922-6
621
K
iru
nd
i (K
iru
nd
i):
Ugi
ze ikib
azo
ico
ari
co c
ose
kuri
iyi
nya
ndik
o, ufi
se u
bure
nga
nzi
ra b
wo
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nka
ub
ufa
sha
mu r
uri
mi rw
awe
ata
gici
ro. K
ugi
ra u
vugi
she
um
use
muzi
, ak
ura
(800)
922-6
621.
Ko
rean
(한국어
): 본
문서에
대해
어떠한
문의사항이라도
있을
경우
, 귀하에게는
귀하가
사용하는
언어로
무료
도움
및 정보를
얻을
권리가
있습니다
. 통역사와
이야기하려면
(800)
922-6
621 로
문의하십시오
.
(8
00)
922-6
621.
(8
00)
922-6
621.
(800)
922-6
621
Oro
mo
(O
rom
ifaa):
San
adi kan
aa w
ajiin
wal
qab
aate
gaf
fi k
amiy
uu y
oo
qab
duu t
anaa
n, G
arga
arsa
arg
ach
uu f
i o
dee
ffan
oo
afa
an k
etiin
kaf
falt
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la a
rgac
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mir
gaa
qab
daa
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urj
um
aan
a dub
aach
uuf,
(800)
922-6
621 b
ilbill
a.
Pen
nsy
lvan
ia D
utc
h (
Deit
sch
): W
ann
du F
roo
ge iw
wer
sel
le D
ocu
men
t h
osc
ht,
du h
osc
ht
die
Rec
ht
um
Hel
fe u
n I
nfo
rmat
ion
zu g
rieg
e in
dei
Sch
pro
och
m
itau
s K
osc
ht.
Um
mit
en
Iw
wer
setz
e zu
sch
wet
ze, ru
ff (
800)
922-6
621 a
a.
Po
lish
(p
ols
ki)
: W
prz
ypad
ku jak
ich
ko
lwie
k p
ytań
zw
iąza
nyc
h z
nin
iejs
zym
do
kum
ente
m m
asz
pra
wo
do
bez
pła
tneg
o u
zysk
ania
po
mo
cy o
raz
info
rmac
ji w
sw
oim
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by
po
rozm
awia
ć z
tłum
acze
m, za
dzw
oń
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d n
um
er (
800)
922-6
621.
Po
rtu
gu
ese
(P
ort
ug
uês)
: Se
tiver
quai
squer
dúvid
as a
cerc
a d
este
do
cum
ento
, te
m o
dir
eito
de
solic
itar
aju
da
e in
form
açõ
es n
o s
eu idio
ma,
sem
qual
quer
cu
sto
. P
ara
fala
r co
m u
m in
térp
rete
, lig
ue
par
a (8
00)
922-6
621.
(800)
922-6
621
28
Lan
gu
ag
e A
ccess
Serv
ices:
10 o
f 11
(800)
922-6
621.
(8
00)
922-6
621.
Sam
oan
(S
am
oa):
Afa
i e
iai n
i o
u f
esili
e u
iga
i le
nei
tusi
, e
iai lo
u ‘ai
a e
mau
a se
fes
oas
oan
i m
a fa
amat
alag
a i lo
u lav
a ga
gan
a e
aun
oa
ma
se t
oto
gi. In
a ia
ta
lan
oa
i se
tag
ata
faal
iliu
, vili
(800)
922-6
621.
Serb
ian
(S
rpsk
i):
Uko
liko
im
ate
bilo
kak
vih
pit
anja
u v
ezi sa
ovim
do
kum
ento
m, im
ate
pra
vo
da
do
bijet
e p
om
oć
i in
form
acije
na
vaš
em jez
iku b
ez ikak
vih
tr
ošk
ova.
Za
razg
ovo
r sa
pre
vo
dio
cem
, p
ozo
vit
e (8
00)
922-6
621.
Sp
an
ish
(E
spañ
ol)
: Si ti
ene
pre
gun
tas
acer
ca d
e es
te d
ocu
men
to, ti
ene
der
ech
o a
rec
ibir
ayu
da
e in
form
ació
n e
n s
u idio
ma,
sin
co
sto
s. P
ara
hab
lar
con
un
in
térp
rete
, lla
me
al (
800)
922-6
621.
Tag
alo
g (
Tag
alo
g):
Kun
g m
ayro
on
kan
g an
um
ang
kat
anun
gan
tun
gko
l sa
do
kum
ento
ng
ito
, m
ay k
arap
atan
kan
g h
um
ingi
ng
tulo
ng
at im
po
rmas
yon
sa
iyo
ng
wik
a n
ang
wal
ang
bay
ad. M
akip
ag-u
sap
sa
isan
g ta
gap
agp
aliw
anag
, ta
wag
an a
ng
(800)
922-6
621.
Th
ai
(ไทย
): หากทา่นมคี าถามใดๆ เกีย่วกบัเอกสารฉบบันี ้ทา่นมสีทิธิท์ีจ่ะไดร้ับความชว่ยเหลอืและขอ้มลูในภาษาของทา่นโดยไมม่คีา่ใชจ้า่ย โดยโทร
(800)
922-6
621 เพือ่พดูคยุกบัลา่ม
(800)
922-6
621.
(8
00)
922-6
621
V
ietn
am
ese
(T
iến
g V
iệt)
: Nếu
quý
vị
có bất
kỳ
thắc
mắc
nào
về
tài liệ
u n
ày, quý
vị
có q
uyề
n n
hận
sự
trợ
giú
p v
à th
ôn
g ti
n bằn
g n
gôn
ngữ
của
quý
vị
ho
àn
toàn
miễ
n p
hí.
Để
trao
đổi vớ
i một
thô
ng
dịc
h v
iên
, h
ãy gọi (8
00)
922-6
621.
.(
800)
922-6
621
(800)
922-6
621.
29
Lan
gu
ag
e A
ccess
Serv
ices:
11 o
f 11
It’s
im
po
rtan
t w
e t
reat
yo
u f
air
ly
Th
at’s
wh
y w
e fo
llo
w f
eder
al c
ivil r
igh
ts law
s in
our
hea
lth
pro
gram
s an
d a
ctiv
itie
s. W
e do
n’t
dis
crim
inat
e, e
xclu
de
peo
ple
, o
r tr
eat
them
dif
fere
ntl
y o
n t
he
bas
is o
f ra
ce, co
lor,
nat
ion
al o
rigi
n, se
x, a
ge o
r dis
abili
ty. F
or
peo
ple
wit
h d
isab
iliti
es, w
e o
ffer
fre
e ai
ds
and s
ervic
es. F
or
peo
ple
wh
ose
pri
mar
y la
ngu
age
isn
’t
En
glis
h, w
e o
ffer
fre
e la
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age
assi
stan
ce s
ervic
es t
hro
ugh
in
terp
rete
rs a
nd o
ther
wri
tten
lan
guag
es. In
tere
sted
in
th
ese
serv
ices
? C
all th
e M
emb
er S
ervic
es
num
ber
on
yo
ur
ID c
ard f
or
hel
p (
TT
Y/
TD
D: 711).
If
you t
hin
k w
e fa
iled t
o o
ffer
th
ese
serv
ices
or
dis
crim
inat
ed b
ased
on
rac
e, c
olo
r, n
atio
nal
ori
gin
, ag
e,
dis
abili
ty, o
r se
x, y
ou c
an f
ile a
co
mp
lain
t, a
lso
kn
ow
n a
s a
grie
van
ce. Y
ou c
an f
ile
a co
mp
lain
t w
ith
our
Co
mp
lian
ce C
oo
rdin
ato
r in
wri
tin
g to
Co
mp
lian
ce
Co
ord
inat
or,
P.O
. B
ox 2
7401, M
ail D
rop
VA
2002-N
160, R
ich
mo
nd, V
A 23279. O
r yo
u c
an f
ile
a co
mp
lain
t w
ith
th
e U
.S. D
epar
tmen
t o
f H
ealt
h a
nd
Hum
an S
ervic
es, O
ffic
e fo
r C
ivil R
igh
ts a
t 200 I
ndep
enden
ce A
ven
ue,
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; R
oo
m 5
09F
, H
HH
Build
ing;
Was
hin
gto
n, D
.C. 20201 o
r b
y ca
llin
g 1-8
00-3
68-
1019 (
TD
D: 1-
800-5
37-7
697)
or
on
line
at h
ttp
s://o
crp
ort
al.h
hs.
gov/o
cr/p
ort
al/
lob
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Co
mp
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rms
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t h
ttp
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hs.
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.htm
l.
30
CAPITAL AREA HEALTH CONSORTIUM
FLEX DENTAL PLAN ________
CATEGORY1-DIAGNOSTIC & PREVENTIVE SERVICES Payable at 100% of usual, customary and reasonable charges at participating dentists:
Initial Oral Exams - 1/36 months
Periodic Oral Exams - 2/Yr
Prophylaxis – 2/Yr
Topical application of fluoride – 2/Yr. to age 19
Periapical and Bitewing X-rays
Repair and relining of dentures-1/year
Palliative Emergency Treatment
Routine Fillings
Simple Extractions
Endodontics
_________
CATEGORY II-BASIC SERVICES Payable at 80% of usual, customary and reasonable charges at participating dentists:
Inlays 1 per tooth every 5 years
Onlays 1 per tooth every 5 years
Crowns 1 per tooth every 5 years
Post & Core 1 per tooth every 5 years
Prostodontics 1 per tooth every 5 years
Night Guards 1 guard every 2 years (for teeth grinders)
Oral Surgery
Space Maintainers
Apicoectomy
Bridges
Anesthesia
Implants & Build-ups
Periodontics
____________________________________________
PRINCIPAL LIMITATIONS AND EXCLUSIONS Services received from a dental or medical department maintained by an employer, a mutual benefit association, labor union,
trustee or other similar person or group; Services for which the member incurs no Dentists’ Charge or which are services of a
type ordinarily performed by a physician, or charges which would not have been made if insurance was not available; Services
with respect to congenital malformations; Services, treatment or supplies furnished by or at the direction of any government,
state or political subdivision; Any items not specifically listed in this Policy; Lost or stolen dentures or denture duplication;
Gold foil restorations; Temporary services and appliances; such as crown or tooth preparations and temporary fillings, crowns,
bridges and dentures; Application of sealants, regardless of reason; Services as determined by the company, that are rendered in
a manner contrary to normal dental practice. A complete list of exclusions appears in the Master Group Policy on file with
your employer or your Certificate of Membership.
This is not a legal policy or contract. It is only a general description of your Blue Cross & Blue Shield benefits. If there are
discrepancies between the dental rider and this summary, the dental rider shall control.
31
WELCOME TO BLUE VIEW VISION!Good news—your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what’s covered, your discounts, and much more!
Transitions and the swirl are registered trademarks of Transitions Optical, Inc.
Blue View VisionSM BVMO C25.130.130Your Blue View Vision networkAnthem Blue Cross and Blue Shield vision members have access to one of the nation’s largest vision networks. Blue View Vision is the only vision plan that gives members the ability to use their in-network benefits at 1-800 CONTACTS, or choose a private practice eye doctor, or go in store to LensCrafters®,Sears OpticalSM, Target Optical®, JCPenney® Optical and most Pearle Vision locations.Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply.
YOUR BLUE VIEW VISION PLAN AT-A-GLANCEVISION PLAN BENEFITS IN-NETWORK OUT-OF-NETWORKEyeglass frames
Once every two calendar years you may select an eyeglass frame and receive an allowance toward the purchase price
$130 allowance, then 20% off any remaining balance
$64 allowance
Eyeglass lenses (Standard)Once every two calendar years you may receive any one of the following lens options:
Standard plastic single vision lenses (1 pair)Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair)
$25 copay$25 copay$25 copay
$36 allowance$54 allowance$69 allowance
Eyeglass lens enhancementsWhen obtaining covered eyewear from a Blue View Vision provider,you may choose to add any of the following lens enhancements at no extra cost.
Lenses (for a child under age 19)Standard Polycarbonate (for a child under age 19)Factory Scratch Coating
$0 copay$0 copay$0 copay
No allowance on lensenhancements when
obtained out-of-network
Contact lenses – once every two calendar yearsPrefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses.
Elective Conventional Lenses; or
Elective Disposable Lenses; or
Non-Elective Contact Lenses
$130 allowance, then 15% off any remaining balance
$130 allowance(no additional discount)
Covered in full
$105 allowance
$105 allowance
$210 allowanceContact lens allowance will only be applied toward the first purchase of contacts made during a benefit period. Any unused amount remaining cannot be used for subsequent purchases in the same benefit period, nor can any unused amount be carried over to the following benefit period.
BLUE VIEW VISION MEMBER EXCLUSIVE! You may use your in-network benefit to order your contact lenses from 1-800 CONTACTS offers a huge in-stock inventory, unbeatable prices, outstanding customer service and free shipping.Just call 1-800 CONTACTS or go to 1800contacts.com for fast and easy ordering of your contact lenses.
EXCLUSIONS & LIMITATIONS (not a comprehensive list)Combined Offers. Not to be combined with any offer, coupon, or in-store advertisement.Excess Amounts. Amounts in excess of covered vision expense.Sunglasses. Sunglasses and accompanying frames.Safety Glasses. Safety glasses and accompanying frames.Not Specifically Listed. Services not specifically listed in this plan as covered services.
Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design.Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power.Orthoptics. Orthoptics or vision training and any associated supplemental testing.
Capital Area Health Consortium
32
Anthem Blue Cross and Blue Shield is the trade name of: In Connecticut: Anthem Health Plans, Inc. In Maine: Anthem Health Plans of Maine, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Independent licensees of the Blue 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 andBlue Shield Association. 10/13
OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay)
Eyeglass lens upgradesWhen obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.
Transitions® Lenses (Adults)Standard Polycarbonate (Adults)Tint (Solid and Gradient)UV CoatingProgressive Lenses1
StandardPremium Tier 1Premium Tier 2Premium Tier 3
Anti-Reflective Coating2
StandardPremium Tier 1 Premium Tier 2
Other Add-ons and Services
$75$40$15$15
$65$85$95
$110
$45$57$68
20% off retail priceAdditional Pairs of EyeglassesAnytime from any Blue View Vision network provider
Complete PairEyeglass materials purchased separately
40% off retail price20% off retail price
Eyewear Accessories Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.
20% off retail price
Conventional Contact Lenses Discount applies to materials only 15% off retail priceSOME OF THE ADDITIONAL SAVINGS AVAILBLE THROUGH OUR SPECIAL OFFERS PROGRAM
After your benefits for the coverage period have been used, you can save on contact lenses with this offer.3
For this and other great offers, login to member services, select discounts, then Vision, Hearing & Dental
Save $20 on orders of $100 or more and get free shipping
Laser vision correction surgeryLASIK refractive surgery.
For this offer and more like it, login to member services, select discounts, then Vision, Hearing & Dental
Discount per eye
1 Please ask your provider for his/her recommendation as well as the progressive brands by tier.2 Please ask your provider for his/her recommendation as well as the coating brands by tier.3 Discount cannot be used in conjunction with your covered benefits.
OUT-OF-NETWORKIf you choose an out-of-network provider, please complete an out-of-network claim form and submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service.
To Fax: 866-293-7373To Email: [email protected] Mail: Blue View Vision
Attn: OON ClaimsP.O. Box 8504 Mason, OH 45040-7111
If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at 1-866-723-0515.
This is a primary vision plan with benefits intended to cover only corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force.
This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the member’s policy, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the member’s policy. Laws in some states may prohibit network providers from discounting products and services that are not covered benefits under the plan. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package.
Employee Rates: $4.00 Employee Only / $7.00 Employee + 1 / $11.20 Family
33
60019ANMENABS_MPS VPOD 06/17
When you’re not feeling well you can get the support you need easily using LiveHealth Online. Whether you have a cold, you’re feeling anxious or need help managing your medication, doctors and mental health professionals are right there, ready to help you feel your best. Using LiveHealth Online you can have a video visit with a board-certif ed doctor, psychiatrist ori licensed therapist from your smartphone, tablet or computer from home or anywhere.
On LiveHealth Online, you can:
See a board-certif ed doctor 24/7.i You don’t need an appointment to see a doctor. They’re always available to assess your condition and send a prescription to the pharmacy you choose, if needed.1 It’s a great option when you have pink eye, a cold, the f u, a fever, allergies, a sinusl infection or another common health issue.
Visit a licensed therapist in four days or less.2 Have a video visit with a therapist to get help with anxiety, depression, grief, panic attacks and more. Schedule your appointment online or call 1-888-548-3432 from 8 a.m. to 8 p.m., seven days a week.
Consult a board-certif ed psychiatrist within two weeks.i 3 If you’re over 18 years old, you can get medication support to help you manage a mental health condition. To schedule your appointment call 1-888-548-3432 from 8 a.m. to 8 p.m., seven days a week.
You’ve got access to affordable and convenient care
Your Anthem plan includes benef ts for video visits usingi LiveHealth Online, so you’ll just pay your share of the costs — usually $59 or less for medical doctor visits, and a 45-minute therapy or psychiatry session usually costs the same as an off cei mental health visit.
,og eht no ro emoh tA latnem dna srotcod
era slanoisseforp htlaeh .uoy rof ereh
Using LiveHealth Online, you can have a private video visit on your smartphone, tablet or computer.
Sign up for LiveHealth Online today -- it’s quick and easy Go to livehealthonline.com or download the app and register on your phone or tablet.
34
1 Prescription availability is def ned by physician judgment and state regulations. Visit the home page of livehealthonline.com to view the service map by state. i2 Appointments subject to availability of a therapist. 3 Prescriptions determined to be a “controlled substance” (as def ned by the Controlled Substances Act under federal law) cannot be prescribed using LiveHealth Online. Psychiatrists on LiveHealth Online will not offer counseling or talk therapy. Appointments subject to availability. i Online counseling is not appropriate for all kinds of problems. If you are in crisis or have suicidal thoughts, it’s important that you seek help immediately. Please call 1-800-784-2433 (National Suicide Prevention Lifeline) or 911 and ask for help. If your issue is an emergency, call 911 or go to your nearest emergency room. LiveHealth Online does not offer emergency services. If you’re a retiree or have coverage that complements your Medicare benef ts, your employer sponsored health plan may not include coverage for online visits using LiveHealth Online. Check your plan documents for details. You can still use LiveHealth Online, but you may have to pay the fulli cost of a visit. Online visits using LiveHealth Online may not be a covered benef t for HRA and HIA+ members. i LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain aff liates administer non-HMO benef ts underwritten by HALIC and HMO benef ts underwritten by HMOiii Missouri, Inc. RIT and certain aff liates only provide administrative services for self-funded plans and do not underwrite benef ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthemii Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benef ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies.i Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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Health and wellness programs designed for your unique needs
ConditionCare
If you have asthma, diabetes, chronic obstructive pulmonary disease (COPD), heart disease or heart failure, ConditionCare can give you the tools and resources you need to take charge of your health. You’ll get:
}} 24/7, toll-free phone access to nurses who can answer health questions.
}} Support from nurse care managers, dietitians and other health care professionals to help you reach your health goals.
}} Educational guides, electronic newsletters and tools to help you learn more about your condition(s).
Future Moms
Having a baby is an exciting time! Future Moms can help you have a healthy pregnancy and a healthy baby. Sign up as soon as you know you’re pregnant. You’ll get:
}} A nurse specializing in obstetrics who can answer your questions, 24/7, and will call to check on your progress.
}} The Mayo Clinic Guide to a Healthy Pregnancy, which explains the changes your body and baby are going through.
}} A screening to check your health risks.
}} Resources to help you make healthier decisions during pregnancy.
}} Free phone access to pharmacists, nutritionists and other specialists, if needed.
}} Other helpful information on labor and delivery, including options and how to prepare.
24/7 NurseLine
Whether it’s 3 a.m. or a lazy Sunday afternoon, you can talk to a registered nurse any time of the day or night.
These nurses can:
}} Answer questions about health concerns.
}} Help you decide where to go for care when your doctor, dentist, or eye doctor isn’t available.
}} Help you find providers and specialists in your area.
}} Enroll you and your dependents in health management programs.
}} Remind you about scheduling important screenings and exams, including dental and vision check ups.
Whether you’re suffering from asthma, expecting a baby or just fighting a cold, our health and wellness programs can help.
Choose an easier way to better health
Get the support you need
Call us to sign up and use these programs at no extra cost: ConditionCare: 866-962-0959
Future Moms: 800-828-5891
24/7 NurseLine: 800-337-4770
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
MCTSH1316A VPOD Rev. 7/18 56056983-123071116
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* You must be 18 years or older to register your own account.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain aff liates administer non-HMO benef ts underwritten by HALIC and HMO benef ts underwritten by HMO Missouri, Inc. RIT and certain aff liates only provide administrative services for self-funded plans and do not underwrite benef ts. In Nevada: Rocky Mountain Hospital and Medicaliiiii Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benef ts in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shieldi Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
13206ANMENABS VPOD Rev 06/19 55674486-122033677
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It’s easy. Everything you need to know about your plan — including medical — in one place. Making your health care journey simple, personal — all about you.
Need help signing up?
Call us at 1-866-755-2680.
ssecca kciuq tog ev’uoY !erac htlaeh ruoy ot
Register on anthem.com or the Sydney mobile app.* Have your member ID card handy to register
1 Go to anthem.com/register
2 Provide the information requested
3 Create a username and password
4 Set your email preferences
5 Follow the prompts to complete your registration
1 Download the free Sydney mobile app and select Register
2 Confirm your identity
3 Create a username and password
4 Confirm your email preferences
5 Follow the prompts to complete your registration
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63658MUMENMUB 02/18 #AG-GEN-001#
We’re here for you – in many languages The law requires us to include a message in all of these different languages. Curious what they say? Here’s the English version: “You have the right to get help in your language for free. Just call the Member Services number on your ID card.” Visually impaired? You can also ask for other formats of this document.
Spanish Usted tiene derecho a recibir ayuda en su idioma en forma gratuita. Simplemente llame al número de Servicios para Miembros que figura en su tarjeta de identificación.
Chinese
ID
Vietnamese Quý vị có quyền nhận miễn phí trợ giúp bằng ngôn ngữ của mình. Chỉ cần gọi số Dịch vụ dành cho thành viên trên thẻ ID của quý vị. Bị khiếm thị? Quý vị cũng có thể hỏi xin định dạng khác của tài liệu này."
Korean
Tagalog May karapatan ka na makakuha ng tulong sa iyong wika nang libre. Tawagan lamang ang numero ng Member Services sa iyong ID card. May kapansanan ka ba sa paningin? Maaari ka ring humiling ng iba pang format ng dokumentong ito.
Russian Вы имеете право на получение бесплатной помощи на вашем языке. Просто позвоните по номеру обслуживания клиентов, указанному на вашей идентификационной карте. Пациенты с нарушением зрения могут заказать документ в другом формате.
Armenian Դուք իրավունք ունեք ստանալ անվճար օգնություն ձեր լեզվով: Պարզապես զանգահարեք Անդամների սպասարկման կենտրոն, որի հեռախոսահամարը նշված է ձեր ID քարտի վրա: Farsi
دریافت کمک تان مادری زبان بھ رایگان صورت بھ تا دارید را حق این شما" روی شده درج) Member Services( اعضا خدمات شماره با است کافی. کنید این توانید می ھستید؟ بینایی اختالل دچار ."بگیرید تماس خود شناسایی کارت .دھید درخواست نیز دیگری ھای فرمت بھ را سند
French Vous pouvez obtenir gratuitement de l’aide dans votre langue. Il vous suffit d’appeler le numéro réservé aux membres qui figure sur votre carte d’identification. Si vous êtes malvoyant, vous pouvez également demander à obtenir ce document sous d’autres formats.
Arabic
قمبر االتصال سوى علیك ما. مجاًنا بلغتك مساعدة على الحصول في الحق لك یمكنك البصر؟ ضعیف أنت ھل. الھویة بطاقة على الموجود األعضاء خدمة .المستند ھذا من أخرى أشكال طلب
Japanese
ID
Haitian Se dwa ou pou w jwenn èd nan lang ou gratis. Annik rele nimewo Sèvis Manm ki sou kat ID ou a. Èske ou gen pwoblèm pou wè? Ou ka mande dokiman sa a nan lòt fòma tou.
Italian Ricevere assistenza nella tua lingua è un tuo diritto. Chiama il numero dei Servizi per i membri riportato sul tuo tesserino. Sei ipovedente? È possibile richiedere questo documento anche in formati diversi Polish Masz prawo do uzyskania darmowej pomocy udzielonej w Twoim języku. Wystarczy zadzwonić na numer działu pomocy znajdujący się na Twojej karcie identyfikacyjnej.
Punjabi
TTY/TTD:711
It’s important we treat you fairly We follow federal civil rights laws in our health programs and activities. By calling Member Services, our members can get free in-language support, and free aids and services if you have a disability. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed in any of these areas, you can mail a complaint to: Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279, or directly to the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201. You can also call 1-800- 368-1019 (TDD: 1-800-537-7697) or visit https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 38
Using your plan
The legal stuff we’re required to tell you
How we keep your information safe and secure
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As a member, you have the right to expect us to protect your personal health information. We take this responsibility very seriously, following all state and federal laws, as well as our own policies.
You also have certain rights and responsibilities when receiving your health care. To learn more about how we protect your privacy, your rights and responsibilities when receiving health care, and your rights under the Women’s Health and Cancer Rights Act, go to anthem.com/privacy. For a printed copy, please contact your Benefits Administrator or Human Resources representative.
How we help manage your care To see if your health benefits will cover a treatment, procedure, hospital stay or medicine, we use a process called utilization management (UM). Our UM team is made up of doctors and pharmacists who want to be sure you get the best treatments for certain health conditions. They review the information your doctor sends us before, during or after your treatment. We also use case managers. They’re licensed health care professionals who work with you and your doctor to help you manage your health conditions. They also help you better understand your health benefits.
To learn more about how we help manage your care, go to anthem.com/memberrights. To request a printed copy, please contact your Benefits Administrator or Human Resources representative.
Special enrollment rights Open enrollment usually happens once a year. That’s the time you can choose a plan, enroll in it or make changes to it. If you choose not to enroll, there are special cases when you’re allowed to enroll during other times of the year. If you had another health plan that was
canceled. If you, your dependents or your spouse are no longer eligible for benefits with another health plan (or if the employer stops contributing to that health plan), you may be able to enroll with us. You must enroll within 31 days after the other health plan ends (or after the employer stops paying for the plan). For example: You and your family are enrolled through your spouse’s health plan at work. Your spouse’s employer stops paying for health coverage. In this case, you and your spouse, as well as other dependents, may be able to enroll in one of our plans.
If you have a new dependent. You gain new dependents from a life event like marriage, birth, adoption or if you have custody of a minor and an adoption is pending. You must enroll within 31 days after the event. For example: If you got married, your new spouse and any new children may be able to enroll in a plan.
If your eligibility for Medicaid or SCHIP changes. You have a special period of 60 days to enroll after:
— You (or your eligible dependents) lose Medicaid or the State Children’s Health Insurance Program (SCHIP) benefits because you’re no longer eligible.
— You (or eligible dependents) become eligible to get help from Medicaid or SCHIP for paying part of the cost of a health plan with us.
Prior Authorization Pass Program All in-network doctors in Connecticut who meet certain criteria are able to participate in Anthem’s Prior Auth Pass Program. Under this program, eligible doctors will no longer need to submit a request and wait for pre-approval for Anthem members* on more than 400 common outpatient medical procedures done in Connecticut.
*Exceptions: BlueCard Host members, Federal Employee Program members, New York State and New York City employees.
Get the full details
Read your Certificate of Coverage, which spells out all the details about your plan. You can it find on anthem.com.
Using your plan
Notes
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Using your plan
Notes
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Using your plan
Notes
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Choosing your plan
It’s time to choose your plan
Using your plan
Notes
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Anthem Blue Cross and Blue Shield is the trade name of: In Connecticut: Anthem Health Plans, Inc. In Maine: Anthem Health Plans of Maine, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
113544ANMENABS Rev. 03/19
Ready to use your plan? Get some extra help
If you have questions, it’s easy to get answers. Contact us through our online Message Center or call the Member Services number on your ID card.