2016 awane ma comp lxr

7/21/2019 2016 AWANE MA COMP LXR

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AWANE: Massachusetts Comp LXR Coverage Period: 0101!01" # 1!$1!01"

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

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

,mporta(t -uestio(s A(s.ers Wh& this Matters:

What is the overalldeductible?

For in-network providers

/1000 individual /!00 family

For out-of-network providers

/000 individual /10000 family

Doesn’t apply to in-networkpreventive care and routineeye exams.

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

Are there otherdeductibles forspecic services?

es. For durable medicale(uipment there is a /!0 deductible.

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

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

For in-network-provieders

/""00 individual /1$!00 family

For out-of-network providers

/10000 individual /!0000 family

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

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

+remiums, penalties for non-compliance, balance-billedcharges, and health care thisplan doesn’t cover.

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

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

o.*he chart starting on page ' describes any limits on whatthe plan will pay for specifc covered services, such as oice

visits.

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

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

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



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(oes this plan use anet$or ofproviders?

es. For a list of in-net$orproviders, seewww.anthem.com or call $-

011-121-3014

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

participating for providers in their net$or . &ee the chartstarting on page ' for how this plan pays dierent kinds ofproviders.

(o I need a referralto see a specialist?

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

Are there servicesthis plan doesn)tcover?

es.&ome of the services this plan doesn’t cover are listed onpage 6. &ee your policy or plan document for additionalinformation about e#cluded services.

•

*opa"!ents are )xed dollar amounts "for example, 7$8% you pay for covered health care, usually when youreceive the service.

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

a!ount for the service. For example, if the plan’s allo$ed a!ount for an overnight hospital stay is7$,222, your coinsurance payment of '29 would be 7'22. *his may change if you haven’t met yourdeductible.

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

provider charges more than the allo$ed a!ount, you may have to pay the dierence. For example, if anout-of-network hospital charges 7$,822 for an overnight stay and the allo$ed a!ount is 7$,222, you mayhave to pay the 7822 dierence. "*his is called balance billin+.%

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

copa"!ents and coinsurance amounts.

Commo(Medica) Eve(t

%ervices 2ou Ma& Need

2our Cost ,f 2ou 3se a(,((et.or5Provider

2our Cost ,f 2ou 3se a(

6utof(et.or5Provider

Limitatio(s 7 E8ceptio(s

+rimary care visit to treat anin:ury or illness

7'8 copay;visit829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<




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Commo(Medica) Eve(t






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

&pecialist visit 712 copay;visit829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<

=ther practitioner oice visit 742 copay;visit829coinsurance

!hiropractic care limited to$' visits per calendar yearcombined in and out ofnetwork.

+reventivecare;screening;immuni>ation

o !harge829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<

If "ou have atest

Diagnostic test "x-ray, bloodwork%


<<<<<<<<<<<<none<<<<<<<<<<<<

Imaging "!*;+* scans, ?@Is% o charge

829

coinsurance <<<<<<<<<<<<none<<<<<<<<<<<<

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

?oreinformation

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

/eneric drugs "@etail;42 dayA?ail;B2 day%

7$8 @etail;742?ail

ot !overed?aintenance ?eds are re(uired tobe )lled mail order after 4 )lls atretail "penalty applies%. If pre-authre(uired C not obtained, drug maynot be covered. !ertain +reventivemeds no copay. If a generice(uivalent is available C brand isprescribed;member will pay brandname cost dierence. +lan usespreferred drug list to identifycoverage.

+referred brand drugs "@etail;42 dayA?ail;B2 day%

748 @etail;706.8?ail

ot !overed

on-preferred brand "@etail;42dayA?ail;B2day%

732 @etail;7$82?ail

ot !overed

&pecialty drugs

ll &pecialtymeds process

through ccredo at the

mail ordercosts.

ot !overed

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

Facility fee "e.g., ambulatorysurgery center%

o charge829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<




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Commo(Medica) Eve(t






If "ou haveoutpatientsur+er"

+hysician;surgeon fees o charge829

coinsurance<<<<<<<<<<<<none<<<<<<<<<<<<

If "ou needi!!ediate!edicalattention

mergency room services

7$82copay;visitEprofessionaland otherservices sub:ectto deductible

7$82copay;visitEprofessionaland otherservices sub:ectto deductible

7$82 copay is waived ifadmitted for inpatient stay.?embers may be balancebilled for out of networkservices.

mergency medicaltransportation

o charge o charge?embers may be balancebilled for out of network

services

rgent care 782 copay 782 copay?embers may be balancebilled for out of networkservices

If "ou have ahospital sta"

Facility fee "e.g., hospital room% o charge829coinsurance

+recerti)cation is re(uired

for Inpatient hospital

admission. 7822 penalty

is applied if an =ut of

etwork admission is not

precerti)ed..

+hysician;surgeon fee o charge829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<




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Commo(Medica) Eve(t






If "ou have!ental healthbehavioralhealth orsubstanceabuse needs

?ental;5ehavioral healthoutpatient services


<<<<<<<<<<<<none<<<<<<<<<<<<

?ental;5ehavioral healthinpatient services


+recerti)cation is re(uiredfor Inpatient hospitaladmission. 7822 penaltyis applied if an =ut ofetwork admission is notprecerti)ed.

&ubstance use disorderoutpatient services


<<<<<<<<<<<<none<<<<<<<<<<<<

&ubstance use disorderinpatient services


+recerti)cation is re(uired

for Inpatient hospitaladmission. 7822 penaltyis applied if an =ut ofetwork admission is notprecerti)ed.

If "ou arepre+nant

+renatal and postnatal care o !harge829coinsurance

<<<<<<<<<<<<none<<<<<<<<<<<<

Delivery and all inpatientservices


<<<<<<<<<<<<none<<<<<<<<<<<<




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Commo(Medica) Eve(t






If "ou needhelp recoverin+or have otherspecial healthneeds

Gome health care o !harge829coinsurance

B2 visits combined in andout of network

@ehabilitation services

712 copay foroutpatientservices. ocharge forinpatient care.

829coinsurance

Himited to$22 inpatientdays for physicial andmedical rehabilitation permember per calendar year.32 visits combined physicaltherapy, speech therapy andoccupational therapy.!ombined in and out ofnetwork.

Gabilitation services

712 copay foroutpatientservices. ocharge forinpatient care

829coinsurance

ll rehabilitation andhabilitation visits counttoward your rehabilitation

visit limit.

&killed nursing care o charge829coinsurance

Himited to $22 inpatientdays per member percalendar year. +recerti)cation is re(uiredor 7822 penalty is applied

Durable medical e(uipment

7'82Deductible then'29coinsurance

7'82Deductible then'29coinsurance

7'82 deductible combinedin and out of network.?embers may be balancebilled for out of networkservices.

Gospice service o charge829coinsurance

+recerti)cation is re(uiredfor Inpatient hospitaladmission or 7822 penalty isapplied




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Commo(Medica) Eve(t






If "our childneeds dental or e"e care

ye exam o !harge829coinsurance

Himited to one exam;yearfor $0 and younger. Himitedto one exam;' years for $Band older.

/lasses ot !overed ot !overed <<<<<<<<<<<<none<<<<<<<<<<<<

Dental check-up ot !overed ot !overed <<<<<<<<<<<<none<<<<<<<<<<<<

E8c)uded %ervices 7 6ther Covered %ervices:

%ervices 2our P)a( oes N6* Cover ./his isn)t a co!plete list' *hec "our polic" or plan docu!ent for othere#cluded services'

cupuncture

!osmetic surgery

Dental care "dult%

Hong-term care

on-emergency care when traveling

outside the .&.

+rivate-duty nursing

@outine foot care

Jeight loss programs

6ther Covered %ervices ./his isn)t a co!plete list' *hec "our polic" or plan docu!ent for other coveredservices and "our costs for these services'

5ariatric surgery

!hiropractic care

Gearing aids "Himitations pply%

!overage provided outside thenited &tates.&ee www.5!5&.com;bluecardworldwide

Infertility treatment "Himits apply%

@outine eye care "dult Himitations pply%


http://www.bcbs.com/bluecardworldwide






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2our Rights to Co(ti(ue Coverage:

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

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

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

=ther limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at $-022-'80-84$0. ou may also contact

your state insurance department, the .&. Department of Habor, mployee 5ene)ts &ecurity dministration at $-033-111-4'6' or www.dol.gov;ebsa, or the .&. Department of Gealth and Guman &ervices at $-066-'36-'4'4 x3$838 orwww.cciio.cms.gov.

2our <rieva(ce a(d Appea)s Rights:

If you have a complaint or are dissatis)ed with a denial of coverage for claims under your plan, you may be able to

appeal or )le a +rievance. For (uestions about your rights, this notice, or assistance, you can contactA

nthem 5lue !ross and 5lue &hield

+.=. 5ox 81$8BHos ngeles, ! B2281-2$8B

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

dditionally, a consumer assistance program can help you )le your appeal. !ontactA

ew Gampshire Department of Insurance'$ &outh Fruit &treet, &uite $1!oncord, G 2442$


http://www.dol.gov/ebsa

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

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

http://www.dol.gov/ebsa

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

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



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%ummar& of 'e(efits a(d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | P)a( *&pe: PPO$.022.08'.41$3www.nh.gov;insuranceconsumersvcsKins.nh.gov

For @I& information contactA

Department of Habor’s mployee 5ene)ts &ecurity dministration$-033-111-5& "4'6'%www.dol.gov;ebsa;healthreform

oes this Coverage Provide Mi(imum Esse(tia) Coverage>

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

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

oes this Coverage Meet the Mi(imum ?a)ue %ta(dard>

*he ordable !are ct establishes a minimum value standard of bene)ts of a health plan. *he minimum value

standard is 329 "actuarial value%. This health coverage does meet the minimum value standard for the

benets it provides.


http://www.nh.gov/insurance

mailto:[email protected]

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

http://www.nh.gov/insurance

mailto:[email protected]

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



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La(guage Access %ervices:

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




@avi(g a a&"normal delivery%

Ma(agi(g t&pe ! diaetes"routine maintenance of

a well-controlled condition%

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Coverage E8amp)es

Coverage for: Individual/Family | P)a( *&pe: PPO

Aout these CoverageE8amp)es:

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

Amou(t o.ed to providers: $7,540

P)a( pa&s $,!70

Patie(t pa&s $","70

%amp)e care costs:

Gospital charges "mother%7',62

2

@outine obstetric care7',$2

2Gospital charges "baby% 7B22

nesthesia 7B22

Haboratory tests 7822

+rescriptions 7'22

@adiology 7'22

Naccines, other preventive 712

/otal24

0

Patie(t pa&s:

Deductibles7$,22

2!opays 7'2

!oinsurance 72

Himits or exclusions 7$82

/otal110

Amou(t o.ed to providers: $5,400

P)a( pa&s $!,"#0

Patie(t pa&s $,"0

%amp)e care costs:

+rescriptions7',B2

2?edical (uipment and&upplies

7$,422

=ice Nisits and +rocedures 7622ducation 7422

Haboratory tests 7$22

Naccines, other preventive 7$22

/otal40

0

Patie(t pa&s:

Deductibles7$,'8

2

!opays 7302!oinsurance 7'22

Himits or exclusions 702

/otal1

0


*his is(ot a costestimator+

Don’t use theseexamples to estimate

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

&ee the next page forimportant information



1! of 14


Coverage E8amp)es

Coverage for: Individual/Family | P)a( *&pe: PPO




-uestio(s a(d a(s.ers aout the Coverage E8amp)es:

What are some of theassumptio(s ehi(d theCoverage E8amp)es>

• !osts don’t include pre!iu!s.

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

• *he patient’s condition was notan excluded or preexisting

condition.• ll services and treatments

started and ended in the samecoverage period.

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

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

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

What does a Coverage E8amp)esho.>

For each treatment situation, the

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

oes the Coverage E8amp)e

predict m& o.( care (eeds> 5o' *reatments shown are :ust

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

oes the Coverage E8amp)epredict m& future e8pe(ses>

5o' !overage xamples are not

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

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

Ca( , use Coverage E8amp)es

to compare p)a(s>

es' Jhen you look at the

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

Are there other costs , shou)dco(sider .he( compari(gp)a(s>

es' n important cost is the

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



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

ou should also considercontributions to accounts suchas health savings accounts"G&s%, Oexible spendingarrangements "F&s% or health

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

2016 awane ma comp lxr

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