benefits paperworklouisville.edu/medicine/gme/benefitspacketfor2014.pdf · generic retail - $8.00...
TRANSCRIPT
-
Benefits
Paperwork 2014
-
TYPE O
F S
ER
VIC
E
Netw
ork
(L
imit
ed t
o U
ofL
Hospit
al, K
osair
and U
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Physic
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them
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Indiv
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$5
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Indiv
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$1
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0 P
CP
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CP;
$0
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Pre
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Mam
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10
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care
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adm
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Card
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to
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Does n
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Does n
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apply
Does n
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None
Does n
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Does n
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2014 H
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Des
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PC
A H
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Annual A
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Annual O
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Maxim
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PC
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Does n
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Annual D
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Physic
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its
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PC
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60
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90
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;
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PC
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20
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dis
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Does n
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N /
A
-
TYPE O
F S
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VIC
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Ou
tpati
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Ou
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60
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80
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50
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Lab S
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10
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10
0%
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60
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80
% a
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50
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X-R
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deducti
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60
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deducti
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90
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deducti
ble
60
% a
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deducti
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80
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ble
50
% a
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Em
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10
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$7
5
copay
10
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$7
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copay
10
0%
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$1
00
copay
10
0%
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er
$1
00
copay
10
0%
aft
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$1
00
copay
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
90
% a
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deducti
ble
80
% a
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deducti
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80
% a
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Men
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bsta
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Inpati
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care
10
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$5
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copay
per
inpati
ent
sta
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UofL
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10
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$5
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copay
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inpati
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sta
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Pla
n p
ays 9
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60
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deducti
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90
% a
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60
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deducti
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80
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50
% a
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it$
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90
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ble
60
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deducti
ble
80
% a
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deducti
ble
50
% a
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deducti
ble
Vis
ion
Vis
ion
Exam
(o
ne r
outi
ne
exam
per
year)
10
0%
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$3
5
copay
10
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5
copay
10
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copay
Not
Covere
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ble
60
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deducti
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80
% a
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deducti
ble
50
% a
fter
deducti
ble
Pre
scri
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on
Dru
gs
Fille
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t R
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Pre
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on D
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Reta
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Pre
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Form
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Fille
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(90
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Form
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Generi
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Non-Form
ula
ry M
ail O
rder
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You P
ay 3
5%
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o $
20
0
maxim
um
Non-Form
ula
ry M
ail O
rder
-
You P
ay 3
5%
, up t
o $
20
0
maxim
um
Non-Form
ula
ry M
ail O
rder
-
You P
ay 3
5%
, up t
o $
20
0
maxim
um
Generi
c M
ail O
rder
- $
7.5
0G
eneri
c M
ail O
rder
- $
16
.00
Generi
c M
ail O
rder
- $
16
.00
Bra
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ula
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ail O
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-
1 1
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ost
for
90
day
supply
Bra
nd F
orm
ula
ry M
ail O
rder
-
You P
ay 1
5%
, up t
o $
12
0
maxim
um
Bra
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ula
ry M
ail O
rder
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You P
ay 1
5%
, up t
o $
12
0
maxim
um
Non-Form
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pay 4
0%
, up t
o $
10
0 m
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Non- F
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Pay 4
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Pay 4
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Non- F
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Pay 4
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Non- F
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You
Pay 4
0%
, up t
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10
0 m
axim
um
Generi
c R
eta
il -
$8
.00
Generi
c R
eta
il -
$5
.00
Generi
c R
eta
il -
$8
.00
Generi
c R
eta
il -
$8
.00
Card
inal
Care
Pla
n p
ays 6
0%
Card
inal
Care
Bra
nd F
orm
ula
ry R
eta
il -
You
Pay 2
0%
, up t
o $
50
maxim
um
10
0%
aft
er
$1
00
copay
Physic
ian O
utp
ati
ent
serv
ices
90
% a
fter
deducti
ble
Bra
nd F
orm
ula
ry R
eta
il -
You
Pay 2
5%
, up t
o $
60
maxim
um
Bra
nd F
orm
ula
ry R
eta
il -
You
Pay 2
5%
, up t
o $
60
maxim
um
Bra
nd F
orm
ula
ry R
eta
il -
You
Pay 2
5%
, up t
o $
60
maxim
um
Not
Covere
d
EPO
90
% a
fter
deducti
ble PC
A H
IGH
EPO
PPO
PC
A H
igh
Pla
n P
ays C
ost
of
Generi
c D
rug-
You P
ay r
em
ain
der,
no
maxim
um
Pla
n P
ays C
ost
of
Generi
c D
rug-
You P
ay r
em
ain
der,
no
maxim
um
Pla
n P
ays C
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of
Generi
c D
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You P
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em
ain
der,
no
maxim
um
Pla
n P
ays C
ost
of
Generi
c D
rug-
You P
ay r
em
ain
der,
no
maxim
um
60
% a
fter
deducti
ble
PPO
PC
A L
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Pla
n P
ays C
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of
Generi
c D
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em
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maxim
um
Bra
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ry M
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5%
, up t
o $
12
0
maxim
um
Non-Form
ula
ry M
ail O
rder
-
You P
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5%
, up t
o $
20
0
maxim
um
Non-Form
ula
ry M
ail O
rder
-
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ay 3
5%
, up t
o $
20
0
maxim
um
Generi
c M
ail O
rder
- $
16
.00
Generi
c M
ail O
rder
- $
16
.00
Bra
nd F
orm
ula
ry M
ail O
rder
-
You P
ay 1
5%
, up t
o $
12
0
maxim
um
Bra
nd F
orm
ula
ry R
eta
il -
You
Pay 2
5%
, up t
o $
60
maxim
um
Generi
c R
eta
il -
$8
.00
50
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
-
Uni
vers
ity o
f Lou
isvi
lle 2
014
Hea
lth P
lan
Rat
es
FT A
ctiv
e W
ith G
HN
Dis
coun
tC
ardi
nal C
are
EPO
PPO
PCA
Hig
hPC
A L
owFT
Act
ive
With
GH
N D
isco
unt
Car
dina
l Car
eEP
OPP
OPC
A H
igh
PCA
Low
Em
ploy
ee C
over
age
75.00
$
96.12
$
78.58
$
27.12
$
25.00
$
Em
ploy
ee C
over
age
90.00
$
115.34
$
94.30
$
32.54
$
30.00
$
Em
ploy
ee +
Spo
use/
Par
tner
/QA
275.00
$
455.04
$
416.46
$
303.24
$
171.64
$
Em
ploy
ee +
Spo
use/
Par
tner
/QA
330.00
$
546.05
$
499.75
$
363.89
$
205.97
$
Em
ploy
ee +
Chi
ldre
n14
2.00
$
228.21
$
196.63
$
104.01
$
25.00
$
Em
ploy
ee +
Chi
ldre
n17
0.40
$
273.85
$
235.96
$
124.81
$
30.00
$
Em
ploy
ee +
Fam
ily
300.00
$
513.24
$
460.62
$
306.24
$
126.78
$
Em
ploy
ee +
Fam
ily
360.00
$
615.89
$
552.74
$
367.49
$
152.14
$
Two
Em
ploy
ee F
amily
(Rat
e P
er E
E)
70.00
$
95.52
$
69.21
$
12.50
$
12.50
$
Two
Em
ploy
ee F
amily
(Rat
e P
er E
E84
.00
$
114.62
$
83.05
$
15.00
$
15.00
$
FT A
ctiv
e W
ithou
t GH
NC
ardi
nal C
are
EPO
PPO
PCA
Hig
hPC
A L
owFT
Act
ive
With
out G
HN
Car
dina
l Car
eEP
OPP
OPC
A H
igh
PCA
Low
Em
ploy
ee C
over
age
115.00
$
136.12
$
118.58
$
67.12
$
65.00
$
Em
ploy
ee C
over
age
138.00
$
163.34
$
142.30
$
80.54
$
78.00
$
Em
ploy
ee +
Spo
use/
Par
tner
/QA
315.00
$
495.04
$
456.46
$
343.24
$
211.64
$
Em
ploy
ee +
Spo
use/
Par
tner
/QA
378.00
$
594.05
$
547.75
$
411.89
$
253.97
$
Em
ploy
ee +
Chi
ldre
n18
2.00
$
268.21
$
236.63
$
144.01
$
65.00
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Em
ploy
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ldre
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8.40
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321.85
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283.96
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Em
ploy
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340.00
$
553.24
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Em
ploy
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408.00
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600.74
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415.49
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Em
ploy
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amily
(Rat
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110.00
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135.52
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109.21
$
52.50
$
52.50
$
Two
Em
ploy
ee F
amily
(Rat
e P
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2.00
$
162.62
$
131.05
$
63.00
$
63.00
$
10 M
onth
PT
Act
ive
Empl
oyee
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Act
ive
With
GH
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207.74
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Em
ploy
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over
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392.58
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375.89
$
353.95
$
289.42
$
249.29
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Em
ploy
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Spo
use/
Par
tner
/QA
750.73
$
810.91
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652.39
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515.33
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Em
ploy
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tner
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900.88
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973.09
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924.84
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782.87
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618.40
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ploy
ee +
Chi
ldre
n57
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591.43
$
558.52
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461.73
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363.93
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Em
ploy
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Chi
ldre
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1.44
$
709.72
$
670.22
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554.08
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436.72
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Em
ploy
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1,05
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ploy
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ldre
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ploy
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ldre
n73
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ploy
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Em
ploy
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Ret
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With
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12 M
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Em
ploy
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12 M
onth
Act
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Em
ploy
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Em
ploy
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over
age
419.34
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390.78
$
349.07
$
238.96
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167.64
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Mon
thly
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M
onth
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ium
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ploy
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ldre
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Em
ploy
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25E
mpl
oyee
Cov
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Em
ploy
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Em
ploy
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use/
Par
tner
/QA
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10 M
onth
Act
ive
Em
ploy
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10 M
onth
Act
ive
Em
ploy
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Em
ploy
ee +
Chi
ldre
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671.42
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Den
tal F
ull-t
ime/
Part
-tim
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onth
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sion
Ful
l-tim
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rt-ti
mM
onth
lyE
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oyee
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5.10
$
906.77
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Prem
ium
sPr
emiu
ms
Em
ploy
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over
age
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90E
mpl
oyee
Cov
erag
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.14
Em
ploy
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ldre
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5.83
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ploy
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ldre
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Em
ploy
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Fam
ily
$101
.81
Em
ploy
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Fam
ily
$14.
17
Visi
on F
ull-t
ime/
Part
-tim
Den
tal F
ull-t
ime/
Part
-tim
e
-
Types of Coverage Network Benefits
Annual Deductible
Individual Deductible Family Deductible
No deductible No deductible
Out-of-Pocket Maximum (Member copayments accumulate toward the OOP maximum)
Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum
$2,000 per year $4,000 per year
Benefit Plan Coinsurance (The amount the Plan pays)
90% coverage
Lifetime Maximum
There is no dollar limit to the amount the Plan will pay for essential benefits during the entire period you are enrolled in this Plan.
No lifetime maximum benefit
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to your member certificate or plan SPD.
Information on Benefit Limits
Out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any combination of network and non-
network benefits unless specifically stated in the benefit category.
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, and much more. Search for a doctor or hospital by choosing the Anthem Blue Access PPO network.
• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Plan Highlights
Your Summary of Benefits
EPO Anthem Blue Access PPO Network
This Plan has no Out of Network Benefits
-
Benefits
Types of Coverage Network Benefits
Ambulance Services (Emergency and non-emergency)
100% after you pay a $100 copayment per trip
Dental Services (Accident only)
90% coverage
Durable Medical Equipment (DME)
100% coverage
Emergency Health Services - Outpatient
100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a network hospital directly from the emergency
room, you will not have to pay this copayment. The benefits for an inpatient stay in a network hospital will apply instead.
Hearing Aids
One per ear every 36 months 100% coverage
Home Health Care
Benefits are limited to 100 visits per year 100% coverage
Hospice Care
100% coverage
Hospital Inpatient Stay
90% coverage
Lab, X-Ray and Major Diagnostics – Outpatient
For Preventive Lab, X-Ray and Diagnostics, refer to the Preventive Care Services category.
Lab services - 100% coverage X-ray and Diagnostic services – 90% coverage
Lab, X-Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine)
X-Ray and Major Diagnostics Lab Services
90% coverage 100% coverage
Mental Health Services
Inpatient - 90% coverage
Outpatient - 100% after you pay a $35 copayment per visit
Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders
Inpatient - 90% coverage
Outpatient - 100% after you pay a $35 copayment per visit
Pharmaceutical Products - Outpatient
This includes medications administered in an outpatient setting, in the physician’s office and by a home health agency.
Physician’s office – 100% coverage All other place of service – 100% after you pay a $35 copay
Physician Fees for Surgical and Medical Services
90% coverage
Physician’s Office Services – Sickness and Injury
Primary Physician 100% after you pay a $0 copayment per visit for U of L PCP, 100%
after you pay a $20 copayment per visit for Anthem PCP
Specialist Physician 100% after you pay a $35 Copayment per visit
-
Types of Coverage
Pregnancy – Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service
category in this Benefit Summary.
For services provided in the physician’s office, a copayment will only apply to the initial office visit
Preventive Care Services (Covered health services include but not limited to:)
Primary Physician Office Visit 100% coverage
Specialist Physician Office Visit 100% coverage
Lab, X-Ray or other preventive tests 100% coverage
Prosthetic Devices
100% coverage
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary.
Rehabilitation Services – Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows:
50 visits combined physical / occupational therapy 30 visits for manipulative therapy
25 visits combined speech / cognitive therapy 25 visits combined respiratory / pulmonary therapy
PT / OT: 100% after $0 copayment for U of L providers, 100% after
$20 copayment for Anthem Blue Access PPO providers Manipulative and all other therapies: 100% after you pay a $35
copayment per visit
Scopic Procedures – Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.
For Preventive Scopic Procedures, refer to the
Preventive Care Services category.
90% coverage
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 120 days per year 100% coverage
Substance Use Disorder Services
Inpatient - 90% coverage
Outpatient - 100% after you pay a $35 copayment per visit
Surgery – Outpatient
100% coverage after you pay $100 copayment
Transplantation Services
90% coverage
For network benefits, services must be received at a Blue Distinction Center for Transplant.
Urgent Care Center Services
100% coverage after you pay a $35 copayment per visit
Vision Examinations
Benefits are limited as follows: 1 routine exam every year 100% coverage after you pay a $35 copayment per visit
-
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26.
When choosing a non-network provider, the member is responsible for any balance due after the plan payment.
Benefit Period: Equals calendar year
Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with the Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice,
internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a
designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings,
immunizations and physician visits are covered.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, 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.
-
1 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Th
is i
s o
nly
a s
um
ma
ry.
If y
ou w
ant
mo
re d
etai
l ab
out
your
cover
age
and c
ost
s, y
ou c
an g
et t
he
com
ple
te t
erm
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th
e po
licy
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n
do
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at w
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them
.co
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y ca
llin
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855-7
47-1
137.
Imp
ort
an
t Q
ue
sti
on
s
An
sw
ers
W
hy t
his
Ma
tte
rs:
Wh
at
is t
he o
vera
ll
ded
ucti
ble
? $0.
See
th
e ch
art
star
tin
g o
n p
age
2 f
or
your
cost
s fo
r se
rvic
es t
his
pla
n c
over
s.
Are
th
ere
oth
er
ded
ucti
ble
s fo
r sp
ecif
ic
serv
ices?
No
. Y
ou d
on
’t h
ave
to m
eet
ded
ucti
ble
s fo
r sp
ecif
ic s
ervic
es, b
ut
see
the
char
t st
arti
ng
on
pag
e 2 f
or
oth
er c
ost
s fo
r se
rvic
es t
his
pla
n c
over
s
Is t
here
an
ou
t–o
f–p
ock
et
lim
it o
n m
y
exp
en
ses?
Yes
. $
2,0
00
In
div
idual
/
$4
,00
0 F
amily
fo
r N
etw
ork
P
rovid
ers.
Th
e o
ut-
of-
po
ck
et
lim
it is
the
mo
st y
ou c
ould
pay
duri
ng
a co
ver
age
per
iod (
usu
ally
on
e ye
ar)
for
your
shar
e o
f th
e co
st o
f co
ver
ed s
ervic
es. T
his
lim
it h
elp
s yo
u p
lan
fo
r h
ealt
h
care
expen
ses.
Wh
at
is n
ot
inclu
ded
in
the o
ut–
of–
po
ck
et
lim
it?
Pre
miu
ms,
Bal
ance
-bill
ed
char
ges
and H
ealt
h c
are
this
p
lan
do
esn
’t c
over
. E
ven
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
ou
t-o
f-p
ock
et
lim
it.
Is t
here
an
ove
rall
an
nu
al
lim
it o
n w
hat
the p
lan
pays?
N
o.
Th
e ch
art
star
tin
g o
n p
age
2 d
escr
ibes
an
y lim
its
on
wh
at t
he
pla
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ill p
ay f
or
spec
ific
cover
ed s
ervic
es, su
ch a
s o
ffic
e vis
its.
Do
es
this
pla
n u
se a
n
etw
ork
of
pro
vid
ers
?
Yes
. See
ww
w.a
nth
em
.co
mo
r ca
ll 1-
855-7
47-1
137 f
or
a lis
t o
f N
etw
ork
pro
vid
ers.
If y
ou u
se a
n in
-net
wo
rk d
oct
or
or
oth
er h
ealt
h c
are
pro
vid
er,
th
is p
lan
will
pay
so
me
or
all
of
the
cost
s o
f co
ver
ed s
ervic
es. B
e aw
are,
yo
ur
in-n
etw
ork
do
cto
r o
r h
osp
ital
may
use
an
o
ut-
of-
net
wo
rk p
rovi
der
for
som
e se
rvic
es. P
lan
s use
th
e te
rm in
-net
wo
rk, p
refe
rred
, o
r p
arti
cip
atin
g fo
r p
rovi
ders
in
th
eir
netw
ork
. See
th
e ch
art
star
tin
g o
n p
age
Err
or!
B
oo
km
ark
no
t d
efi
ned
. fo
r h
ow
th
is p
lan
pay
s dif
fere
nt
kin
ds
of
pro
vid
ers
.
Do
I n
eed
a r
efe
rral
to
see a
sp
ecia
list
? N
o. Y
ou d
on
’t n
eed a
ref
erra
l to
se
e a
spec
ialis
t.
Yo
u c
an s
ee t
he
specia
list
yo
u c
ho
ose
wit
ho
ut
per
mis
sio
n f
rom
th
is p
lan
.
Are
th
ere
serv
ices
this
p
lan
do
esn
’t c
ove
r?
Yes
. So
me
of
the
serv
ices
th
is p
lan
do
esn
’t c
over
are
lis
ted o
n p
age
6. See
yo
ur
po
licy
or
pla
n
do
cum
ent
for
addit
ion
al in
form
atio
n a
bo
ut
exclu
ded
serv
ices.
O
MB
Contr
ol
Nu
mb
ers
1545
-22
29
,
1210
-01
47
, an
d 0
93
8-1
146
Rel
ease
d o
n A
pri
l 2
3, 2
013
(corr
ecte
d)
-
2 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Co
paym
en
ts a
re f
ixed
do
llar
amo
un
ts (
for
exam
ple
, $1
5)
you p
ay f
or
cover
ed h
ealt
h c
are,
usu
ally
when
yo
u r
ecei
ve
the
serv
ice.
Co
insu
ran
ce is
your
sh
are
of
the
cost
s o
f a
cover
ed s
ervic
e, c
alcu
late
d a
s a
per
cen
t o
f th
e all
ow
ed
am
ou
nt
for
the
serv
ice.
Fo
r ex
amp
le, if
th
e p
lan
’s a
llo
wed
am
ou
nt
for
an o
ver
nig
ht
ho
spit
al s
tay
is $
1,0
00, yo
ur
Co
insu
ran
ce p
aym
ent
of
20%
wo
uld
be
$200. T
his
may
ch
ange
if
you h
aven
’t m
et y
our
ded
ucti
ble
.
Th
e am
oun
t th
e p
lan
pay
s fo
r co
ver
ed s
ervic
es is
bas
ed o
n t
he
all
ow
ed
am
ou
nt.
If
an o
ut-
of-
net
wo
rk p
rovi
der
char
ges
mo
re t
han
th
e all
ow
ed
am
ou
nt,
yo
u m
ay h
ave
to p
ay t
he
dif
fere
nce
. F
or
exam
ple
, if
an
out-
of-
net
wo
rk h
osp
ital
ch
arge
s $1
,500 f
or
an o
ver
nig
ht
stay
an
d
the
all
ow
ed
am
ou
nt
is $
1,0
00, yo
u m
ay h
ave
to p
ay t
he
$500 d
iffe
ren
ce. (T
his
is
calle
d b
ala
nce b
illi
ng
.)
Th
is p
lan
may
en
coura
ge y
ou t
o u
se N
etw
ork
pro
vid
ers
by
char
gin
g yo
u lo
wer
ded
ucti
ble
s, c
op
aym
en
ts a
nd C
oin
sura
nce a
mo
un
ts.
Co
mm
on
Me
dic
al E
ve
nt
Se
rvic
es
Yo
u M
ay N
ee
d
Yo
ur
Co
st
If
Yo
u U
se
a
Netw
ork
P
rovid
er
Yo
ur
Co
st
If
Yo
u U
se
a
No
n-N
etw
ork
P
rovid
er
Lim
itati
on
s &
Exc
ep
tio
ns
If y
ou
vis
it a
healt
h
care
pro
vid
er’
s o
ffic
e
or
cli
nic
Pri
mar
y ca
re v
isit
to
tre
at a
n in
jury
or
illn
ess
$20 C
op
ay/V
isit
N
ot
Co
ver
ed
––––
––––––––n
on
e––––––––––––
Sp
ecia
list
vis
it
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
––––
––––––––n
on
e––––––––––––
Oth
er p
ract
itio
ner
off
ice
vis
it
$35 C
op
ay/V
isit
fo
r M
anip
ula
tive
Tre
atm
ent
N
ot
Co
ver
ed
Co
ver
age
is lim
ited
to
30 v
isit
s fo
r
Man
ipula
tive
trea
tmen
t.
Acu
pun
cture
is
No
t C
over
ed.
Pre
ven
tive
care
/sc
reen
ing/
imm
un
izat
ion
N
o C
ost
Sh
are
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
If y
ou
have
a t
est
Dia
gno
stic
tes
t (x
-ray
, b
loo
d w
ork
) 10
% C
oin
sura
nce
N
ot
Co
ver
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it
for
bel
ow
ser
vic
es.
Dia
gno
sis
of
Sle
ep D
iso
rder
s, G
ene
Exp
ress
ion
Pro
filin
g fo
r M
anag
ing
Bre
ast
Can
cer
Tre
atm
ent
and G
enet
ic T
esti
ng
for
Can
cer
Susc
epti
bili
ty.
Imag
ing
(CT
/P
ET
sca
ns,
MR
Is)
10
% C
oin
sura
nce
N
ot
Co
ver
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it
for
bel
ow
ser
vic
e.
MR
I G
uid
ed H
igh
In
ten
sity
Fo
cuse
d
Ult
raso
un
d A
bla
tio
n o
f U
teri
ne
Fib
roid
s.
-
3 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Co
mm
on
Me
dic
al E
ve
nt
Se
rvic
es
Yo
u M
ay N
ee
d
Yo
ur
Co
st
If
Yo
u U
se
a
Netw
ork
P
rovid
er
Yo
ur
Co
st
If
Yo
u U
se
a
No
n-N
etw
ork
P
rovid
er
Lim
itati
on
s &
Exc
ep
tio
ns
If y
ou
need
dru
gs
to
treat
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
lable
at
w
ww
.
Pre
scri
pti
on
Dru
g G
ener
ic
Gen
eric
Ret
ail -
$8.0
0/G
ener
ic
Mai
l O
rder
-
$16.0
0
No
t C
over
ed*
*Wh
ile p
resc
rip
tio
ns
are
no
t co
ver
ed a
t P
oin
t o
f Sal
e at
a N
on
-Net
wo
rk p
rovid
er,
they
wo
uld
be
cover
ed a
t co
ntr
acte
d r
ate
thro
ugh
a m
anual
cla
im.
Pre
scri
pti
on
Dru
g B
ran
d F
orm
ula
ry
Bra
nd F
orm
ula
ry
Ret
ail -
Yo
u P
ay
25%
, up
to
$60
max
imum
/B
ran
d
Fo
rmula
ry M
ail
Ord
er -
Yo
u P
ay
15%
, up
to
$120
max
imum
No
t C
over
ed*
*Wh
ile p
resc
rip
tio
ns
are
no
t co
ver
ed a
t P
oin
t o
f Sal
e at
a N
on
-Net
wo
rk p
rovid
er,
they
wo
uld
be
cover
ed a
t co
ntr
acte
d r
ate
thro
ugh
a m
anual
cla
im.
Pre
scri
pti
on
Dru
g N
on
Fo
rmula
ry
No
n-
Fo
rmula
ry
Ret
ail -
Yo
u P
ay
40%
, up
to
$100
max
imum
/N
on
-F
orm
ula
ry M
ail
Ord
er -
Yo
u P
ay
35%
, up
to
$200
max
imum
No
t C
over
ed*
*Wh
ile p
resc
rip
tio
ns
are
no
t co
ver
ed a
t P
oin
t o
f Sal
e at
a N
on
-Net
wo
rk p
rovid
er,
they
wo
uld
be
cover
ed a
t co
ntr
acte
d r
ate
thro
ugh
a m
anual
cla
im.
Pre
scri
pti
on
Dru
g B
ran
d f
or
wh
ich
a
Gen
eric
equiv
alen
t is
avai
lab
le -
ret
ail o
r m
ail
ord
er
Pla
n P
ays
Co
st o
f G
ener
ic D
rug-
Y
ou P
ay
rem
ain
der
, n
o
max
imum
No
t C
over
ed*
*Wh
ile p
resc
rip
tio
ns
are
no
t co
ver
ed a
t P
oin
t o
f Sal
e at
a N
on
-Net
wo
rk p
rovid
er,
they
wo
uld
be
cover
ed a
t co
ntr
acte
d r
ate
thro
ugh
a m
anual
cla
im.
If y
ou
have
o
utp
ati
en
t su
rgery
F
acilit
y fe
e (e
.g.,
amb
ula
tory
surg
ery
cen
ter)
$10
0
Co
pay
/Surg
ery
No
t C
over
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it
for
bel
ow
surg
ery.
Gen
der
Rea
ssig
nm
ent
Surg
ery:
Hum
an O
rgan
and B
on
e M
arro
w/Ste
m C
ell T
ran
spla
nts
. P
leas
e ca
ll th
e p
lan
fo
r ex
cluded
det
ails
.
http://www.[insert]/
-
4 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Co
mm
on
Me
dic
al E
ve
nt
Se
rvic
es
Yo
u M
ay N
ee
d
Yo
ur
Co
st
If
Yo
u U
se
a
Netw
ork
P
rovid
er
Yo
ur
Co
st
If
Yo
u U
se
a
No
n-N
etw
ork
P
rovid
er
Lim
itati
on
s &
Exc
ep
tio
ns
Ph
ysic
ian
/su
rgeo
n f
ees
10%
Co
insu
ran
ce
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
If y
ou
need
im
med
iate
med
ical
att
en
tio
n
Em
erge
ncy
ro
om
ser
vic
es
$10
0 C
opay
/V
isit
$10
0 C
op
ay/V
isit
If a
dm
itte
d, th
e E
R c
op
ay is
wai
ved
.
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
if
requir
e n
oti
fica
tio
n n
o lat
er t
han
2
busi
nes
s day
s af
ter
adm
issi
on
may
res
ult
in
no
n-c
over
age
or
reduce
d b
enef
it.
Em
erge
ncy
med
ical
tra
nsp
ort
atio
n
$10
0 C
opay
/ T
rip
N
ot
Co
ver
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it
for
Air
Am
bula
nce
(ex
cludes
911 in
itia
ted
emer
gen
cy t
ran
spo
rt).
Urg
ent
care
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
––––
––––––––n
on
e––––––––––––
If y
ou
have
a
ho
spit
al
stay
Fac
ilit
y fe
e (e
.g.,
ho
spit
al r
oo
m)
10%
Co
insu
ran
ce
No
t C
over
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it.
Ph
ysic
ian
/su
rgeo
n f
ee
10%
Co
insu
ran
ce
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
-
5 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Co
mm
on
Me
dic
al E
ve
nt
Se
rvic
es
Yo
u M
ay N
ee
d
Yo
ur
Co
st
If
Yo
u U
se
a
Netw
ork
P
rovid
er
Yo
ur
Co
st
If
Yo
u U
se
a
No
n-N
etw
ork
P
rovid
er
Lim
itati
on
s &
Exc
ep
tio
ns
If y
ou
have
men
tal
healt
h,
beh
avi
ora
l h
ealt
h,
or
sub
stan
ce
ab
use
need
s
Men
tal/
Beh
avio
ral h
ealt
h o
utp
atie
nt
serv
ices
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d
ben
efit
s fo
r In
ten
sive
Outp
atie
nt
ther
apy(
IOP
).
Men
tal/
Beh
avio
ral h
ealt
h in
pat
ien
t se
rvic
es
10%
Co
insu
ran
ce
No
t C
over
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it.
Sub
stan
ce a
buse
dis
ord
er o
utp
atie
nt
serv
ices
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d
ben
efit
s fo
r In
ten
sive
Outp
atie
nt
ther
apy(
IOP
).
Sub
stan
ce a
buse
dis
ord
er in
pat
ien
t se
rvic
es
10%
Co
insu
ran
ce
No
t C
over
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it.
If y
ou
are
pre
gn
an
t
Pre
nat
al a
nd p
ost
nat
al c
are
No
Co
st S
har
e N
ot
Co
ver
ed
In-N
etw
ork
ben
efit
ap
plie
s fo
r fi
rst
init
ial
vis
it o
nly
. Y
our
do
cto
r’s
char
ges
for
del
iver
y ar
e par
t o
f p
ren
atal
an
d p
ost
nat
al
care
. T
her
e m
ay b
e o
ther
lev
els
of
cost
sh
are
that
are
co
nti
nge
nt
on
ho
w s
ervic
es
are
pro
vid
ed, p
leas
e se
e yo
ur
form
al
con
trac
t o
f co
ver
age
for
a co
mp
lete
ex
pla
nat
ion
.
Del
iver
y an
d a
ll in
pat
ien
t se
rvic
es
10%
Co
insu
ran
ce
No
t C
over
ed
Ap
plie
s to
In
pat
ien
t fa
cilit
y. O
ther
co
st
shar
es m
ay a
pp
ly d
epen
din
g o
n t
he
serv
ice
pro
vid
ed. F
ailu
re t
o o
bta
in p
re-
auth
ori
zati
on
may
res
ult
in
no
n-c
over
age
or
reduce
d b
enef
it.
-
6 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Co
mm
on
Me
dic
al E
ve
nt
Se
rvic
es
Yo
u M
ay N
ee
d
Yo
ur
Co
st
If
Yo
u U
se
a
Netw
ork
P
rovid
er
Yo
ur
Co
st
If
Yo
u U
se
a
No
n-N
etw
ork
P
rovid
er
Lim
itati
on
s &
Exc
ep
tio
ns
If y
ou
need
help
re
co
veri
ng
or
have
o
ther
specia
l h
ealt
h
need
s
Ho
me
hea
lth
car
e N
o C
ost
Sh
are
No
t C
over
ed
Co
ver
age
is lim
ited
to
100 v
isit
s p
er
cale
ndar
yea
r.
Reh
abili
tati
on
ser
vic
es
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
No
Co
st S
har
e fo
r O
ccup
atio
nal
an
d
Ph
ysic
al t
her
apy
for
Net
wo
rk p
rovid
ers.
C
over
age
is lim
ited
to
50 v
isit
s p
er
cale
ndar
yea
r co
mb
ined
fo
r O
ccup
atio
nal
an
d P
hys
ical
th
erap
y. C
over
age
is lim
ited
to
25 v
isit
s fo
r ea
ch P
ulm
on
ary
and
Sp
eech
th
erap
y. P
re-a
uth
ori
zati
on
may
be
requir
ed a
fter
th
e in
itia
l tw
elve
(12)
vis
its.
P
leas
e ca
ll th
e p
lan
fo
r ac
coun
t-sp
ecif
ic
det
ails
.
Hab
ilita
tio
n s
ervic
es
$35 C
op
ay/V
isit
N
ot
Co
ver
ed
No
Co
st S
har
e fo
r O
ccup
atio
nal
an
d
Ph
ysic
al t
her
apy
for
Net
wo
rk p
rovid
ers.
A
ll R
ehab
ilita
tio
n a
nd H
abili
tati
on
vis
its
count
tow
ard y
our
Reh
abili
tati
on
vis
it
limit
. P
re-a
uth
ori
zati
on
may
be
requir
ed
afte
r th
e in
itia
l tw
elve
(12)
vis
its.
P
leas
e ca
ll th
e p
lan
fo
r ac
coun
t-sp
ecif
ic d
etai
ls.
Skille
d n
urs
ing
care
N
o C
ost
Sh
are
No
t C
over
ed
Co
ver
age
is lim
ited
to
120 d
ays
per
ca
len
dar
yea
r.
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it.
Dura
ble
med
ical
equip
men
t N
o C
ost
Sh
are
No
t C
over
ed
Fai
lure
to
ob
tain
pre
-auth
ori
zati
on
may
re
sult
in
no
n-c
over
age
or
reduce
d b
enef
it.
Ho
spic
e se
rvic
e N
o C
ost
Sh
are
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
If y
ou
need
den
tal
or
eye c
are
Eye
exa
m
$20 C
op
ay/V
isit
N
ot
Co
ver
ed
Co
ver
age
is lim
ited
to
on
e ex
am e
ver
y ye
ar.
Gla
sses
N
ot
Co
ver
ed
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
Den
tal ch
eck-u
p
No
t C
over
ed
No
t C
over
ed
––––
––––––––n
on
e––––––––––––
-
7 o
f 10
Un
ive
rsit
y o
f L
ou
isvil
le-E
PO
Med
ical
Pla
n
Co
ve
rag
e P
eri
od
: 0
1/0
1/2
01
4 –
12
/31
/201
4
Su
mm
ary
of
Ben
efi
ts a
nd
Co
ve
rag
e:
Wha
t th
is P
lan C
ove
rs &
Wha
t it C
osts
C
ove
rag
e f
or:
In
div
idu
al/F
am
ily | P
lan
Typ
e:
EP
O
Qu
est
ion
s: C
all 1-
855-7
47-1
137 o
r vis
it u
s at
ww
w.a
nth
em
.co
m.
If
yo
u a
ren
’t c
lear
ab
out
any
of
the
un
der
lined
ter
ms
use
d in
th
is f
orm
, se
e th
e G
loss
ary.
Yo
u c
an v
iew
th
e G
loss
ary
at w
ww
.an
them
.co
m o
r ca
ll 1-8
55-7
47-1
137 t
o r
eques
t a
cop
y.
Ex
clu
de
d S
erv
ices
& O
ther
Co
ve
red
Se
rvic
es
:
Se
rvic
es
Yo
ur
Pla
n D
oe
s N
OT
Co
ve
r (T
his
isn
’t a
co
mp
lete
lis
t. C
heck
yo
ur
po
licy o
r p
lan
do
cu
men
t fo
r o
ther
exclu
ded
serv
ices.
)
Acu
pun
cture
Co
smet
ic s
urg
ery
Den
tal ca
re
Lo
ng-
term
car
e
Pri
vat
e-duty
nurs
ing
Ro
uti
ne
foo
t ca
re
Wei
ght
loss
pro
gram
s
Oth
er
Co
ve
red
Se
rvic
es
(T
his
isn
’t a
co
mp
lete
lis
t. C
heck
yo
ur
po
licy o
r p
lan
do
cu
men
t fo
r o
ther
co
vere
d s
erv
ices
an
d y
ou
r co
sts
for
these
se
rvic
es.
)
Bar
iatr
ic s
urg
ery(
On
ly f
or
Mo
rbid
Ob
esit
y)
Ch
iro
pra
ctic
car
e (M
anip
ula
tive
Tre
atm
ent)
Ro
uti
ne
eye
care
Hea
rin
g ai
ds
Infe
rtili
ty t
reat
men
t (l
imit
ed t
o $
5,0
00 p
er
Co
ver
ed P
erso
n p
er lif
etim
e)
Mo
st C
over
age
pro
vid
ed o
uts
ide
the
Un
ited
Sta
tes.
See
ww
w.b
cbs.
com
/b
luec
ardw
orl
dw
ide
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e:
If y
ou lo
se c
over
age
un
der
th
e p
lan
, th
en, d
epen
din
g up
on
th
e ci
rcum
stan
ces,
Fed
eral
an
d S
tate
law
s m
ay p
rovid
e p
rote
ctio
ns
that
allo
w y
ou t
o k
eep
hea
lth
co
ver
age.
An
y su
ch r
igh
ts m
ay b
e lim
ited
in
dura
tio
n a
nd w
ill r
equir
e yo
u t
o p
ay a
pre
miu
m, w
hic
h m
ay b
e si
gnif
ican
tly
hig
her
th
an t
he
pre
miu
m y
ou
pay
w
hile
co
ver
ed u
nder
th
e p
lan
. O
ther
lim
itat
ion
s o
n y
our
righ