Summary Plan Description ANTHEM BLUE CROSS MEDICAL BENEFITS

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1 Summary Plan Description ANTHEM BLUE CROSS MEDICAL BENEFITS Effective 1/1/2013

2 ANTHEM BLUE CROSS MEDICAL BENEFITS TABLE OF CONTENTS INTRODUCTION TO THE ANTHEM BLUE CROSS MEDICAL BENEFITS 1 Anthem Blue Cross Benefit Options 1 Using PPO Providers 2 What Do the PPO and PPO Plus Medical Benefits Cover? 3 Prescription Drugs 3 YOUR MEDICAL BENEFITS AND COVERED SERVICES AT A GLANCE 4 HOW ANTHEM BLUE CROSS BENEFITS WORK 8 Covered Expense 9 Annual Deductibles 9 Copay 10 Annual Out-of-Pocket Limit 10 Annual Out-of-Pocket Limit (continued) 11 Maximum Lifetime Benefit 11 COVERED ANTHEM BLUE CROSS MEDICAL SERVICES AND BENEFITS 12 Acupuncture 12 Adult Preventive Services (19 years and older) 12 Allergy Injections and Allergy Testing 13 Ambulance 14 Ambulatory Surgical Center Services 14 Cervical Cancer Screening (Pap Smear) 14 Colorectal Cancer Screening (Colonoscopy) 15 Contraceptives 15 Cosmetic Surgery 15 Dental Services 15 Diagnostic Services 16 Durable Medical Equipment 16 Emergency Care 17 Hearing Aids or Tests 18 Home Health Care 18 Home Infusion Therapy 19 Hospice Care 20 Hospital Charges -- Inpatient Care 21 Hospital Charges -- Outpatient Care 21 Immunizations 22 Infertility Treatment 22 Mammography Screening 22 Mental or Nervous Disorders, Including Substance Abuse 23 Nutritional Counseling 23 Outpatient Occupational Therapy 24 Effective 1/1/2013 i Anthem Blue Cross Medical

3 Organ and Tissue Transplants 24 Organ Transplant Travel Expense 25 Physical Exams (Full-time and Part-time Associates) 26 Physical Therapy and Physical Medicine 28 Physician s Services 29 Pregnancy 29 Prostate Cancer Screening 29 Second Surgical Opinions 30 Skilled Nursing Care Facilities 30 Speech Therapy 31 Spinal Manipulations 32 Temporomandibular Joint (TMJ) Syndrome 32 Well Baby Care 33 Well Child Care 33 Well Child Preventive Care and Immunizations (through age 18) 33 Wigs 34 MEDICAL REVIEW OF ANTHEM BLUE CROSS MEDICAL BENEFITS 35 Review Programs 35 Medical Necessity 35 Note Regarding Secondary Coverage 36 Utilization Review Program 36 Utilization Review Requirements 37 Pre-service Reviews 38 Concurrent Reviews 38 Retrospective Reviews 39 Disagreement with Medical Review Decisions 39 Medical Necessity Review Process 40 Quality Assurance 42 Newborns and Mothers Health Protection Act 42 Personal Case Management 42 Alternative Treatment Plan 43 Authorization Program for Organ and Tissue Transplants 44 Transplant Travel Expense Benefits 44 LIMITATIONS AND EXCLUSIONS 46 Acupressure 46 Air Conditioners 46 Chronic Pain 46 Contraceptive Devices 46 Cosmetic Surgery 46 Crime 46 Custodial Care or Rest Cures 47 Dental Services or Supplies 47 Diabetic Supplies 47 Drugs and Medications (Outpatient) 47 Education or Counseling 47 Exercise Equipment 47 Excess Amounts 47 Effective 1/1/2013 ii Anthem Blue Cross Medical

4 Experimental or Investigative 47 Eye Surgery for Refractive Defects 47 Food Supplements 47 Government Treatment 47 Immunizations 48 Infertility Treatment 48 Inpatient Diagnostic Tests 48 Lifestyle Programs 48 No Coverage in Effect 48 Not Medically Necessary 48 Not Specifically Listed 48 Nuclear Energy 48 Obesity 48 Optometric Services or Supplies 48 Orthodontia 48 Orthoptics 48 Personal Items 49 Prior Disabling Conditions 49 Services of Relatives 49 Sex Transformation 49 Sterilization Reversal 49 Telephone and Facsimile Machine Consultations 49 Voluntary Payment 49 War-Related 49 Work-Related 49 DEFINITIONS UNDER ANTHEM BLUE CROSS MEDICAL BENEFITS 50 Centers of Medical Excellence 50 Covered Expense 50 Custodial Care 50 Day Treatment Center 50 Experimental Procedures or Medications 50 Hospice 50 Hospital 51 Infertility 51 Investigative Procedures or Medications 51 Medically Necessary 51 Mental or Nervous Disorders 52 Negotiated Rate 53 Non-contracting Hospital 53 Non-PPO 53 Orthotic Devices 53 Physician 54 PPO 54 Preventive Care Services 55 Primary Care Provider (PCP) 55 Prosthetic Devices 55 Reasonable and Customary Charge 55 Effective 1/1/2013 iii Anthem Blue Cross Medical

5 Specialist 56 Wigs 56 PRESCRIPTION DRUG BENEFITS 57 How the Plan Works 57 Copay 58 Covered Prescriptions 58 Benefits 58 Maintenance Drugs 59 Mandatory Mail Program 59 Prior Authorization Requirements 59 Process for Prior Authorization 60 Prior Authorization Process at a Retail Pharmacy 60 Prior Authorization Process Through the Mail-Order Program 61 Coverage Limits 61 Step Therapy 62 Quantity Limitations 62 Benefits When You Use a Participating Retail Pharmacy 62 Benefits When You Use a Non-Participating Pharmacy 64 Mail Service Program 64 Comparison of Prescription Benefits 66 Preventive Medications 68 Exclusions 68 Note Regarding Infertility Drugs 69 Definitions 69 MEDICAL BENEFITS: CLAIMS AND APPEALS 70 DEFINITIONS 70 Adverse Benefit Determination 70 Appeal 71 Final Internal Adverse Benefit Determination 71 Post-Service Claim 71 Pre-Service Claim 71 Urgent Care Claim 71 CLAIM DETERMINATIONS 71 Claims Involving Urgent Care (Before Care Has Been Received) 71 Claims Involving Non-Urgent Care (Before Care Has Been Received) 72 Claims Involving Concurrent Care Decisions (While Care is Being Received) 72 Post-Service Medical Claims (After Care Has Been Received) 73 How to File Post-Service Medical Claims 74 Where to Send Post-Service Medical Claims 74 When to File Post-Service Medical Claims 75 When Post-Service Medical Claims are Determined 75 Notice of Initial Claim Denial 76 How to Request a Review of a Denied Claim 77 LEVEL ONE APPEAL 77 LEVEL TWO APPEAL 78 VOLUNTARY APPEALS 79 How to File a Voluntary Appeal for an External Review 80 Effective 1/1/2013 iv Anthem Blue Cross Medical

6 Preliminary Review 81 Referral to ERO 81 How to File a Voluntary Appeal for an Expedited External Review 82 Referral of Expedited Review to ERO 82 How to File a Voluntary Appeal to the Plan 83 PRESCRIPTION DRUG BENEFITS: CLAIMS AND APPEALS 84 DEFINITIONS 84 Adverse Benefit Determination 84 Appeal 84 Final Adverse Benefit Determination 84 Urgent Care Claim 85 CLAIMS 85 Outpatient Prescription Drug Claims Participating Retail Pharmacies 85 Outpatient Prescription Drug Claims Non-Participating Pharmacies 86 Urgent Care Claims 86 Direct Claims 86 When to File Prescription Claims 87 When Claims are Determined 87 Notice of Initial Claim Denial 88 How to Request Review of a Denied Claim 89 LEVEL ONE APPEAL 89 Level One Appeal of Non-Urgent Care Claims 89 Level One Appeal of Urgent Care Claims 90 LEVEL TWO APPEAL 91 VOLUNTARY APPEALS 92 How to File a Voluntary Appeal for External Review 92 How to File a Voluntary Appeal for a Non-Urgent External Review 93 How to File a Voluntary Appeal for an Urgent External Review 94 How to File a Voluntary Appeal to the Plan 94 ERISA 95 COORDINATION OF BENEFITS UNDER ANTHEM BLUE CROSS 96 Types of Plans Covered 96 Coordination Rules 97 Additional Provisions 98 Rights of Recovery or Subrogation 98 IMPORTANT INFORMATION ABOUT MEDICARE 99 When You Become Eligible 99 Medicare for Active Associates Based on Age 99 Medicare for Active Associates Based on Disability 100 CONVERTING TO AN INDIVIDUAL POLICY 102 Eligibility 102 How to Apply for Coverage 102 Type of Coverage 102 Exclusions 103 Cost of Conversion Coverage 103 Effective 1/1/2013 v Anthem Blue Cross Medical

7 Effective Date 103 Effective 1/1/2013 vi Anthem Blue Cross Medical

8 INTRODUCTION TO THE ANTHEM BLUE CROSS MEDICAL BENEFITS The Capital Group Companies, Inc. has contracted with Anthem Blue Cross Life and Health to assist in providing and administering medical benefits under The Health and Welfare Benefits Plan for Employees of the Capital Group Companies, Plan Number 501 ( the Plan ). In some locations, Anthem Blue Cross Life and Health uses the name Anthem Blue Cross (CA), Anthem Blue Cross Blue Shield (IN, GA, NV, VA), and Blue Cross Blue Shield (AZ, IL, TX, Washington D.C.) For purposes of the Plan, the Overview section, and referenced Plans and SPDs, all applicable Anthem Blue Cross Life and Health entities shall be referred to simply as Anthem Blue Cross. The Overview section explains who is eligible for coverage under the Anthem Blue Cross portion of the Plan and when coverage for these benefits starts and ends. Anthem Blue Cross Benefit Options The Anthem Blue Cross benefits under the Plan consist of two separate benefit options, PPO and PPO Plus: The PPO provides a generous level of medical coverage for you and your family. The PPO Plus provides a higher level of medical coverage for you and your family. Your Anthem Blue Cross benefit options PPO or PPO Plus depend on the option you select at enrollment. The Overview section explains when and how you can enroll for your choice of Anthem Blue Cross medical benefits. The Anthem Blue Cross medical benefits under the Plan have a large network of participating providers hospitals, outpatient facilities, physicians, and other health care professionals who have contracted with Anthem Blue Cross to offer health care services at lower, negotiated rates. These are called PPO Providers. A listing of PPO Providers is available at no cost by calling the toll-free number on your plan identification card. Provider listings are also found online at Effective 1/1/ Anthem Blue Cross Medical

9 Anthem Blue Cross Benefit Options (continued) Using PPO Providers The PPO and PPO Plus benefits are flexible so that you can change back and forth between PPO and non-ppo providers each time you need medical services. The exact benefits you receive and your out-of-pocket cost depend on your plan option (PPO or PPO Plus) and whether the provider who treats you belongs to the PPO. Using PPO providers helps you reduce your cost for hospital, physician and other medical services. When you use providers in the PPO network, the Anthem Blue Cross benefits pay a higher benefit level for many services. You are not responsible for covered charges above the negotiated rate when you receive care from PPO network providers. Anthem Blue Cross PPO contracted providers have agreed to accept the negotiated rate as the actual charge for that service. You will be responsible for any deductible and for your share of the cost or copay. When you use non-ppo providers, the Anthem Blue Cross benefits pay a lower amount, subject to certain limits, deductibles, and copays.* In some unique situations, authorized referrals to non-ppo providers will be covered at the PPO coverage level when all of the following criteria are met: There is no PPO provider who practices the appropriate specialty, provides the required services or has the necessary facilities within 30 miles of your home; You are referred to the non-ppo provider by a physician who is a PPO provider; and The services are authorized by the Review Center before services are received. The Review Center s telephone number is shown on your identification card. * Reimbursement for non-ppo facilities in California will be reimbursed as a percentage of covered services based on Anthem s fee schedule. Effective 1/1/ Anthem Blue Cross Medical

10 What Do the PPO and PPO Plus Medical Benefits Cover? Prescription Drugs The PPO medical benefits and the PPO Plus medical benefits work basically the same way and cover the same types of services, including: Hospital services and emergency services Medical services provided in a physician s office Medical services provided outside a physician's office Maternity care Well baby and well child care through age 18 Diagnostic services Anthem Blue Cross s prescription drug benefits are administered by Express Scripts/Medco Health Solutions, Inc. ( Express Scripts/Medco ). These benefits are described separately on pages Effective 1/1/ Anthem Blue Cross Medical

11 YOUR MEDICAL BENEFITS AND COVERED SERVICES AT A GLANCE MEDICAL BENEFITS The following chart summarizes your Anthem Blue Cross medical benefits: Benefit Features PPO Plus Benefits PPO Benefits Covered Expenses PPO Non-PPO PPO Non-PPO The covered expense is the PPO negotiated rate or fee. You are not responsible for charges above the negotiated rate or fee. However, you may receive a bill or be asked to pay all or a portion of the maximum allowed amount to the extent you have not met your deductible or have a copay. The covered expense is the customary and reasonable charge for professional services or the reasonable charge for institutional services. You are responsible for any difference between the covered expense and the provider s actual charge, in addition to any deductible, percentage coinsurance and dollar copay amounts. The covered expense is the PPO negotiated rate or fee. You are not responsible for charges above the negotiated rate or fee. However, you may receive a bill or be asked to pay all or a portion of the maximum allowed amount to the extent you have not met your deductible or have a copay. Maximum Lifetime Benefit Unlimited Unlimited The covered expense is the customary and reasonable charge for professional services or the reasonable charge for institutional services. You are responsible for any difference between the covered expense and the provider s actual charge, in addition to any deductible, percentage coinsurance and dollar copay amounts. Annual Deductible Annual Out-of-Pocket Limit for PPO Providers The following expenses are not applied toward the annual out-ofpocket limit: deductibles or copayments; non-covered expenses; drugs for infertility treatment, or out-patient prescription drugs; or charges by non-ppo providers in excess of customary and reasonable charges. $300 per covered individual with a maximum deductible of $750 per family per year. You must meet the annual deductible before benefits are payable for most covered services. $450 per covered individual with a maximum deductible of $1,125 per family per year. You must meet the annual deductible before benefits are payable for most covered services. After an individual pays $2,000 or a family pays $5,000 in a year for covered services provided by a PPO Provider, the Anthem Blue Cross benefits will pay 100% of the covered expenses incurred by that person during the rest of the year for services received from such PPO Providers. The 100% payment level will not apply to deductibles or copayments; drugs for infertility treatment, out-patient prescription drugs; or charges by non-ppo providers in excess of customary and reasonable charges. $500 per covered individual with a maximum deductible of $1,250 per family per year. You must meet the annual deductible before benefits are payable for most covered services. $750 per covered individual with a maximum deductible of $1,875 per family per year. You must meet the annual deductible before benefits are payable for most covered services. After an individual pays $4,000 or a family pays $10,000 in a year for covered services provided by a PPO Provider, the Anthem Blue Cross benefits will pay 100% of the covered expenses incurred by that person during the rest of the year for services received from such PPO Providers. The 100% payment level will not apply to deductibles or copayments; drugs for infertility treatment, or out-patient prescription drugs; or charges by non-ppo providers in excess of customary and reasonable charges. Effective 1/1/ Anthem Blue Cross Medical

12 Benefit Features PPO Plus Benefits PPO Benefits Annual Out-of-Pocket Limit for Non-PPO Providers The following expenses are not applied toward the annual out-ofpocket limit: deductibles or copayments; non-covered expenses; expenses for treatment of drugs for infertility treatment, or out-patient prescription drugs; or charges by Non-PPO providers in excess of customary and reasonable charges. PPO Non-PPO PPO Non-PPO After an individual pays $3,000 or a family pays $7,500 in a year for covered services provided by a Non-PPO Provider, the Anthem Blue Cross benefits will pay 100% of the covered expenses incurred by that person during the rest of the year for services received from such Non-PPO Providers. The 100% payment level will not apply to deductibles or copayments; nor to covered expenses incurred for the treatment of drugs for infertility treatment, out-patient prescription drugs; or charges by Non-PPO providers in excess of customary and reasonable charges. After an individual pays $6,000 or a family pays $15,000 in a year for covered services provided by a Non-PPO Provider, the Anthem Blue Cross benefits will pay 100% of the covered expenses incurred by that person during the rest of the year for services received from such Non-PPO Providers. The 100% payment level will not apply to deductibles or copayments; nor to covered expenses incurred for the treatment of drugs for infertility treatment, or out-patient prescription drugs; or charges by Non-PPO providers in excess of customary and reasonable charges. COVERED SERVICES The following chart summarizes your Anthem Blue Cross covered services: Covered Services PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Adult Preventive Services (19 years and older) 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Ambulatory Surgical Centers Outpatient surgery, services, and supplies (non-professional) 90% of negotiated rate, subject to annual deductible. 70% of covered 80% of negotiated rate, subject to annual deductible. 50% of covered Diagnostic X-ray and Lab Exams (Outpatient) 100% of negotiated rate; no deductible applies, unless services are rendered by a hospital. 70% of covered 100% of negotiated rate; no deductible applies, unless services are rendered by a hospital. 50% of covered Durable Medical Equipment 100% of negotiated rate; no deductible applies. 70% of covered 100% of negotiated rate; no deductible applies. 50% of covered Emergency Care (Facility) Emergency room services and supplies Inpatient hospital services and supplies Ambulatory Surgical Center services and supplies 90% of negotiated rate, subject to annual deductible. 90% of covered 80% of negotiated rate, subject to annual deductible. 80% of covered Emergency Care (Physician Services) 100% of negotiated rate; no deductible applies. 100% of covered 100% of negotiated rate; no deductible applies. 100% of covered Effective 1/1/ Anthem Blue Cross Medical

13 Covered Services PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Home Health Care Includes services of a RN, medical social worker or occupational, speech, respiratory or physical therapist. Services of a health aide when ordered and supervised by a RN and in conjunction with the services of a RN or therapist. 100% of negotiated rate; no deductible applies. 1 70% of covered 1 100% of negotiated rate; no deductible applies. 1 50% of covered 1 Hospital Medical Services Inpatient Semi-private room, meals and special diets, and ancillary services, including: Operating and special treatment rooms General nursing care Drugs, medications, and oxygen administered in the hospital Blood and blood products Lab & X-ray 90% of negotiated rate, subject to annual deductible. 1 70% of covered 1 80% of negotiated rate, subject to annual deductible. 1 50% of covered 1 Outpatient Outpatient medical and surgical services and supplies (nonprofessional) 90% of negotiated rate, subject to annual deductible. 70% of covered 80% of negotiated rate, subject to annual deductible. 50% of covered Maternity Care Paid as any other condition Paid as any other condition Paid as any other condition Paid as any other condition Physician Medical Services Inpatient Hospital Visits Skilled nursing facility visits Surgeon and surgical assistant Anesthesiologist or anesthetist 100% of negotiated rate, no deductible applies. 70% of covered 100% of negotiated rate, no deductible applies. 50% of covered Office Visits Primary Care (PCP) 2 Specialist (e.g., non-pcp) 100% of negotiated rate after you pay a $20 copay per PCP visit (or $35 copay per specialist visit). No deductible applies. 70% of covered 100% of negotiated rate after you pay a $30 copay per PCP visit (or $45 copay per specialist visit). No deductible applies. 50% of covered 1 Benefits require prior authorization from the Review Center. If service is not pre-authorized, your benefits may be reduced. See pages Primary Care Providers (PCPs) are Family Practitioners, General Practitioners, Internists, Pediatricians, OB/GYNs, and Nurse Practitioners. Effective 1/1/ Anthem Blue Cross Medical

14 Covered Services PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Physical Exams (routine check-ups for full-time and part-time associates) Full-time Associates 100% of negotiated rate; no copayment applies; no deductible applies. 70% of covered expenses; subject to 100% of negotiated rate; no copayment applies; no deductible applies. 50% of covered expenses; subject to Part-time Associates Not available Not available 100% of negotiated rate; no copayment applies; no deductible applies. 50% of covered expenses; subject to Physical Therapy and Physical Medicine Outpatient 100% of negotiated rate after you pay a $35 copay per visit; no deductible applies. 70% of covered 100% of negotiated rate after you pay a $45 copay per visit; no deductible applies. 50% of covered Inpatient 100% of negotiated rate; no deductible applies. 70% of covered 100% of negotiated rate; no deductible applies. 50% of covered Skilled Nursing Facilities Semi-private room, services, and supplies. Benefits are limited to 100 days each calendar year. 90% of negotiated rate; subject to annual deductible. 1 70% of covered 1 80% of negotiated rate; subject to annual deductible. 1 50% of covered 1 Spinal Manipulation Maximum 26 visits per calendar year 100% of negotiated rate after you pay a $35 copay per visit; no deductible applies. 70% of covered 100% of negotiated rate after you pay a $45 copay per visit; no deductible applies. 50% of covered Treatment of Mental or Nervous Disorders, including Substance Abuse 90% of negotiated rate, subject to annual deductible. 1 70% of covered 1 80% of negotiated rate, subject to annual deductible. 1 50% of covered 1 Inpatient or Day Treatment Centers 90% of covered annual deductible, if referred by EAP. 80% of covered expenses subject to annual deductible, if referred by EAP. Outpatient 100% of negotiated rate after you pay a $20 copay per visit. No deductible applies. 70% of covered 100% of negotiated rate after you pay a $30 copay per visit. No deductible applies. 50% of covered Well Baby/ Child Care Preventive Care and Immunizations (through age 18) 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Routine Physical Exams and Immunizations See also the General Information section regarding Your Rights under the Women s Health and Cancer Rights Act of Effective 1/1/ Anthem Blue Cross Medical

15 HOW ANTHEM BLUE CROSS BENEFITS WORK The PPO and the PPO Plus benefits cover the same types of medical services. The amount of benefits paid by the Anthem Blue Cross medical benefits portion under the Plan and your share of costs depends on which PPO option you choose at enrollment. Both PPO options provide greater benefits when you use a PPO provider for covered medical services. The chart on pages 4-7 provides a summary of the benefits offered by each PPO option. Important terms, such as covered expense, deductible and copay, are explained below to help you understand how Anthem Blue Cross medical benefits work under the Plan. See Covered Medical Services and Benefits on pages for details about the Anthem Blue Cross s benefits for each type of covered medical service. Medical Review on pages explains when you should receive pre-authorization from the Anthem Blue Cross Review Center before your medical treatment starts. Limitations and Exclusions on pages explains items that are not covered or for which benefits may be limited. The Anthem Blue Cross medical benefits are available only to the extent: The services you receive are medically necessary (including any procedure or treatment prescribed by a physician that aids in the recovery of the patient s ailment or accident); Applicable deductibles and copays have been paid; Charges do not exceed Anthem Blue Cross medical benefit limits; and Charges for services are within the customary and reasonable range in the geographic area where services are provided. The Anthem Blue Cross s medical benefits may be reduced or not payable if the charges are covered under another health plan (for example, if your spouse works and has medical coverage through his or her employer). See pages for information about Coordination of Benefits. Effective 1/1/ Anthem Blue Cross Medical

16 Covered Expense Annual Deductibles The covered expense is the charge upon which Anthem Blue Cross bases its benefit. If you receive covered services from a PPO provider, the covered expense is the provider s negotiated rate. PPO providers have agreed with Anthem Blue Cross not to charge more than the negotiated rate. If you receive covered services from a non-ppo provider, any charge exceeding the reasonable and customary charge determined by Anthem Blue Cross will not be considered a covered expense. To receive coverage for many services, you must first meet your annual calendar year deductible. This is the initial expense you must pay before your medical plan will pay most benefits. If the deductible applies to the service you receive, the deductible must be satisfied before Anthem Blue Cross will pay benefits. If you use providers both in and out of network, you will need to satisfy each deductible separately. If you enroll in the PPO Plus benefit option and use an innetwork PPO provider, your annual deductible is $300 per covered person, to a maximum of $750 per family. This means you must pay the first $300 in covered medical expenses each year for each covered individual, to a maximum of $750 if you have family coverage. A new deductible will apply each calendar year. If you enroll in the PPO Plus benefit option and use an out-ofnetwork PPO provider, your annual deductible is $450 per covered person, to a maximum of $1,125 per family. This means you must pay the first $450 in covered medical expenses each year for each covered individual, to a maximum of $1,125 if you have family coverage. A new deductible will apply each calendar year. If you enroll in the PPO benefit option and use an in-network PPO provider, your annual deductible is $500 per covered person, to a maximum of $1,250 per family. This means you must pay the first $500 in medical expenses for each covered individual, to a maximum of $1,250 if you have family coverage. A new deductible will apply each calendar year. If you enroll in the PPO benefit option and use an out-ofnetwork PPO provider, your annual deductible is $750 per covered person, to a maximum of $1,875 per family. This means you must pay the first $750 in medical expenses for each covered individual, to a maximum of $1,875 if you have family coverage. A new deductible will apply each calendar year. Effective 1/1/ Anthem Blue Cross Medical

17 Copay A copay is a specific portion of the cost that you must pay for a particular covered service. For example, for PPO office visits to a Primary Care Provider (PCP) you must pay a $20 copay (PPO Plus benefits) or $30 copay (PPO benefits) per visit and Anthem Blue Cross pays the rest. For PPO office visits to a specialist, your copay is $35 (PPO Plus benefits) or $45 (PPO benefits). You are responsible for paying the required copay at the time you receive services. Copays may also be expressed as a percentage; for example under the PPO Plus benefits option you pay 10% and Anthem Blue Cross pays 90% for hospital charges at a PPO facility. Annual Out-of-Pocket Limit The Anthem Blue Cross medical benefits portion of the Plan has an annual out-of-pocket limit to reduce the amount you have to pay for most covered services in any year. If enrolled in the PPO Plus benefits and a PPO Provider is used, your annual out-of-pocket limit is $2,000 per covered person (up to $5,000 per family). If enrolled in the PPO benefits and a PPO Provider is used, your annual out-ofpocket limit is $4,000 per covered person (up to $10,000 per family). If enrolled in the PPO Plus benefits and a non-ppo Provider is used, your annual out-of-pocket limit is $3,000 per covered person (up to $7,500 per family). If enrolled in the PPO benefits and a non-ppo Provider is used, your annual out-of-pocket limit is $6,000 per covered person (up to $15,000 per family). These charges do not count toward the out-of-pocket limit: Charges used to meet your annual deductible and your copays for office visits; Charges for non-covered services; Charges for out-patient prescription drugs; Charges for drugs to treat infertility; and Charges by non-ppo providers that are in excess of customary and reasonable charges. Effective 1/1/ Anthem Blue Cross Medical

18 Annual Out-of-Pocket Limit (continued) After you reach your annual out-of-pocket limit, Anthem Blue Cross will pay 100% of most covered services for the rest of the calendar year. However, benefits will not increase to 100% for out-patient prescription drugs and drugs to treat infertility. Also, you will remain responsible for paying the copays for regular office visits and for charges by non-ppo providers that exceed reasonable and customary charges. The following chart summarizes your Annual Out-of-Pocket Limit: Benefits Feature PPO Plus Benefits PPO Benefits Annual Deductible In-network Annual Deductible Out-ofnetwork Annual Out-of-Pocket Limit for PPO Providers Annual Out-of-Pocket Limit for Non-PPO Providers $300 per person $750 per family $450 per person $1,125 per family $2,000 per person $5,000 per family $3,000 per person $7,500 per family $500 per person $1,250 per family $750 per person $1,875 per family $4,000 per person $10,000 per family $6,000 per person $15,000 per family Maximum Lifetime Benefit There is an unlimited maximum lifetime benefit per person. The lifetime infertility benefit maximum for all charges incurred in connection with infertility testing, treatment, and prescription drugs is $20,000. Effective 1/1/ Anthem Blue Cross Medical

19 COVERED ANTHEM BLUE CROSS MEDICAL SERVICES AND BENEFITS The covered benefits described in this section apply to the medical expenses for you or your covered dependents. Acupuncture Services of a certified acupuncturist, a doctor of medicine, a doctor of osteopathy, a podiatrist, or a dentist for acupuncture treatment to treat a disease, illness or injury are covered. Benefits for acupuncture are paid as follows: Acupuncture PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Inpatient 90% of negotiated rate; no deductible applies. 70% of covered 80% of negotiated rate; no deductible applies. 50% of covered Outpatient 100% of negotiated rate after you pay a $35 copay per visit; no deductible applies. 70% of covered 100% of negotiated rate after you pay a $45 copay per visit; no deductible applies. 50% of covered Adult Preventive Services (19 years and older) Adult preventive care services include routine physical exams, screenings, tests, well women s visits and vaccines, which are performed by your doctor as precautionary. Adult Preventive Services do not cover services used to diagnose or find the cause of existing symptoms. The office visit related to, and supplies provided in connection with, the services rendered are covered. The annual deductible and copays will not apply to Adult Preventive Services when performed by a participating provider because these services are considered to be Preventive Care Services. Please contact Anthem Member Services at (888) for a list of covered Adult Preventive Care Services. A Physical exam is available to all full-time and part-time associates. The associate, the associate s spouse or spouse equivalent and covered, qualified dependents age 19 and older become eligible for the physical exam benefit upon the Effective 1/1/ Anthem Blue Cross Medical

20 Adult Preventive Services (19 years and older) (continued) associate s date of hire. The Anthem PPO Plus level of benefits coverage is not available to part-time associates. Please see the Physical Exam section on pages for more detailed information about this benefit. See the definition of Preventive Care Services in the Definitions section for more information about services that are covered by this Plan as preventive care services. For more information on how benefits are paid when Adult Preventive Services are performed by PPO providers and non- PPO providers, please see the individual sections Cervical Cancer Screening (Pap Smear), Colorectal Cancer Screening (Colonoscopy), Mammography Screening, Prostate Cancer Screening and Immunizations. Adult Preventive Services (19 years and older) PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Office Visit 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Allergy Injections and Allergy Testing Allergy injections and allergy testing administered in a Physician's office are covered. Benefits for allergy injections are paid as follows: Allergy Injections PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Office Visit 100% of negotiated rate after you pay a $20 copay per PCP visit (or $35 copay for specialist visit); no deductible applies. 70% of covered 100% of negotiated rate after you pay a $30 copay per PCP visit (or $45 copay for specialist visit); no deductible applies. 50% of covered Injections 100% of negotiated rate; no deductible applies. 70% of covered 100% of negotiated rate; no deductible applies. 50% of covered Effective 1/1/ Anthem Blue Cross Medical

21 Ambulance Transportation by ground and air ambulance to the nearest hospital where appropriate treatment is available when it is medically necessary because of an emergency is covered. Services such as electrocardiograms and administration of intravenous solutions or oxygen provided by a licensed person are also covered. Benefits for ambulance services are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 90% of base charge, mileage, and non-reusable supplies to transport you to the nearest hospital where appropriate treatment is available, subject to 80% of base charge, mileage, and non-reusable supplies to transport you to the nearest hospital where appropriate treatment is available, subject to annual deductible. Ambulatory Surgical Center Services Charges for services and supplies provided by an ambulatory surgical center in connection with outpatient surgery is covered. Benefits for ambulatory surgical center services are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 90% of negotiated rate, subject to annual deductible. 70% of covered 80% of negotiated rate, subject to annual deductible. 50% of covered Cervical Cancer Screening (Pap Smear) Annual routine and diagnostic cervical cancer screening test is covered when the test is prescribed by a nurse practitioner, certified nurse midwife, or physician who is providing care to the patient and operating within the scope of his or her license. Benefits for pap smears are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Effective 1/1/ Anthem Blue Cross Medical

22 Colorectal Cancer Screening (Colonoscopy) Annual routine and diagnostic colorectal cancer screening tests, including colonoscopy or sigmoidoscopy and related anesthesia are covered, when the screening test is performed as a result of a referral by a physician who is providing care to the patient and operating within the scope of his or her license. Benefits are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Contraceptives Services and supplies provided in connection with the following methods of contraception are covered: Injectable drugs and implants for birth control, administered in a physician s office, if medically necessary. Intrauterine contraceptive devices (IUDs) and diaphragms, dispensed by a physician, if medically necessary. Professional services of a physician in connection with the prescribing, fitting, and insertion of intrauterine contraceptive devices or diaphragms. Cosmetic Surgery Dental Services Charges for, or related to, treatment or operations to improve appearance are covered only if they are for repair of disfigurement due to an accident that occurs while the patient is covered by Anthem Blue Cross medical benefits and the treatment begins within 90 days after the accident, or as soon as medically appropriate, or for correction of a birth defect. See Hospital Charges Inpatient, Hospital Charges Outpatient, and Physician s Services below. Services of a physician (M.D.) or dentist (D.D.S. or D.M.D.) solely to treat an accidental injury to natural teeth are covered. Coverage shall be limited to only such services that are medically necessary to repair the damage done by the accidental injury and/or restore function lost as a direct result of the accidental injury. Damage to natural teeth due to chewing or biting is not accidental injury. Effective 1/1/ Anthem Blue Cross Medical

23 Diagnostic Services Medically necessary diagnostic tests, services and supplies are covered, including: Laboratory tests; X-rays; Electrocardiograms (EKG); Computerized Axial Tomography (CAT) Scan; and Magnetic Resonance Imaging (MRI). Benefits for diagnostic services are paid as follows: Diagnostic Services PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Inpatient 90% of negotiated rate, subject to 70% of covered 80% of negotiated rate, subject to 50% of covered Outpatient 100% of negotiated rate; no deductible applies unless by hospital then 90% after deductible. 70% of covered 100% of negotiated rate; no deductible applies unless by hospital then 80% after deductible. 50% of covered Durable Medical Equipment The rental or purchase of medical equipment and supplies that are ordered by a Physician are covered, subject to the following limitations: Manufactured specifically for medical use and of no further use when medical needs end; and For the exclusive use of the patient and not primarily for comfort, hygiene, environmental control, or exercise. Pre-certification rules will apply to services and durable medical equipment listed on Anthem s national precertification list. Please contact Anthem to find out if a service and/or durable medical equipment requires precertification. Effective 1/1/ Anthem Blue Cross Medical

24 Durable Medical Equipment (continued) Durable medical equipment includes: Wheelchairs, hospital-type beds, and mechanical equipment to treat respiratory paralysis; The first supply and medically necessary replacement of prosthetic and orthotic devices and services; and Dialysis equipment and supplies. Benefits for durable medical equipment are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no deductible applies. 70% of covered expenses, subject to annual deductible. 100% of negotiated rate; no deductible applies. 50% of covered expenses, subject to annual deductible. Emergency Care The following items are covered when medically necessary to treat an emergency condition (as defined below): Emergency room services and supplies; Ambulatory surgical center services and supplies; Inpatient hospital services and supplies; and Physician s services. An emergency condition is a sudden, serious, and unexpected acute illness or injury, or sudden and unexpected severe pain, which could permanently endanger your health if medical treatment is not received immediately. Benefits for emergency care are paid as follows: Emergency Care PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Facilities Services and Supplies 90% of negotiated rate, subject to 90% of covered 80% of negotiated rate, subject to 80% of covered Physician Services 100% of negotiated rate; no deductible applies. 100% of covered 100% of negotiated rate; no deductible applies. 100% of covered Effective 1/1/ Anthem Blue Cross Medical

25 Hearing Aids or Tests Routine hearing tests are covered to determine the medical necessity of a hearing aid. Hearing aid covered benefit amount will vary (up to a maximum of $5,000 every 36 months) based on the type of hearing aid determined medically necessary. Any amounts in excess of the expense covered by Anthem Blue Cross benefits will not be considered a covered benefit and are not payable. Benefits for hearing aids or tests are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no deductible applies. 70% of covered expenses, subject to annual deductible. 100% of negotiated rate; no deductible applies. 50% of covered expenses, subject to annual deductible. Home Health Care The following services provided by a licensed home health agency or visiting nurse association are covered: Services of a registered nurse; Services of a licensed therapist for physical therapy, occupational therapy, speech therapy, or respiratory therapy; Services of a medical social service worker; Services of a health aide who is employed by (or who contracts with) a home health agency or visiting nurse association. Services must be ordered and supervised by or visiting nurse association as professional coordinator. These services are covered only if you are also receiving the services listed in the first two bullets above; and a registered nurse employed by the home health agency Medically necessary supplies provided by the home health agency or visiting nurse association. Benefits will be limited to 100 visits during a calendar year. One home health visit is defined as a period of covered service of up to four hours during any one day. Home health care services are subject to prior authorization to determine medical necessity. Please refer to Medical Review on pages for more information. Home health care services are not covered if received while you are receiving benefits under Hospice Care below. Effective 1/1/ Anthem Blue Cross Medical

26 Home Health Care (continued) Benefits for home health care are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no deductible applies. 70% of covered 100% of negotiated rate; no deductible applies. 50% of covered Home Infusion Therapy Services of a licensed home infusion therapy provider are covered for the intravenous administration of your total daily nutritional intake or fluid requirements, medication related to illness or injury, chemotherapy, antibiotic therapy, aerosol therapy, tocolytic therapy, special therapy, intravenous hydration, or pain management. The following services and supplies are covered: Medication, ancillary medical supplies and supply delivery (not to exceed a 14 day supply); however, medication which is delivered but not administered is not covered; Pharmacy compounding and dispensing services (including pharmacy support) for intravenous solutions and medications; Hospital and home clinical visits related to the administration of infusion therapy, including skilled nursing services including those provided for patient or alternative caregiver training, and visits to monitor the therapy; Rental and purchase charges for durable medical equipment (as shown above) and maintenance and repair charges for such equipment; and Laboratory services to monitor the patient s response to therapy regimen. The maximum payment will not exceed $600 for services or supplies received during any one day from a home infusion therapy provider which is not a PPO provider. Services are subject to prior authorization from the Review Center to determine medical necessity. See Medical Review on pages for details. Effective 1/1/ Anthem Blue Cross Medical

27 Home Infusion Therapy (continued) Benefits for home infusion therapy are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no deductible applies. 70% of covered expenses (up to $600 per day), subject to 100% of negotiated rate; no deductible applies. 50% of covered expenses (up to $600 per day), subject to Hospice Care If you are suffering from a terminal illness, Anthem Blue Cross will work with your Physician in the development of your treatment plan and will pay for: Room and board charges in an inpatient hospice unit; Services of a registered nurse, licensed practical nurse and licensed vocational nurse; Services of a licensed therapist for physical therapy, occupational therapy, speech therapy and respiratory therapy; Medical social services; Services of a home health aide; Dietary and nutritional guidance. Nutritional support such as intravenous feeding or hyperalimentation; Drugs and medicines approved for general use by the Food and Drug Administration that are available only if prescribed by a Physician; Medical supplies, including oxygen and related respiratory therapy supplies; Palliative care (care which controls pain and relieves symptoms, but does not cure) which is appropriate for the illness; and Up to four visits for bereavement counseling for your family will be available in the 12-month period after your death. Benefits are $25 for each visit. Effective 1/1/ Anthem Blue Cross Medical

28 Hospice Care (continued) Benefits for hospice care are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 90% of covered annual deductible. 80% of covered annual deductible. Hospital Charges -- Inpatient Care Services and supplies provided by a hospital are covered. Charges are covered based on the hospital's two-bed room for each day of confinement, as well as the cost of other medically necessary hospital services and supplies. To receive the highest level of benefits, you should select a hospital in the PPO network. You should have your hospital stay certified by the Review Center, which is staffed by nurses and physicians employed by Anthem Blue Cross. The doctors and nurses at the Review Center will assure the medical necessity and appropriateness of care and the setting in which the care is to be provided. See Medical Review on pages for details about hospital stay certifications. Benefits for inpatient hospital care are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 90% of negotiated rate, subject to annual deductible. 70% of covered 80% of negotiated rate, subject to annual deductible. 50% of covered Hospital Charges -- Outpatient Care Hospital services and supplies are covered when you receive care on an outpatient basis, including surgical centers. Examples of outpatient hospital services include surgery and anesthesia, kidney dialysis, and chemotherapy. Benefits for outpatient hospital care are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 90% of negotiated rate, subject to annual deductible. 70% of covered 80% of negotiated rate, subject to annual deductible. 50% of covered Effective 1/1/ Anthem Blue Cross Medical

29 Immunizations Preventive Immunizations are covered at 100% with no copay, if administered by a PPO provider. If these immunizations are administered by a Non-PPO provider, the standard Non-PPO provider coinsurance applies. Immunizations administered at a pharmacy are not covered. Please contact Anthem Member Services at (888) for a list of covered Preventive Immunizations. Infertility Treatment The following infertility treatments are covered on the same basis as for any other illness, subject to the maximum lifetime infertility benefit: Medical testing and services to diagnose infertility, and Medical services and supplies furnished in connection with sterilization reversal, in vitro fertilization, gamete intrafallopian transfer, or similar procedures. The Plan will pay 50% of the covered expense, after the deductible, for prescription drugs used to treat infertility. If an infertility claim is billed with an office visit, office visit benefits should apply. The Plan s maximum lifetime infertility benefit for all charges incurred in connection with infertility testing, treatment, and prescription drugs is $20,000. PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Paid at the applicable benefit level for the services billed. Paid at the applicable benefit level for the services billed. Mammography Screening Annual routine and diagnostic mammograms are covered as prescribed by a Physician. Benefits for mammograms are paid as follows: PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO 100% of negotiated rate; no copay applies; no deductible applies. 70% of covered 100% of negotiated rate; no copay applies; no deductible applies. 50% of covered Effective 1/1/ Anthem Blue Cross Medical

30 Mental or Nervous Disorders, Including Substance Abuse Benefits for treatment of mental or nervous disorders are covered, including substance abuse. For treatment as an inpatient or by a day treatment center, you should have your stay certified by the Review Center, which is staffed by nurses and physicians employed by Anthem Blue Cross. See Medical Review on pages for details. The mental or nervous disorders and substance abuse benefits are summarized in the chart below: Mental or Nervous Disorders, Including Substance Abuse PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO Treatment of Mental or Nervous Disorders including Substance Abuse Inpatient or Day Treatment Centers 90% of negotiated rate, subject to 70% of covered expenses per visit, subject to annual deductible. 90% of covered expenses subject to annual deductible, if referred by EAP. 80% of negotiated rate, subject to 50% of covered expenses per visit, subject to annual deductible. 80% of covered expenses subject to annual deductible, if referred by EAP. Outpatient 100% of negotiated rate after you pay a $20 copay per visit. No deductible applies. 70% of covered 100% of negotiated rate after you pay a $30 copay per visit. No deductible applies. 50% of covered Nutritional Counseling Services and supplies provided in connection with nutritional counseling are covered, up to six (6) visits per calendar year. Benefits for nutritional counseling are paid as follows: Nutritional Counseling PPO Plus Benefits PPO Benefits PPO Non-PPO PPO Non-PPO No Diabetes Diagnosis 90% of negotiated rate; no deductible applies. 70% of covered 80% of negotiated rate; no deductible applies. 50% of covered Diabetes Diagnosis 100% of negotiated rate after you pay a $20 copay per visit; no deductible applies. 70% of covered 100% of negotiated rate after you pay a $30 copay per visit; no deductible applies. 50% of covered the annual deductible. Effective 1/1/ Anthem Blue Cross Medical

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