Anthem Blue Cross Life nd Helth Insurnce Compny University of Southern Cliforni Custom Premier 800/20%/20% Summry of Benefits nd Coverge: Wht this Pln Covers & Wht it Costs Coverge Period: 01/01/2015-12/31/2015 Coverge for: Individul/Fmily Pln Type: This is only summry. If you wnt more detil bout your coverge nd costs, you cn get the complete terms in the policy or pln document t http://www.nthem.com/c or by clling 1-855-333-5730. Importnt Questions Wht is the overll deductible? Are there other deductibles for specific services? Is there n out of pocket limit on my expenses? Answers For s $800 Member/$1,600 Fmily For Non- s $2,400 Member/$4,800 Fmily Does not pply to Preventive Cre. nd Non- deductibles re seprte nd do not count towrds ech other. Yes. Yes. $25/Member for Brnd Prescription Drugs. $500/Admission for Non-Anthem Blue Cross Hospitl or Residentil Tretment Center; wived for Emergency dmission. $150/Admission for Non-Anthem Blue Cross ASC or Outptient hospitl; wived for Emergency dmission. $250/Admission for Hospitl or Residentil Tretment Center if utiliztion review not obtined; wived for Emergency dmission $500/Admission for Non- Hospitl or Residentil Tretment Center if utiliztion review not obtined; wived for Emergency dmission. $100/Visit for Emergency Room Services; wived if dmitted directly from ER. Yes. For s $3,200 Member/$9,600 Fmily For Non- s $12,700 Member/$25,400 Fmily nd Non- out-of-pocket re seprte nd do not count towrds ech other. Why this Mtters: You must py ll the costs up to the deductible mount before this pln begins to py for covered services you use. Check your policy or pln document to see when the deductible strts over (usully, but not lwys, Jnury 1st). See the chrt strting on pge 3 for how much you py for covered services fter you meet the deductible. You must py ll of the costs for these services up to the specific deductible mount before this pln begins to py for these services. The out-of-pocket limit is the most you could py during coverge period (usully one yer) for your shre of the cost of covered services. This limit helps you pln for helth cre expenses. Questions: Cll 1-855-333-5730 or visit us t http://www.nthem.com/c. If you ren t cler bout ny of the underlined terms used in this form, see the Glossry. You cn view the Glossry t www.cciio.cms.gov or cll 1-855-333-5730 to request copy. 1 of 14
Wht is not included in the out of pocket limit? Is there n overll nnul limit on wht the pln pys? Does this pln use network of providers? Do I need referrl to see specilist? Are there services this pln doesn t cover? Premiums, Blnce-billed chrges nd Helth cre this pln doesn t cover. No. Yes. See http://www.nthem.com/c or cll 1-855-333-5730 for list of s. No. You don t need referrl to see specilist. Yes. Even though you py these expenses, they don t count towrd the out of pocket limit. The chrt strting on pge 3 describes ny limits on wht the pln will py for specific covered services, such s office visits. If you use n in-network doctor or other helth cre provider, this pln will py some or ll of the costs of covered services. Be wre, your in-network doctor or hospitl my use n out-ofnetwork provider for some services. Plns use the term innetwork, preferred, or prticipting for providers in their network. See the chrt strting on pge 3 for how this pln pys different kinds of providers. You cn see the specilist you choose without permission from this pln. Some of the services this pln doesn t cover re listed on pge 10. See your policy or pln document for dditionl informtion bout excluded services. Copyments re fixed dollr mounts (for exmple, $15) you py for covered helth cre, usully when you receive the service. Coinsurnce is your shre of the costs of covered service, clculted s percent of the llowed mount for the service. For exmple, if the pln s llowed mount for n overnight hospitl sty is $1,000, your coinsurnce pyment of 20% would be $200. This my chnge if you hven t met your deductible. The mount the pln pys for covered services is bsed on the llowed mount. If n out-of-network provider chrges more thn the llowed mount, you my hve to py the difference. For exmple, if n out-of-network hospitl chrges $1,500 for n overnight sty nd the llowed mount is $1,000, you my hve to py the $500 difference. (This is clled blnce billing.) This pln my encourge you to use providers by chrging you lower deductibles, copyments nd coinsurnce mounts. Common If you visit helth cre provider s office or clinic My Need Primry cre visit to tret n injury or illness You Use Non- --------none-------- Specilist visit --------none-------- 2 of 14
Common If you hve test My Need Other prctitioner office visit Preventive cre/ screening/ immuniztion Dignostic test (xry, blood work) Imging (CT/PET scns, MRIs) Chiroprctor Acupuncturist Chiroprctor Acupuncturist You Use Non- Chiroprctor Acupuncturist --------none-------- No Cost Shre No Cost Shre --------none-------- Lb Office X-Ry Office Lb Office X-Ry Office Lb Office X-Ry Office --------none-------- Subject to utiliztion review. Costs my vry by site of service. You should refer to your forml contrct of coverge for detils. 3 of 14
Common If you need drugs to tret your illness or condition More informtion bout prescription drug coverge is vilble t https://www.nthe m.com/c/helthinsurnce/providerdirectory/serchcrit eri?brnding=abc &provtype=rx My Need Generic drugs (includes dibetic supplies) Brnd nme formulry drugs Brnd nme nonformulry drugs (includes compound drugs; retil only) Specilty drugs (includes selfdministered injectble drugs, except insulin) $10 Copy/ prescription (retil) $25 Copy/ prescription (home delivery) $25 Copy/ prescription (retil) $63 Copy/ prescription (home delivery) $40 Copy/ prescription (retil) $100 Copy/ prescription (home delivery) (retil only) with $100 mx nd (home delivery) with $300 mx $10 Copy/ prescription (retil) $25 Copy/ prescription (home delivery) $25 Copy/ prescription (retil) $63 Copy/ prescription (home delivery) $40 Copy/ prescription (retil) $100 Copy/ prescription (home delivery) (retil only) with $100 mx nd (home delivery) with $300 mx You Use Non- $10 Copy/ prescription plus 50% of the remining prescription drug mximum llowed mount nd costs in excess of the prescription drug mximum llowed mount $25 Copy/ prescription plus 50% of the remining prescription drug mximum llowed mount nd costs in excess of the prescription drug mximum llowed mount $40 Copy/ prescription plus 50% of the remining prescription drug mximum llowed mount nd costs in excess of the prescription drug mximum llowed mount Not Covered For Non-Network: Member pys the retil phrmcy copy plus 50%. Covers up to 30 dy supply for Retil phrmcy or 90 dy supply for Home Delivery. 30-dy supply; 60-dy supply for Federlly Clssified Schedule II Attention Deficit Disorder drugs tht require triplicte prescription require double copy vilble only t Retil Phrmcy. For Non-Network: Member pys the retil phrmcy copy plus 50%. For Non-Prticipting Phrmcies, compound drugs & specilty phrmcy drugs re not covered nd my only be obtined through the specilty phrmcy progrm. 30-dy supply for Specilty Phrmcy. 4 of 14
Common If you hve outptient surgery If you need immedite medicl ttention My Need Fcility fee (e.g., mbultory surgery center) Physicin/surgeon fees Emergency room services Emergency medicl trnsporttion You Use Non- 40% Coinsurnce $150/dmission deductible pplies for Non-Anthem Blue Cross ASC hospitl or Outptient Hospitl; wived for emergency dmissions. --------none-------- 10% Coinsurnce 10% Coinsurnce 10% Coinsurnce Additionl deductible of $100 pplies, wived if dmitted in ptient. This is for the hospitl/fcility chrge only. The ER physicin chrge my be seprte. --------none-------- Urgent cre Costs my vry by site of service. You should refer to your forml contrct of coverge for detils. 5 of 14
Common If you hve hospitl sty My Need Fcility fee (e.g., hospitl room) Physicin/surgeon fee You Use Non- 40% Coinsurnce $500/dmission deductible pplies for Non-Anthem Blue Cross hospitls or residentil tretment centers; wived for emergency dmissions. $150/dmission deductible pplies for Non- Anthem Blue Cross ASC or Outptient hospitl; wived for emergency dmissions. Filure to obtin utiliztion review will result in n dditionl $500 deductible for Non-Anthem hospitls or residentil tretment centers; wived for emergency dmissions. Filure to obtin utiliztion review will result in n dditionl $250 deductible for hospitls or residentil tretment centers; wived for emergency dmissions.subject to utiliztion review for inptient services; wived for emergency dmissions. --------none-------- 6 of 14
Common If you hve mentl helth, behviorl helth, or substnce buse needs If you re pregnnt My Need helth outptient services helth inptient services Substnce use disorder outptient services Substnce use disorder inptient services Prentl nd postntl cre Helth Office Visit Helth Fcility Visit Fcility Chrges Helth Office Visit Helth Fcility Visit Fcility Chrges You Use Non- Helth Office Visit Helth Fcility Visit Fcility Chrges Substnce Abuse Office Visit Substnce Abuse Fcility Visit Fcility Chrges Substnce Abuse Office Visit Substnce Abuse Fcility Visit Fcility Chrges Substnce Abuse Office Visit Substnce Abuse Fcility Visit Fcility Chrges --------none-------- This is for fcility professionl services only. Plese refer to your hospitl sty for fcility fee. --------none-------- This is for fcility professionl services only. Plese refer to your hospitl sty for fcility fee. --------none-------- 7 of 14
Common My Need Delivery nd ll inptient services You Use Non- 40% Coinsurnce $500/dmission deductible pplies for Non-Anthem Blue Cross hospitls; wived for emergency dmissions. Filure to obtin utiliztion review will result in n dditionl $500 deductible for Non-Anthem hospitls; wived for emergency dmissions. Filure to obtin utiliztion review will result in n dditionl $250 deductible for hospitls; wived for emergency dmissions.subject to utiliztion review for inptient services; wived for emergency dmissions. 8 of 14
Common If you need help recovering or hve other specil helth needs If your child needs dentl or eye cre My Need You Use Non- Home helth cre Rehbilittion services Hbilittion services Subject to utiliztion review. Coverge is limited to totl of 100 visits, In-Network nd Non-Network combined per benefit period (one visit by home helth ide equls four hours or less; not covered while inusred receives hospice cre). Services from In-Network nd Non-Network count towrds your limit. --------none-------- --------none-------- Skilled nursing cre Subject to utiliztion review. Coverge is limited to combined totl of 100 dys per benefit period for services received from In- Network & Non-Network s. My be subject to utiliztion review. Durble medicl equipment Hospice service --------none-------- Eye exm Not Covered Not Covered Not Covered --------none-------- Glsses Not Covered Not Covered Not Covered --------none-------- Dentl check-up Not Covered Not Covered Not Covered --------none-------- 9 of 14
Excluded Services & Other Covered Services: r Pln Does NOT Cover (This isn t complete list. Check your policy or pln document for other excluded services.) Cosmetic surgery Dentl cre (Adult) Infertility tretment Long-term cre Privte-duty nursing Routine eye cre (Adult) Routine foot cre (Unless you hve been dignosed with dibetes. Consult your forml contrct of coverge.) Weight loss progrms Other Covered Services (This isn t complete list. Check your policy or pln document for other covered services nd your costs for these services.) Acupuncture Britric surgery (For morbid obesity, consult your forml contrct of coverge.) Chiroprctic cre Hering ids (Coverge is limited to one hering id per er every three yers.) Most coverge provided outside the United Sttes. See www.bcbs.com/bluecrdworldwide Your Rights to Continue Coverge: If you lose coverge under the pln, then, depending upon the circumstnces, Federl nd Stte lws my provide protections tht llow you to keep helth coverge. Any such rights my be limited in durtion nd will require you to py premium, which my be significntly higher thn the premium you py while covered under the pln. Other limittions on your rights to continue coverge my lso pply. For more informtion on your rights to continue coverge, contct the pln t 1-855-333-5730. You my lso contct your stte insurnce deprtment, the U.S. Deprtment of Lbor, Employee Benefits Security Administrtion t 1-866-444-3272 or www.dol.gov/ebs, or the U.S. Deprtment of Helth nd Humn Services t 1-877-267-2323 x61565 or www.cciio.cms.gov. 10 of 14
Your Grievnce nd Appels Rights: If you hve complint or re disstisfied with denil of coverge for clims under your pln, you my be ble to ppel or file grievnce. For questions bout your rights, this notice, or ssistnce, you cn contct: Anthem Blue Cross Life nd Helth Insurnce Compny ATTN: Appels or Grievnce P.O. Box 4310 Woodlnd Hills, CA 91367 Or Contct: Deprtment of Lbor s Employee Benefits Security Administrtion t 1-866-444-EBSA (3272) or www.dol.gov/ebs/helthreform Cliforni Deprtment of Insurnce Consumer Communictions Bureu Helth Unit 500 South Spring Street, South Tower Los Angeles, CA 90013 (800) 927-HELP (4357) (800) 482-4833 TDD www.insurnce.c.gov A consumer ssistnce progrm cn help you file your ppel. Contct: Consumer Communictions Bureu Helth Unit 500 South Spring Street, South Tower Los Angeles, CA 90013 (800) 927-HELP (4357) (800) 482-4833 TDD www.insurnce.c.gov Does this Coverge Provide Minimum Essentil Coverge? The Affordble Cre Act requires most people to hve helth cre coverge tht qulifies s minimum essentil coverge. This pln or policy does provide minimum essentil coverge. Does this Coverge Meet the Minimum Vlue Stndrd? The Affordble Cre Act estblishes minimum vlue stndrd of benefits of helth pln. The minimum vlue stndrd is 60% (cturil vlue). This helth coverge does meet the minimum vlue stndrd for the benefits it provides. 11 of 14
Lnguge Access Services: To see exmples of how this pln might cover costs for smple medicl sitution, see the next pge. 12 of 14
About these Coverge Exmples: These exmples show how this pln might cover medicl cre in given situtions. Use these exmples to see, in generl, how much finncil protection smple ptient might get if they re covered under different plns. This is not cost estimtor. Don t use these exmples to estimte your ctul costs under this pln. The ctul cre you receive will be different from these exmples, nd the cost of tht cre will lso be different. See the next pge for importnt informtion bout these exmples. Hving bby (norml delivery) Amount owed to providers: $7,550 Pln pys: $5,920 Ptient pys: $1,620 Smple cre costs: Hospitl chrges (mother) $2,700 Routine obstetric cre $2,100 Hospitl chrges (bby) $900 Anesthesi $900 Lbortory tests $500 Prescriptions $200 Rdiology $200 Vccines, other preventive $50 Totl $7,550 Ptient pys: Deductibles $0 Copys $20 Coinsurnce $1,450 Limits or exclusions $150 Totl $1,620 Mnging type 2 dibetes (routine mintennce of well-controlled condition) Amount owed to providers: $5,500 Pln pys: $4,440 Ptient pys: $960 Smple cre costs: Prescriptions $2,900 Medicl Equipment nd Supplies $1,500 Office Visits nd Procedures $700 Eduction $500 Lbortory tests $100 Vccines, other preventive $100 Totl $5,500 Ptient pys: Deductibles $0 Copys $400 Coinsurnce $480 Limits or exclusions $80 Totl $960 13 of 14
Questions nd nswers bout the Coverge Exmples: Wht re some of the ssumptions behind the Coverge Exmples? Costs don t include premiums. Smple cre costs re bsed on ntionl verges supplied by the U.S. Deprtment of Helth nd Humn Services, nd ren t specific to prticulr geogrphic re or helth pln. The ptient s condition ws not n excluded or preexisting condition. All services nd tretments strted nd ended in the sme coverge period. There re no other medicl expenses for ny member covered under this pln. Out-of-pocket expenses re bsed only on treting the condition in the exmple. The ptient received ll cre from innetwork providers. If the ptient hd received cre from out-of-network providers, costs would hve been higher. Wht does Coverge Exmple show? For ech tretment sitution, the Coverge Exmple helps you see how deductibles, copyments, nd coinsurnce cn dd up. It lso helps you see wht expenses might be left up to you to py becuse the service or tretment isn t covered or pyment is limited. Does the Coverge Exmple predict my own cre needs? No. Tretments shown re just exmples. The cre you would receive for this condition could be different bsed on your doctor s dvice, your ge, how serious your condition is, nd mny other fctors. Does the Coverge Exmple predict my future expenses? No. Coverge Exmples re not cost estimtors. You cn t use the exmples to estimte costs for n ctul condition. They re for comprtive purposes only. Your own costs will be different depending on the cre you receive, the prices your providers chrge, nd the reimbursement your helth pln llows. Cn I use Coverge Exmples to compre plns? Yes. When you look t the Summry of Benefits nd Coverge for other plns, you ll find the sme Coverge Exmples. When you compre plns, check the Ptient Pys box in ech exmple. The smller tht number, the more coverge the pln provides. Are there other costs I should consider when compring plns? Yes. An importnt cost is the premium you py. Generlly, the lower your premium, the more you ll py in out-ofpocket costs, such s copyments, deductibles, nd coinsurnce. You should lso consider contributions to ccounts such s helth svings ccounts (HSAs), flexible spending rrngements (FSAs) or helth reimbursement ccounts (HRAs) tht help you py out-of-pocket expenses. Questions: Cll 1-855-333-5730 or visit us t http://www.nthem.com/c. If you ren t cler bout ny of the underlined terms used in this form, see the Glossry. You cn view the Glossry t www.cciio.cms.gov or cll 1-855-333-5730 to request copy. 14 of 14