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2015 MA INDUSTRY PPO SBC

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2015 MA INDUSTRY PPO SBC
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  1  of 15 AWANE: Massachusetts Industry PPO Coverage Period: 01/01/015!1/ 1/015#u$$ary of %enefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family|  P&an 'y(e: PPO 'his is on&y a su$$ary) If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at  www.anthem.com  or by calling 1-844-404-6843 . I$(ortant *uestionsAns+ersWhy this Matters:  What is the overall deductible? For in-network providers ,1-.50   individual  / , -500   familyFor out-of-network providers ,5-000   individual  / ,10-000   familyDoesn’t apply to in-network preventive care, routine eye exams or outpatient labsx-rays or ultrasounds. !ou must pay all the costs up to the deductible amount before this   plan begins to pay for covered services you use. heck your policy or plan document to see when the deductible starts over #usually, but not always, $anuary %st&. 'ee the chart starting on page ( for how much you pay for covered services after you meet the deductible .  Are there other deductibles for specic services?  !es. For durable medical e)uipment there is a ,50  deductible.  !ou must pay all of the costs for these services up to the speci*c deductible  amount before this plan begins to pay for these services. !s there an out of poc#et limit on m$ e%penses? For in-network providers ,-00   individual  / ,1 -00   family For out-of-network providers ,10-000   individual  / ,0-000   family+he out-of-poc#et limit is the most you could pay during a coverage period #usually one year& for your share of the costof covered services. +his limit helps you plan for health care expenses.  What is not includedin the out of poc#et limit? alance-illed charges, ealth are this plan doesn’tcover, remiums, /ut-of-network deductibles, and /ut-of-network pharmacy claims.0ven though you pay these expenses, they don’t count toward the out-of-poc#et limit . &uestions'   all 1-844-404-6843 or visit us at  www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the 1lossary. !ou can view the 1lossaryat  www.anthem.com  or call 1-844-404-6843  to re)uest a copy.    of 15 AWANE: Massachusetts Industry PPO Coverage Period: 01/01/015!1/ 1/015#u$$ary of %enefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family|  P&an 'y(e: PPO !s there an overall annual limit on whatthe plan pa$s? 2o.+he chart starting on page ( describes any limits on what the plan will pay for specifc  covered services, such as o3ice  visits. (oes this plan use a networ# of providers?  !es. For a list of preferred providers , see www.anthem.com or call %-455-565-745(If you use an in-network doctor or other health care provider  , this   plan will pay some or all of the costs of covered services. e aware, your in-network doctor or hospital may use an out-of-network provider   for some services. lans use the term in-network, preferred , or participating   for providers  in their networ#  . 'ee the chart starting on page ( for how this plan pays di3erent kinds of providers . (o ! need a referral to see a specialist? 2o. !ou can see the specialist  you choose without permission from this plan.  Are there services this plan doesn)t cover?  !es.'ome of the services this   plan doesn’t cover are listed on page 7. 'ee your policy or plan document for additional information about e%cluded services . ã *opa$ments  are *xed dollar amounts #for example, 8%9& you pay for covered health care, usually when youreceive the service. ã *oinsurance  is  your share of the costs of a covered service, calculated as a percent of the allowed amount  for the service. For example, if the plan’s allowed amount  for an overnight hospital stay is 8%,666, your coinsurance  payment of :6; would be 8:66. +his may change if you haven’t met your deductible . ã +he amount the plan pays for covered services is based on the allowed amount . If an out-of-network   provider   charges more than the allowed amount , you may have to pay the di3erence. For example, if an out-of-network hospital charges 8%,966 for an overnight stay and the allowed amount  is 8%,666, you may have to pay the 8966 di3erence. #+his is called balance billin+ .& ã +his plan may encourage you to use in-network providers  by charging you lower deductibles , copa$ments  and coinsurance  amounts. &uestions'   all 1-844-404-6843 or visit us at  www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the 1lossary. !ou can view the 1lossaryat  www.anthem.com  or call 1-844-404-6843  to re)uest a copy.   of 15 AWANE: Massachusetts Industry PPO Coverage Period: 01/01/015!1/ 1/015#u$$ary of %enefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family|  P&an 'y(e: PPO Co$$onMedica& Event#ervices ou May Need our Cost If  ou se anIn!net+or2Provider  our Cost If  ou se anOut!of!net+or2Provider 3i$itations 4 Ece(tions !f $ou visit a health care provider)s o,ice or clinic rimary care visit to treat an in<ury or illness8(9 copayvisit96; coinsurance============none============'pecialist visit876 copay visit96; coinsurance============none============/ther practitioner o3ice visit hiropractor876 copayvisit >cupuncturist2ot covered hiropractor96; coinsurance >cupuncturist2ot covered hiropractic limited to %:  visits per member per calendar year.reventive carescreeningimmuni?ation2o ost 'hare96; coinsurance============none============ !f $ou have a test Diagnostic test #x-ray, blood work&2o ost 'hare96; coinsurance osts may vary by site of service.Imaging # +0+ scans, @AIs& :6; coinsurance96; coinsurance============none============ &uestions'   all 1-844-404-6843 or visit us at  www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the 1lossary. !ou can view the 1lossaryat  www.anthem.com  or call 1-844-404-6843  to re)uest a copy.  6  of 15 AWANE: Massachusetts Industry PPO Coverage Period: 01/01/015!1/ 1/015#u$$ary of %enefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family|  P&an 'y(e: PPO Co$$onMedica& Event#ervices ou May Need our Cost If  ou se anIn!net+or2Provider  our Cost If  ou se anOut!of!net+or2Provider 3i$itations 4 Ece(tions !f $ou need dru+s to treat  $our illness or condition @ore information about prescription dru+ covera+e  is available at www.express-scripts.com1eneric drugs #Aetail(6 dayB @ailC6 day& 8%6 Aetail8:6@ail 2ot overed @aintenance @eds are re)uired to be *lled mail order after ( *lls at retail #penalty applies&. If pre-auth re)uired not obtained, drug may not be covered. ertain reventive meds no copay. If a generic e)uivalent is available  brand is prescribedmember will pay brand name cost di3erence. lan uses preferred drug list to identify coverage. referred brand drugs   #Aetail(6 dayB @ailC6 day& 8(9 Aetail84E.9 @ail 2ot overed 2on-preferred brand #Aetail(6dayB @ailC6day&876 Aetail8%96 @ail 2ot overed'pecialty drugs  >ll 'pecialty meds process through  >ccredo at the mail order costs. 2ot overed +he mail order cost will be based on the medication tier #generic, preferred, non-preferred&. 'pecialty meds can not be *lled at retail pharmacies. !f $ou have outpatient sur+er$  Facility fee #e.g., ambulatory surgery center&:6; coinsurance96; coinsurance============none============hysiciansurgeon fees:6; coinsurance96; coinsurance============none============ &uestions'   all 1-844-404-6843 or visit us at  www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the 1lossary. !ou can view the 1lossaryat  www.anthem.com  or call 1-844-404-6843  to re)uest a copy.
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