1
of
15
Awane: Maine Comprehensive LXR EPO
Coverage Period: 01/01/2015 12/!1/2015 #mmar$ of %enefi&s and Coverage:
What this Plan Covers & What it Costs
Coverage for:
Individual/Family |
P'an ($pe:
EPO
(his is on'$ a s#mmar$)
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
www.anthem.com
or by calling
1-855-271-4549
.
*mpor&an& +#es&ionsAnswers,h$ &his Ma&&ers:
What is the overall deductible?
For in-network providers
-1.000
individual /
-2.500
familyDoesn’t apply to in-network preventive careand routine eye eam. !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 seci!c services?
!es.
25#
deductible for Durable )edical *+uipment per member per calendar year. !ou must pay all of the costs for these services up to the specic
deductible
amount before this plan begins to pay for these services.
$s there an out%of%oc&et limit on m' e(enses?
!es. For in-network providers
-.!50
individual /
-12.00
family he
out-of-oc&et limit
is the most you could pay during a coverageperiod #usually one year& for your share of the cost of covered services. his limit helps you plan for health care epenses.
What is not included in the out%of%oc&et limit?
alance-illed charges, ealth are this plan doesn’t cover, 0remiums, and 1ut-of-network pharmacy claims.*ven though you pay these epenses, they don’t count toward the
out-of-oc&et limit
.
$s there an overall annual limit on what the lan a's?
2o. he chart starting on page ( describes any limits on what the plan will pay for
specifc
covered services, such as o3ice visits.
)uestions*
all
1-855-271-4549
or visit us at
www.anthem.com
If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat
www.anthem.com
or call
1-855-271-4549
to re+uest a copy.
2
of
15
Awane: Maine Comprehensive LXR EPO
Coverage Period: 01/01/2015 12/!1/2015 #mmar$ of %enefi&s and Coverage:
What this Plan Covers & What it Costs
Coverage for:
Individual/Family |
P'an ($pe:
EPO
+oes this lan use a networ& of roviders?
!es. For a list of
referred roviders
, see www.anthem.comor call %-566-78%-969:If you use an in-network doctor or other health care
rovider
, 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
rovider
for some services. 0lans use the term in-network,
referred
, or participating
for
roviders
in their
networ&
. 'ee the chart starting on page ( for how this plan pays di3erent kinds of
roviders
.
+o $ need a referral to see a secialist?
2o. !ou can see the
secialist
you choose without permission from this plan.
Are there services this landoesn,t cover?
!es.'ome of the services this
plan doesn’t cover are listed on page 6. 'ee your policy or plan document for additional information about
e(cluded services
.
ã
oa'ments
are ed dollar amounts #for eample, ;%6& 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 eample, if the plan’s
allowed amount
for an overnight hospital stay is ;%,<<<, your
coinsurance
payment of 7<= would be ;7<<. 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
rovider
charges more than the
allowed amount
, you may have to pay the di3erence. For eample, if an out-of-network hospital charges ;%,6<< for an overnight stay and the
allowed amount
is ;%,<<<, you may have to pay the ;6<< di3erence. #his is called
balance billin
.&
ã
his plan may encourage you to use
in-networ&
roviders
by charging you lower
deductibles
,
coa'ments
and
coinsurance
amounts.
)uestions*
all
1-855-271-4549
or visit us at
www.anthem.com
If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat
www.anthem.com
or call
1-855-271-4549
to re+uest a copy.
!
of
15
Awane: Maine Comprehensive LXR EPO
Coverage Period: 01/01/2015 12/!1/2015 #mmar$ of %enefi&s and Coverage:
What this Plan Covers & What it Costs
Coverage for:
Individual/Family |
P'an ($pe:
EPO
CommonMedia' Even& ervies o# Ma$ 3eed o#r Cos& *f o# 4se an*nne&worProvider o#r Cos& *f o# 4se anO#&ofne&worProvider Limi&a&ions 6 E7ep&ions
$f 'ou visit a health care rovider,s o/ice or clinic
0rimary care visit to treat an in>ury or illness;(< copay/visit 2ot overed????????????none????????????'pecialist visit;6< copay/visit2ot overed????????????none????????????1ther practitioner o3ice visit hiropractor;6< copay/visit @cupuncturist2ot covered hiropractor2ot overed @cupuncturist2ot covered ????????????none????????????0reventive care/screening/immuniAation2o ost 'hare2ot overed????????????none????????????
$f 'ou have a test
Diagnostic test #-ray, blood work&<= coinsurance2ot overed????????????none????????????Imaging # /0* scans, )BIs& <= coinsurance2ot overed????????????none????????????
$f 'ou need drus to treat 'our illness or condition
4eneric drugs
#Betail/(< dayC )ail/:<day&
;%6 Betail/;(<)ail
2ot overed
If pre-auth re+uired not obtained, drug may not be covered. ertain 0reventive meds no copay. If a generic e+uivalent is available brand is prescribed/member will pay brand name cost di3erence. 0lan uses preferred drug list to identify coverage.
0referred brand drugs
#Betail/(< dayC )ail/:< day&
;(6 Betail/;58.6)ail
2ot overed
2on-preferred brand #Betail/(<dayC )ail/:<day&;8< Betail/;%86)ail
2ot overed
)uestions*
all
1-855-271-4549
or visit us at
www.anthem.com
If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat
www.anthem.com
or call
1-855-271-4549
to re+uest a copy.
8
of
15
Awane: Maine Comprehensive LXR EPO
Coverage Period: 01/01/2015 12/!1/2015 #mmar$ of %enefi&s and Coverage:
What this Plan Covers & What it Costs
Coverage for:
Individual/Family |
P'an ($pe:
EPO
CommonMedia' Even& ervies o# Ma$ 3eed o#r Cos& *f o# 4se an*nne&worProvider o#r Cos& *f o# 4se anO#&ofne&worProvider Limi&a&ions 6 E7ep&ions
)ore information about
rescrition
'pecialty drugs @ll 'pecialtymeds processthrough @ccredo atthe mail ordercosts. 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 outatient surer'
Facility fee #e.g., ambulatory surgery center&<= coinsurance2ot overed????????????none????????????0hysician/surgeon fees<= coinsurance2ot overed????????????none????????????
$f 'ou need immediate medical attention
*mergency room services;76< copay /visitE professional and other services sub>ect to deductible ;76< copay/visitE professional and other services sub>ect to deductible ;76< opay waived if admitted. )ember may be balance billed for out of network services.*mergency medical transportation<= coinsurance<= coinsurance)ember may be balance billed for out of network services.rgent care;6< copay/visit 2ot overed????????????none????????????
$f 'ou have a hosital sta'
Facility fee #e.g., hospital room&<= coinsurance<= coinsurance0hysical )edicine and Behabilitation limited to %<< days per member per calendar year.0hysician/surgeon fee<= coinsurance<= coinsurance????????????none????????????
)uestions*
all
1-855-271-4549
or visit us at
www.anthem.com
If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat
www.anthem.com
or call
1-855-271-4549
to re+uest a copy.