2015 ME COMP LXR EPO SBC

  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 eam. !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 seci!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 specic 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 epenses.  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 epenses, 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 secialist? 2o. !ou can see the secialist  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 oa'ments  are ed dollar amounts #for eample, ;%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 eample, 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 eample, 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 , coa'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 ($pe: EPO CommonMedia' Even& ervies o# Ma$ 3eed o#r Cos& *f  o# 4se an*nne&worProvider  o#r Cos& *f  o# 4se anO#&ofne&worProvider Limi&a&ions 6 E7ep&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???????????? $f 'ou need drus to treat  'our illness or condition 4eneric drugs #Betail/(< dayC )ail/:<day& ;%6 Betail/;(<)ail 2ot overed If pre-auth re+uired  not obtained, drug may not be covered. ertain 0reventive meds no copay. If a generic e+uivalent is available  brand is prescribed/member will pay brand name cost di3erence. 0lan uses preferred drug list to identify coverage. 0referred brand drugs   #Betail/(< dayC )ail/:< day& ;(6 Betail/;58.6)ail 2ot overed 2on-preferred brand #Betail/(<dayC )ail/:<day&;8< Betail/;%86)ail 2ot overed )uestions*   all 1-855-271-4549  or visit us at  www.anthem.com If you aren’t clear about any of the underlined terms used in this form, see the 4lossary. !ou can view the 4lossaryat  www.anthem.com  or call 1-855-271-4549  to re+uest a copy.  8  of 15 Awane: Maine Comprehensive LXR EPO Coverage Period: 01/01/2015  12/!1/2015 #mmar$ of %enefi&s and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |  P'an ($pe: EPO CommonMedia' Even& ervies o# Ma$ 3eed o#r Cos& *f  o# 4se an*nne&worProvider  o#r Cos& *f  o# 4se anO#&ofne&worProvider Limi&a&ions 6 E7ep&ions )ore information about rescrition '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 outatient surer'  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 hosital 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.