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Anthem BlueCross BlueShieldBlue Access® PPO Option D54 / Rx Option 7

SG Blue Access PPO Option D54 w/Rx7 10/12

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 04/01/2013 - 03/31/2014

Coverage For: Individual/Family | Plan Type: PPO

Questions: Call 1-855-333-5735 or visit us at www.anthem.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov or call 1-855-333-5735 to request a copy.

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.anthem.com or by calling 1-855-333-5735.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$1500 single / $3000 family forIn-Network Provider$3000 single / $6000 family forNon-Network ProviderDoes not apply to In-NetworkPreventive Care, EmergencyRoom Services, Copayments,Hospice and Prescription Drugs In-Network Provider and Non-Network Provider deductiblesare separate and do not counttowards each other.

You must pay all the costs up to the deductible amount before this health insurance planbegins to pay for covered services you use. Check your policy to see when the deductiblestarts over (usually, but not always, January 1st.) See the chart starting on page3 for how much you pay for covered services after you meet the deductible.

Are there otherdeductibles for specificservices?

No.You don’t have to meet deductibles for specific services, but see the chart starting on page3 for other costs for services this plan covers.

Is there an out-of-pocketlimit on my expenses?

Yes; In-Network ProviderSingle: $2500, Family: $5000Non-Network Provider Single:$6000, Family: $12000 In-Network Provider and Non-Network Provider out-of-pocketare separate and do not counttowards each other.

The out-of-pocket limit is the most you could pay during a policy period for your share ofthe cost of covered services. This limit helps you plan for health care expenses.

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Important Questions Answers Why this Matters:

What is not included inthe out-of-pocket limit?

Balance-Billed Charges,Copayments, Health Care ThisPlan Doesn't Cover, Premiums,Costs Related to PrescriptionDrugs Covered Under thePrescription Drug Plan, Non-Network Human Organ andTissue Transplant services .

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overallannual limit on what theinsurer pays?

No. This policy has no overallannual limit on the amount itwill pay each year.

The chart starting on page 3 describes any limits on what the insurer will pay for specificcovered services, such as office visits.

Does this plan use anetwork of providers?

Yes. See www.anthem.com orcall 1-855-333-5735 for a list ofparticipating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or allof the costs of covered services. Plans use the terms in-network, preferred, or participatingto refer to providers in their network.

Do I need a referral tosee a specialist?

No, you do not need a referralto see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services thisplan doesn't cover?

Yes.Some of the services this plan doesn’t cover are listed on page 9. See your policy or plandocument for additional information about excluded services.

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• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

• Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may changeif you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use In-Network Provider by charging you lower deductibles, co-payments and co-insurance amounts.

CommonMedical Event

Services You May Need

Your Cost IfYou Use a In-

NetworkProvider

Your Cost IfYou Use a Non-

NetworkProvider

Limitations & Exceptions

If you visit a healthcare provider's officeor clinic

Primary care visit to treat aninjury or illness

$30 copay 40% coinsurance ––––––––none––––––––

Specialist visit $60 copay 40% coinsurance ––––––––none––––––––

Other practitioner office visit

ManipulativeTherapy

$60 copay

AcupuncturistNot covered

ManipulativeTherapy

40% coinsuranceAcupuncturistNot covered

Manipulative TherapyCoverage is limited to a total of 12 visits, In-Network Provider and Non-Network Providercombined per year.Costs may vary by site of service. You should referto your formal contract of coverage for details.

Preventive care/screening/immunizations

No cost share 40% coinsurance ––––––––none––––––––

If you have a testDiagnostic test (x-ray, bloodwork)

Lab - OfficeNo cost shareX-Ray - OfficeNo cost share

Lab - Office40% coinsuranceX-Ray - Office

40% coinsurance

Lab - OfficeCosts may vary by site of service. You should referto your formal contract of coverage for details.X-Ray - OfficeCosts may vary by site of service. You should referto your formal contract of coverage for details.

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance ––––––––none––––––––

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CommonMedical Event



NetworkProvider


NetworkProvider


If you need drugs totreat your illness orcondition

More informationabout prescriptiondrug coverage isavailable atwww.anthem.com/pharmacyinformation/

Tier 1 – Typically Generic$10 copay/

prescription (retailand mail order)

50% coinsurance(retail only) with

$40 minimum perscript

If the member selects a brand drug when a genericequivalent is available the member is responsible forthe generic copay + the cost difference between thegeneric and brand equivalent. If the physicianindicates no substitutions the member is onlyresponsible for the brand copay.Covers up to a 30 day supply (retail pharmacy),Covers up to a 90 day supply (mail order program)

Tier 2 – TypicallyPreferred/Formulary Brand

$25 copay/prescription (retail

only) and $65copay/prescription(mail order only)




Tier 3 – Typically Non-preferred/Non-formulary and SpecialtyDrugs

$40 copay/prescription (retail

only) and $120copay/prescription(mail order only)




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CommonMedical Event



NetworkProvider


NetworkProvider


Tier 4 – Typically Specialty Drugs25% coinsurancewith $200 max



If the member selects a brand drug when a genericequivalent is available the member is responsible forthe generic copay + the cost difference between thegeneric and brand equivalent. If the physicianindicates no substitutions the member is onlyresponsible for the brand copay.Covers up to a 30 day supply (retail pharmacy),Covers up to a 90 day supply (mail order program)$2500 annual out-of-pocket limit per member(Specialty drug network must be used for in-network coverage.)

If you haveoutpatient Surgery

Facility Fee (e.g., ambulatorysurgery center)

20% coinsurance 40% coinsurance ––––––––none––––––––

Physician/Surgeon Fees 20% coinsurance 40% coinsurance ––––––––none––––––––

If you needimmediate medicalattention

Emergency Room Services$250 copay and

then 20%coinsurance

$250 copay andthen 20%

coinsurancecopay waived if admitted

Emergency MedicalTransportation

20% coinsurance 20% coinsurance ––––––––none––––––––

Urgent Care $75 copay 40% coinsurance ––––––––none––––––––

If you have a hospitalstay

Facility Fee (e.g., hospital room) 20% coinsurance 40% coinsurance

Physical medicine and rehabilitation services(including day rehabilitation programs) are limitedto 60 days of care regardless of the provider’snetwork status.

Physician/surgeon fee 20% coinsurance 40% coinsurance ––––––––none––––––––

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CommonMedical Event



NetworkProvider


NetworkProvider


If you have mentalhealth, behavioralhealth, or substanceabuse needs

Mental/Behavioral healthoutpatient services

Mental/BehavioralHealth Office Visit

$60 copay Mental/Behavioral

Health FacilityVisit - Facility

Charges20% coinsurance

Mental/BehavioralHealth Office Visit40% coinsurance

Mental/BehavioralHealth FacilityVisit - Facility

Charges40% coinsurance

Mental/Behavioral Health Office VisitCoverage is limited to 30 visits per yearIn-Network. Non-Network coverage is limited to 10visits annual max..Outpatient and office services count towards thelimit.Limitations and cost shares may vary by site ofservice. You should refer to your formal contract ofcoverage for details.Behavioral health and substance abuse care counttowards your day or visit limit.

Mental/Behavioral healthinpatient services

20% coinsurance 40% coinsurance

Coverage is limited to 30 days per yearIn-Networkand Non-Network and reflects room and boardand professional services..Behavioral health and substance abuse care counttowards your day or visit limit.

Substance use disorder outpatientservices

Substance AbuseOffice Visit$60 copay

Substance AbuseFacility Visit -

Facility Charges20% coinsurance

Substance AbuseOffice Visit

40% coinsuranceSubstance AbuseFacility Visit -

Facility Charges40% coinsurance

Substance Abuse Office VisitCoverage is limited to 30 visits per yearIn-Network. Non-Network coverage is limited to 10visits annual max..Outpatient and office services count towards thelimit.Limitations and cost shares may vary by site ofservice. You should refer to your formal contract ofcoverage for details.Behavioral health and substance abuse care counttowards your day or visit limit.Substance Abuse Facility Visit - Facility ChargesAlcoholism outpatient (non-network) limited to 10visits.

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CommonMedical Event



NetworkProvider


NetworkProvider


Substance use disorder inpatientservices

20% coinsurance 40% coinsurance

Coverage is limited to 30 days per yearand reflectsroom and board and professional services.Behavioral health and substance abuse care bothcount towards your day or visit limit. AlcoholismInpatient (non-network) limited to 1 day. Inpatientand outpatient substance abuse rehabilitationprograms are limited to 1 episode per benefitperiod (Network and Non-Network).Services from In-Network Provider and Non-Network Provider count towards your limit.

If you are pregnant Prenatal and postnatal care 20% coinsurance 40% coinsuranceYour doctor’s charges for delivery are part ofprenatal and postnatal care.

Delivery and all inpatient services 20% coinsurance 40% coinsuranceApplies to inpatient facility. Other cost shares mayapply depending on services provided.

If you need helprecovering or haveother special healthneeds

Home Health Care 20% coinsurance 40% coinsurance

Coverage is limited to 100 visits per yearDoes notinclude I.V. therapy.Services from In-Network Provider and Non-Network Provider count towards your limit.

Rehabilitation Services $60 copay 40% coinsurance

Coverage for physical therapy is limited to 20 visitsper year, occupational therapy is limited to 20 visitsper year, speech therapy is limited to 20 visits peryear, cardiac rehabilitation is limited to 36 visits peryear, and pulmonary rehabilitation is limited to 20visits per year.Outpatient and office services count towards thelimit.Limitations and cost shares may vary by site ofservice. You should refer to your formal contract ofcoverage for details.Services from In-Network Provider and Non-Network Provider count towards your limit.

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CommonMedical Event



NetworkProvider


NetworkProvider


Habilitation Services 20% coinsurance 40% coinsurance

Costs may vary by site of service. You should referto your formal contract of coverage for details.Habilitation visits count towards yourRehabilitation limit.

Skilled Nursing Care 20% coinsurance 40% coinsuranceCoverage is limited to a total of 90 days, In-Network Provider and Non-Network Providercombined per year.

Durable medical equipment 20% coinsurance 40% coinsurance ––––––––none––––––––

Hospice service No cost share No cost share ––––––––none––––––––

If your child needsdental or eye care

Eye exam $30 copay 40% coinsurance

Coverage is for vision exam only. Consult yourformal contract of coverage.Costs may vary by site of service. You should referto your formal contract of coverage for details.

Glasses Not covered Not covered ––––––––none––––––––

Dental check-up Not covered Not covered ––––––––none––––––––

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture

• Bariatric surgery

• Cosmetic surgery

• Dental care (adult)

• Hearing aids

• Infertility treatment

• Long- term care

• Routine foot care unless you have been

diagnosed with diabetes. Consult your formal

contract of coverage.

• Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

• Chiropractic care

• Most coverage provided outside the United

States. See

www.bcbs.com/bluecardworldwide.

• Private-duty nursing Limited to $50,000 per

benefit period with a lifetime max of

$100,000

• Routine eye care (adult) for vision exam only.

Consult your formal contract of coverage.

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Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-855-333-5735. You may also contact your state insurance department, theDepartment of Labor’s Employee BenefitsSecurity Administration1-866-444-EBSA (3272)www.dol.gov/ebsa/healthreform.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact:

Anthem BlueCross BlueShieldATTN: AppealsP.O. Box 105568Atlanta, GA 30348-5568

Or Contact:

Department of Labor’s Employee BenefitsSecurity Administration at1-866-444-EBSA(3272) orwww.dol.gov/ebsa/healthreform

Ohio Department of Insurance50 West Town Street, Third Floor, Suite 300Columbus, OH 43215800-686-1526 or 614-644-2673

—————— To see examples of how this plan might cover costs for a sample medical situation, see the next page. ——————

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About These CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

This isnot a costestimator.

Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from these examples,and the cost of that care willalso be different.

See the next page forimportant information aboutthese examples.

Having a baby(normal delivery)

Amount owed to providers: $7,540Plan pays: $4,920Patient pays: $2,620

Sample care costs:Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:Total Deductibles $1,500

Co-pays $0

Co-insurance $1,000

Limits or exclusions $120

Total $2,620

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

Amount owed to providers: $5,400Plan pays: $3,160Patient pays: $2,240

Sample care costs:Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:Total Deductibles $1,500

Co-pays $480

Co-insurance $180

Limits or exclusions $80

Total $2,240

Note: These numbers assume the patient isparticipating in our diabetes wellness program.If you have diabetes and do not participate inthe wellness program, your costs may behigher. For more information about thediabetes wellness program, please contact:www.anthem.com or 1-855-333-5735.

of 12Questions: Call 1-855-333-5735 or visit us at www.anthem.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary atwww.cciio.cms.gov or call 1-855-333-5735 to request a copy.

Questions and answers about the Coverage Examples:

What are some of theassumptions behind theCoverage Examples?

• Costs don't include premiums.• Sample care costs are based on national

averages supplied by the U.S. Departmentof Health and Human Services, and aren'tspecific to a particular geographic area orhealth plan.

• The patient's condition was not anexcluded or preexisting condition.

• All services and treatments started andended in the same coverage period.

• There are no other medical expenses forany member covered under this plan.

• Out-of-pocket expenses are based only ontreating the condition in the example.

• The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.

What does a CoverageExample show?For each treatment situation, the CoverageExample helps you see how deductibles, co-payments, and co-insurance can add up. Italso helps you see what expenses might beleft up to you to pay because the service ortreatment isn't covered or payment islimited.

Does the Coverage Examplepredict my own care needs?

No. Treatments shown are just examples.The care you would receive for this conditioncould be different based on your doctor'sadvice, your age, how serious your conditionis, and many other factors.

Does the Coverage Examplepredict my future expenses?

No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Can I use CoverageExamples to compareplans?

Yes. When you look at the Summary ofBenefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the"Patient Pays" box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs Ishould consider whencomparing plans?

Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you'll pay in out-of-pocket costs, such as co-payments,deductibles, and co-insurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.

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