Summary of benefits for bluesecure ppo plan anthem inc

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Summary of Benefits for BlueSecure PPO Plan

This is a general benefit summary for this health plan. A complete listing and description of benefits, limitations, and exclusions are found in the Certificate. Copayment options reflect the amount the member will pay, coinsurance options reflect the amount that Anthem will pay. Any outpatient covered service not elsewhere listed in this summary of benefits, but otherwise eligible for coverage, will be paid by Anthem at the coinsurance after deductible level of benefit.

Annual Deductible Deductibles are per calendar year.

Deductibles apply only to specified services.

Deductibles contribute toward the out-of-pocket annual maximum.

In-Network

(Participating Provider)

Individual:

Family:

$2,500

$7,500 aggregate

One member may not contribute any more than the individual deductible toward the family deductible.

Out-of-Network

(Non-Participating Provider)

Individual:

Family:

$5,000

$15,000 aggregate

One member may not contribute any more than the individual deductible toward the family deductible.

For non-participating providers, the member must pay the difference between the maximum allowed amount and the nonparticipating provider's billed charges, unless noted otherwise. Charges in excess of the maximum allowed amount do not count toward the satisfaction of the deductible. Please see the section of your certificate entitled About Your Health Coverage for details about cost sharing requirements.

Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. Independent licensees of the Blue Cross and Blue Shield Association. ? ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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In-Network (Participating Provider)

Out-of-Pocket Annual Maximum All copayments, coinsurance and deductible amounts contribute to the out-of-pocket annual maximum except as follows:

Individual: $6,350

a) Out-of-network coinsurance amounts related to temporomandibular joint syndrome. b) Out-of-network coinsurance amounts related to human organ and tissue transplants. c) Prescription drug copayments and coinsurances. Some covered services have a maximum number of days, visits or dollar amounts. These maximums apply even if the applicable out-of-pocket annual maximum is satisfied.

Family: $12,700 aggregate

One member may not contribute any more than the individual out-ofpocket annual maximum toward the family out-ofpocket annual maximum.

Out-of-Network (Non-Participating Provider)

Individual: $12,700

Family: $25,400 aggregate

One member may not contribute any more than the individual out-ofpocket annual maximum toward the family out-ofpocket annual maximum.

The difference between billed charges and the maximum allowed amount for nonparticipating providers does not count toward the member's out-of-pocket maximum amount. Even once the out-ofpocket maximum is satisfied, the member will still be responsible for paying the difference between the maximum allowed amount and the non-participating provider's billed charges.

Lifetime Maximum Benefit No lifetime maximum.

Other Applicable Maximums

Applied behavior analysis treatment for autism spectrum disorder is limited to a maximum benefit of 500 hours per year for members under 18 years of age or, if enrolled in high school, until the member reaches 22 years of age.

Services

In-Network (Participating Provider)

1. Physician Visits

a) Physician office visits and physician consultations

$30 copayment per visit for PCP provider care and $60 copayment per visit for specialists

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Out-of-Network (Non-Participating

Provider)

Additional Information

50% coinsurance after deductible

For laboratory, pathology and x-ray services performed in conjunction with a physician's office visit. See section 4 for payment

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Services

In-Network (Participating Provider)

b) Services related to physician office visit including but not limited to, allergy testing, allergy injections, or office surgeries

80% coinsurance after deductible

c) Inpatient physician visits 80% coinsurance after deductible

d) Online Care Visit

$30 copayment per visit

2. Retail Health Clinic

a) Retail Health clinic visit $30 copayment per visit

b) Laboratory and Pathology No charge performed in and billed by a Retail Health clinic

c) X-ray performed in and billed by a retail health clinic

$30 copayment

3. Preventive Care

Preventive care services that meet the requirements of federal and state law including screenings, immunizations and office visits.

4. Diagnostic Services, Laboratory, Pathology, and X-ray

No charge

a) Laboratory and Pathology No charge performed in and billed by a physician's office, urgent care center or independent /freestanding lab

b) X-ray performed in a physician's office, urgent care center or freestanding facility

$30 copayment

c) Laboratory, Pathology, and X-ray performed in an outpatient facility

80% coinsurance after deductible

d) MRI/MRA, PET, CT scans, nuclear medicine and other high tech services

80% coinsurance after deductible

Out-of-Network (Non-Participating

Provider) 50% coinsurance after deductible

50% coinsurance after deductible Not Covered

50% coinsurance after deductible 50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

Additional Information

information.

Physician visits include diabetic management and limited family planning services (see certificate for covered services).

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Services

5. Maternity Care a) Prenatal care

b) Delivery & inpatient baby care

In-Network (Participating Provider)

$200 copayment for the first prenatal care office visit/delivery from the physician

80% coinsurance after deductible

Out-of-Network (Non-Participating

Provider)

50% coinsurance after deductible

50% coinsurance after deductible

6. Outpatient Therapies: Physical therapy, occupational therapy, speech therapy, cardiac rehabilitation and spinal manipulations/ acupuncture

a) Outpatient physical therapy, occupational therapy, speech therapy and cardiac rehabilitation

80% coinsurance after deductible

50% coinsurance after deductible

b) Outpatient spinal manipulations and acupuncture

7. Hospital Care/Other Facility Services

a) Inpatient

b) Inpatient - acute rehabilitation therapy

c) Outpatient Surgery

8. Emergency Care

$30 copayment per visit

50% coinsurance after deductible

80% coinsurance after deductible

80% coinsurance after deductible

80% coinsurance after deductible

80% coinsurance after $150 copayment per emergency room visit

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

80% coinsurance after $150 copayment per emergency room visit

Additional Information

For laboratory, pathology and x-ray services performed in conjunction with a physician's office visit. See section 4 for payment information. Limited to one routine ultrasound per pregnancy.

Limited to 20 visits each of physical, occupational and speech therapy per member per year. Benefits are paid up to 36 visits for cardiac rehabilitation.

Limited to 12 visits per member per year.

Limited to 30 inpatient days per member per year.

Copayment is waived if admitted.

Member cost share responsibility for Outof-Network services will be the same as In-Network services.

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Services

In-Network (Participating Provider)

9. Urgent Care

Facility, urgent care center, or after hours at a physician office 10. Ambulance Services

$60 copayment per visit

a) Ground Services

80% coinsurance after deductible

Out-of-Network (Non-Participating

Provider)

50% coinsurance after deductible

80% coinsurance after deductible

Additional Information

For laboratory, pathology and x-ray services see section 4 for payment information.

b) Air and Water Services

80% coinsurance after deductible

11. Mental Health and Substance Abuse Care

a) Inpatient

80% coinsurance after deductible

b) Outpatient

- Office visit/professional $30 copayment per visit

- Facility

80% coinsurance after deductible

12. Medical Supplies and Equipment

80% coinsurance after deductible

13. Home Health Care

80% coinsurance after deductible

14. Chemotherapy, Hemodialysis, and Radiation Therapy

a) Inpatient

80% coinsurance after deductible

b) Outpatient

80% coinsurance after deductible

15. Skilled Nursing Facility 80% coinsurance after deductible

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80% coinsurance after deductible

50% coinsurance after deductible 50% coinsurance after deductible 50% coinsurance after deductible

50% coinsurance after deductible

Air and Water services are limited to a combined maximum benefit of $5,000 per trip.

Includes diabetic supplies and equipment, medical supplies, durable medical equipment, oxygen and equipment, orthopedic appliances, prosthetic devices and other appliances. Limited to 100 visits per member per year.

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

Limited to 100 inpatient days per member per year.

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Services

16. Hospice Care 17. Human Organ and

Tissue Transplants a) Inpatient

b) Outpatient

In-Network (Participating Provider)

No charge

Out-of-Network (Non-Participating

Provider)

70% coinsurance after deductible

80% coinsurance after deductible

50% coinsurance after deductible

$30 copayment per visit PCP provider care and $60 copayment per visit for specialists

50% coinsurance after deductible

18. Temporomandibular Joint Syndrome

a) Inpatient Surgery

b) Outpatient Surgery

c) Outpatient Physician Visits

19. Enteral Formula and Special Foods

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

80% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

50% coinsurance after deductible

Additional Information

See the certificate for details on covered transplants. Transportation and lodging services are limited to a maximum benefit of $10,000 per transplant; unrelated donor searches for bone marrow and stem cells are limited to a maximum benefit of $30,000 per transplant.

Special food products that are prescribed or ordered by a physician as medically necessary is allowed.

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