CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
This is only
y a summarry. If you want more detail abouut your coveragee and costs, you can get the com
mplete terms in th
he policy or plan
n
document at ww
ww.anthem.com
m or by calling 1-800-542-9402.
1
Importa
ant Questions
s
Answerrs
Why
W this Matters:
What is the overall
deductiible?
Combineed in-network an
nd out-ofnetwork:
$600 Ind
dividual/$1,200
0 Family
aggregatee
Does nott apply to preven
ntive care.
You
Y must pay alll the costs up too the deductiblee amount beforee this plan beginss to
pay
p for covered services you usee. Check your po
olicy or plan doccument to see wh
hen
the deductible starts over (usuaally, but not alwaays, January 1st).. See the chart
starting on page 2 for how muchh you pay for co
overed services affter you meet the
deductible.
Are therre other
deductiibles for specific
servicess?
No.
You
Y don’t have to meet deducttibles for specifiic services, but seee the chart
starting on page 2 for other costts for services th
his plan covers.
Is theree an out–of–poccket
limit on
n my expenses??
Combineed in-network an
nd out-ofnetwork:
$2,000 Individual/$4,0
I
000 Family
aggregatee
The
T out-of-pocket limit is the m
most you could pay during a covverage period
(usually one yearr) for your sharee of the cost of ccovered services. This limit helpss
you
y plan for heaalth care expensees.
What is not included in
n
the out––of–pocket limiit?
Deductib
bles, premiums, balance-billed
b
et
Even though yo
ou pay these expeenses, they don’tt count toward the out-of-pocke
charges, copayments,
c
and
d health care
limit.
l
this plan doesn’t cover.
Is theree an overall ann
nual
limit on
n what the plan
pays?
Yes. Infeertility diagnosticc services
have a liffetime maximum
m of
$2,000/m
member in- and out-ofo
network combined.
Bariatric surgery has a peer occurrence
maximum
m benefit of $15,000 per
member for services receeived from a
designateed facility; total per
p
occurrence maximum benefit shall
not exceeed $15,000 per member
m
inand out-o
of-network comb
bined.
This
T plan will paay for covered seervices only up tto this limit durin
ng each coveragee
ove
period,
p
even if your
y
own need iss greater. You’re responsible for all expenses abo
this limit. The chart
c
starting on page 2 describes specific coveragee limits, such as
limits
l
on the num
mber of office vvisits.
Out-of-networkk maximum beneefit for bariatric ssurgery is $1,5000.
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
1 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Does th
his plan use a
network
k of providers?
Yes. See www.anthem.co
om or call 1800-542-9402 for a list off
participatting providers.
Plans use the terrm in-network, p
preferred, or parrticipating for prroviders in theirr
network. See th
he chart starting oon page 2 for ho
ow this plan payss different kinds of
providers.
p
Do I neeed a referral to see
a speciaalist?
No.
You
Y can see the specialist you cchoose without permission from
m this plan.
Are therre services this
plan doesn’t cover?
Yes.
Some of the servvices this plan dooesn’t cover are listed on page 55. See your policyy
or plan documen
nt for additionall information abo
out excluded seervices.
 Copaymennts are fixed dolllar amounts (for example, $15) you
y pay for coverred health care, uusually when youu receive the serrvice.
 Coinsurance is your share of
o the costs of a covered service,, calculated as a percent
p
of the alllowed amountt for the service. For example, if
the plan’s allowed
a
amountt for an overnigh
ht hospital stay iss $1,000, your co
oinsurance paym
ment of 20% wo
ould be $200. Th
his may change if
i
you haven’tt met your dedu
uctible.
 The amounnt the plan pays for
f covered serviices is based on the allowed am
mount. If an out--of-network provvider charges m
more than the
allowed am
mount, you may have to pay the difference. For example, if an out-of-network hhospital charges $$1,500 for an ovvernight stay and
the allowed
d amount is $1,0000, you may haave to pay the $500 difference. (T
This is called ballance billing.)
 This plan may
m encourage yo
ou to use in-netw
work providerss by charging youu lower deductib
bles, copaymen
nts and coinsurance amounts.
Commo
on
Medica
al Event
Services You May Need
Primary care viisit to treat an injury or
illness
Specialist visit
If you vvisit a health
care pro
ovider’s office
Other practitio
oner office visit
or clinicc
If you h
have a test
Preventive caree/screening/
immunization
Diagnostic testt (x-ray, blood work)
w
Imaging (CT/P
PET scans, MRIs)
Yo
our Cost If
Yo
ou Use an
In
n-Network
Provider
Your Cos
st If
You Use an
Limitattions & Excep
ptions
Out-of-Netw
work
Provide
er
c
20% coinsurance
20% coinsuraance
––––––––––––––none––––––––––––––
20% coinsurance
c
20% coinsuraance
20% coinsurance
c
20% coinsuraance
No co
opayment
(100%
% covered)
20% coinsurance
c
20% coinsurance
c
No copaymennt
(100% covereed)
20% coinsuraance
20% coinsuraance
––––––––––––––none––––––––––––––
p
Chiropractic care is limitted to 12 visits per
calendarr year, combinedd in- and out-ofnetworkk.
Coveredd preventive caree services are nott
subject tto deductible.
––––––––––––––none––––––––––––––
––––––––––––––none––––––––––––––
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
2 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Commo
on
Medica
al Event
Services You May Need
If you n
need drugs to
treat your illness or
conditio
on
Tier 1 prescripttion drugs
Tier 2 prescripttion drugs
Tier 3 prescripttion drugs
Tier 4 prescripttion drugs
If you h
have
outpatieent surgery
Facility fee (e.gg., ambulatory suurgery
center)
Physician/surggeon fees
If you h
have a
hospitall stay
Your Cos
st If
You Use an
Limitattions & Excep
ptions
Out-of-Netw
work
Provide
er
20% coinsuraance
20% coinsuraance
20% coinsuraance
Retail in
ncludes a 30-day supply.
More infformation
about prrescription
drug co
overage is
availablee at
www.antthem.com
If you n
need
immediiate medical
attentio
on
Yo
our Cost If
Yo
ou Use an
In
n-Network
Provider
20% coinsurance
c
20% coinsurance
c
20% coinsurance
c
20% coinsurance
c
20% coinsuraance
c
20% coinsurance
20% coinsuraance
––––––––––––––none––––––––––––––
20% coinsurance
c
20% coinsuraance
Emergency roo
om services
20% coinsurance
c
20% coinsuraance
Emergency meedical transportattion
20% coinsurance
c
20% coinsuraance
Urgent care
20% coinsurance
c
20% coinsuraance
Facility fee (e.gg., hospital room
m)
20% coinsurance
c
20% coinsuraance
Physician/surggeon fee
20% coinsurance
c
20% coinsuraance
––––––––––––––none––––––––––––––
If admittted to the facilityy, failure to obtaain
pre-auth
horization (no latter than 24 hourrs
after adm
mission) may ressult in reduced or
o
no coverage.
Maximuum benefit of $2,,000 for ground
and $5,0000 for air per triip.
––––––––––––––none––––––––––––––
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
––––––––––––––none––––––––––––––
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
3 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Commo
on
Medica
al Event
If you h
have mental
health, b
behavioral
health, or substance
abuse n
needs
If you aare pregnant
If you n
need help
recoveriing or have
other sp
pecial health
needs
If your cchild needs
dental o
or eye care
Services You May Need
Mental/Behaviioral health outp
patient
services
Mental/Behaviioral health inpattient
services
Substance use disorder
d
outpatieent
services
Substance use disorder
d
inpatien
nt
services
Prenatal and po
ostnatal care
Yo
our Cost If
Yo
ou Use an
In
n-Network
Provider
Your Cos
st If
You Use an
Limitattions & Excep
ptions
Out-of-Netw
work
Provide
er
20% coinsurance
c
20% coinsuraance
––––––––––––––none––––––––––––––
c
20% coinsurance
20% coinsuraance
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
20% coinsurance
c
20% coinsuraance
––––––––––––––none––––––––––––––
20% coinsurance
c
20% coinsuraance
20% coinsurance
c
20% coinsuraance
Delivery and alll inpatient servicces
20% coinsurance
c
20% coinsuraance
Home health care
20% coinsurance
c
20% coinsuraance
Rehabilitation services
s
20% coinsurance
c
20% coinsuraance
Habilitation serrvices
20% coinsurance
c
20% coinsuraance
Skilled nursing care
Not covered
Not covered
Durable medical equipment
20% coinsurance
c
20% coinsuraance
Hospice service
20% coinsurance
c
20% coinsuraance
Eye exam
Glasses
Dental check-u
up
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
––––––––––––––none––––––––––––––
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
––––––––––––––none––––––––––––––
Outpatieent coverage of p
physical,
occupatiional and speech
h therapies.
All rehab
bilitation and haabilitation visits
mit.
count to
oward your rehab
bilitation visit lim
––––––––––––––none––––––––––––––
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
Failure tto obtain pre-autthorization may
result in
n reduced or no ccoverage.
––––––––––––––none––––––––––––––
––––––––––––––none––––––––––––––
––––––––––––––none––––––––––––––
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
4 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Exclud
ded Service
es & Other Covered
C
Services:
Service
es Your Plan Does NOT Co
over (This isn’tt a complete lisst. Check your policy
p
or plan d
document for o
other excluded sservices.) •
Acup
puncture
•
Infertility
I
treatm
ment
•
Routine eyee care (Adult)
•
Cosm
metic surgery
•
Long-term
L
care
•
Routine foo
ot care
•
Den
ntal care (Adult)
•
Weight losss programs
Other C
Covered Serv
vices (This isn’’t a complete lisst. Check your policy or plan document
d
for oother covered seervices and you
ur costs for thesse
servicess.) •
Bariaatric surgery (lim
mits apply)
•
Hearing
H
aids (lim
mits apply)
•
Chirropractic care (lim
mits apply)
•
Most
M coverage provided outside the United
States.
S
See www..BCBS.com/blueecardworldwide
•
Private duty nursing (lim
mits apply)
Your R
Rights to Co
ontinue Cov
verage:
If you lo
ose coverage und
der the plan, then
n, depending upo
on the circumstaances, Federal an
nd State laws maay provide protecctions that allow
w you to keep heaalth
coveragee. Any such righ
hts may be limiteed in duration an
nd will require yo
ou to pay a prem
mium, which maay be significantlyy higher than thee premium you pay
p
while co
overed under the plan. Other lim
mitations on yourr rights to contin
nue coverage maay also apply.
For morre information on
o your rights to
o continue coverrage, contact your Human Reso
ources/Benefits Office. You maay also contact yyour state insuraance
ment
departm
ment, the U.S. Deepartment of Lab
bor, Employee Benefits
B
Securityy Administration
n at 1-866-444-32272 or www.doll.gov/ebsa, or th
he U.S. Departm
of Healtth and Human Seervices at 1-877--267-2323 x615665 or www.cciio.cms.gov.
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
5 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Your G
Grievance and
a Appeals
s Rights:
If you haave a complaint or are dissatisfieed with a denial of
o coverage for claims
c
under youur plan, you mayy be able to appeeal or file a grievvance. For
question
ns about your rigghts, this notice, or assistance, yo
ou can contact:
Anthem Blue Cross and Blue Shield
Appeals Department
700 Broaadway, CAT CO
O0104-0430
Denver, CO 80273
Addition
nally, a consumer assistance proggram can help yo
ou file your appeeal. Contact:
Colorado Division of In
nsurance
ICARE Section
1560 Bro
oadway, Suite 8550
Denver, CO 80202
Does this Covera
age Provide Minimum Essential
E
Co
overage?
The Affo
fordable Care Acct requires most people
p
to have health
h
care coverrage that qualifiees as “minimum essential coveragge.” This plan oor policy does
providee minimum esseential coveragee.
Does this Covera
age Meet the
e Minimum Value Stand
dard?
The Affo
fordable Care Acct establishes a minimum
m
value sttandard of beneffits of a health plan.
p
The minimuum value standarrd is 60% (actuaarial value). This
health ccoverage does meet
m the minim
mum value standard for the beenefits it provid
des.
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
6 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Summa
ary of Benefitts and Covera
age: What this Plan Covers & What it CosttsCoverage fo
or: Individual/F
Family | Plan T
Type: Traditional
Langu
uage Access
s Services:
–––––––––––––––
–––––––––To seee examples of how this
t plan might covver costs for a samplle medical situationn, see the next page.–––––––––––––––––––––––
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
7 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Coverage fo
for: Individual/Family | Plan T
Type: Traditional
Covera
age Examples
s
Abou
ut these Coverage
C
e
Exam
mples:
These exxamples show ho
ow this plan migght cover
medical care in given situ
uations. Use these
examplees to see, in general, how much financial
fi
protectio
on a sample patient might get if they are
covered under different plans.
This is
not a co
ost
estimato
or.
Don’tt use these examples to
estimaate your actual costs
underr this plan. The actual
a
care yyou receive will be
b
differeent from these
examp
ples, and the cosst of
that caare will also be
differeent.
See th
he next page for
imporrtant information
n about
these examples. Hav
ving a baby
Mana
aging type 2 diabetes
(no
ormal delivery)
((routine mainten
nance of
aw
well-controlled ccondition)
 Amount
A
owed
d to providers
s: $7,540
 Plan
P
pays $5,560
 Patient
P
pays $1,980
$
 Amount o
owed to proviiders: $5,400
 Plan pays
s $3,920
 Patient pa
ays $1,480
Sa
ample care costs:
Hospital
H
charges (mother)
(
Ro
outine obstetric care
Hospital
H
charges (baby)
(
An
nesthesia
Laaboratory tests
Prrescriptions
Raadiology
Vaaccines, other prreventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample carre costs:
Prescriptionss
Medical Equuipment and Sup
pplies
Office Visitss and Proceduress
Education
Laboratory ttests
Vaccines, oth
her preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Pa
atient pays:
Deductibles
Co
opays
Co
oinsurance
Liimits or exclusions
Total
$600
$0
$1,380
$0
$1,980
Patient pay
ys:
Deductibles
Copays
Coinsurance
Limits or excclusions
Total
$600
$0
$880
$0
$1,480
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
8 of
o 9 CHEIBA/Anthem BCBS Custom
C
Plu
us Plan
Covera
age Examples
s
Coverage Period: Plan Year 01/01/20
015 – 12/31/20
015
Coverage fo
for: Individual/Family | Plan T
Type: Traditional
Ques
stions an
nd answers about the Cove
erage Exa
amples:
What are some of the
assum
mptions beh
hind the
Coverrage Examp
ples?







Cossts don’t include premiums.
Sam
mple care costs are
a based on national
averages supplied by
b the U.S.
Dep
partment of Heaalth and Human
Servvices, and aren’t specific to a
partticular geographic area or health plan.
Thee patient’s condition was not an
excluded condition..
All services and treaatments started and
a
endded in the same coverage
c
period.
Theere are no other medical expensees for
anyy member covereed under this plaan.
Out-of-pocket expeenses are based only
o
on treating the cond
dition in the example.
Thee patient received
d all care from in
nnetw
work providers.. If the patient had
h
receeived care from out-of-network
pro
oviders, costs wo
ould have been higher.
h
What
W
does a Coverage Example
E
show?
Can I us
se Coverage
e Examples
to comp
pare plans?
Fo
or each treatmen
nt situation, the Coverage
C
Exxample helps yo
ou see how dedu
uctibles,
co
opayments, and
d coinsurance can add up. It
also helps you seee what expenses might
m
be left
up
p to you to pay because
b
the serviice or
treeatment isn’t covvered or paymen
nt is limited.
Yes. W
When you look at the Summary of
Does
D
the Cov
verage Example
predict my own
o
care nee
eds?
 No. Treatmennts shown are just examples.
The care you would
w
receive forr this
condition could
d be different baased on your
doctor’s advicee, your age, how serious your
condition is, an
nd many other faactors.
Does
D
the Cov
verage Example
predict my fu
uture expen
nses?
No. Coverage Examples are not
n cost
estimators. Youu can’t use the exxamples to
estimate costs for
f an actual con
ndition. They
are for comparrative purposes only.
o
Your
own costs will be different dep
pending on
the care you receive, the prices your
providers charrge, and the reim
mbursement
your health plaan allows.
Benefits and Coverage ffor other plans,
you’ll fin
nd the same Covverage Examples.
When yo
ou compare plan
ns, check the
“Patientt Pays” box in eaach example. Thee
smaller tthat number, thee more coverage
the plan provides.
Are therre other cos
sts I should
conside
er when com
mparing
plans?
m
Yes. Ann important costt is the premium
you pay. Generally, the lower your
premium
m, the more youu’ll pay in out-offpocket ccosts, such as cop
payments,
deductiibles, and coinsu
urance. You
should aalso consider con
ntributions to
accountss such as health savings accountss
(HSAs), flexible spendin
ng arrangements
(FSAs) o
or health reimbuursement accounts
(HRAs) that help you paay out-of-pockett
expensess.
Questio
ons: Call 1-800-5542-9402 or visitt us at www.anth
hem.com
If you arren’t clear about any of the undeerlined terms useed in this form, see
s the Glossary.. You can view tthe Glossary
at www..anthem.com or
o call 1-800-542--9402 to requestt a copy.
9 of
o 9