Anthem Classic HMO 20/40/500 admit/250 OP SBC
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 04/01/2024 - 03/31/2025 ® Anthem BlueCross Coverage for: Individual + Family | Plan Type: HMO Anthem Classic HMO 20/40/500 admit/250 OP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (855) 333-5730 to request a copy. Important Questions Answers Why This Matters: What is the overall $0 See the Common Medical Events chart below for your costs for services this plan covers. deductible? Are there services Yes. Primary Care. Specialist This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Visit. Preventive Care. Certain But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? Prescription Drugs. For more services without cost sharing and before you meet your deductible. See a list of covered information see below. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of- $2,500/person or $5,000/family The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this for In-Network Providers. other family members in this plan, they have to meet their own out-of-pocket limits until the plan? overall family out-of-pocket limit has been met. What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this plan limit? doesn't cover. Will you pay less if Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s you use a network www.anthem.com/find- network. You will pay the most if you use an out-of-network provider, and you might receive provider? care/?alphaprefix=JMV a bill from a provider for the difference between the provider’s charge and what your plan or call (855) 333-5730 for a list of pays (balance billing). Be aware, your network provider might use an out-of-network provider network providers. Costs may for some services (such as lab work). Check with your provider before you get services. vary by site of service and how the provider bills. Do you need a referral Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if to see a specialist? you have a referral before you see the specialist. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. CA/LG/Anthem Classic HMO 20/40/500 admit/250 OP/AN9Z/01-24 Page 1 of 11
Common What You Will Pay Limitations, Exceptions, & Medical Event Services You May Need In-Network Provider Non-Network Provider Other Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $20/visit Not covered Virtual visits (Telehealth) injury or illness benefits available. If you visit a Specialist visit $40/visit Not covered Virtual visits (Telehealth) health care benefits available. provider’s office You may have to pay for services or clinic Preventive care/screening/ that aren't preventive. Ask your immunization No charge Not covered provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood No charge Not covered --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) $100/service Not covered --------none-------- Typically Lower Cost Generic $5/prescription (retail) and Not covered (retail and home (Tier 1a) $10/prescription (home delivery) If you need drugs delivery) to treat your $15/prescription (retail) and Not covered (retail and home Most home delivery is 90-day illness or Typically Generic (Tier 1b) $30/prescription (home delivery) supply. For more information, condition delivery) refer to “Essential Drug List” at More information Typically Preferred Brand & $30/prescription (retail) and Not covered (retail and home http://www.anthem.com/pharm about prescription Non-Preferred Generic Drugs $75/prescription (home delivery) acyinformation/ drug coverage is (Tier 2) delivery) *See Prescription Drug section available at Typically Non-Preferred Brand $50/prescription (retail) and Not covered (retail and home of the plan or policy document http://www.anthe and Generic drugs (Tier 3) $125/prescription (home delivery) (e.g. evidence of coverage or m.com/pharmacyi delivery) certificate). nformation/ Typically Preferred Specialty 30% coinsurance up to Not covered (retail and home (brand and generic) (Tier 4) $250/prescription (retail and delivery) home delivery) If you have Facility fee (e.g., ambulatory $250/visit Not covered --------none-------- outpatient surgery center) surgery Physician/surgeon fees No charge Not covered --------none-------- Copayment waived if admitted. Emergency room care $125/visit Covered as In-Network No charge for Emergency Room If you need Physician Fee. immediate Emergency medical Non-emergency Non-Network medical attention transportation $100/trip Covered as In-Network Ambulance Services are limited to $50,000 per trip. Urgent care $20/visit Covered as In-Network --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 2 of 11
Common What You Will Pay Limitations, Exceptions, & Medical Event Services You May Need In-Network Provider Non-Network Provider Other Important Information (You will pay the least) (You will pay the most) 150 days/benefit period for Inpatient rehabilitation and If you have a Facility fee (e.g., hospital room) $500/admission Not covered skilled nursing services hospital stay combined for In-Network Providers. Physician/surgeon fees No charge Not covered --------none-------- Office Visit Office Visit Office Visit 988 lifeline/mobile crisis team $20/visit Not covered covered as In-Network. Virtual If you need Outpatient services Other Outpatient Other Outpatient visits (Telehealth) benefits mental health, No charge Not covered available. behavioral health, Other Outpatient or substance --------none-------- abuse services No charge for Inpatient Physician Fee In-Network Inpatient services $500/admission Not covered Providers. No Coverage for Inpatient Physician Fee Non- Network Providers. Office visits $20/visit Not covered Maternity care may include tests Childbirth/delivery professional No charge Not covered and services described elsewhere If you are services in the SBC (i.e., ultrasound). pregnant Childbirth/delivery facility *Coverage includes fertility services $500/admission Not covered preservation services, see Fertility Preservation section. Home health care $20/visit Not covered 100 visits/benefit period for In- Network Providers. Rehabilitation services $20/visit Not covered *See Therapy Services section. If you need help Habilitation services $20/visit Not covered recovering or 150 days/benefit period for have other Inpatient rehabilitation and special health Skilled nursing care No charge Not covered skilled nursing services needs combined for In-Network Providers. Durable medical equipment 20% coinsurance Not covered *See Durable Medical Equipment Section Hospice services No charge Not covered --------none-------- If your child Children’s eye exam No charge Not covered *See Vision Services section * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 11
Common What You Will Pay Limitations, Exceptions, & Medical Event Services You May Need In-Network Provider Non-Network Provider Other Important Information (You will pay the least) (You will pay the most) needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Children’s dental check-up Cosmetic surgery Dental care (Adult) Glasses for a child Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside Routine foot care unless you have been Weight loss programs the U.S. diagnosed with diabetes Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture 20 visits/benefit period Bariatric surgery Chiropractic care 20 visits/benefit period Private-duty nursing in a Home Setting only Routine eye care (Adult) 1 exam/benefit period Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Managed Health Care, California Help Center, 980 9th Street, Suite 500, Sacramento, CA 95814-2725, (888) 466-2219, https://www.dmhc.ca.gov/, Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 4310, Woodland Hills, CA 91365-4310 Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 4 of 11
Department of Managed Health Care, California Help Center, 980 9th Street, Suite 500, Sacramento, CA 95814-2725, (888) 466-2219, https://www.dmhc.ca.gov/ California Consumer Assistance Program, Operated by the California Department of Managed Health Care, 980 9th St, Suite #500, Sacramento, CA 95814, (888) 466-2219, https://www.dmhc.ca.gov/ Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 5 of 11
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost- sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care) The plan’s overall deductible $0 The plan’s overall deductible $0 The plan’s overall deductible $0 Specialist copayment $40 Specialist copayment $40 Specialist copayment $40 Hospital (facility) copayment $500 Hospital (facility) copayment $500 Hospital (facility) copayment $500 Other coinsurance 0% Other coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies) Childbirth/Delivery Professional Services education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $0 Deductibles $0 Deductibles $0 Copayments $1,000 Copayments $1,200 Copayments $600 Coinsurance $0 Coinsurance $0 Coinsurance $50 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $1,060 The total Joe would pay is $1,220 The total Mia would pay is $650 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 11
Language Access Services: (TTY/TDD: 711) Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar me një përkthyes, telefononi 1-888-254-2721 Amharic (አማርኛ): ስለዚህ ሰነድ ማንኛውም ጥያቄ ካለዎት በራስዎ ቋንቋ እርዳታ እና ይህን መረጃ በነጻ የማግኘት መብት አለዎት። አስተርጓሚ ለማናገር 1- 888-254-2721 ይደውሉ። . 1-888-254-2721 Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ 1-888-254-2721: 1-888-254-2721. 1-888-254-2721 1-888-254-2721 Chinese (中文)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通話，請致電1-888-254-2721。 1-888-254-2721. Dutch (Nederlands): Bij vragen over dit document hebt u recht op hulp en informatie in uw taal zonder bijkomende kosten. Als u een tolk wilt spreken, belt u 1-888-254-2721. 1-888-254-2721 Page 7 of 11
Language Access Services: French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le 1-888-254-2721. German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, bitte wählen Sie 1-888-254-2721. Greek (Ελληνικά) UV WXYZY Z[X\V ]^_`aYb cXYZdef gY Z_ ^]`\V Whh`]i_, WXYZY Z_ jde]akg] V] lfmYZY m_noYd] e]d ^lp`_i_`aYb cZp hlqcc] c]b jk`YfV/ rd] V] gdlncYZY gY ef^_d_V jdY`gpVW], ZplYikVncZY cZ_ 1-888-254-2721. Gujarati (ગુજરાતી): જો આ દસ્તાવેજ અંગે આપને કોઈપણ પ્રશ્નો હોય તો, કોઈપણ ખર્ચ વગર આપની ભાષામાં મદદ અને માહિતી મેળવવાનો તમને અધિકાર છે. દુભાષિયા સાથે વાત કરવા માટે, કોલ કરો 1-888-254-2721. Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele 1-888-254-2721. 1-888-254-2721 Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yam tsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau 1-888-254-2721. Igbo (Igbo): Ọ bụr ụ na ị nwere ajụjụ ọ bụla gbasara akwụkwọ a, ị nwere ikike ịnweta enyemaka na ozi n'asụsụ gị na akwụghị ụgwọ ọ bụla. Ka gị na ọkọwa okwu kwuo okwu, kpọọ 1-888-254-2721. Ilokano (Ilokano): Nu addaan ka iti aniaman a saludsod panggep iti daytoy a dokumento, adda karbengam a makaala ti tulong ken impormasyon babaen ti lenguahem nga awan ti bayad na. Tapno makatungtong ti maysa nga tagipatarus, awagan ti 1-888-254-2721. Indonesian (Bahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasi dalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi 1-888-254-2721. Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero 1-888-254-2721 1-888-254-2721 Page 8 of 11
Language Access Services: 1-888-254-2721 Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugishe umusemuzi, akura 1-888-254-2721. Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가 있 습니다. 통역사와 이야기하려면1-888-254-2721 로 문의하십시오. 1-888-254-2721. 1-888-254-2721. 1-888-254-2721 Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, 1-888-254-2721 bilbilla. Pennsylvania Dutch (Deitsch): Wann du Frooge iwwer selle Document hoscht, du hoscht die Recht um Helfe un Information zu griege in dei Schprooch mitaus Koscht. Um mit en Iwwersetze zu schwetze, ruff 1-888-254-2721 aa. Polish (polski): W przypadku jakichkolwiek -& u G0vG & z niniejszym dokumentem masz prawo do * G-w + uzyskania pomocy oraz informacji w swoim FxG&A%/ Aby - " G 0 y z w% G , G G0 u pod numer 1-888-254-2721. Portuguese (Português): Se tiver quaisquer dúvidas acerca deste documento, tem o direito de solicitar ajuda e informações no seu idioma, sem qualquer custo. Para falar com um intérprete, ligue para 1-888-254-2721. 1-888-254-2721 Page 9 of 11
Language Access Services: 1-888-254-2721. 1-888-254-2721. Samoan (Samoa): Afai e iai ni ou fesili e uiga i lenei tusi, e iai lou ‘aia e maua se fesoasoani ma faamatalaga i lou lava gagana e aunoa ma se totogi. Ina ia talanoa i se tagata faaliliu, vili 1-888-254-2721. Serbian (Srpski): Ukoliko imate bilo kakvih pitanja u vezi sa ovim dokumentom, imate pravo da dobijete - y i informacije na vašem jeziku bez ikakvih troškova. Za razgovor sa prevodiocem, pozovite 1-888-254-2721. Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al 1-888-254-2721. Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang 1-888-254-2721. Thai (ไทย): หากท่านมีคำถามใดๆ เกี่ยวกับเอกสารฉบับนี้ ท่านมีสิทธิ์ที่จะได้รับความช่วยเหลือและข้อมูลในภาษาของท่านโดยไม่มีค่าใช้จ่าย โดยโทร 1- 888-254-2721 เพื่อพูดคุยกับล่าม 1-888-254-2721. 1-888-254-2721 Vietnamese (Tiếng Việt): Nếu quý vị có bất A thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. „ể trao …ổi với một thông dịch viên, hãy gọi 1-888-254-2721. . 1-888-254-2721 1-888-254-2721. Page 10 of 11
Language Access Services: It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Page 11 of 11