Anthem Classic PPO 500/30/50/20 SBC
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 04/01/2024 - 3/31/2025 ® Anthem BlueCross Coverage for: Individual + Family | Plan Type: PPO Anthem Classic PPO 500/30/50/20 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 $500/person or $1,500/family for Generally, you must pay all of the costs from providers up to the deductible amount before deductible? In-Network Providers. this plan begins to pay. If you have other family members on the plan, each family member $1,500/person or $4,500/family must meet their own individual deductible until the total amount of deductible expenses paid for Non-Network Providers. by all family members meets the overall family 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- $4,000/person or $8,000/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? $12,000/person or overall family out-of-pocket limit has been met. $24,000/family for Non-Network Providers. What is not included Pre-Authorization Penalties, Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket Premiums, balance-billing limit? charges, and health care this plan 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=JPU 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. CA/LG/Anthem Classic PPO 500/30/50/20/AN9K/01-24 Page 1 of 12
Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. 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 $30/visit deductible does not 40% coinsurance Virtual visits (Telehealth) injury or illness apply benefits available. If you visit a Specialist visit $50/visit deductible does not 40% coinsurance Virtual visits (Telehealth) health care apply 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 40% coinsurance provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance 40% coinsurance --------none-------- If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance $800 maximum/service for Non- Network Providers. $5/prescription, deductible 50% coinsurance up to Typically Lower Cost Generic does not apply (retail) and $250/prescription, deductible (Tier 1a) $10/prescription, deductible does not apply (retail) and Not does not apply (home covered (home delivery) If you need drugs delivery) to treat your $15/prescription, deductible 50% coinsurance up to Most home delivery is 90-day illness or does not apply (retail) and $250/prescription, deductible supply. For more information, condition Typically Generic (Tier 1b) $30/prescription, deductible does not apply (retail) and Not refer to “Essential Drug List” at More information does not apply (home covered (home delivery) http://www.anthem.com/pharm about prescription delivery) acyinformation/ drug coverage is $30/prescription, deductible 50% coinsurance up to *See Prescription Drug section available at Typically Preferred Brand & does not apply (retail) and $250/prescription, deductible of the plan or policy document http://www.anthe Non-Preferred Generic Drugs $75/prescription, deductible does not apply (retail) and Not (e.g. evidence of coverage or m.com/pharmacyi (Tier 2) does not apply (home covered (home delivery) certificate). nformation/ delivery) $50/prescription, deductible 50% coinsurance up to Typically Non-Preferred Brand does not apply (retail) and $250/prescription, deductible and Generic drugs (Tier 3) $125/prescription, deductible does not apply (retail) and Not does not apply (home covered (home delivery) delivery) * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 2 of 12
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) 30% coinsurance up to 50% coinsurance up to Typically Preferred Specialty $250/prescription, deductible $250/prescription, deductible (brand and generic) (Tier 4) does not apply (retail and does not apply (retail) and Not home delivery) covered (home delivery) If you have Facility fee (e.g., ambulatory 20% coinsurance 40% coinsurance $350 maximum/admission for outpatient surgery center) Non-Network Providers. surgery Physician/surgeon fees 20% coinsurance 40% coinsurance --------none-------- $150/visit, then 20% Copayment waived if admitted. Emergency room care coinsurance Covered as In-Network 20% coinsurance for Emergency If you need Room Physician Fee. immediate Emergency medical Non-emergency Non-Network medical attention transportation 20% coinsurance Covered as In-Network Ambulance Services are limited to $50,000 per trip. Urgent care $30/visit deductible does not 40% coinsurance --------none-------- apply $500 penalty if Non-Network preauthorization is not obtained. $1,000 maximum/day for Non- If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Emergency Admissions to Non- hospital stay Network Providers. 150 days/benefit period for Inpatient rehabilitation and skilled nursing services combined. Physician/surgeon fees 20% coinsurance 40% coinsurance --------none-------- Office Visit If you need Office Visit Office Visit 988 lifeline/mobile crisis team mental health, $30/visit deductible does not 40% coinsurance covered as In-Network. Virtual behavioral health, Outpatient services apply Other Outpatient visits (Telehealth) benefits or substance Other Outpatient 40% coinsurance available. abuse services 20% coinsurance Other Outpatient --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 3 of 12
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) $1,000 maximum/day for Non- Emergency Admissions to Non- Network Providers. 20% Inpatient services 20% coinsurance 40% coinsurance coinsurance for Inpatient Physician Fee In-Network Providers. 40% coinsurance for Inpatient Physician Fee Non- Network Providers. Office visits $30/visit deductible does not 40% coinsurance $1,000 maximum/day for Non- apply Emergency Admissions to Non- Childbirth/delivery professional 20% coinsurance 40% coinsurance Network Providers. Maternity If you are services care may include tests and pregnant services described elsewhere in Childbirth/delivery facility the SBC (i.e., ultrasound). services 20% coinsurance 40% coinsurance *Coverage includes fertility preservation services, see Fertility Preservation section. Home health care 20% coinsurance 40% coinsurance 100 visits/benefit period. Rehabilitation services 20% coinsurance 40% coinsurance *See Therapy Services section. If you need help Habilitation services 20% coinsurance 40% coinsurance recovering or 150 days/benefit period for have other Skilled nursing care 20% coinsurance 40% coinsurance Inpatient rehabilitation and special health skilled nursing services needs combined. Durable medical equipment 20% coinsurance 40% coinsurance *See Durable Medical Equipment Section Hospice services No charge 40% coinsurance --------none-------- If your child Children’s eye exam No charge $0 copayment up to plan's needs dental or Maximum Allowed Amount *See Vision Services section eye care Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- * For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/. Page 4 of 12
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 (In-Network) Chiropractic care 30 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 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/ Page 5 of 12
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 6 of 12
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 $500 The plan’s overall deductible $500 The plan’s overall deductible $500 Specialist copayment $50 Specialist copayment $50 Specialist copayment $50 Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% Other coinsurance 20% Other coinsurance 20% 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 $500 Deductibles $100 Deductibles $500 Copayments $10 Copayments $1,300 Copayments $300 Coinsurance $2,400 Coinsurance $0 Coinsurance $300 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 $2,970 The total Joe would pay is $1,420 The total Mia would pay is $1,100 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 12
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 8 of 12
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 9 of 12
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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 , x 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 7 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 11 of 12
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 12 of 12