Anthem Br PPO 5200 20%

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Questions:Call (855) 711-8949 or visit us atwww.anthem.com NV/I/F/Anthem Bronze Pathway X PPO 5200/20%/1X81/NA/01-16If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryatwww.cciio.cms.govor call (855) 711-8949 to request a copy.

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Anthem Blue Cross and Blue ShieldAnthem Bronze Pathway X PPO 5200/20%Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 12/31/2016

Coverage for: Individual + Family | Plan Type: PPO

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 https://eoc.anthem.com/eocdps/1X81IND01012016 or by calling (855) 711-8949.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$5,200person / $10,400familyfor In-Network Providers. Doesnot apply to Preventive Care.$13,000person / $26,000familyfor Out-of-Network Providers.

You must pay all costs up to the deductibleamount before this plan begins to pay for

covered services you use. Check your policy or plan document to see when the deductible

starts over (usually, but not always, January 1st). See the chart starting on page 3 for how

much you pay for covered services after you meet the deductible.

Are there other

deductibles for specificservices?

No.You don't have to meet deductiblesfor specific services, but see the chart starting on page

3 for other costs for services this plan covers.

Is there anoutofpocket limit onmy expenses?

Yes; $6,850person / $13,700family for In-NetworkProviders. $17,125person /$34,250family for Out-of-Network Providers.

The out-of-pocket limitis the most you could pay during a coverage period (usually one

year) for your share of the cost of covered services. This limit helps you plan for health care

expenses.

What is not included in

the outofpocket

limit?

Premiums, Balance-Billedcharges, and Health Care thisplan doesn't cover.

Even though you pay these expenses, they dont count toward the outof

pocket limit.

Is there an overallannual limit on whatthe plan pays?

No.The chart starting on page 3 describes any limits on what the plan will pay for specific

covered services, such as office visits.

Does this plan use anetwork of providers?

Yes.For a list of In-Networkproviders, seewww.anthem.comor call (855) 711-8949. Dentaland Vision benefits may access

If you use an in-network doctor or other health careprovider

, this plan will pay some or all

of the costs of covered services. Be aware, your in-network doctor or hospital may use an

out-of-networkproviderfor some services. Plans use the term in-network,preferred, or

participating forprovidersin their network. See the chart starting on page 3 for how this

plan pays different kinds ofproviders.

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Important Questions Answers Why this Matters:

a different network ofproviders.

Do I need a referral tosee a specialist?

No; you do not need a referral

to see a specialist. You can see the specialistyou choose without permission from this plan.

Are there services thisplan doesnt cover? Yes.

Some of the services this plan doesnt cover are listed on page 7. See your policy or plandocument for additional information about excluded services.

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

Coinsurance isyourshare of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plans allowed amount for an overnight hospital stay is $1,000, your coinsurancepayment of 20% would be $200. This may change ifyou havent met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-networkprovider 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 providers by charging you lower deductibles, copaymentsand coinsuranceamounts

CommonMedical Event

Services You May NeedYour Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

If you visit ahealth careproviders officeor clinic

Primary care visit to treat an injuryor illness

$35 copay per visit forthe first 2 visits and

then 20% coinsurance50% coinsurance

All office visit copayments counttowards the same 2 visit limit.

Specialist visit 20% coinsurance 50% coinsurance --------none--------

Other practitioner office visit

Chiropractor20% coinsurance

AcupunctureNot covered

Chiropractor50% coinsurance

AcupunctureNot covered

Chiropractor

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 50 visits perbenefit period.Acupuncture--------none--------

Preventivecare/screening/immunization

No charge 50% coinsurance --------none--------

If you have a test

Diagnostic test (x-ray, blood work)

Lab Office20% coinsurance

X-Ray Office20% coinsurance

Lab Office50% coinsurance

X-Ray Office50% coinsurance

Lab Office--------none--------

X-Ray Office--------none--------

Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance --------none--------

If you need drugsto treat yourillness orcondition

More informationaboutprescription

drug coverageis

Tier1 - Typically Generic20% coinsurance (retail

and home delivery)

50% coinsurance (retailonly home delivery not

covered)

Covers up to a 30 day supply (retail

pharmacy). Covers up to a 90 day

supply (home delivery program). No

coverage for non-formulary drugs.

Maintenance medications are subject

to mandatory home delivery services

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CommonMedical Event




available athttp://www.anthem.com/pharmacyinformation/

Anthem SelectDrug List

after the initial supply has been

dispensed at a retail pharmacy.

Applies to all tiers.

Tier2 - Typically Preferred / Brand20% coinsurance (retail

and home delivery)

50% coinsurance (retail

only home delivery notcovered)

Covers up to a 30 day supply (retailpharmacy). Covers up to a 90 daysupply (home delivery program). Nocoverage for non-formulary drugs.

Tier3 - Typically Non-Preferred /Specialty Drugs

20% coinsurance (retailand home delivery)


covered)


Tier4 - Typically Specialty Drugs20% coinsurance (retail

and home delivery)


covered)


If you haveoutpatient surgery

Facility fee (e.g., ambulatory surgerycenter)

20% coinsurance 50% coinsurance --------none--------

Physician/surgeon fees 20% coinsurance 50% coinsurance --------none--------If you needimmediatemedical attention

Emergency room services$500 copay per visit andthen 20% coinsurance

Covered as In-Network Copay waived if admitted.

Emergency medical transportation 20% coinsurance Covered as In-Network --------none--------

Urgent care$50 copay per visit andthen 20% coinsurance

Covered as In-Network --------none--------

If you have ahospital stay Facility fee (e.g., hospital room)

$500 copay peradmission and then

20% coinsurance

50% coinsurance --------none--------

Physician/surgeon fee 20% coinsurance 50% coinsurance --------none--------If you have mentalhealth, behavioralhealth, orsubstance abuseneeds

Mental/Behavioral health outpatientservices

Mental/BehavioralHealth Office Visit20% coinsurance

Mental/BehavioralHealth Facility Visit -

Facility Charges20% coinsurance

Mental/BehavioralHealth Office Visit50% coinsurance

Mental/BehavioralHealth Facility Visit -

Facility Charges50% coinsurance

Mental/BehavioralHealth Office Visit--------none--------Mental/BehavioralHealth Facility Visit - Facility Charges--------none--------

Mental/Behavioral health inpatient $500 copay per 50% coinsurance --------none--------
http://www.anthem.com/pharmacyinformation/http://www.anthem.com/pharmacyinformation/http://www.anthem.com/pharmacyinformation/http://www.anthem.com/pharmacyinformation/http://www.anthem.com/pharmacyinformation/http://www.anthem.com/pharmacyinformation/

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CommonMedical Event




servicesadmission and then20% coinsurance

Substance use disorder outpatientservices

Substance Use OfficeVisit

20% coinsuranceSubstance Use Facility

Visit - Facility Charges20% coinsurance

Substance Use OfficeVisit

50% coinsuranceSubstance Use Facility

Visit - Facility Charges50% coinsurance

Substance Use Office Visit--------none--------Substance Use Facility Visit - Facility

Charges--------none--------

Substance use disorder inpatientservices

$500 copay peradmission and then20% coinsurance

50% coinsurance --------none--------

If you arepregnant

Prenatal and postnatal care 20% coinsurance 50% coinsurance --------none--------

Delivery and all inpatient services$500 copay per

admission and then20% coinsurance

50% coinsuranceApplies to inpatient facility. Othercost shares may apply depending onservices provided.

If you need help

recovering or haveother specialhealth needs

Home health care 20% coinsurance 50% coinsurance

Coverage for In-Network Providers

and Non-Network Providerscombined is limited to 30 visits perbenefit period.

Rehabilitation services 20% coinsurance 50% coinsurance

Coverage for physical therapy,occupational therapy and speechtherapy combined In-NetworkProviders and Non-NetworkProviders combined is limited to 120visits per benefit period.

Habilitation services 20% coinsurance 50% coinsurance

Habilitation and Rehabilitation visits

count towards your Rehabilitationlimit.

Skilled nursing care 20% coinsurance 50% coinsurance

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 100 days perbenefit period.

Durable medical equipment 20% coinsurance 50% coinsurance --------none--------

Hospice service 20% coinsurance 50% coinsurance --------none--------If your childneeds dental or

Eye exam No charge No chargeCoverage for In-Network Providersand Non-Network Providers

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CommonMedical Event




eye care combined is limited to 1 exam perbenefit period. Coverage for Non-Network Providers is limited to $30maximum benefit per visit.

Glasses No charge No charge

Coverage for In-Network Providersand Non-Network Providers

combined is limited to 1 unit perbenefit period. Coverage for bifocallenses is limited to $40 maximumbenefit per occurrence, single visionlenses is limited to $25 maximumbenefit per occurrence, trifocal lensesis limited to $55 maximum benefit peroccurrence, and frames is limited to$45 maximum benefit per occurrence.Apply to Non-Network Providers.

Dental check-up 10% coinsurance 30% coinsurance Frequencies and limitations for thisservice may vary.

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Excluded Services & Other Covered Services:

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

Acupuncture

Cosmetic surgery

Dental care (Adult)

Long-term care

Non-Formulary drugs

Routine eye care (Adult)

Routine foot care

Weight loss programs

Other Covered Services(This isnt a complete list. Check your policy or plan document for other covered services and your costs for these

services.)

Bariatric surgery Coverage is limited to 1unit every 5 years.

Chiropractic care Coverage is limited to

50 visits per benefit period. Hearing aids Coverage is limited to 1 unit

every 3 years.

Infertility treatment Coverage is limitedto 6 cycle per lifetime.

Most coverage provided outside theUnited States. Seewww.bcbs.com/bluecardworldwide.

Private-duty nursing Coverage is limitedto 30 visits per benefit period.
http://www.bcbs.com/bluecardworldwide.http://www.bcbs.com/bluecardworldwide.

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Your Rights to Continue Coverage:Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay yourpremium. There are exceptions,however, such as if:

You commit fraud

The insurer stops offering services in the State

You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at (855) 711-8949. You may also contact your state insurance department at:

Nevada Division of Insurance1818 E. College Pkwy.,Suite 103Carson City, NV 89706(775) 687-0700(888) 872-3234Nevada Division of Insurance2501 East Sahara Ave.,Suite 302Las Vegas, NV 89104(702) 486-4009(888) 872-3234

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 appealor file a grievance. For questionsabout your rights, this notice, or assistance, you can contact:

ATTN: Grievances and AppealsP.O. Box 10330Reno, NV 89520

Nevada Division of Insurance1818 E. College Pkwy.,Suite 103Carson City, NV 89706(775) 687-0700(888) 872-3234Nevada Division of Insurance2501 East Sahara Ave.,Suite 302Las Vegas, NV 89104(702) 486-4009(888) 872-3234

Office of Consumer HealthAssistanceGovernor's Consumer HealthAdvocate555 East Washington Ave #4800Las Vegas, NV 89101(702) 486-3587(888) 333-1597http://dhhs.nv.gov/Programs/CHA/[email protected]
http://dhhs.nv.gov/Programs/CHA/http://dhhs.nv.gov/Programs/CHA/http://localhost/var/www/apps/conversion/tmp/scratch_5/[email protected]://dhhs.nv.gov/Programs/CHA/http://dhhs.nv.gov/Programs/CHA/

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Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage.This plan or policy doesprovide minimum essential coverage.

Language Access Services:

ID

Doo bee atah niliigoo e dooda, shika adoowo nzinigo t din kjgo, t shood ba naanh ya sidh bich naabdkiid. E doo biigha daago nibanijago hoaaag bich hodiiln. Haid iinitaago eya, t shood din ya ath halneg n bsh bee hane wlta biki siniilg bikhgo bich hodiiln.

Si no es miembro todava y necesita ayuda en idioma espaol, le suplicamos que se ponga en contacto con su agente de ventas o con el administrador de sugrupo. Si ya est inscrito, le rogamos que llame al nmero de servicio de atencin al cliente que aparece en su tarjeta de identificacin.

Kung hindi ka pa miyembro at kailangan ng tulong sa wikang Tagalog, mangyaring makipag-ugnayan sa iyong sales representative o administrator ng iyongpangkat. Kung naka-enroll ka na, mangyaring makipag-ugnayan sa serbisyo para sa customer gamit ang numero sa iyong ID card.

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 financial

protection a sample patient might get if they arecovered under different plans.

This isnot a costestimator.

Dont use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost of thatcare will also be different.

See the next page forimportant information aboutthese examples.

Having a baby(normal delivery)

n Amount owed to providers:$7,540n Plan pays $1,940

n Patient pays $5,600

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:

Deductibles $5,200

Copays $0

Coinsurance $400

Limits or exclusions $0

Total $5,600

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

n Amount owed to providers:$5,400n Plan pays $500

n Patient pays $4,900

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:

Deductibles $4,500

Copays $200

Coinsurance $0

Limits or exclusions $200

Total $4,900

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Questions:Call (855) 711-8949 or visit us atwww.anthem.com NV/I/F/Anthem Bronze Pathway X PPO 5200/20%/1X81/NA/01-16If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryatwww.cciio.cms.govor call (855) 711-8949 to request a copy.

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Questions and answers about the Coverage Examples:

What are some of the assumptionsbehind the Coverage Examples?

Costs dont includepremiums.

Sample care costs are based on nationalaverages supplied by the U.S. Department

of Health and Human Services, and arentspecific to a particular geographic area orhealth plan.

The patients 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 on

treating the condition in the example. The patient received all care from in-

networkproviders. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.

What does a Coverage Exampleshow?

For each treatment situation, the Coverage Examplehelps you see howdeductibles, copayments, and coinsurancecan add up. Italso helps you see what expenses might be

left up to you to pay because the service ortreatment isnt covered or payment is limited.

Does the Coverage Example predictmy own care needs?

No.Treatments shown are just examples.The care you would receive for this conditioncould be different based on your doctorsadvice, your age, how serious your condition

is, and many other factors.

Does the Coverage Example predictmy future expenses?

No. Coverage Examples are notcostestimators. You cant use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be different

depending on the care you receive, theprices yourproviders charge, and thereimbursement your health plan allows.

Can I use Coverage Examples tocompare plans?

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

Are there other costs I shouldconsider when comparingplans?

Yes.An important cost is thepremiumyou pay. Generally, the lower yourpremium, the more youll pay in out-of-pocket costs, such as copayments,deductibles, and coinsurance. 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.

Documents

Anthem Br PPO 5200 20%