protection a sample patient might get if they are covered under different plans. â« Amount owed to providers: $7,540. â« Plan pays $7,370. â« Patient pays $170.
If you do not have this technology, you can ... to manage a budget, finalize divorce papers or find child ... Explore the effects of drugs and ... psychological aspects of violent workplace behaviors. ... for Suicide Following the Release of 13 Reaso
Page 1. 1. 26162CAEENABC 08/17. Anthem Blue Cross. Your go-to training resource .... managers and other leaders at your organization. .... work performance.
Jan 1, 2019 - Please contact SilverScript Customer Care at 1-844-819-3075 for additional information. .... Section 3.1 Your plan membership card â Use it to get all covered .... Medicare (the Centers for Medicare & Medicaid Services) will notify Si
Your doctor's charge for delivery are part of prenatal and postnatal care. 20% coinsurance. 40% coinsurance. Other practitioner visits: Retail health clinic.
Your doctor's charge for delivery are part of prenatal and postnatal care. 0% coinsurance. 30% coinsurance. Other practitioner visits: Retail health clinic.
Prostate Cancer Screenings. All plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for.
Copay is either Primary Care Physician or Specialist Physician for the first prenatal visit ... 20 visits per year combined for Acupuncture and Massage Therapy .... Preventive Rx Plus: Deductible is waived for certain drugs for diabetes, asthma,.
Coverage Period: 10/01/2016-09/30/2017. Summary of Benefits and Coverage: What this Plan .... Rx. Supplies of more than 30 days are not allowed. If you have.
Jan 1, 2015 - Important Questions Answers. Why this ... medical plan, refer to the separate Summary of. Benefits and ... (This is called balance billing.).
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019– 12/31/2019 Anthem Blue Cross: LAUSD Actives EPO Plan (CA Residents) Coverage for: Individual + Family | Plan Type: EPO 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/ca/fi. 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 (800) 700-3739 to request a copy. Important Questions What is the overall deductible?
Are there services covered before you meet your deductible? Are there other deductibles for specific services?
What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider?
Answers Active member: 0.5% of prior fiscal year salary. Active family: 3 times member deductible. Rounded to the next higher $50. Minimum deductible/member is $100. Maximum deductible/member is $800. Yes. Preventive care for EPO Providers.
Yes. $100/visit for Emergency room services (waived if admitted directly from ER). There are no other specific deductibles. $7,500/member for InNetwork Providers.
Deductibles, Premiums, balance-billing charges, and health care this plan doesn't cover. Yes, EPO. See www.anthem.com/ca or call (800) 700-3739 for a list of network providers.
Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan
pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist?
You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event
If you visit a health care provider’s office or clinic
If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available. If you have outpatient surgery
Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Tier 1 - Typically Generic Tier 2 - Typically Preferred / Brand Tier 3 - Typically Non-Preferred / Specialty Drugs Tier 4 - Typically Specialty (brand and generic) Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care
If you need immediate medical attention
What You Will Pay EPO Provider Non-EPO Provider (You will pay the least) (You will pay the most)
Limitations, Exceptions, & Other Important Information
--------none-------You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Limitations, Exceptions, & Other Important Information services are provided. --------none---------------none-------Office Visit --------none-------Other Outpatient --------none-------20% coinsurance for Inpatient Physician Fee EPO Providers. No coverage for Inpatient Physician Fee Non-EPO Providers. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).
100 visits/benefit period for EPO Providers. One visit by home health aide equals four hours or less; not covered while member receives hospice care.
20% coinsurance 20% coinsurance
Not covered Not covered
*See Therapy Services section
20% coinsurance 20% coinsurance Not covered Not covered Not covered
Not covered Not covered Not covered Not covered Not covered
100 days limit/benefit period for EPO Providers. --------none---------------none-------*See Vision Services section *See Dental Services section
* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/ca/fi. 3 of 10
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.) Cosmetic surgery Dental care (adult) Dental Check-up Eye exams for a child Glasses for a child Infertility treatment Long- term care Non-emergency care when traveling outside Private-duty nursing the U.S. Routine eye care (adult) Routine foot care unless you have been Weight loss programs diagnosed with diabetes.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Abortion Acupuncture 12 visits/benefit period. Bariatric surgery Chiropractic care 24 visits/benefit period. Hearing aids one hearing aid/ear every three years. 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) HMO-2219. Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform. 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 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) HMO-2219 California Department of Managed Health Care Help Center, 980 9th Street, Suite 500, Sacramento, CA 95814, (888) 466-2219, www.healthhelp.ca.gov, [email protected]
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––– The plan would be responsible for the other costs of these EXAMPLE covered services. 4 of 10
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 (9 months of in-network pre-natal care and a hospital delivery) $100 20% 20% 20%
The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost
In this example, Peg would pay:
Managing Joe’s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost
What isn’t covered Limits or exclusions The total Peg would pay is
In this example, Joe would pay:
Cost Sharing Deductibles Copayments Coinsurance
$100 20% 20% 20%
Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost
Deductibles Copayments Coinsurance
What isn’t covered Limits or exclusions The total Joe would pay is
In this example, Mia would pay:
Cost Sharing $100 $0 $2,500
$100 20% 20% 20%
Cost Sharing $100 $0 $200 $6,000 $6,300
Deductibles Copayments Coinsurance
$200 $0 $400
What isn’t covered Limits or exclusions The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 10
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 (800) 700-3739 Amharic (አማርኛ)፦ ስለዚህ ሰነድ ማንኛውም ጥያቄ ካለዎት በራስዎ ቋንቋ እርዳታ እና ይህን መረጃ በነጻ የማግኘት መብት አለዎት። አስተርጓሚ ለማናገር (800) 700-3739 ይደውሉ። .(800) 700-3739 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՝ (800) 700-3739:
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(800) 700-3739. 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 (800) 700-3739. (800) 700-3739 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 (800) 700-3739.
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(800) 700-3739 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 (800) 700-3739. 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 (800) 700-3739. 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 (800) 700-3739. 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 (800) 700-3739. 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 (800) 700-3739
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Language Access Services: (800) 700-3739 Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugishe umusemuzi, akura (800) 700-3739. Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가 있습니다. 통역사와 이야기하려면 (800) 700-3739 로 문의하십시오.
(800) 700-3739 Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, (800) 700-3739 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 (800) 700-3739 aa. Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer (800) 700-3739. 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 (800) 700-3739.
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Language Access Services: (800) 700-3739.
(800) 700-3739. 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 (800) 700-3739. Serbian (Srpski): Ukoliko imate bilo kakvih pitanja u vezi sa ovim dokumentom, imate pravo da dobijete pomoć i informacije na vašem jeziku bez ikakvih troškova. Za razgovor sa prevodiocem, pozovite (800) 700-3739. 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 (800) 700-3739. 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 (800) 700-3739. ิ ธิท Thai (ไทย): หากท่านมีคาถามใดๆ เกีย ่ วกับเอกสารฉบับนี้ ท่านมีสท ์ จ ี่ ะได ้รับความชว่ ยเหลือและข ้อมูลในภาษาของท่านโดยไม่มค ี า่ ใชจ่้ าย โดยโทร (800) 700-3739 เพือ ่ พูดคุยกับล่าม
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.(800) 700-3739 (800) 700-3739.
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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 1-800-3681019 (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.