AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 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 plan document at www.anthem.com or by calling 1-800-852-6592. Important Questions Answers For in-network providers $2,000 individual / $4,000 family For out-of-network providers $5,000 individual / $10,000 family Doesnt apply to in-network preventive care and routine eye exams. Yes. For durable medical equipment there is a $250 deductible. For in-network providers $6,350 individual/$12,700 family For out-of-network providers $10,000 individual / $20,000 family Premiums, penalties for non-compliance, balance-billed charges, pharmacy claims, and health care this plan doesnt cover. No. Why this Matters: You must pay all the costs up to the deductible amount 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 2 for how much you pay for covered services after you meet the deductible. 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 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 the overall deductible?

Are there other deductibles for specific services? Is there an outof pocket limit on my expenses?

What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays?

Even though you pay these expenses, they dont count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 1 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: PPO If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of Yes. For a list of in-network covered services. Be aware, your in-network doctor or Does this plan use a providers, see hospital may use an out-of-network provider for some network of www.anthem.com or call services. Plans use the term in-network, preferred, or providers? 1-800-852-6592 participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesnt cover? No. Yes. You can see the specialist you choose without permission from this plan. Some of the services this plan doesnt cover are listed on page 6. See your policy or plan document for additional information about excluded services.

AWANE: Massachusetts PPO 2000

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

receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the 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, copayments and coinsurance amounts. Common Medical Event If you visit a health care Your Cost If You Use an In-network Provider $25 copay/visit Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance

Services You May Need Primary care visit to treat an injury or illness

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 2 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need Medical Event In-network Provider $40 Specialist visit copay/visit providers office or clinic Other practitioner office visit Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs (Retail/30 day: If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medco.com If you have outpatient surgery
Mail/90 day) Preferred brand drugs (Retail/30 day: Mail/90 day)

$40 copay/visit No Charge No Charge No Charge

$10 Retail/$20 Mail
$35 Retail/$87.5 Mail $60 Retail/$150 Mail

If you have a test

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance Chiropractic care is limited to 50% 12 visits per calendar year coinsurance combined in and out of network. 50% none coinsurance 50% none coinsurance 50% none coinsurance Not Covered Not Covered Not Covered
Maintenance Meds are required to be filled mail order after 3 fills at retail (penalty applies). If pre-auth required & not obtained, drug may not be covered. Certain Preventive meds no copay. If a generic equivalent is available & brand is prescribed/member will pay brand name cost difference. Plan uses preferred drug list to identify coverage.

Non-preferred brand (Retail/30day: Mail/90day)

Specialty drugs

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

All Specialty meds process through Not Covered Accredo at the mail order costs. 50% No Charge coinsurance 50% No Charge coinsurance

The mail order cost will be based on the medication tier (generic, preferred, non-preferred). Specialty meds can not be filled at retail pharmacies.

none none

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 3 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need Medical Event In-network Provider $150 copay / visit; professional Emergency room services and other services subject to deductible If you need immediate Emergency medical No Charge medical transportation attention $75 copay/ visit; professional Urgent care and other services subject to deductible If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee No Charge No Charge

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider $150 copay / visit; $150 copay is waived if professional admitted for inpatient stay. and other Members may be balance billed services for out of network services. subject to deductible Members may be balance billed No Charge for out of network services $75 copay/ visit; professional Members may be balance billed and other for out of network services services subject to deductible Precertification is required for 50% Inpatient hospital admission or coinsurance $500 penalty is applied. 50% none coinsurance

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 4 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need Medical Event In-network Provider Mental/Behavioral health $25 outpatient services copay/visit If you have Mental/Behavioral health No Charge mental health, inpatient services behavioral health, or Substance use disorder $25 substance outpatient services copay/visit abuse needs Substance use disorder inpatient No Charge services If you are pregnant Prenatal and postnatal care Delivery and all inpatient services No Charge No Charge

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance Precertification is required for 50% Inpatient hospital admission or coinsurance $500 penalty is applied. 50% none coinsurance Precertification is required for 50% Inpatient hospital admission or coinsurance $500 penalty is applied. 50% none coinsurance 50% none coinsurance

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 5 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need Medical Event In-network Provider Home health care No Charge

Rehabilitation services

$40 copay for outpatient services. No charge for inpatient care. $40 copay for outpatient services. No charge for inpatient care. No Charge $250 Deductible then 20% coinsurance No Charge

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider 50% none coinsurance Inpatient physical medicine rehabilitation is limited to 100 days per member per calendar year. Limited to 60 visits 50% combined physical therapy, coinsurance speech therapy and occupational therapy. All therapy limits are combined in and out of network. 50% coinsurance All rehabilitation and habilitation visits count toward your rehabilitation visit limit. Limited to 100 inpatient daysper member per calendar year. Precertification is required or $500 penalty is applied. $250 deductible combined in and out of network. Member may be balance billed for out of network services. Precertification is required for Inpatient hospital admission or $500 penalty is applied.

If you need help recovering Habilitation services or have other special health needs Skilled nursing care

50% coinsurance $250 Deductible then 20% coinsurance 50% coinsurance

Durable medical equipment

Hospice service

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 6 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Your Cost If Common You Use an Services You May Need Medical Event In-network Provider Eye exam If your child needs dental or eye care Glasses Dental check-up No Charge Not Covered Not Covered

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO Your Cost If You Use an Limitations & Exceptions Out-of-network Provider Limited to one exam per 50% calendar year for 18 and coinsurance younger. Limited to one exam every 2 years for 19 and older. Not Covered none Not Covered none

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 Private-duty nursing

Non-emergency care when traveling Routine foot care outside the U.S. 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 Chiropractic care Infertility treatment Coverage provided outside the Hearing aids (Limitations Apply) United States. Routine eye care (Adult See www.BCBS.com/bluecardworldwi Limitations apply) de

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 7 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-258-5318. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 8 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO

Your Grievance and Appeals Rights:

f you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross and Blue Shield P.O. Box 518 North Haven, Connecticut 06473-0518 For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back of prescription member ID card or visit www.express-scripts.com. Additionally, a consumer assistance program can help you file your appeal. Contact: New Hampshire Department of Insurance 21 South Fruit St. Suite 14 Concord, NH 03301 1-800-852-3416 www.nh.gov/insurance consumersvcs@ins.nh.gov For ERISA information contact: Department of Labors Employee Benefits Security Administration 1-866-444-EBSA (3272) www.dol.gov/ebsa/healthreform

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 9 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO

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 does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call 1-800-852-6592 or visit us at www.anthem.com 10 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

AWANE: Massachusetts PPO 2000

Coverage Examples

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual/Family | Plan Type: PPO

About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having a baby
(normal delivery)

Managing type 2 diabetes

(routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,320 Patient pays $2,080 Sample care costs: $2,70 0 $2,10 0 $900 $900 $500 $200 $200 $40 $7,54 0 $2000 $0 $0 $150 $2,15 0 Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1,97 0 $0 $30 $80 $2,08 0 $2,90 0 $1,30 0 $700 $300 $100 $100 $5,40 0

This is not a cost Amount owed to providers: $7,540 estimator. Plan pays $5,390
Patient pays $2,150 Dont use these examples to estimate Sample care costs: your actual costs under Hospital (mother) this plan.charges The actual care you receive will be Routine obstetric care different from these examples, and the cost Hospital charges (baby) of that care will also be Anesthesia different. Laboratory tests Prescriptions See the next page for Radiology important information Vaccines, other preventive about these examples. Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total

Questions: Call 1-800-852-6592 or visit us at www.anthem.com 11 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anthem.com or call 1-800-852-6592 to request a copy.

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?
Costs dont include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and arent specific to a particular geographic area or health plan. The patients condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any 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-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isnt covered or payment is limited.

No. Coverage Examples are not

cost estimators. You cant use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Does the Coverage Example predict my own care needs?

Can I use Coverage Examples to compare plans?

No. Treatments shown are just

examples. The care you would receive for this condition could be different based on your doctors advice, your age, how serious your condition is, and many other factors.

Yes. When you look at the

Summary of Benefits and Coverage for other plans, youll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides.

Does the Coverage Example predict my future expenses?

Are there other costs I should consider when comparing plans?

Yes. An important cost is the

premium you pay. Generally, the lower your premium, the more youll pay in out-of-pocket

costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.