Virginia Effective January 1, 2019 Anthem Balanced Funding products
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1 Virginia Effective January 1, 2019 Anthem Balanced Funding products 05518VAEENBVA 8/18
2 Anthem or Balanced + product type + copay or deductible/coinsurance/out-of-pocket maximum PPO POS 25// // // // // //7000 Anthem Balanced OAPOS 25//5500 Contract code 1 $0/$0 L09Q L09S L09N L09U L09Y L0A2 L09J $0/$0 $500/$1,500 $1,000/$3,000 $2,000/$4,000 $3,000/$6,000 $5,500/$11,000 $4,000/$8,000 $6,000/$12,000 $5,500/$11,000 PCP: $30 RHC: $30 PCP: $50 RHC: $50 PCP: $40 RHC: $40 $25 $45 $35 coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance Pharmacy deductible5 (individual/family) $10/$40/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up $15/$45/25% up to 0 per script/25% up $15/$45/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up 2 2
3 Anthem or Balanced + product type + copay or deductible/coinsurance/out-of-pocket maximum POS PPO HSA Anthem Balanced OAPOS 500//5000 Anthem Balanced OAPOS 1000//4500 Anthem Balanced OAPOS 2000//4000 Anthem Balanced OAPOS 3000//6000 Anthem Balanced OAPOS 4500// //7000 w/hsa 6550//6550 w/hsa Contract code 1 L09L L0AE L09W L0A0 L0A4 L0AA L0A6 $500/$1,500 $1,000/$3,000 $2,000/$4,000 $3,000/$6,000 $4,000/$8,000 $6,000/$12,000 PCP: $30 RHC: $30 PCP: $50 RHC: $50 PCP: $40 RHC: $40 $25 $45 $35 Pharmacy deductible5 (individual/family) $10/$40/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up $10/$40/25% up to 0 per script/25% up $15/$45/25% up to 0 per script/25% up $15/$45/25% up to 0 per script/25% up 3 3
4 Anthem or Balanced + product type + copay or deductible/coinsurance/out-of-pocket maximum POS HSA Anthem Balanced OAPOS 5000//7000 w/hsa Anthem Balanced OAPOS 6550//6550 w/hsa Contract code 1 L0AC L0A8 Pharmacy deductible 5 (individual/family) 4 4
5 Together, we make a real difference! We want to thank you, again, for trusting us with the health of your employees. We know that offering health coverage is a big and very important decision for your business. This valuable coverage is one we re committed to in every way from helping your employees get and stay healthy to helping you, and them, save as much as possible through lower cost plan and care options. If you ever have any questions, please feel free to call your Anthem representative. Our purpose is to transform health care with trusted and caring solutions. And it s great that we can do this together! anthem.com This brochure refers to the Booklet form numbers: ABCBS-VA-PPO-ABF (1/19) and AHK-VA-HMOPOS-ABF (1/19). This is not a contract or policy. This guide is not a contract with Anthem Blue Cross and Blue Shield (Anthem). If there is any difference between this guide and the Booklet, Member Booklet, Summaries of Benefits, and related amendments, the provisions of the Booklet, Member Booklet, Summaries of Benefits and related amendments will govern. For more information, please call your broker or Anthem representative. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
Important Questions Answers Why this Matters: In-network: $200/Individual; $400/Family Out-of-network: $1,000/Individual; $2,000/Family
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 https://eoc.anthem.com/eocdps/aso or by calling 1-800-451-1527.
Important Questions Answers Why this Matters: In-network: $500/Individual; $1,000/Family Out-of-network:
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 1-800-445-7490. Important Questions
Important Questions Answers Why this Matters:
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 https://eoc.anthem.com/eocdps/aso or by calling 1-800-451-1527.
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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 1-800-295-4119. Important Questions
Important Questions Answers Why this Matters:
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Important Questions Answers Why this Matters: For in-network providers AND out-of-network providers combined: $1,750 Individual; $4,250 Family
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 https://eoc.anthem.com/eocdps/aso by calling 1-800-582-6941.
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Ohio University: Blue Access PPO Package 007 AFSMCE Bargaining Unit Coverage Period: 07/01/ /30/2015 Summary of Benefits and Coverage:
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Anthem Blue Cross University of California Student Health Insurance Plan (UC SHIP) Custom UC San Francisco
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You don t have to meet deductibles for specific services. 1 of 10 *Precertification may be required GE_ _ _SBC
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Important Questions Answers Why this Matters: For in-network providers, $2,600 individual / $5,000 family For out-of-network providers,
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 1-855-255-9952. Important Questions
Important Questions Answers Why this Matters:
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 1-888-224-4902. Important Questions
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Primary care visit to treat an injury or illness 10% coinsurance 30% coinsurance. Specialist care visit 10% coinsurance 30% coinsurance
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Important Questions Answers Why this Matters: $2,850 individual / $5,650. providers
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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 https://eoc.anthem.com/eocdps/fi or by calling 1-888-650-4047.
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Even though you pay these expenses, they don t count toward the out-ofpocket limit.
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Important Questions Answers Why this Matters: $100 Member/$200 Family for PCP Benefit level. $250 Member/$500 Family for Self-Referred Benefit level.
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Important Questions Answers Why this Matters:
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Important Questions Answers Why this Matters: What is the overall deductible?
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limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
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LIFE HAS A PLAN. Your Benefit Plan Details. Hamilton College. Group Name. A nonprofit independent licensee of the Blue Cross Blue Shield Association
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Important Questions Answers Why this Matters:
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/ca or by calling 1-800-574-2751. Important
You don t have to meet deductibles for specific services.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 Highmark Blue Cross Blue Shield: Affordablue $500/$1500/$4000 Coverage
Cummins Central Power, LLC Coverage Period: 05/01/ /30/2016
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more detail about