MSA_Anthem_PPO Summary-2023 : simplebooklet.com

NH_SOB_ANT_SVR_PRB_3000_30%_9100_PPO_OFF_TW_6UMJ_01012023_57601NH0350013_00 Page 1 of 16Anthem® Health Plans of NH, INC. (DBA Anthem® Blue Cross and Blue Shield)Your 2023 Contract Code: 6UMJYour Plan: Anthem Silver Preferred Blue PPO 3000/30%/9100Your Network: Preferred Blue PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. Unless stated otherwise, the limitations for in- and out-of-network services are combined and services received in an office, Site of Service Provider, or outpatient facility are combined across all outpatient settings. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderOverall Deductible$3,000 person /$6,000 family$6,000 person /$12,000 family Overall Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. $9,100 person /$18,200 family$18,200 person /$36,400 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per member deductible and per member out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per member deductible or per member out-of-pocket limit. In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Your copays, coinsurance and deductible count toward your out-of-pocket limit. However, member cost sharing for adult vision services do not apply toward the out-of-pocket limit. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Medical Chats and Virtual Visits for Primary Care from our Online Provider K Health, through its affiliated Provider groups are covered at No charge.Virtual Visits from online provider LiveHealth Online for urgent/acute medical and mental health and substance abuse care via www.livehealthonline.com are covered at $10 copay per visit deductible does not apply.9

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Page 2 of 16Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderPreferred PCP virtual and office$5 copay per visit deductible does not applyNot applicablePrimary Care (PCP) virtual and office $40 copay per visit deductible does not apply0% coinsurance after deductible is metMental Health and Substance Abuse Care virtual and office$40 copay per visit deductible does not apply50% coinsurance after deductible is metSpecialist Care virtual and office$80 copay per visit deductible does not apply0% coinsurance after deductible is metOther Practitioner VisitsRoutine Maternity Care (Prenatal and Postnatal)In-Network preventive prenatal services are covered at 100%. 30% coinsurance after deductible is met50% coinsurance after deductible is metRetail Health Clinic$40 copay per visit deductible does not apply50% coinsurance after deductible is metChiropractic ServicesCoverage is limited to 36 visits per benefit period. Benefit limit does not apply to Osteopathic manipulative treatment. $40 copay per visit deductible does not apply50% coinsurance after deductible is metAcupunctureCoverage is limited to 20 visits per benefit period. $40 copay per visit deductible does not apply50% coinsurance after deductible is metOther Services in an OfficeAllergy Testing30% coinsurance after deductible is met50% coinsurance after deductible is met Prescription Drugs - Dispensed in the officeFor the drugs itself dispensed in the office through infusion/injection. 30% coinsurance after deductible is met50% coinsurance after deductible is met Surgery30% coinsurance after deductible is met50% coinsurance after deductible is met 10

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Page 3 of 16Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderPreventive care/screenings/immunizationsIn-network preventive care is not subject to deductible, if your plan has a deductible. No charge50% coinsurance after deductible is metPreventive care for Chronic Conditions per IRS guidelinesNo charge50% coinsurance after deductible is metDiagnostic Services LabOfficeNo charge50% coinsurance after deductible is met Preferred Reference LabNo charge50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metX-Ray Office30% coinsurance after deductible is met50% coinsurance after deductible is met Site of Service Provider$150 copay per visit deductible does not apply50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metAdvanced Diagnostic Imaging - for example: MRI, PET and CAT scansOffice30% coinsurance after deductible is met50% coinsurance after deductible is met Site of Service Provider$250 copay per service deductible does not apply50% coinsurance after deductible is met11

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Page 4 of 16Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metUrgent CareWalk-in Center/Walk-in Doctor's Office Visit$40 copay per visit deductible does not apply0% coinsurance after deductible is metUrgent Care Center VisitIn-Network Urgent Care benefit limited to preferred New Hampshire locations. Cost may vary by site of service. $100 copay per visit deductible does not apply0% coinsurance after deductible is metOther Urgent Care Services30% coinsurance after deductible is met 50% coinsurance after deductible is met Emergency CareEmergency Room Facility ServicesEmergency Room copay is waived if directly admitted to the hospital. $350 copay per visit after deductible is metCovered as In-NetworkEmergency Room Doctor and Other Services 30% coinsurance after deductible is metCovered as In-NetworkEmergency Room Mental Health and Substance Abuse Doctor Services$40 copay per visit after deductible is metCovered as In-NetworkAmbulance Transportation Non-emergency, Non-Network ambulance services are limited to an Anthem maximum payment of $50,000 per trip. 30% coinsurance after deductible is metCovered as In-NetworkOutpatient Mental Health and Substance Abuse Care at a FacilityFacility Fees 30% coinsurance after deductible is met50% coinsurance after deductible is metDoctor Services 30% coinsurance after deductible is met50% coinsurance after deductible is met12

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Page 5 of 16Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderOutpatient SurgeryFacility FeesHospital 30% coinsurance after deductible is met0% coinsurance after deductible is metSite of Service Provider$250 copay per visit deductible does not apply0% coinsurance after deductible is metDoctor and Other ServicesHospital30% coinsurance after deductible is met50% coinsurance after deductible is metSite of Service ProviderNo charge50% coinsurance after deductible is metHospital Stay (all Inpatient stays including Maternity, Mental Health and Substance Abuse)Facility fees (for example, room & board)Coverage for Inpatient physical medicine and rehabilitation including day rehabilitation programs is limited to 100 days per benefit period. 30% coinsurance after deductible is met0% coinsurance after deductible is metPhysician and other services including surgeon fees30% coinsurance after deductible is met50% coinsurance after deductible is metHome Health CareCoverage excludes Private Duty nursing services. 30% coinsurance after deductible is met0% coinsurance after deductible is metRehabilitation services (for example, physical/speech/occupational therapy)Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 visits combined per benefit period. Benefit limit does not apply when performed as part of Early Intervention Services. Office$40 copay per visit deductible does not apply50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is met13

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Page 6 of 16Covered Medical BenefitsCost if you use an In-Network ProviderCost if you use a Non-Network ProviderHabilitation services (for example, physical/speech/occupational therapy)Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 visits combined per benefit period. Benefit limit does not apply when performed as part of Early Intervention Services. Office$40 copay per visit deductible does not apply50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metPulmonary rehabilitation Office$80 copay per visit deductible does not apply50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metCardiac rehabilitationOffice$80 copay per visit deductible does not apply50% coinsurance after deductible is metOutpatient Hospital30% coinsurance after deductible is met50% coinsurance after deductible is metDialysis/Hemodialysis office and outpatient hospital30% coinsurance after deductible is met50% coinsurance after deductible is metChemo/Radiation Therapy office and outpatient hospital 30% coinsurance after deductible is met50% coinsurance after deductible is metSkilled Nursing Care (in a facility)Coverage is limited to 100 days per benefit period. 30% coinsurance after deductible is met50% coinsurance after deductible is met14

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Page 8 of 16Covered Prescription Drug BenefitsCost if you use a Tier 1 In-Network PharmacyCost if you use a Tier 2 In-Network PharmacyCost if you use an Out-of-Network PharmacyPharmacy DeductibleNot applicableNot applicable Not applicable Pharmacy Out of Pocket LimitCombined with In-Network medical out of pocket limitCombined with In-Network medical out of pocket limitCombined with Non-Network medical out of pocket limitPrescription Drug CoverageNetwork: Rx Choice Tiered NetworkDrug List: Select Drugs not included on the Select drug list will not be covered.Day Supply Limits:Retail Pharmacy 30 day supply (cost shares noted below)Retail 90 Pharmacy 90 day supply (cost shares noted below)Home Delivery Pharmacy 90 day supply (maximum cost shares noted below) Maintenance medications are available through CarelonRx Mail (IngenioRx will become CarelonRx on January 1, 2023). You will need to call us on the number on your ID card to sign up when you first use the service. Specialty Pharmacy 30 day supply (cost shares noted below for retail and home delivery apply). We may require certain drugs with special handling, provider coordination or patient education be filled by our designated specialty pharmacy.Tier 1a - Typically Lower Cost GenericEach 90 day supply script filled at Retail 90 pharmacies is subject to 3 times the 30 day supply cost share(s) charged at Tier 1 In-Network and Tier 2 In-Network Retail Pharmacies. $3 copay per prescription (retail) and $8 copay per prescription (home delivery)$13 copay per prescription (retail only)50% coinsurance (retail only)Tier 1b - Typically GenericEach 90 day supply script filled at Retail 90 pharmacies is subject to 3 times the 30 day supply cost share(s) charged at Tier 1 In-Network and Tier 2 In-Network Retail Pharmacies. $25 copay per prescription (retail) and $63 copay per prescription (home delivery)$35 copay per prescription (retail only)50% coinsurance (retail only)Tier 2 - Typically Preferred BrandEach 90 day supply script filled at Retail 90 pharmacies is subject to 3 times the 30 day supply cost share(s) charged at Tier 1 In-Network and Tier 2 In-Network Retail Pharmacies. $80 copay per prescription (retail) and $240 copay per prescription (home delivery)$90 copay per prescription (retail only)50% coinsurance (retail only)Tier 3 - Typically Non-Preferred BrandEach 90 day supply script filled at Retail 90 pharmacies is subject to 3 times the 30 day supply cost share(s) charged at Tier 1 In-Network and Tier 2 In-Network Retail Pharmacies. 30% coinsurance up to $400 per prescription (retail) and 30% coinsurance up to $1,200 per prescription (home delivery)40% coinsurance up to $500 per prescription (retail only)50% coinsurance (retail only) 16

MSA_Anthem_PPO Summary-2023

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