182490 Pw E182490

User Manual: 182490

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NV ABF HSA1 RX1 (01-2014) NV ABF HSA $1500_90% (10_30_50_30% Rx).s0114
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Summary of Benefits for
Anthem Balanced Funding HSA 1
$1500-90% 10/30/50/30%
This is a general benefit summary for this health plan. A complete listing and description of benefits, limitations, and
exclusions are found in the benefit booklet. Copayment options reflect the amount the member will pay, coinsurance
options reflect the amount that this plan will pay.
In-Network
(Participating Provider)
Out-of-Network
(Non-Participating Provider)
Annual Deductible
Deductibles are per
calendar year.
Individual coverage,
the insured pays a
$1,500 deductible
per member’s
benefit year
Family coverage,
the family pays a
$3,000 deductible
per member’s
benefit year
If you select family
membership (2 or
more members
enrolled), no
individual deductible
applies and the
family deductible
must be met before
this plan provides
benefits to any
family member. The
family deductible
amount is met as
follows: (1) When
one individual has
satisfied the family
deductible, that
family member and
all other family
members are
eligible for benefits,
or (2) When no
family member
meets the family
deductible on their
own, but the family
members
collectively meet the
entire family
deductible, then all
family members will
be eligib
le for
benefits
Individual coverage,
the insured pays a
$3,000 deductible
per member’s
benefit year
Family coverage,
the family pays a
$6,000 deductible
per member’s
benefit year
If you select family
membership (2 or
more members
e
nrolled), no
individual deductible
applies and the
family deductible
must be met before
this plan provides
benefits to any
family member. The
family deductible
amount is met as
follows: (1) When
one individual has
satisfied the family
deductible, that
family member and
all other family
members are
eligible for benefits,
or (2) When no
family member
meets the family
deductible on their
own, but the family
members
collectively meet the
entire family
deductible, then all
family members will
be eligible for
benefits
The benefits described in this summary of benefits are funded by the Employer who is responsible for their payment. Anthem provides administr
ative claims payment services
only and does not assume any financial risk or obligation with respect to claims.
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colo
rado, Inc. dba HMO Nevada. Independent licensees of the Blue
Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross a
nd Blue
Shield Association.
Si usted necesita ayuda en español para entender éste documento, puede solicitarla gratis llamando al número de servicio al c
liente que aparece en su tarjeta de identificación o
en su folleto de inscripción.
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In-Network
(Participating Provider)
Out-of-Network
(Non-Participating Provider)
Out-of-Pocket Annual
Maximum
All coinsurance and
deductible contributes
towards the out-of-pocket
annual maximum.
Some covered services
have a maximum number of
days, visits or dollar
amounts. These maximums
apply even if the applicable
out-of-pocket annual
maximum is satisfied.
Individual:
$3,000
Family:
$6,000
If you select family
membership (2 or
more members
enrolled), no
individual out-of-
pocket maximum
applies and the
family out-of-pocket
maximum must be
met. The family out-
of-pocket maximum
amount is met as
follows: (1) When
one individual has
satisfied the family
out-of-pocket
maximum, each
family member has
satisfied the family
out-of-pocket
maximum amount,
or (2) When no
family member
meets the family
out-of-pocket
annual maximum,
but the family
members
collectively meet the
entire family out-of-
pocket annual
maximum, then
each family member
has satisfied the
family out-of-pocket
maximum amount.
Individual:
$9,000
Family:
$18,000
If you select family
membership (2 or
more members
enrolled), no
individual out-of-
pocket maximum
applies and the
family out-of-pocket
maximum must be
met. The family out-
of-pocket maximum
amo
unt is met as
follows: (1) When
one individual has
satisfied the family
out-of-pocket
maximum, each
family member has
satisfied the family
out-of-pocket
maximum amount,
or (2) When no
family member
meets the family
out-of-pocket
annual maximum,
but the family
members
collectively meet the
entire family out-of-
pocket annual
maximum, then
each family member
has satisfied the
family out-of-pocket
maximum amount.
Lifetime Maximum Benefit
No lifetime maximum
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Services
In Network
(Participating Provider)
Out-of-Network
(Non-Participating
Provider)
Information
1. Physician Visits
a) Physician office visits and
physician consultations
b) Services related to
physician office visit
including but not limited
to, allergy testing, allergy
injections, or office
surgeries
c) Inpatient physician visits
90% coinsurance after
deductible
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
Physician visits
include diabetic
management and
limited family
planning services
(see benefit booklet
for additional details).
2. Retail Health Clinic
90% coinsurance after
deductible
70% coinsurance after
deductible
3. Preventive Care
Preventive care services that
meet the requirements of
federal law including
screenings, immunizations
and office visits.
No charge
70% coinsurance after
deductible
4. Diagnostic Services,
Laboratory, Pathology,
and X-ray
a) Laboratory, Pathology,
and X-ray
b) MRI/MRA, PET, CT
scans, nuclear medicine
and other high tech
services
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
Services billed by a
hospital are included
in the hospital
inpatient/outpatient
benefits.
5.
Maternity Care
a) Prenatal care
b) Delivery & inpatient baby
care
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
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Services
In Network
(Participating Provider)
Out-of-Network
(Non-Participating
Provider)
Information
6. Outpatient Therapies:
Physical therapy,
occupational therapy,
speech therapy, cardiac
rehabilitation and spinal
manipulations/
acupuncture
a) Outpatient physical
therapy, occupational
therapy, speech therapy
and cardiac rehabilitation
b) Outpatient spinal
manipulations and
acupuncture
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
Limited to 20 visits
each of physical,
occupational and
speech therapy per
member per year.
Benefits are paid up
to 36 visits for cardiac
rehabilitation.
Limited to 12 visits
per member per year
7. Hospital Care/Other
Facility Services
a) Inpatient
b) Inpatient - acute
rehabilitation therapy
c) Outpatient Surgery
90% coinsurance after
deductible
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
Limited to 30
inpatient days per
member per year.
8. Emergency Care
90% coinsurance after
deductible
90% coinsurance after
deductible
responsibility for Out-
of-Network services
will be the same as
9. Urgent Care
90% coinsurance after
deductible
70% coinsurance after
deductible
10.
Ambulance Services
a) Ground Services
b) Air Services
90% coinsurance after
deductible
90% coinsurance after
deductible
90% coinsurance after
deductible
90% coinsurance after
deductible
Benefits are paid for
medically necessary
ground or air
ambulance
transportation.
11. Mental Health and
Substance Abuse Care
a) Inpatient
b) Outpatient
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
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Services
In Network
(Participating Provider)
Out-of-Network
(Non-Participating
Provider)
Information
12. Medical Supplies and
Equipment
90% coinsurance after
deductible
70% coinsurance after
deductible
supplies and
equipment, medical
supplies, durable
medical equipment,
oxygen and
equipment,
orthopedic
appliances, prosthetic
devices and other
appliances.
Wigs for alopecia
resulting from
chemotherapy and
radiation therapy are
limited to a maximum
benefit of $500 per
member per year.
13. Home Health Care
90% coinsurance after
deductible
70% coinsurance after
deductible
14. Chemotherapy,
Hemodialysis, and
Radiation Therapy
a) Inpatient
b) Outpatient
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
15.
Skilled Nursing Facility
90% coinsurance after
deductible
70% coinsurance after
deductible
inpatient days per
member per year.
16. Hospice Care
90% coinsurance after
deductible
70% coinsurance after
deductible
17. Human Organ and
Tissue Transplants
a) Inpatient
b) Outpatient
90% coinsurance after
deductible
90% coinsurance after
deductible
70% coinsurance after
deductible
70% coinsurance after
deductible
booklet for details on
covered transplants.
Transportation and
lodging services are
limited to a maximum
benefit of $10,000
per transplant;
unrelated donor
searches are limited
to a maximum benefit
of $30,000 per
transplant.
18. Enteral Formula and
Special Foods
90% coinsurance after
deductible
70% coinsurance after
deductible
that are prescribed or
ordered by a
physician as
medically necessary
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Services
Additional Information
19. Prescription
Drugs
a) Outpatient Retail
Pharmacy Drugs
b) Mail Order
Pharmacy Drugs
c) Specialty
Pharmacy Drugs
After deductible is satisfied you pay a tier 1 $10 copayment
per prescription, tier 2 $30 copayment per prescription, tier 3
$50 copayment per prescription, tier 4 30% copayment per
prescription when received from a contracted pharmacy or
30% copayment after deductible when received from a non-
contracted pharmacy
After deductible is satisfied you pay a tier 1 $10 copayment
per prescription, tier 2 $60 copayment per prescription, tier 3
$100 copayment per prescription, tier 4 30% copayment per
prescription for a 90-day supply.
After deductible is satisfied you pay a tier 1 $10 copayment
per prescription, tier 2 $30 copayment per prescription, tier 3
$50 copayment per prescription, tier 4 30% copayment per
prescription. Specialty pharmacy drugs are not available via
mail order.
The following applies to a), b) and c) above:
For the tier 4 outpatient retail pharmacy drugs or specialty
pharmacy dr
ugs, the maximum member copayment per
prescription is $250 per 30-
day supply at a contracted
pharmacy or a maximum member copayment per
prescription of $500 per 90-day supply for mail order.
Prescription drugs will always be dispensed as ordered by
your provider and by applicable state pharmacy regulations,
however you may have higher out-of-pocket expenses. You
may request, or your provider may order, the brand-name
drug. However, if a generic drug is available, you will be
responsible for the cost difference between the generic and
brand-name drug, in addition to your tier 1 copayment. By
law, generic and brand-name drugs must meet the same
standards for safety, strength, and effectiveness. This plan
reserves the right, at our discretion, to remove certain higher
cost generic drugs. For drugs on our approved list, call
customer service at (866) 837-4596.
Available up to a 30-day
supply.
Available only through a
contracted Pharmacy
Benefits Manager (PBM) mail
order service up to a 90-day
supply.
Not available at a
non-contracted PBM.
Available up to a 30-day
supply. Specialty pharmacy
drugs are high-cost,
injectable, infuse
d, oral or
inhaled medications that
generally require close
supervision and monitoring of
their effect on the patient by a
medical professional. They
are often unavailable at an
outpatient retail pharmacy or
mail order pharmacy since
these drugs may require
special handling such as
temperature controlled
packaging and overnight
delivery. These specialty
pharmacy drugs are available
only on an in-network basis
from
the PBM. Specialty
pharmacy drugs are not
available at non-contracted
pharmacies.
CDHP Disclosure (01-2014)
1
Benefit Summary Disclosure Information
This disclosure statement provides only a brief description of some important features and limitations of your plan. The
benefit booklet itself sets forth in the detail the rights and obligations of both you and the insurance company. It is
important that you review the benefit booklet once you are enrolled.
Coverage for treatment as part of a clinical trial:
Includes coverage for medical treatment provided in a Phase I, Phase II, Phase III or Phase IV clinical trial for the
treatment of cancer or in a Phase II, Phase III or Phase IV study or clinical trial for the treatment of chronic fatigue
syndrome conducted in the state of Nevada.
Coverage for medical treatment is limited to:
• Any drug or device approved for sale by the Food and Drug Administration.
• The cost of any reasonably necessary health care services required from the medical treatment or complications
thereof arising out of the medical treatment provided in the clinical trial.
• The initial consultation to determine whether the person is eligible to participate in a clinical trial.
• Health care services required for the clinically appropriate monitoring of the person during the clinical trial.
Coverage for the management and treatment of diabetes
Includes coverage for medication, equipment, supplies, and appliances that are medically necessary for the treatment of
diabetes type I, type II, and gestational diabetes.
Coverage for self-management of diabetes, including:
• The training and education provided to a person covered under the contract after initial diagnosis of diabetes which is
medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and
the proper use of equipment and supplies for the treatment of diabetes.
• Training and education which is medically necessary as a result of a subsequent diagnosis that indicates a significant
change in the symptoms or condition of the program of self-management of diabetes.
• Training and education which is medically necessary because of the development of new techniques and treatment
for diabetes.
Medically Necessary
An intervention that is or will be provided for the diagnosis, evaluation and treatment of a condition, illness, disease or
injury and that this plan, subject to a member’s right to appeal, solely determines to be:
• Medically appropriate for and consistent with the symptoms and proper diagnosis or treatment of the condition, illness,
disease or injury.
• Obtained from a physician and/or licensed, certified or registered provider.
• Provided in accordance with applicable medical and/or professional standards.
• Known to be effective, as proven by scientific evidence, in materially improving health outcomes.
• The most appropriate supply, setting or level of service that can safely be provided to the member and which cannot
be omitted consistent with recognized professional standards of care (which, in the case of hospitalization, also
means that safe and adequate care could not be obtained as an outpatient).
• Cost-effective compared to alternative interventions, including no intervention (“cost effective” does not mean lowest
cost).
• Not experimental/investigational.
• Not primarily for the convenience of the member, the member’s family or the provider.
• Not otherwise subject to an exclusion under the benefit booklet.
CDHP Disclosure (01-2014)
2
The fact that a physician and/or provider may prescribe, order, recommend or approve care, treatment, services or
supplies does not, of itself, make such care, treatment, services or supplies medically necessary.
Maximum allowed amount
Reimbursement for services rendered by participating and non-participating providers is based on this health benefits plan
maximum allowed amount for the covered service that the member receives.
NOTE: This plan will apply the in network level of benefits and the member will not be required to pay more for
the services than if the services had been received from a participating provider in the following circumstances:
• Emergency care (where rendered either within or outside the State of Nevada)
• Where in-patient hospital care at a non-participating hospital is necessary due to the nature of the treatment
• Where in-patient hospital care at a non-participating hospital is necessary due to participating provider hospital
capacity
• When a member has received a preauthorized network exception
Emergency
Emergency means a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that a
prudent person would believe that the absence of immediate medical attention could result in:
• Serious jeopardy to the health of the member, or
• Serious jeopardy to the health of an unborn child, or
• Serious impairment to bodily functions, or
• Serious and permanent dysfunction of any bodily organ or part.
Maximum Benefits
Some services or supplies may have an annual or lifetime maximum benefit, be sure to review you summary of benefits
for further details on what services may have a maximum benefit.
Limitations and Exclusions
This plan does not cover some services. The plan includes limitations and exclusions to protect against duplicate or
unnecessary services that could unfairly offset the cost of health care coverage for the entire plan. Following are
examples of the plan’s limitations and exclusions (please consult your benefit booklet for an exhaustive listing of
exclusions and limitations):
• Benefits provided under any local, state, or federal laws, including Workers’ Compensation and Medicare
• Cosmetic surgery
• Services by a family member
• Weight-reduction services and medications
• Complications from non-covered services
• Our payment allowance will be reduced or denied from what would have been paid if pre-certification is not obtained
prior to receiving inpatient hospital services and outpatient surgeries.
• Most services, such as non-emergency hospital admissions or surgical procedures require prior authorization.
• Alternative or complementary medicine. Services in this category include, but are not limited to, holistic medicine,
homeopathy, hypnosis, aromatherapy, massage therapy, reike therapy, herbal medicine, vitamin or dietary products
or therapies, naturopathy, thermography, orthomolecular therapy, contact reflex analysis, bioenergial synchronization
technique (BEST), clonics or iridology.
• Artificial conception
• Services received before the effective date of coverage.
• Biofeedback.
CDHP Disclosure (01-2014)
3
• Chelating agents except for providing treatment for heavy metal poisoning.
• Services or supplies provided as part of clinical research, except where required by law or allowed by Anthem.
• Convalescent care
• Convenience, luxury, deluxe services or equipment. Such services and supplies include but are not limited to, guest
trays, beauty or barber shop services, gift shop purchases, telephone charges, television, admission kits, personal
laundry services, and hot and/or cold packs, equipment or appliances, which include comfort, luxury, or convenience
items (e.g. wheelchair sidecars, fashion eyeglass frames, or cryocuff unit). Equipment or appliances the member
requests that include more features than needed for the medical condition are considered luxury, deluxe and
convenience items (e.g., motorized equipment when manually operated equipment can be used such as electric
wheelchairs or electric scooters).
• Court ordered services unless those services are otherwise covered under the certificate.
• Custodial care.
• Dental services, including accident related dental services, dental anesthesia for children, temporomandibular joint
therapy or surgery.
• Inpatient care received after the date Anthem, using managed care guidelines, determines discharge is appropriate.
• Hospital care if the member leaves a hospital against the medical advice of the physician, charges which are a direct
result of the member’s knowing and voluntary non-compliance of medically necessary care with prescribed medical
treatment are not eligible for coverage.
• Domiciliary care such as care provided in residential, non-treatment institution, halfway house or school.
• Services and supplies already covered by other valid coverage.
• Experimental/Investigative procedures.
• Genetic counseling.
• Government operated facility such as a military medical facility or veterans administration facility unless authorized by
Anthem.
• Hair loss, drugs, wigs, hairpieces, artificial hairpieces, hair or cranial prosthesis, hair transplants or implants even if
there is a physician prescription, and a medical reason for the hair loss.
• Hearing aids or routine hearing tests.
• Hypnosis, whether for medical or anesthesia purposes.
• This coverage does not cover any loss to which a contributing cause was the member’s commission of or attempt to
commit a felony which they are convicted of.
• Therapies for learning deficiencies and/or behavioral problems.
• Maintenance therapy.
• Services and supplies that are not medically necessary.
• Charges for failure to keep a scheduled appointment.
• Neuropsychiatric testing.
• Non-covered providers who include but are not limited to:
o Health spa or health fitness centers (whether or not services are provided by a licensed or registered provider).
o School infirmary.
o Halfway house.
o Massage therapist.
o Nursing home.
CDHP Disclosure (01-2014)
4
o Dental or medical services sponsored by or for an employer, mutual benefit association, labor union, trustee, or
any similar person or group.
• Non-medical expenses, including but not limited to:
o Adoption expenses.
o Educational classes and supplies not provided by the member’s provider unless specifically allowed as a benefit
under this benefit booklet.
o Vocational training services and supplies.
o Mailing and/or shipping and handling expenses.
o Interest expenses and delinquent payment fees.
o Modifications to home, vehicle, or workplace regardless of medical condition or disability.
o Membership fees for spas, health clubs, personal trainers, or other such facilities even if medically
recommended, regardless of any therapeutic value.
o Personal convenience items such as air conditioners, humidifiers, or exercise equipment.
o Personal services such as haircuts, shampoos, guest meals, and radio or televisions.
o Voice synthesizers or other communication devices, except as specifically allowed by Anthem’s medical policy.
• Upper or lower jaw augmentation or reductions (orthognathic surgery) even if the condition is due to a genetic
congenital imperfection or acquired characteristic.
• Any items available without a prescription such as over the counter items and items usually stocked in the home for
general use including but not limited to bandages, gauze, tape, cotton swabs, dressing, thermometers, heating pads,
and petroleum jelly. This coverage does not cover laboratory test kits for home use. These include but are not limited
to, home pregnancy tests and home HIV tests.
• Benefits are not provided for care received after coverage is terminated.
• Private duty nursing services.
• Private rooms are not covered.
• Charges for services and supplies when the member has received a professional or courtesy discount from a provider
or where the member’s portion of the payment is waived due or professional courtesy or discount.
• Peripheral bone density testing. This coverage does not cover whole body CT scan or routine screening except as
described by medical policy or as provided in the benefit booklet.
• Charges for the preparation of medical reports or itemized bills or charges for duplication of medical records from the
provider when requested by the member.
• Services or supplies necessitated by injuries which a member intentionally self-inflicted, except where the law
prohibits such an exclusion.
• Services or supplies related to sex change operations, reversals of such procedures, complications of such
procedures, services, supplies or medications related to a sex change operation.
• Treatment of sexual dysfunction or impotence including all services, supplies or prescription drugs used for the
treatment.
• Services and supplies which may be reimbursed by a third party
• Travel or lodging expenses for the member, member’s family or the physician except as travel or lodging expenses
related to human organ and tissue transplants.
• Routine eye examinations, routine refractive examinations, eyeglasses, contact lenses (even if there is a medical
diagnosis which requires the use of contact lenses), or prescriptions for such services and supplies. Surgical, medical,
or hospital service and/or supply rendered in connection with any procedure designed to correct farsightedness,
nearsightedness, or astigmatism. Vision therapy, including but not limited to, treatment such as vision training,
orthoptics, eye training or training for eye exercises.
CDHP Disclosure (01-2014)
5
• Services or supplies necessary to treat disease or injury resulting from war, civil war, insurrection, rebellion, or
revolution.
• Acupuncture except for pain management and chiropractic services except for spinal manipulation. Limited to a
combined maximum of 12 visits per calendar year.
• Whole blood, blood plasma and blood derivatives received from community sources or replaced through donor credit.
• Bariatric surgery services.
• Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or
other surgeries) when services are rendered for cosmetic purposes.
• Treatment for autism spectrum disorder.
• Hospice care is covered, but supportive care and services to the family after the death of the patient are not covered.
• Off-label use of FDA-approved prescription drugs.
Rate determinations
Rates are calculated based on allowable case characteristics of member age, geographic rating area, dependent
enrollment, and tobacco use.
Provider Directories
Copies of provider directories may be obtained by calling the customer service department or accessing the information
on our Internet site at www.Anthem.com.
Provider Network
Under this plan, members choose physicians, hospitals and other health care providers from the Anthem preferred
provider organization (PPO) network. Using the PPO network can mean substantial savings. If care is received outside
the PPO network, the member will pay a higher deductible and coinsurance and charges over the Maximum Allowed
Amount.

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