Small Group product guide

Transcription

Virginia | Effective January 1, 2016
Small Group
product guide
We put the same passion into our health plans,
that you put into your business
53744VAEENBVA 01/16
Running a small business takes courage and a lot of hard work. You make
important decisions every day. And choosing the right health plan is
definitely one of them.
accessible
That’s why we’ve made it easy, with plan designs that speak to who you
are, how you run your business and your bottom line. And because you’re
choosing a plan from Anthem Blue Cross and Blue Shield and/or its
affiliate HealthKeepers, Inc. (Anthem),1 you can count on the quality and
stability our customers have come to know for over 75 years.
affordable
Today, we want you to know, it’s your purpose that’s at the heart of our
promise: To build the ultimate benefits package for every single type of
small business and make it accessible, affordable and personal.
personal
Now let’s find you the perfect plan.
1 Anthem HealthKeepers products are offered by HealthKeepers, Inc. and all other products referred to in this piece are offered through Anthem Blue Cross and Blue Shield.
Welcome to Anthem and
HealthKeepers, Inc. for
small businesses
Tell us about you
Your size, your people, your budget
Do you like your current plan, but need to lower costs? Check.
}}
Would your employees like incentives to stay healthy? Got them.
}}
Want a high-deductible plan that offers more ways to save? Done.
}}
Are you a big fan of lots of bells and whistles? Ring.
}}
We’re ready to give you that special something you won’t find anywhere else. And like
any great relationship, when you’re happy, we’re happy. And that’s pretty healthy.
So let’s get to it!
1
Accessible
Welcome to a new kind of doctor-patient relationship
created just for our members
It’s called Enhanced Personal Health Care and it’s the kind of care everybody wants
Our new model puts patients in a unique circle of care, making them the central focus on a team approach
to their overall health. We do this by:
Paying doctors for value over volume when they improve patient health, meet quality standards and
lower costs.
}}
Giving doctors added support with the right tools and strategies to help strengthen the doctor-patient
relationship so they can spend more time with patients and coordinate their care with other doctors.
}}
Improving the patient experience with better access to a primary care physician (PCP) who cares for the
“whole person” and becomes their health care champion and helps them navigate the health care system.
}}
Value over
volume
Detailed patient
reports
Better
coordinated care
Proactive health
and wellness
More convenient
access
A stronger doctorpatient relationship
Providers benefit from
Tools and resources
Rewards for meeting
quality standards
Patients benefit from
More doctorpatient time
Quality-driven care
A personalized
care team
Enhanced Personal Health Care: a physician’s perspective
“ This partnership is truly refreshing. It’s a practice that’s centered on the patient. That’s why
we have extended hours and systems in place to try and help the patients receive the care
that they require. It’s a win for everybody. The more doctors we can get involved in the
process, I think the better the health care system in general will be.
”
2
– Frank Maselli, M.D., Family Practitioner, Riverdale Family Practice
Accessible
Total In-Network PCP numbers are data
collected as of July 2015.
Enhanced Personal Health Care
is patient-centered and
compensates doctors for the
quality of care they give, not the
number of patients they see.
54,639 network providers
participate in Enhanced Personal Health Care (EPHC)
21%
Those providers care for approximately
4.0 million members
of members are already
attributed to an EPHC provider
46%
of network providers
already participate in EPHC
The advantages are undeniable
}
Fewer inpatient and emergency
room visits
}
Reduced re-admission rates
Significant increase in referrals to
preferred labs
Increased provider follow-up visits
after a patient is discharged
More weekend hours for members
}
Improved quality and utilization scores
3
Accessible
Employees have access to care, anytime, anywhere with
LiveHealth Online — all it takes is an Internet connection
With LiveHealth Online, your employees can have face-to-face
conversations with board-certified doctors right from their
computer or mobile device, 24/7. In just seconds, they can connect
to a doctor to address nonemergency health issues right away.
No driving, no waiting, in no time!
ACCESSIBLE
INNOVATIONS
DOCTORS AT THE
IN CARE = SPEED OF
LIGHT
LiveHealth Online employee benefit
No appointments, no waiting rooms
}}
Easy to use
}}
LiveHealth Online employer benefit
Innovative solution—a quick and easy way for your
employees to see a doctor
}}
Increased productivity—employees will spend less time
traveling to, and waiting at, other sites of care
}}
Board-certified doctors
}}
Available for nonmembers
}}
Doctors diagnose health issues and may
prescribe medicine1
}}
Cost effective (average fee of $49)
}}
2
4
92%
85%
85%
90%
had a positive
experience
resolved
their issue
avoided
extra costs
reported
saving time
2 LiveHealth Online Consumer Post Visit Survey results.
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raessitatur? Rum idus et eribusam reic tese
LiveHealth Online
delivers
high
member satisfaction
dolupita
sum
lacitaquam
aut pratur abo.
1 Prescription availability is defined by physician judgment and state regulations. LiveHealth
Online is available in most states and is expected to expand to more in the near future. Visit
the home page of livehealthonline.com to view the service map by state.
To learn more,
watch the videos at
livehealthonline.com
The power behind a Blue Cross and Blue Shield plan
Our strength is backed by some serious numbers
Providing health coverage for more than 100 million members is pretty powerful, but we’re also about creating healthier
communities and investing in the future for our people and our businesses.
100%
92%
DEEP NETWORK
DISCOUNTS
SOURCE: Blue Cross Blue Shield Association, 2013 statistics.
VA Acute care hospitals
are in-network2
+
LARGEST
NETWORKS
+
2x total membership than our
largest competition
1 in 3 Americans
97%
U.S. Hospitals are in the
BlueCard® program1
U.S. Doctors are in the
BlueCard® program1
2 Internal data, July 2015.
1 Blue Cross and Blue Shield Association, 2013 statistics.
That means you, our small business employers. When you choose Anthem and HealthKeepers, Inc., you’ll enjoy
unparalleled network discounts, innovative health and wellness programs and access to the highest quality of care.
is covered by a Blue Cross and Blue Shield plan
SIGNIFICANT
SAVINGS
=
HIGHEST
MEMBER SATISFACTION
RATINGS
600K new members
for 2014, plus 250,000 for 2015
381 Fortune 500 companies
have a Blue Cross and Blue Shield plan
5
.... Affordable
Medical plans to fit every type of business need
With unbeatable health and wellness extras that deliver superior long-term value
Get ready to meet your match! No matter what the size of your business and your unique needs and
preferences, you’ll find the right health plan, right here. We offer a full range of high-quality plans for every
budget. Our commitment to you is to get it exactly right.
Here’s a brief explanation of the types of health plans we offer. For specific information, you can refer to the
product grids at the back of this brochure.
A preferred provider organization allows members to see providers in network or out of network. Members
pay substantially less out of pocket when they use a provider in the PPO network. There’s no need to get a
referral to see a specialist.
PPO
Point of service allows members to see providers in the network or outside of the network. Members pay
substantially less out of pocket when they use a provider in the POS network. To see a specialist, members must
get a referral from their PCP.
POS
Open access point of service allows members to see providers in the network or outside the network.
Members pay substantially less out-of-pocket when they use a provider in the OAPOS network. No referrals
are needed to see specialist.
OA
POS
HDHP
High-deductible health plans feature higher deductibles than traditional insurance plans. They can
be paired with a health savings account or a health reimbursement account allowing members to pay for
qualified out-of-pocket medical expenses.
HSA
Health savings account is a savings account members can fund with pretax dollars and
apply toward qualified health care expenses, including prescriptions.
HRA
Health reimbursement accounts are funded by a yearly allocation from employers and are used for
first-dollar coverage.
Shared funding is a new funding solution for Small Group employers with 15 to 99 or more employees.
It’s similar to a fully insured plan where employers pay a fixed payment based on enrollment each month, but if
employees are healthy and have low usage of benefits, then employers could get money back at the end of the year.
6
Affordable
If you’re looking for a
new option with
savings potential, then
shared funding could
be right for you
With a fully insured plan, you pay a set
premium each month (varies only by
enrollment) and no matter how much or
how little your employees use the plan,
you pay the same amount. With Anthem
Shared Funding, you get the same
predictability of a fully insured plan with
fixed monthly payments, but when your
group’s claims are better than expected,
you could get money back. You can also
save on some of the premium and health
care reform taxes!
How does shared funding work?
You make a fixed monthly
payment that covers all of
your health care costs
Unlike fully insured plans, if you
have a healthier than expected year,
you could get money back
Predictable monthly payments with
a limit on financial responsibility
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iliscius raessitatur? Rum idus et eribusam reic teseSAVE ON
EXCESS
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ipsa dolupita sum
CLAIMS
lacitaquam aut pratur abo. Toris ute quibus volupit plibust
ENJOY COVERAGE FOR
premium tax and
health care reform taxes
7
.... Affordable
Pharmacy benefits
Together with medical — better and easier than ever
You may not know it, but pharmacy benefits are the most widely used benefits. That’s why we’re
not just pricing a bottle of pills, or focusing on pharmacy costs alone — we’re looking at the
bigger picture — the value of better health.
And we make it easy. You can offer your employees access to the care they need and you get
one seamless, simple experience: one website, one contact, one account team, one contract
and one invoice. Our pharmacy and medical experts are at the same table, have the same
resources and work together to help your employees live healthier.
Better health and lower costs of care begin with
better medication management
With our pharmacy, clinical and cost-of-care programs, we are helping your employees live healthier.
Helping manage
chronic conditions
Addressing
medication gaps
Improving adherence
to taking medications
as prescribed
Saving money with generics,
home delivery and a broad
network of pharmacies
Here’s how we do it
Medication Review
A confidential pharmacy summary for
MyHealth Note
A confidential health care summary for
8
When pharmacy and medical are combined, we can target members with specific
messaging such as cost savings for generics and therapeutic equivalents. And we can coordinate
that messaging between the member and the physician to identify and close gaps in care, switch
members to more effective and less expensive drugs and communicate safety concerns.
Medication Review
MyHealth Note
A monthly member mailing that
includes recent pharmacy claims,
information about current drugs
they’re taking, safety concerns and
ways to save money.
By combining members’ medical,
pharmacy and lab data with benefit
information, we can make
recommendations, coordinate with
doctors and notify members.
Medical
Pharmacy
More effective and affordable
health care
Outcomes for MyHealth Advantage using our pharmacy data when compared to carveout pharmacy data. Results based on most recent, measureable 12 months of data
available for clinical and cost-of-care programs for enterprise commercial business.
By combining medical and pharmacy and
coordinating these benefits systemwide, we are writing
a prescription for more effective and more affordable
health care for you and your employees.
The results
speak for
themselves
28%
37%
26%
MORE
MORE
MORE
gaps in care
identified
accurate
communications
sent to members
gaps in care
closed within
12 months
Let’s get technical
with pharmacy
It’s easy to fill p escriptions, check copays or
coinsurance and more by going to anthem.com
or downloading our mobile app.
We are closing the gap between giving members
information and getting them to act on it.
9
.... Affordable
For all your health care needs,
Anthem is your total health solution
See how our medical, dental, vision, life and disability
plans work together for your employees health and
your bottom line.
Strong alone,
better together
Meet your one carrier, one solution: Anthem Whole Health ConnectionSM
Clinically coordinated care
through our connected
health plan portfolio
We believe health care should serve the whole person — head to toe,
at each stage of life. It should also be easy to administer, so you don’t
get bogged down in paperwork.
}}
Let us tell you about how you can have one solution for all your
Benefits from one source,
so you spend less energy
managing multiple plans
}}
health benefits needs.
Through electronic health records, we get claims and clinical data
from network dentists, eye doctors, primary care physicians and
care coordinators, which allows us to create more complete health
profiles for our members.
Strong local and
national networks
}}
Competitive pricing
}}
The advantages can’t be matched by even the best stand-alone carriers.
A brand you can trust
}}
Medical
Dental
Disability
Vision
Life
Anthem Whole Health Connection
10
Quality care.
Lower costs.
88%
89%
82%
of employers say increased provider
communications improves care
of employees believe they’d get
better service with connected plans
of employers understand that
integration saves money
SOURCE: Internal survey data
Real choice.
Anthem dental
Our Dental Prime and Dental Complete plans are built for greater choices, better oral health
and ultimate business value.
A huge network
Access to one of the largest dental networks in the nation,
with 98,000+ unique dentists and 251,000
access points
30% to 32%
International emergency
average savings on covered services1
1 Average in-network claims savings for Dental Complete plans.
2 Academy of General Dentistry Know Your Teeth website: Warning Signs in the Mouth Can Save Lives. (Rev. January 2012).
Dental program for emergency services while traveling
or working abroad
We’re helping change the face of health care by
simplifying how our medical and dental plans
work together — delivering more complete care
at an affordable cost with less hassle.
Medical
Dental
Better overall health
Good dental health and early detection can play an important role in helping your employees stay healthy.
In fact, 90% of the body’s diseases show signs and symptoms in the mouth.2
Dentists often have the first opportunity to notice early signs of a chronic disease. Our Dental Prime and Dental
Complete plans offer these benefits for optimal oral and overall health.
That’s why many of our plans have 100% coverage for preventive services, such as exams, cleanings and X-rays.
In addition, we have automatic enrollment for an additional cleaning or periodontal treatment for pregnant and
diabetic members engaged in one of our diabetic or maternal health care management programs.
For product details, see the grid at back of this brochure.
Brush biopsy
benefit to help detect oral cancer
100% in-network
coverage
Extra cleaning or
peridontal treatment
for cleanings, exams and X-rays
for pregnant and diabetic members
“Ask a hygienist”
Email questions to licensed dental
professionals and get quick, private
personalized advice at no extra cost
11
More doctors, better discounts and
a clear path to overall health with Blue View VisionSM
3X
Vision care plays a powerful role in early detection and more
effective management of chronic conditions. In fact, eye exams
are an important avenue to identify high-risk conditions like
diabetes, high blood pressure and high cholesterol.
Medical
Vision
Total health view
People are 3x more likely to get an annual
eye exam than an annual physical1
Members can use in-network
benefits and get savings from:
When we connect Blue View Vision with our medical plans
through electronic health records, providers can see the
total health of the member which helps them deliver better,
more informed care. It also leads to lower costs and simplified
plan management.
Connection of care2
Claims and clinical data go into members’ electronic health files
}}
Vision providers can see information quickly
}}
Automatic referrals go to our ConditionCare program if a health issue is found
}}
For a list of Blue View Vision plans, see the grid at the back of this brochure.
Bigger discounts
More doctors
The industry’s best discounts including
35% to 40% off extra glasses3
Less hassle
Over 33,000 doctors at more than
26,000 locations nationwide
Simplified administration from
enrollment through claims processing
At the heart of Anthem’s more personalized approach to
health care is building better connections between employers
and employees, patients and doctors, people and better health.
12
1 Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion.
2 Any member information, claims data and health history shared is relevant and HIPAA-compliant.
3 Laws in some states may prohibit network providers from discounting products and services that are not covered benefits under the plan.
.... Affordable
Anthem vision
Let’s protect your employees against the unexpected
It’s time to talk about life and disability coverage that goes way beyond a check.
When a life-changing event happens, you can count on Anthem to be there with superior service
from a caring staff, quick payment of claims and support services for employees and their families.
We offer a wide variety of options, so you can tailor a benefits program to your employees’ needs
and your budget, all from one single point of contact.
}}We can help you with Social Security
disability filings and approvals
Anthem life and disability features
}}You get a designated service team with
industry-leading claims turnaround
times with 99.9% accuracy*
Timely payments and support services
}}
}}Identity theft recovery services
Benefits employees can use before and after a loss
}}
Simplified benefit administration and dedicated customer service
}}
Support services that help employees get back to work and back to life
}}
}}All customer service calls are
answered live
*Internal data 2014
Personalized service from Claims Management team
}}
Long-term
disability
Short-term
disability
Voluntary
Anthem life
and disability
Life
Accidental
death and
dismemberment
L
E
-A
DD
ED
Resource
Advisor
E
C
N
ENHA
E
VA
U
N
Beneficiary
Companion
Travel
assistance
TS
comprehensive plans
with special features
M
13
.... Affordable
Life and disability
A new way of looking at it
90%
When it comes to life and disability insurance, we do more than just send a check.
We give employees and their families valuable extras.
of disabilities are caused by illness,
not accidents1
Travel assistance
Members with life coverage have a safety
net if an emergency arises while they’re
more than 100 miles away from home
Medical
Resource Advisor
Emotional, legal and financial support for
members with life and disability coverage
Disability
Improved outcomes
When you package disability
with one of our medical plans ...
your employees are connected with teams of
clinical, behavioral health, vocational rehabilitation
and counseling specialists who can help them get
back to life and back to work.
Beneficiary Companion
You get Guaranteed Issue!
Newborn Parenting
Resources
Provides eight weeks of personal life coaching
services to help new mothers transition back to
work and work-life balance2
14
That means some of our life and disability
coverage options are available without your
employees having to go through health
underwriting — and there are no health
questionnaires to fill out.
1 Council for Disability Awareness, Chances of a Disability, 2012.
2 Available with short-term disability.
Help for families after a death, dealing with death
certificates, creditors and more for members
with life and disability coverage
15
.... Affordable
You want to offer dental, vision, life and disability
coverage, but you just can’t cover the cost.
That’s ok. We’ve got another way.
100%
paid by the employee
16
We understand it can be a tough balancing act. You want to
offer a competitive benefits package that helps attract and
retain the best employees, but your dollars only go so far.
That’s why we offer a voluntary portfolio for dental, vision, life
and disability plans at no extra cost to you. You pick the plan
designs and your employees choose the coverage at affordable
group rates. And because the employee pays 100% of these
costs, there is no negative impact on your bottom line.
Voluntary plans offer you a way
to strengthen the value of your
benefits plan and improve employee
satisfaction, at no extra cost to you.
No extra
cost
17
Personal
Take your employees’ health (and yours) to the next level
With our Total Population Health solution
It’s time to get personal. Everyone has their own unique set of health issues and goals. So we built our
wellness programs to speak to everyone on the wellness spectrum — from the super healthy to those
needing immediate support. Our programs are managed by a team of experts who connect members
to the right programs for their specific needs. This way, no one falls through the cracks.
Medical directors
Care management nurses
Disease management
Total Population Health connects
primary care providers and our health
management teams for better results.
LiveHealth Online
Doctor and member connections
Pharmacy
Clinical programs
Medical management
}}
Health coaching/advocacy
}}
Disease management
}}
Behavioral health
}}
Maternity
}}
Gaps in care
}}
18
Specialty
Behavioral health
Wellness programs
Lifestyle improvement programs
(Healthy Lifestyles)
}}
Preventive alerts
}}
24/7 NurseLine
}}
Online resources
Well-being Assessment
}}
Discounts
}}
Provider cost/quality information
}}
Online wellness coaching
}}
Communication campaigns
}}
\\\|
MyHealth Advantage is an outreach
program that helps members stay current
with their health care and save money. By
analyzing member health data and history,
the program identifies possible health risks,
care gaps and savings options. Care gaps are
sent to providers as well to ensure the best
care possible.
24/7 NurseLine is staffed with registered
nurses who are just a phone call away at any
time. Nurses can answer questions about a
medical concern or help members choose the
right level of care. Members can call the same
phone line and listen to hundreds of health
topics in the AudioHealth Library. The recordings
are available in English and Spanish.
Healthy Lifestyles is an online health
resource that helps members transform
their behaviors and improve their health
in a variety of areas including weight,
nutrition, physical activity, tobacco use,
stress and depression. Some plans may
include incentives.
LiveHealth Online gives members 24/7
access to doctors through a mobile device or
a computer with a webcam. Board-certified
doctors can evaluate nonemergency illnesses
or conditions and prescribe basic
medications, if needed,3 for $49 or less
depending on health plan benefits.4
The ConditionCare program teams up
members with nurse coaches and other
health professionals who give them
holistic, integrated and seamless health
management for chronic conditions
including asthma, chronic obstructive
pulmonary disease (COPD) and heart disease.
Of those members in the program, 90% were
satisfied with their ConditionCare nurse
interactions and felt the tools and materials
were easy to understand.1
Case Management nurses help members
deal with complex health issues and
navigate the health care system. Backed by
a team of physicians, pharmacists, exercise
physiologists and others — our nurses have
the latest information on treatment options.
Future Moms helps moms-to-be have a
healthy pregnancy. Experienced nurses
provide individualized care for pregnant
members to help ensure a full-term, healthy
baby. Of those members in the program,
90% said the information and tools helped
them have a healthy pregnancy.2
Personal
Find a whole world of health and wellness programs right here with your Anthem plan.
The Cancer Care Quality Program is
a new innovative initiative that allows
oncologists to compare planned cancer
treatments against evidence-based clinical
criteria and potentially receive enhanced
reimbursement. A goal of the program is to
promote access to quality, evidence-based,
affordable health care for our members and
to provide the framework to begin changing
the cancer care paradigm. This program also
allows our members to be identified earlier
for our Case Management program.
1 Voice of the Customer 2014 Year-End Annual Wellness Report for ConditionCare.
2 Internal Health and Wellness Solutions Member Satisfaction Study, 2014.
3 Prescription availability is defined by physician judgment and state regulations. LiveHealth Online is available in most states and is expected to expand to more in the near future.
Visit the home page of livehealthonline.com to view the service map by state.
4 Doctors using the LiveHealth Online tool charge an average fee of $49.
19
Testimonials
Personal
Vince, IT
Future Moms
Vince is the go-to guy for computer issues and
almost everything else technical. Always in
control, no one thought he’d be such a
Meet
SB Office
Supplies
Devon, Operations
Healthy Lifestyles
When the office elevator went out, Devon had to
walk up two flights of stairs. By the time he got
to his desk, he looked like he was caught in a
nervous wreck when he found out his wife,
downpour. Unfettered, he grabbed his usual
Mary was expecting. He’s been hounding
breakfast doughnut and opened his first email.
everyone with questions, even the mail lady.
Michelle, the office manager tells him about
Anthem’s Future Moms program and gives
It was from Anthem’s Healthy Lifestyles program
A story of health and
wellness benefits in action
him the number. As soon as he gets home,
and it was about weight management! He
double checked to see if maybe it was actually
from his wife. But then he remembered
Vince and Mary call Future Moms and are
doing an online health survey at
connected to Mandie, a registered
anthem.com where he answered questions
nurse who talks to them about risk
about his weight concerns. Maybe it was
factors, screenings and healthy choices
a sign. He logged into Healthy Lifestyles,
for safe deliveries. Mandie is going to
completed his personalized well-being plan
SB OFFICE SUPPLIES
send them books and more resources
and made a commitment to start working
and tells them to call anytime because
toward his health goals. Now he has access to
Future Moms nurses are available 24/7.
resources for weight management, online tools
Mary called back twice, that night.
for fitness and nutrition and support from online
coaches and communities.
Georgi, Accounting
24/7 NurseLine
Raja, Warehouse
ConditionCare
Raja,
Warehouse
Mark, Sales
ConditionCare
LiveHealth Online
Georgi’s daughter, Tina, is an 8-year-old soccer fiend who
Raja never
has dealt
stops
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his coughing
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defi
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nitely wrong.
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when she
and feels an asthma
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The nurse says Tina’s temperature
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One of nurse, Kacey, who
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the to
world
an urgent
because
care
she had these
down,
great
Raja talked with Kacey about
to send
taking
her information
her
and
Mark
helpful
can’t resources
believe he’s
and
connected
maybe she’ll
with even
a
resources
center.
Theatnurse
her fifingertips
nds several
to help
in-network
her child get better quickly.
medication, using an inhaler and
throw
avoiding
in some earplugs. board-certified doctor in seconds who gives
urgent care centers near Georgi. One of them is
triggers. Kacey promised to follow up with Raja
him a diagnosis: “You have a virus. Go home,
right around the corner. Soon Tina is back up to
soon, but in the meantime, she plans to send
get some rest and if you don’t feel better in a
speed and Georgi feels like the best mom in the
her information and helpful resources and
few days, follow up with your primary care
world because she had these great resources at
maybe she’ll even throw in some earplugs.
doctor.” Mark follows the doctor’s directions
her fingertips to help her child get better quickly.
20
and the whole office feels better.
So what else can we do for you?
A lot! We’ve got great tools and resources to make managing health care easier than ever.
Like any great relationship, we’ll always be right by your side so your employees can find the help they’re
looking for, whatever their health needs and goals. And we’ve made it easy for you to get started.
Here’s what we’re talking about:
 A wellness toolkit to help you create a culture of health, right at work
Time Well Spent® is our online health and wellness resource that has all kinds of ways to communicate
important health information to your employees about specific health issues (like diabetes and asthma)
and overall health improvement. It comes at no extra cost to you and has information on dental, vision,
life and disability — and even some in Spanish. Here’s just a sample:
Start your company’s journey to wellness!
Health kits
Health articles
Promotional materials
Wellness Calendar
Employer guide to wellness
Go to timewellspent.anthem.com
 Easier plan administration
EmployerAccess at anthem.com has everything you need for more efficient benefits administration.
Our quick, easy-to-access online tool makes it simple to enroll members, check eligibility, view your
contract, check on coverage and more — in one spot. It’s our job to help you save time and make doing
business with us easier than ever before.
With EmployerAccess you can:
PAY BILL
Process enrollment changes
View your group’s benefits
View and pay bills
Add new subscribers
Register online today
Just go to anthem.com, select Employer and then your state. It’s that easy.
21
Personal
We’ve also got all this for your employees ...
 Connect to care anywhere with our mobile app
Our Anthem mobile app can make it easier than ever for your employees to manage their health
care. They can just download the free app and always be prepared.
Find a doctor
Get a virtual ID card
Compare provider
costs and quality
Manage prescription
benefits
View claims
Download today
Available for free from Google PlayTM or the App StoreSM.
 Visit a doctor with our LiveHealth Online app
Employees can connect to a doctor anytime, anywhere. They can sign up for
LiveHealth Online and have a face-to-face conversation on their computer or
mobile device.
 Visit anthem.com for 24/7 information
Get tools and resources on topics like nutrition, weight loss and tobacco use
}}
Join online communities for added support from people with similar experiences
}}
Find a doctor or hospital in the network and nearby
}}
Compare and evaluate different hospitals for quality and cost
}}
Get discounts on healthy living products and services
}}
Order a new ID card or print a temporary one
}}
View benefits or check on a claim
}}
Submit benefit questions
}}
22
anthem.com
 Getting more social
We’re bringing health and wellness to the forefront of daily living by sharing the health with our
members and the entire social stratosphere. So while you’re posting, sharing, tweeting or just
plain emailing, why not add a little health into the mix?
Just search “Health. Join in.”
Follow us for motivation, inspiration, recipes, workouts and some great healthy fun.
Anthem.com is now
available in Spanish:
es.anthem.com
23
What’s new for 2016?
See what upcoming Affordable Care Act changes could mean for your group
Beginning on January 1, 2016, the Affordable Care Act (ACA) redefines the number of
employees that make up a small group. Currently, small groups are defined as having
2 to 50 employees, but in 2016, the definition changes to having 2 to 100 employees.
This change will affect the types of health plans that groups with 51 to 100 employees can
choose from. It also changes the way premiums are calculated and how groups are rated.
Rating methods
In 2016, Anthem will be offering composite and member rating for small group employers
with 2 to 100 employees on ACA-compliant plans.
2015/2016 member rating
2016 ACA-composite rating
This is the process of calculating health
insurance premium costs separately for each
employee and enrolled dependents based on
their age. For example:
The cost of coverage is averaged over the
entire group, so everybody pays the same
regardless of age. Rates are broken out by
contract types, for example:
Employee rate = employee premium
Employee
Employee rate +
spouse/dependent rate =
family premium*
Employee + spouse
Employee + child(ren)
Family
* Rates capped at three dependents under the age of 21.
More resources to help you
Learn more about ACA, also known as health care reform, by going to our blog
at blog.makinghealthcarereformwork.com. Here you can stay up to date with
the impacts and changes that may affect your business. See what leading
industry experts have to say about ACA, wellness in the workplace and the best
ways to manage costs.
24
Pediatric vision EHB
All of our Small Group medical plans include pediatric vision essential health benefits for covered
children up to age 19, which includes coverage for vision exams and glasses or contacts. Members can
see any provider in the Blue View VisionSM network, which includes retailers such as 1-800 CONTACTS®,
LensCrafters®, Pearle Vision®, Sears OpticalSM, Target Optical® and JCPenney® Optical.
Covered children can choose from a selection of frames and contact lenses.
Pediatric vision EHB benefit grid
In-network
Out-of-network1
Routine eye exam (once every calendar year)
$0 copay
$30 reimbursement
Lenses — single, bifocal, trifocal (once every calendar year)
Lens treatments
UV coating
Standard factory scratch coating
Standard polycarbonate lenses
Standard Transitions® lenses
Standard progressive lenses
$0 copay
$25, $40, $55 reimbursement
Covered in full
Covered in full
Covered in full
Covered in full
Covered in full
N/A
N/A
N/A
N/A
$40 reimbursement
Frames (once every calendar year)
$0 copay, Formulary
$45 reimbursement
Elective contact lenses
(once every calendar year — in lieu of eyeglasses)
$0 copay, Formulary
$60 reimbursement
Nonelective contact lenses (once every calendar year)
Covered in Full
$210 reimbursement
1 Out-of-network usage will follow medical. PPO medical plans will have OON and HMO medical plans will not have OON.
Pediatric dental EHB
All of our small group medical plans include pediatric dental EHBs, which provide important coverage
for kids up to age 19, including preventive care, fillings and more extensive services like medically
necessary orthodontia. Members can see any provider in the Dental Prime network.
Pediatric dental EHB benefit grid
In-network
Out-of-network
Diagnostic and preventive services
(cleanings, exams and X-rays) — not subject to deductible
90%
70%
Basic services (fillings)
60%
50%
Endodontic, periodontal, oral surgery and major services
50%
50%
Medically necessary orthodontia (12-month waiting period)
50%
50%
Because these benefits are part of a medical plan, they share a combined deductible and
out-of-pocket maximum. Diagnostic and preventive services like cleanings, exams and X-rays are
not subject to the deductible, so members can take advantage of them right away. These benefits
have no annual maximum.
25
It’s time to
meet your match
You’ll find it here, in one of the most comprehensive
product portfolios in the market
We know each employer has a unique mix of employees and needs. So we designed
a great portfolio of plan options that allows you to create the ultimate benefits
package that’s perfect for your group. It’s a simple but strong strategy that gets right
to the heart of the matter: the health of your business.
So let’s get started. See which type of plan speaks to
what’s most important to you.
Like what you
have, but need
lower costs?
26
Employees
have healthy
living down to
a science?
Want savings
for you and your
employees?
How about a health
plan with all the
bells and whistles?
Basic plan design
For employers who want to keep the type of
plan they have, but need to lower costs
If you like your current plan, but the cost has got
you worried, this can be a great option. Do you
like predictable costs (like knowing copay amounts
for office visits)? You can still offer that, but save
money by increasing the cost share when an
employee uses a benefit, for example, with higher
copays and deductibles:
Same great products and benefit structure
}}
Same great network
}}
Higher copays and deductibles
}}
Lower premiums
}}
In-network preventive care covered 100%
}}
In the product grids that follow, start with our silver
and bronze plans.
High-deductible
health plans
An alternative benefit option that offers
savings for you and your employees
When employees have a greater stake in the game,
they’ll most likely make smarter health care
decisions and use their benefits more wisely. With
this plan option, employees have more control over
how they spend their health care dollars, and could
save on premiums. These plans, also known as
consumer-driven health plans (CDHP)s, can be paired
with a health savings account (HSA), which offers tax
savings to employees, or an employer-funded health
reimbursement account (HRA):
Higher deductibles
}}
Lower premiums
}}
HSA-qualified plan options
}}
}}
Healthy Support
In the product grids that follow, look for HSA or HRA
in the plan name.
If your employees have healthy living down
to a science, you can actually bank on that
There’s value in healthier employees, and here’s a
good way to make that work for everyone. These plans
are like our basic plans, but offer some additional ways
to bring the price down. It also gives employees
incentives for getting healthy and staying healthy:
Anthem Select Drug List designed for more
savings, like using more generics
}}
Wellness package provides up to $700 in
incentives for employees who take healthy actions
A richer plan design
The one with all the bells and whistles
These are the plans that your employees may be
most familiar with. They have predictable costs, like
offering lower copays and deductibles. And
employees have access to a strong network of
doctors and hospitals, so there’s a great chance they
can stick with the doctors they know and love:
}}
}}
In the product grids that follow, look for plus in the
plan name.
Rich benefits
}}
Large networks
}}
Most inclusive list of covered drugs
}}
}}
In the product grids that follow, start with our
platinum and gold plans.
27
Product details
The plan naming structure includes these elements:
brand + metal tier + product type + copay or deductible/coinsurance/out-of-pocket maximum
Platinum plans
POS
PPO
Plan
type
Plan name
Contract
code1
Network name (CY/PY)
Out-of-pocket
Embedded/
Deductible
maximum
nonembedded2 (individual/family) Coinsurance (individual/family)
Anthem Platinum PPO 10/10%/2500
KeyCare
1NBP/1N5D
Embedded
N/A
10%
$2,500/$5,000
KeyCare
1P55/1P57
Embedded
N/A
10%
$4,000/$8,000
KeyCare
1NBM/1N72
Embedded
N/A
20%
$3,000/$6,000
Anthem HealthKeepers Platinum OAPOS 10/10%/2500
HealthKeepers
1NBR/1N5H
Embedded
N/A
10%
$2,500/$5,000
HealthKeepers
1P43/1P45
Embedded
N/A
10%
$4,000/$8,000
HealthKeepers
1NBH/1N75
Embedded
N/A
20%
$3,000/$6,000
Anthem Gold PPO 35/20%/6350
KeyCare
1P6G/1P6J
Embedded
N/A
20%
$6,350/$12,700
KeyCare
1P6L/1P6N
Embedded
N/A
30%
$5,000/$10,000
KeyCare
1NB6/1N77
Embedded
N/A
30%
$5,500/$11,000
KeyCare
1NE0/1N6P
Embedded
$500/$1,500
20%
$4,500/$9,000
KeyCare
1P6U/1P6W
Embedded
$500/$1,500
30%
$5,000/$10,000
KeyCare
1NDF/1NAK
Embedded
$750/$2,250
20%
$4,000/$8,000
KeyCare
1ND6/1NA9
Embedded
$1,000/$3,000
20%
$3,000/$6,000
KeyCare
1N85/1N6G
Embedded
$1,000/$3,000
20%
$3,500/$7,000
KeyCare
1NCX/1NAW
Embedded
$1,000/$3,000
30%
$2,500/$5,000
KeyCare
1NDR/1NB1
Embedded
$1,500/$3,000
20%
$3,500/$7,000
KeyCare
1N88/1N6V
Embedded
$1,500/$3,000
30%
$4,250/$8,500
KeyCare
1NDD/1N70
Embedded
$2,000/$4,000
20%
$3,500/$7,000
Anthem HealthKeepers Gold OAPOS 35/20%/6350
HealthKeepers
1P68/1P6A
Embedded
N/A
20%
$6,350/$12,700
HealthKeepers
1P6C/1P6E
Embedded
N/A
30%
$5,000/$10,000
HealthKeepers
1NCN/1N6W
Embedded
N/A
30%
$5,500/$11,000
Anthem HealthKeepers Gold POS 500/20%/4000 Plus
HealthKeepers
1P6Y/1P70
Embedded
$500/$1,500
20%
$4,000/$8,000
HealthKeepers
1ND4/1N6R
Embedded
$500/$1,500
20%
$4,500/$9,000
HealthKeepers
1P6Q/1P6S
Embedded
$500/$1,500
30%
$5,000/$10,000
HealthKeepers
1NDK/1N95
Embedded
$750/$2,250
20%
$4,000/$8,000
Anthem HealthKeepers Gold POS 1000/0%/4000
HealthKeepers
1P76/1P78
Embedded
$1,000/$3,000
0%
$4,000/$8,000
HealthKeepers
1N8G/1NAJ
Embedded
$1,000/$3,000
20%
$3,000/$6,000
Anthem HealthKeepers Gold POS 1000/20%/3000 Plus
HealthKeepers
1ZEK/1ZE8
Embedded
$1,000/$3,000
20%
$3,000/$6,000
HealthKeepers
1NDA/1N74
Embedded
$1,000/$3,000
20%
$3,500/$7,000
HealthKeepers
1NDP/1N99
Embedded
$1,000/$3,000
30%
$2,500/$5,000
HealthKeepers
1NDW/1NB9
Embedded
$1,500/$3,000
20%
$3,500/$7,000
HealthKeepers
1NBG/1N6T
Embedded
$1,500/$3,000
30%
$4,250/$8,500
HealthKeepers
1ND7/1N6X
Embedded
$2,000/$4,000
20%
$3,500/$7,000
POS
PPO
Gold plans
28
1 CY = Calendar Year, PY = Plan Year. Please see benefit proposal for final contract code.
2 Here’s a reminder of nonembedded versus embedded deductible products: Nonembedded Accumulation: All family members have a shared deductible and out-of-pocket (OOP) maximum, regardless of the number of
family members. The entire deductible must be satisfied before any one member of the family can begin receiving benefits. The entire OOP must be satisfied before the family has satisfied the OOP maximum. Embedded
Accumulation: Each member has an individual deductible/OOP amount. Any deductible amount contributed by an individual family member will apply to the family deductible amount, but no individual family member is
required to contribute more to the family deductible than their individual deductible amount. The OOP accumulates on an embedded basis also.
The below overview represents in-network benefits. For more plan information, please refer to the
Summary of Benefits (SOB). To find a specific SOB for any of these plans, visit sgplans.anthem.com.
All product offerings are subject to regulatory review and approval and are subject to change.
Office visit
(PCP3/specialist)
Hospital inpatient
Pharmacy:4 30-day supply
(tier 1/tier 2/tier 3/tier4)
Urgent care
Emergency room
Outpatient surgery
Drug
list
Healthy
Support
$10/$20
$20
$200
$15/$30
$30
$200
$250
$250 per day for 3 days
$10/$35/$70/25% up to $250
N
N/A
$250
$10/$35/$70/25% up to $250
N
N/A
$10/$35
$35
$200
$250
$5/$35/$60/25% up to $250
N
N/A
$10/$20
$20
$200
$250
$10/$35/$70/25% up to $250
N
N/A
$15/$30
$30
$200
$250
$10/$35/$70/25% up to $250
N
N/A
$10/$35
$35
$200
$250
$5/$35/$60/25% up to $250
N
N/A
$35/$65
$65
$250
Deductible/coinsurance
$10/$35/$70/25% up to $250
N
N/A
$25/$50
$50
$250
$10/$35/$70/25% up to $250
N
N/A
$35/$60
$60
$200
$250
$15/$40/$80/25% up to $250
N
N/A
$25/$50
$50
$300
$10/$35/$70/25% up to $250
N
N/A
$25/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
$10/$35/$70/25% up to $250
N
N/A
N
N/A
$25/$50
$50
$250
$10/$35/$70/25% up to $250
N
N/A
N
N/A
$25/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
$20/$60
$60
$200
$10/$35/$70/25% up to $250
N
N/A
$30/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
$35/$65
$65
$250
$10/$35/$70/25% up to $250
N
N/A
$25/$50
$50
$250
$10/$35/$70/25% up to $250
N
N/A
$35/$60
$60
$200
$250
$15/$40/$80/25% up to $250
N
N/A
$25 — 3 visits before
Deductible, then
tier 1: 20% tier 2: 40%
Deductible, then
tier 1: 20% tier 2: 40%
$15/$40/$80/30% up to $500
S
Get Active
$25/$50
$50
$300
$10/$35/$70/25% up to $250
N
N/A
$25/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
$10/$35/$70/25% up to $250
N
N/A
Deductible, then
$20/$40
Deductible, then $40
per day for 3 days
Deductible, then $15/$40/
$80/25% up to $250
S
N/A
N
N/A
$15/$40/$80/30% up to $500
S
Get Active
$25/$50
$50
$250
$10/$35/$70/25% up to $250
N
N/A
N
N/A
$25/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
$20/$60
$60
$200
$10/$35/$70/25% up to $250
N
N/A
$30/$50
$50
$200
$10/$35/$70/25% up to $250
N
N/A
3 Some plans may include a reduced cost share when seeing an Enhanced Personal Health Care provider. Contact your Anthem Sales representative for details.
4 Pharmacy deductible, when applicable, does not apply to tier 1 drugs.
29
Product details
Gold plans (continued)
POS CDHP
PPO CDHP
Plan
type
Plan name
Contract
code1
Out-of-pocket
Embedded/
Deductible
maximum
Anthem Gold PPO 1500E/20%/5000 w/ HRA
(Employer contribution $500)
KeyCare
1N8A/1NA8
Embedded
$1,500/$3,000
20%
$5,000/$10,000
Anthem Gold PPO 2000/0%/2000 w/ HSA
KeyCare
1NCZ/1NAU
Nonembedded
$2,000/$4,000
0%
$2,000/$4,000
Anthem Gold PPO 2000E/20%/5000 w/ HRA
KeyCare
1NE1/1N9D
Embedded
$2,000/$4,000
20%
$5,000/$10,000
Anthem Gold PPO 2600E/30%/4750 w/ HSA
(Employer contribution $1,000)
KeyCare
1NCU/1NAY
Embedded
$2,600/$5,200
30%
$4,750/$9,500
Anthem Gold PPO 3425/0%/3425 w/ HRA
KeyCare
1NDU/1N9F
Nonembedded
$3,425/$6,850
0%
$3,425/$6,850
Anthem HealthKeepers Gold OAPOS 1500E/20%/5000 w/ HRA
HealthKeepers
1ND1/1N97
Embedded
$1,500/$3,000
20%
$5,000/$10,000
Anthem HealthKeepers Gold OAPOS 2000/0%/2000 w/ HSA
HealthKeepers
1ND2/1NAS
Nonembedded
$2,000/$4,000
0%
$2,000/$4,000
Anthem HealthKeepers Gold OAPOS 2000E/20%/5000 w/ HRA
HealthKeepers
1NE5/1N9B
Embedded
$2,000/$4,000
20%
$5,000/$10,000
Anthem HealthKeepers Gold OAPOS 2600E/30%/4750 w/ HSA
(Employer contribution $1,000)
HealthKeepers
1NDH/1NAM
Embedded
$2,600/$5,200
30%
$4,750/$9,500
Anthem HealthKeepers Gold POS 3250/0%/3250 Plus w/ HRA
HealthKeepers
2063/1ZDU
Nonembedded
$3,250/$6,500
0%
$3,250/$6,500
Anthem HealthKeepers Gold OAPOS 3425/0%/3425 w/ HRA
HealthKeepers
1NDQ/1N9H
Nonembedded
$3,425/$6,850
0%
$3,425/$6,850
Anthem Silver PPO 2000/30%/4750
KeyCare
1P7S/1P7U
Embedded
$2,000/$4,000
30%
$4,750/$9,500
KeyCare
1N7E/1N6C
Embedded
$2,000/$4,000
50%
$6,350/$12,700
KeyCare
1N7J/1N5V
Embedded
$4,000/$8,000
20%
$6,850/$13,700
Anthem HealthKeepers Silver POS 1250/40%/5500 Plus
HealthKeepers
1P72/1P74
Embedded
$1,250/$2,500
40%
$5,500/$11,000
HealthKeepers
1ZEM/206A
Embedded
$1,500/$3,000
35%
$5,500/$11,000
Anthem HealthKeepers Silver POS 2000E/0%/6000
HealthKeepers
1P7F/1P7H
Embedded
$2,000/$4,000
0%
$6,000/$12,000
Anthem HealthKeepers Silver OAPOS 2000/30%/4750
HealthKeepers
1P7N/1P7Q
Embedded
$2,000/$4,000
30%
$4,750/$9,500
HealthKeepers
1N8M/1N6E
Embedded
$2,000/$4,000
50%
$6,350/$12,700
HealthKeepers
1ZEF/1ZEB
Embedded
$2,500/$5,000
30%
$5,000/$10,000
Anthem HealthKeepers Silver POS 3000/0%/6500
HealthKeepers
1P7A/1P7C
Embedded
$3,000/$6,000
0%
$6,500/$13,000
HealthKeepers
1ZE9/205U
Embedded
$3,000/$6,000
20%
$4,500/$9,000
HealthKeepers
1NC2/1N6J
Embedded
$4,000/$8,000
20%
$6,850/$13,700
POS
PPO
Silver plans
1 CY = Calendar Year, PY = Plan Year. Please see benefit proposal for final contract code.
30
Office visit
(PCP3/specialist)
Urgent care
Emergency room
Outpatient surgery
Hospital inpatient
Drug
list
Healthy
Support
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
N
N/A
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
N
N/A
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
S
Get Active
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
N
N/A
$50/$75
$75
$300
$15/$40/$80/25% up to $250
N
N/A
$40/$60
$60
$300
$250 Deductible, then
$15/$40/$80/25% up to $250
N
N/A
Deductible, then
tier 1: 40% tier 2: 50%
Deductible, then
tier 1: 40% tier 2: 50%
$15/$40/$80/30% up to $500
S
Get Active
$15/$40/$80/30% up to $500
S
Get Active
Deductible, then
$30/$60
per day for 3 days
Deductible, then
$15/$50/$90/30%
S
N/A
N
N/A
$50/$75
$75
$300
$15/$40/$80/25% up to $250
N
N/A
$15/$40/$80/30% up to $500
S
Get Active
Deductible, then
$20/$40
per day for 3 days
Deductible, then
$15/$40/$80/25% up to $250
S
N/A
$15/$40/$80/30% up to $500
S
Get Active
$40/$60
$60
$300
$15/$40/$80/25% up to $250
N
N/A
31
Product details
Silver plans (continued)
POS CDHP
PPO CDHP
Plan
type
Plan name
Contract
code1
Out-of-pocket
Embedded/
Deductible
maximum
Anthem Silver PPO 2600E/20%/4500 w/ HSA
KeyCare
1NBU/1N9M
Embedded
$2,600/$5,200
20%
$4,500/$9,000
KeyCare
1N9Y/1NDM
Embedded
$2,800/$5,600
20%
$4,000/$8,000
Anthem Silver PPO 3400/0%/3400 w/ HSA
KeyCare
1N9T/1NE6
Nonembedded
$3,400/$6,800
0%
$3,400/$6,800
KeyCare
1NAC/1NAZ
Embedded
$3,500/$7,000
0%
$3,500/$7,000
Anthem Silver PPO 5500E/0%/5500 w/ HRA
KeyCare
1NA3/1N8D
Embedded
$5,500/$11,000
0%
$5,500/$11,000
Anthem HealthKeepers Silver OAPOS 2600E/20%/4500 w/ HSA
HealthKeepers
1NBF/1N9P
Embedded
$2,600/$5,200
20%
$4,500/$9,000
Anthem HealthKeepers Silver POS 2600E/30%/4500 Plus w/ HSA
HealthKeepers
205W/1ZE0
Embedded
$2,600/$5,200
30%
$4,500/$9,000
HealthKeepers
1N7P/1N8N
Embedded
$2,800/$5,600
20%
$4,000/$8,000
Anthem HealthKeepers Silver OAPOS 3400/0%/3400 w/ HSA
HealthKeepers
1N8X/1N80
Nonembedded
$3,400/$6,800
0%
$3,400/$6,800
HealthKeepers
1NAA/1NAF
Embedded
$3,500/$7,000
0%
$3,500/$7,000
Anthem HealthKeepers Silver OAPOS 5500E/0%/5500 w/ HRA
HealthKeepers
1N7L/1N93
Embedded
$5,500/$11,000
0%
$5,500/$11,000
Anthem HealthKeepers Bronze POS 5900/0%/6850 Plus
HealthKeepers
1ZE4/1ZE5
Embedded
$5,900/$11,800
0%
$6,850/$13,700
Anthem Bronze PPO 6000E/0%/6000 w/ HSA
KeyCare
1N7T/1N6L
Embedded
$6,000/$12,000
0%
$6,000/$12,000
Anthem HealthKeepers Bronze POS 4250E/30%/6550 Plus w/ HSA HealthKeepers
205T/1ZDY
Embedded
$4,250/$8,500
30%
$6,550/$13,100
205V/2061
Embedded
$4,500/$9,000
40%
$6,550/$13,100
1ZEJ/1ZE1
Embedded
$4,750/$9,500
20%
$6,550/$13,100
Anthem HealthKeepers Bronze OAPOS 6000E/0%/6000 w/ HSA
HealthKeepers
1NA7/1N5T
Embedded
$6,000/$12,000
0%
$6,000/$12,000
Anthem HealthKeepers Bronze POS 6300E/0%/6300 Plus w/ HSA
HealthKeepers
1ZEN/1ZDW
Embedded
$6,300/$12,600
0%
$6,300/$12,600
Anthem HealthKeepers Gold X OAPOS 3000/0%/4000
HealthKeepers
1P7K
Embedded
$3,000/$6,000
0%
$4,000/$8,000
Anthem HealthKeepers Gold Pathway X POS 500/20%/5000 Plus
Pathway X tiered
Hospital
2064
Embedded
$500/$1,500
20%
$5,000/$10,000
X tiered
Anthem HealthKeepers Gold Pathway X POS 1000/20%/2900 Plus Pathway
Hospital
1P7L
Embedded
$1,000/$3,000
20%
$2,900/$5,800
Anthem HealthKeepers Silver X POS 2500/0%/5000
HealthKeepers
1P7D
Embedded
$2,500/$5,000
0%
$5,000/$10,000
Anthem HealthKeepers Silver X OAPOS 4500E/0%/6000
HealthKeepers
1P7J
Embedded
$4,500/$9,000
0%
$6,000/$12,000
Anthem HealthKeepers Silver Pathway X POS 2000/30%/5500
Plus
Pathway X tiered
Hospital
2060
Embedded
$2,000/$4,000
30%
$5,500/$11,000
Anthem HealthKeepers Bronze Pathway X POS 5000E/20%/6550
Plus w/ HSA
Pathway X tiered
Hospital
1P66
Embedded
$5,000/$10,000
20%
$6,550/$13,100
Anthem HealthKeepers Bronze Pathway X POS 6000E/0%/6000
Plus w/ HSA
Pathway X tiered
Hospital
2062
Embedded
$6,000/$12,000
0%
$6,000/$12,000
POS CDHP
PPO
CDHP
POS
Bronze plans
POS CDHP
POS
SHOP plans
32
1 CY = Calendar Year, PY = Plan Year. Our SHOP plans are only available as calendar year. Please see benefit proposal for final contract code.
Office visit
(PCP3/specialist)
Urgent care
Emergency room
Outpatient surgery
Hospital inpatient
Drug
list
Healthy
Support
N
N/A
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
N
N/A
Deductible, then
$20/$35
Deductible, then
$15/$40/$80/30%
S
Get Active
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
$35 — 3 visits before ded
Deductible
Deductible
Deductible
Deductible
$15/$40/$80/30% up to $500
S
Get Active
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
S
Get Active
Deductible, then
$25/$50
40%
40%
Deductible, then
$15/$50/$90/40%
S
Get Active
S
Get Active
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
N
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
S
Get Active
$15/$35
$100
$200
Deductible
Deductible
$15/$40/$80/25% up to $250
N
N/A
$15/$40/$80/30% up to $500
S
Get Active
$15/$40/$80/30% up to $500
S
Get Active
Deductible, then
$30/$60
per day for 3 days
Deductible, then
$15/$50/$90/30%
S
N/A
Deductible
Deductible
Deductible
Deductible
Deductible
$15/$40/$80/25% up to $250
N
N/A
$15/$40/$80/30% up to $500
S
Get Active
Deductible, then
$30/$60
Deductible, then
$15/$40/$80/25%
S
Get Active
Deductible
Deductible
Deductible
Deductible
Deductible
Deductible
S
Get Active
33
Product details
Dental Prime and Dental Complete
Plans with more coverage choices
When we created the Dental Prime and Dental Complete
plans, we made sure they could be custom fit. That means
lots of choices in coverage, including options for:
Dental implants.
2016 Dental Prime and
Dental Complete plans (new business only)
}}
Composite (tooth-colored) fillings on any tooth, not
just the front teeth.
}}
Orthodontic benefits for kids and adults, or kids only.
Diagnostic and preventive services
Basic services
Major services
}}
Annual maximum carryover, which lets members carry over
some unused benefits to the next year.
}}
Pediatric dental EHB benefits are included with your
medical plan. You can also add adult dental coverage or
supplement the pediatric dental EHB to a higher level of
coverage by purchasing one of our standalone Dental Prime
and Dental Complete plans. See the grid that follows for
more information.
Value, Classic and Enhanced dental plans
For groups of 2 to 100, we offer a choice of dental plans
that use our Dental Complete and the deeper discounted
Dental Prime networks. You can choose from our Value,
Classic and Enhanced levels. So you can select the level
that fits your needs and budget:
Value dental plans cover the basics like cleanings,
exams, X-rays and fillings.
}}
Classic dental plans cover basic dental services, as well
as most major services.
}}
Enhanced dental plans have the most coverage, with
choices for higher levels of coverage/annual maximums
and lower coinsurance for members.
}}
34
Endodontic, periodontal and oral surgery services
Implants
Posterior composites
Orthodontia
Annual deductible
(per person/family)
Annual benefit maximum and orthodontia maximum
Waiting periods
(major and orthodontia)
Annual maximum carryover
Out-of-network reimbursement
Dental network
In 2016, we will be offering the below dental plans. These dental plans allow for streamlined administration providing
groups that have Anthem medical and Anthem dental with the convenience of one bill, one payment.
Value
Classic
Enhanced
Voluntary
Passive
Passive
Passive
Active
Passive
100%/100%
100%/100%
100%/100%
100%/100%
100%/100%
80%/80%
80%/80%
90%/90%
90%/80%
80%/80%
Not covered
50%/50%
60%/60%
60%/50%
50%/50%
Not covered
Basic, Major
Basic
Basic
Major
Not covered
Not covered, covered
Covered
Covered
Not covered
Not covered
Covered
Covered
Covered
Covered
Not covered
Not covered,
children only or
children and adults
Not covered or
children only
Not covered or
children only
Not covered, children
$50/$150
$50/150
$25/$75, $50/$150
$25/$75, $50/$150
$50/$150
$1,000
$1,000
$1,500, $2,000, $2,500
$1,500, $2,000, $2,500
$1,000, $1,500, $2,000
No waiting period
No waiting period
No waiting period
No waiting period
12-month waiting period
Yes
Yes
Yes
Yes
Yes
90th
90th
90th
90th
90th
Complete
Complete
Complete
Complete
The above is a summary. See the Certificate of Coverage with the Schedule of Benefits and any riders associated
with the plan for complete coverage details and related terms and conditions.
For renewing business, please contact your Anthem representative for a complete copy
of the plan options available.
35
Product details
Get vision coverage and see increased productivity
Blue View Vision stand-alone plans (2 to 100 employees)
Copay1 for
Eye exam/
Frames/Contact
Eyeglass lenses lenses allowance2 Eye exam
Eyeglass lenses
Frames
Contact lenses
A1
$10/$0
$130/$130
Once per calendar year
A2
$15/$0
$120/$115
Material only
Full service
Plan
Exam only3
Frequency
A3
$10/$10
$130/$130
A4
$10/$20
$130/$130
A5
$20/$20
$130/$130
A6
$10/$25
$130/$130
B1
$10/$0
$130/$130
Once every other calendar year Once per calendar year
B2
$10/$20
$100/$100
B3
$10/$20
$130/$130
B4
$20/$20
$130/$130
B5
$10/$10
$130/$130
B6
$10/$25
$130/$130
C1
$10/$0
$130/$130
Once every other calendar year
Once every other calendar year Once every other calendar year
C2
$10/$20
$130/$130
C3
$20/$20
$130/$130
C4
$25/$0
$120/$115
C5
$10/$20
$100/$100
C6
$20/$20
$100/$100
C7
$20/$20
$130/$80
C8
$10/$25
$130/$130
C9
$30/$30
$100/$100
MO1 Not covered/$10
$130/$130
Not covered
MO2 Not covered/$10
$130/$130
Not covered
MO3 Not covered/$0
$130/$130
Not covered
MO4 Not covered/$20
$130/$130
Not covered
MO5 Not covered/$20
$130/$130
Not covered
MO6 Not covered/$0
$130/$130
Not covered
E01
$0/Not covered
Not covered
Not covered
Not covered
Not covered
E02 $5/Not covered
Not covered
Not covered
Not covered
Not covered
E03 $10/Not covered
Not covered
Not covered
Not covered
Not covered
E04 $15/Not covered
Not covered
Not covered
Not covered
Not covered
E05 $20/Not covered
Not covered
Not covered
Not covered
Not covered
1 Above amounts reflect in-network copays and allowances.
2 Benefits include coverage for member’s choice of eyeglass lenses or contact lenses, but not both. Nonelective contacts covered in full.
3 Retention plans only.
36
Pediatric vision is included in all of our
Small Group medical plans. Some plans
may also include adult vision benefits.
For more information, contact your broker
or Anthem Sales representative.
37
Exclusions and limitations
Request a copy of the Combined Evidence of Coverage/Member Booklet for comprehensive details on covered services,
limitations and exclusions. These exclusions and limitations will apply to all members enrolled in any of the products
described in this brochure unless otherwise noted.
All exclusions and limitations are subject to regulatory review and approval.
1.
2.
3.
4.
5.
38
Abortion
Services, supplies, prescription drugs, and other care for elective (voluntary)
abortions and/or fetal reduction surgery (applies to Anthem HealthKeepers
SHOP plans):
a) This exclusion does not apply to therapeutic abortions, which are
abortions performed to save the life of the mother or as a result of
incest or rape.
Acts of war, disasters or nuclear accidents
In the event of a major disaster, epidemic, war, or other event beyond our
control, we will make a good faith effort to give you covered services. We will
not be responsible for any delay or failure to give services due to lack of
available facilities or staff:
a) Benefits will not be given for any illness or injury that is a result of war,
service in the armed forces, a nuclear explosion, nuclear accident,
release of nuclear energy, a riot or civil disobedience.
Administrative charges:
a) Charges to complete claim forms.
b) Charges to get medical records or reports.
c) Membership, administrative, or access fees charged by doctors or other
providers. Examples include, but are not limited to, fees for educational
brochures or calling you to give you test results.
Alternative/complementary medicine
Services or supplies for alternative or complementary medicine. This includes,
but is not limited to:
a) Acupuncture
b) Holistic medicine
c) Homeopathic medicine
d) Hypnosis
e) Aroma therapy
f) Massage and massage therapy
g) Reiki therapy
h) Herbal, vitamin or dietary products or therapies
i) Naturopathy
j) Thermography
k) Orthomolecular therapy
l) Contact reflex analysis
m) Bioenergetic synchronization technique (BEST)
n) Iridology — study of the iris
o) Auditory integration therapy (AIT)
p) Colonic irrigation
q) Magnetic innervation therapy
r) Electromagnetic therapy
s) Neurofeedback/biofeedback
Before effective date or after termination date
Charges for care you get before your effective date or after your coverage
ends, except as written in this plan.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Certain providers
Services you get from providers that are not licensed by law to provide
covered services as defined in this booklet. Examples include, but are not
limited to, masseurs or masseuses (massage therapists), physical therapist
technicians, and athletic trainers.
Charges over the maximum allowed amount
Charges over the maximum allowed amount for covered services.
Charges not supported by medical records
Charges for services not described in your medical records.
Chiropractic/manipulation therapy
Any manipulation therapy or chiropractic service not authorized by ASHG
(applies to HealthKeepers plans).
Complications of noncovered services
Care for problems directly related to a service that is not covered by
this plan. Directly related means that the care took place as a direct result
of the noncovered service and would not have taken place without the
noncovered service.
Contraceptives
Contraceptive devices including diaphragms, intra uterine devices (IUDs), and
implants (this exclusion only applies if employer group has qualified to opt out
of this coverage).
Cosmetic services
Treatments, services, prescription drugs, equipment, or supplies given for
cosmetic services. Cosmetic services are meant to preserve, change, or
improve how you look or are given for psychiatric, psychological, or social
reasons. No benefits are available for surgery or treatments to change the
texture or look of your skin or to change the size, shape or look of facial or
body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts).
This exclusion does not apply to:
a) Surgery or procedures to correct deformity caused by disease,
trauma, or previous therapeutic process.
b) Surgery or procedures to correct congenital abnormalities that
cause functional impairment.
c) Surgery or procedures on newborn children to correct
congenital abnormalities.
The plan will not consider the patient’s mental state in deciding
if surgery is cosmetic.
Court-ordered testing
Court-ordered testing or care unless medically necessary.
Custodial care
Custodial care, convalescent care or rest cures. This exclusion does not apply
to hospice services.
Dental services:
a) Dental care for members age 19 or older.
b) Dental services not listed as covered in this booklet.
c) Services of anesthesiologists, unless required by law.
d) Intravenous and non-intravenous conscious sedation, analgesia, and
general anesthesia when given separate from a covered oral surgery
services and given by a dentist or by an employee of the dentist when
the service is performed in his or her office who is certified in their
profession to provide anesthesia services.
e) Dental services, appliances or restorations that are necessary to
alter, restore or maintain occlusion, including, but not limited to:
increasing vertical dimension, replacing or stabilizing tooth structure
lost by attrition, realignment of teeth, periodontal splinting and
gnathologic recordings.
f) Canal prep and fitting of preformed dowel and post.
g) Occlusal procedures.
h) Onlays or permanent crowns when the tooth does not have decay,
fracture or has been endodontically treated.
i) Services or supplies that have the primary purpose of improving the
appearance of your teeth. This includes, but is not limited to,
tooth-whitening agents or tooth bonding.
j) Case presentations.
k) Athletic mouth guards, enamel microabrasion and odontoplasty.
l) Retreatment or additional treatment necessary to correct or relieve the
results of treatment previously covered under the plan.
m) Bacteriologic tests for determination of periodontal disease or
pathologic agents.
n) The controlled release of therapeutic agents or biologic modifiers used
to aid in soft tissue and osseous tissue regeneration.
o) Collection of oral cytology sample via scraping of the oral mucosa.
p) Separate services billed when they are an inherent component of
another covered service.
q) Pin retention is not covered when billed separately from
restoration procedure.
r) Services for the replacement of an existing partial denture
with a bridge.
s) Incomplete, interim or temporary services, including, but not limited to,
fixed prosthetic appliances (dentures, partials or bridges).
t) Additional, elective or enhanced prosthodontic procedures including,
but not limited to, connector bar(s), stress breakers and
precision attachments.
u) Placement or removal of sedative filling, base or liner used under a
restoration when it is billed separately from a restoration procedure.
v) Pulp vitality tests.
w) Adjunctive diagnostic tests.
x) Analgesia, analgesia agents, anxiolysis nitrous oxide, medicines, or
drugs for nonsurgical or surgical dental care.
y) Incomplete root canals.
z) Cone beam images.
aa) Anatomical crown exposure.
bb) Temporary anchorage devices.
cc) Sinus augmentation.
dd) Oral hygiene instructions.
ee) Repair or replacement of lost/broken appliances.
ff) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or
nonresorbable filling material(s) and the procedures used to prepare
and place material(s) in the canals (root).
gg) Root canal obstruction, internal root repair of perforation defects,
incomplete endodontic treatment and bleaching of discolored teeth.
16. Educational services
Services or supplies for teaching, vocational, or self-training purposes, except
as listed in this booklet.
17. Experimental or investigational services
Services or supplies that we find are experimental or investigational. This also
applies to services related to experimental or investigational services,
whether you get them before, during, or after you get the experimental or
investigational service or supply:
a) The fact that a service or supply is the only available treatment
will not make it a covered service if we conclude it is experimental
or investigational.
18. Eyeglasses and contact lenses
Eyeglasses and contact lenses to correct your eyesight unless listed as
covered in this booklet. This exclusion does not apply to lenses needed after a
covered eye surgery or accidental injury.
19. Eye exercises
Orthoptics and vision therapy.
20. Eye surgery
Eye surgery to fix errors of refraction, such as near-sightedness. This
includes, but is not limited to, LASIK, radial keratotomy or keratomileusis, and
excimer laser refractive keratectomy.
21. Family members
Services prescribed, ordered, referred by or given by a member of
your immediate family, including your spouse, child, brother, sister, parent,
in-law or self.
22. Foot care
Routine foot care unless medically necessary. This exclusion applies to
cutting or removing corns and calluses; trimming nails; cleaning and
preventive foot care, including, but not limited to:
a) Cleaning and soaking the feet.
b) Applying skin creams to care for skin tone.
c) Other services that are given when there is not an illness, injury or
symptom involving the foot.
This exclusion does not apply to the treatment of corns, calluses, and care of
toenails for patients with diabetes or vascular disease.
23. Foot orthotics
Foot orthotics, orthopedic shoes or footwear or support items unless used for
an illness affecting the lower limbs, such as severe diabetes.
24. Foot surgery
Surgical treatment of flat feet; subluxation of the foot; weak, strained,
unstable feet; tarsalgia; metatarsalgia; hyperkeratoses.
25. Free care
Services you would not have to pay for if you didn’t have this plan. This
includes, but is not limited to government programs, services during a jail or
prison sentence, services you get from Workers’ Compensation, and services
from free clinics.
If Workers’ Compensation benefits are not available to you, this exclusion
does not apply. This exclusion will apply if you get the benefits in whole or in
part. This exclusion also applies whether or not you claim the benefits or
compensation, and whether or not you get payments from any third party.
26. Hearing aids
Hearing aids or exams to prescribe or fit hearing aids, unless listed as covered
in this booklet. This exclusion does not apply to cochlear implants.
39
Exclusions and Limitations
27. Health club memberships and fitness services
Health club memberships, workout equipment, charges from a physical
fitness or personal trainer, or any other charges for activities, equipment, or
facilities used for physical fitness, even if ordered by a Doctor. This exclusion
also applies to health spas.
28. Home care:
a) Services given by registered nurses and other health workers who are
not employees of or working under an approved arrangement with a
home health care provider.
b) Food, housing, homemaker services and home delivered meals.
29. Infertility treatment
Treatment related to infertility.
30. Maintenance therapy
Treatment given when no further gains are clear or likely to occur.
Maintenance therapy includes care that helps you keep your current level of
function and prevents loss of that function, but does not result in any change
for the better.
31. Medical equipment and supplies:
a) Replacement or repair of purchased or rental equipment because of
misuse, abuse, or loss/theft.
b) Surgical supports, corsets, or articles of clothing unless needed to
recover from surgery or injury.
c) Nonmedically necessary enhancements to standard equipment and devices.
32. Medicare
Services for which benefits are payable under Medicare Parts A, and/or B,
or would have been payable if you had applied for Parts A and/or B, except
as required by federal law. If you do not enroll in Medicare Part B, we will
calculate benefits as if you had enrolled. You should sign up for Medicare
Part B as soon as possible to avoid large out-of-pocket costs.
33. Missed or canceled appointments
Charges for missed or canceled appointments.
34. Nonmedically necessary services
Services we conclude are not medically necessary. This includes services that
do not meet our medical policy, clinical coverage, or benefit policy guidelines.
35. Nutritional or dietary supplements
Nutritional and/or dietary supplements, except as described in this booklet or
that we must cover by law. This exclusion includes, but is not limited to,
nutritional formulas and dietary supplements that you can buy over the
counter and those you can get without a written prescription or from a
licensed pharmacist.
36. Oral surgery
Extraction of teeth, surgery for impacted teeth and other oral surgeries for to
treat the teeth or bones and gums directly supporting the teeth, except as
listed in this booklet.
37. Personal care and convenience:
a) Items for personal comfort, convenience, protection, cleanliness such
as air conditioners, humidifiers, water purifiers, sports helmets, raised
toilet seats, and shower chairs
b) First aid supplies and other items kept in the home for general use
(bandages, cotton-tipped applicators, thermometers, petroleum jelly,
tape, nonsterile gloves, heating pads)
c) Home workout or therapy equipment, including treadmills and home gyms
d) Pools, whirlpools, spas, or hydrotherapy equipment
e) Hypoallergenic pillows, mattresses, or waterbeds
40
f) Residential, auto, or place of business structural changes (ramps, lifts,
elevator chairs, escalators, elevators, stair glides, emergency alert
equipment, handrails).
38. Prescription benefit exclusions
Certain items are not covered under the prescription drug Retail or Home
Delivery (Mail Order) Pharmacy benefit:
a) Administration charges
Charges for the administration of any drug except for covered
immunizations as approved by us or the Pharmacy Benefit Manager (PBM).
b) Compound drugs
Compound drugs unless all of the ingredients are FDA-approved and
require a prescription to dispense, and the compound medication is not
essentially the same as an FDA-approved product from a drug
manufacturer. Exceptions to non-FDA approved compound ingredients
may include multisource, nonproprietary vehicles and/or
pharmaceutical adjuvants.
c) Contraceptives
Contraceptive drugs, injectable contraceptive drugs and patches unless
we must cover them by law (this exclusion only applies if employer
group has qualified to opt out of this coverage).
d) Contrary to approved medical and professional standards
Drugs given to you or prescribed in a way that is against approved
medical and professional standards of practice.
e) Delivery charges
Charges for delivery of prescription drugs.
f) Drugs given at the provider’s office/facility
Drugs you take at the time and place where you are given them or where
the prescription Order is issued. This includes samples given by a doctor.
This exclusion does not apply to drugs used with a diagnostic service,
drugs given during chemotherapy in the office or drugs covered under the
medical and surgical supplies benefit — they are covered services.
g) Drugs not on the Anthem prescription drug list (a formulary)
You can get a copy of the list by calling us or visiting our website
at anthem.com.
h) Drugs that do not need a prescription
Drugs that do not need a prescription by federal law (including drugs
that need a prescription by state law, but not by federal law), except for
injectable insulin.
This exclusion does not apply to over-the-counter drugs that we must
cover under federal law when recommended by the U.S. Preventive
Services Task Force and prescribed by a physician.
i) Drugs over quantity or age limits
Drugs in quantities which are over the limits set by the plan, or which
are over any age limits set by us.
j) Drugs over the quantity prescribed or refills after one year
Drugs in amounts over the quantity prescribed, or for any refill given
more than one year after the date of the original prescription order.
k) Infertility drugs
Drugs used in assisted reproductive technology procedures to achieve
conception (e.g., IVF, ZIFT, GIFT.)
l) Items covered as durable medical equipment (DME)
Therapeutic DME, devices and supplies except peak flow meters,
spacers, and blood glucose monitors. Items not covered under the
prescription drug enefit at a retail or home delivery (mail order)
pharmacy benefit may be covered under the durable medical equipment
and medical devices benefit.
39.
40.
41.
42.
43.
44.
45.
46.
m) Items covered under the allergy services benefit
Allergy desensitization products or allergy serum. While not covered
under the prescription drug benefit at a retail or home delivery (mail
order) pharmacy” benefit, these items may be covered under the allergy
services benefit.
n) Home delivery providers other than the PBM’s home delivery provider
Prescription drugs dispensed by any home delivery provider other than the
PBM’s home delivery provider, unless we must cover them by law.
o) Nonapproved drugs
Drugs not approved by the FDA.
p) Off-label use
Off-label use, unless we must cover the use by law or if we,
or the PBM, approve it.
q) Onychomycosis drugs
Drugs for onychomycosis (toenail fungus) except when we allow it to
treat Members who are immuno-compromised or diabetic.
r) Over-the-counter items
Drugs, devices and products, or prescription legend drugs with
over-the -counter equivalents and any drugs, devices or products that
are therapeutically comparable to an over-the-counter drug, device, or
product. This includes prescription legend drugs when any version or
strength becomes available over the counter.
This exclusion does not apply to over-the-counter products that we must
cover as a preventive care benefit under federal law with a prescription.
s) Sex-change drugs
Drugs for sex-change surgery.
t) Sexual-dysfunction drugs
Drugs to treat sexual or erectile problems.
u) Syringes
Hypodermic syringes except when given for use with insulin and other
covered self-injectable drugs and medicine.
v) Weight-loss drugs
Any drug mainly used for weight loss
Private-duty nursing
Private-duty nursing services, unless listed as covered in this booklet.
Your coverage does not include benefits for private-duty nurses in the
inpatient setting.
Prosthetics
Prosthetics for sports or cosmetic purposes. This includes wigs and
scalp hair prosthetics.
Sex change
Services and supplies for a sex change and/or the reversal of a sex change.
Sexual dysfunction
Services or supplies for male or female sexual problems.
Stand-by charges
Stand-by charges of a doctor or other provider.
Sterilization
Services to reverse elective sterilization (this exclusion applies to all except
for those employer groups who qualify to out of this coverage).
Sterilization
For female sterilization or reversal of sterilization (this exclusion only applies
if the employer group has qualified to opt out of this coverage).
Surrogate mother services
Services or supplies for a person not covered under this plan for a surrogate
pregnancy (including, but not limited to, the bearing of a child by another
woman for an infertile couple).
47. Telemedicine
Noninteractive telemedicine services, such as audio-only
telephone conversations, electronic mail message, fax
transmissions or online questionnaire.
48. Temporomandibular joint treatment
Fixed or removable appliances which move or reposition the teeth, fillings, or
prosthetics (crowns, bridges, dentures).
49. Travel costs
Mileage, lodging, meals, and other member-related travel costs except as
described in this plan.
50. Vein treatment
Treatment of varicose veins or telangiectatic dermal veins
(spider veins) by any method (including sclerotherapy or other surgeries) for
cosmetic purposes.
51. Vision services:
a) Eyeglass lenses, frames, or contact lenses for members age 19 and
older, unless listed as covered in this booklet.
b) Safety glasses and accompanying frames.
c) For two pairs of glasses in lieu of bifocals.
d) Plano lenses (lenses that have no refractive power).
e) Lost or broken lenses or frames if the member has already received
benefits during a benefit period.
f) Vision services not listed as covered in this booklet.
g) Cosmetic lenses or options.
h) Blended lenses.
i) Oversize lenses.
j) Sunglasses and accompanying frames.
k) For services or supplies combined with any other offer, coupon or
in-store advertisement.
l) For members to age 19, no benefits are available for frames or contact
lenses not on the Anthem formulary.
m) Certain frames in which the manufacturer imposes a no-discount policy.
52. Vision services
Vision services not described as covered services in this booklet.
53. Waived cost-shares out of network
For any service for which you are responsible under the terms of this plan to
pay a copayment, coinsurance or deductible, and the copayment, coinsurance
or deductible is waived by an out-of-network provider.
54. Weight-loss programs
Programs, whether or not under medical supervision, unless listed as covered
in this booklet.
This exclusion includes, but is not limited to, commercial weight-loss programs
(Weight Watchers®, Jenny Craig®, LA Weight Loss®) and fasting programs.
55. Weight-loss surgery
Bariatric surgery. This includes, but is not limited to, Roux-en-Y (RNY),
Laparoscopic gastric bypass surgery or other gastric bypass surgery
(surgeries that lower stomach capacity and divert partly digested food from
the duodenum to the jejunum, the section of the small intestine extending
from the duodenum), or gastroplasty, (surgeries that reduce stomach size), or
gastric banding procedures.
41
The most detailed description of benefits, exclusions and restrictions can be found in the following
group policies and Certificate Booklets which can be requested by calling Customer Service.
AHK-VA-HMOPOS-EOC (1/16)
AHK-VA-HMOPOS-SOB-R2fG11 (1/16)
AHK-VA-HMOPOS-SOB-R2fS1 (1/16)
AHK-VA-HMOPOS-SOB-RVA-2gG1 (1/16)
AHK-VA-HMOPOS-SOB-RVA-2gS1 (1/16)
AHK-VA-HMOPOS-SOB-T1dG7 (1/16)
AHK-VA-HMOPOS-SOB-T1dG8 (1/16)
AHK-VA-HMOPOS-SOB-T1G17 (1/16)
AHK-VA-HMOPOS-SOB-T1P3 (1/16)
AHK-VA-HMOPOS-SOB-T2G11R-VA (1/16)
AHK-VA-HMOPOS-SOB-T2IG1-VA-rxA (1/16)
AHK-VA-HMOPOS-SOB-T2IS2-VA-rxA (1/16)
AHK-VA-HMOPOS-SOB-T2S15R (1/16)
AHK-VA-HMOPOS-SOB-T2S5R-VA (1/16)
AHK-VA-HMOPOS-SOB-R3B2-HSA (1/16)
AHK-VA-HMOPOS-SOB-R3bB1-HSA (1/16)
AHK-VA-HMOPOS-SOB-R3bB25-HSA (1/16)
AHK-VA-HMOPOS-SOB-R3bS1-VA-rxA (1/16)
AHK-VA-HMOPOS-SOB-R3bS2-VA-rxA (1/16)
AHK-VA-HMOPOS-SOB-R3bS6-HSA (1/16)
AHK-VA-HMOPOS-SOB-RVA2gG1 (1/16)
AHK-VA-HMOPOS-SOB-RVA2gS1 (1/16)
AHK-VA-HMOPOS-SOB-T2G56-R-VA (1/16)
AHK-VA-HMOPOS-SOB-T3S204-rxF (1/16)
ABCBS-VA-PPO-SOB-T1P100 (1/16)
AHK-VA-HMOPOS-SOB-R3G28-HRA (1/16)
AHK-VA-HMOPOS-SOB-T3B13-HSA (1/16)
AHK-VA-HMOPOS-SOB-T3G11-HSA (1/16)
AHK-VA-HMOPOS-SOB-T3G27-HRA (1/16)
AHK-VA-HMOPOS-SOB-T3G7-HSA (1/16)
AHK-VA-HMOPOS-SOB-T3S15-HSA (1/16)
AHK-VA-HMOPOS-SOB-T3S221 (1/16)
AHK-VA-HMOPOS-SOB-T3S28-HRA (1/16)
AHK-VA-HMOPOS-SOB-T3G-VA1 (1/16)
AHK-VA-HMOPOS-SOB-R2fB1 (1/16)
ABCBS-VA-PPO-SOB-T1dG7 (1/16)
ABCBS-VA-PPO-COC (1/16)
ABCBS-VA-PPO-SOB-T1G17 (1/16)
ABCBS-VA-PPO-SOB-T2G11R-VA (1/16)
AHK-VA-HMOPOS-SOB-T2S15-R-VA (1/16)
AHK-VA-HMOPOS-SOB-T2S5-R-VA (1/16)
ABCBS-VA-PPO-SOB-T3B13 HSA (1/16)
ABCBS-VA-PPO-SOB-T3G11-HSA (1/16)
ABCBS-VA-PPO-SOB-T3G27-HRA (1/16)
ABCBS-VA-PPO-SOB-T3G7-HSA (1/16)
ABCBS-VA-PPO-SOB-T3S15-HSA (1/16)
ABCBS-VA-PPO-SOB-T3S221 (1/16)
ABCBS-VA-PPO-SOB-T3S28-HRA (1/16)
ABCBS-VA-PPO-SOB-T3G-VA1 (1/16)
This is not a contract or policy. This brochure is not a contract with Anthem Blue Cross and Blue Shield or its affiliate HealthKeepers, Inc. If there is any difference
between this brochure and the Evidence of Coverage, Member Booklet, Summaries of Benefits, and related Amendments, the provisions of the Evidence of
Coverage, Member Booklet, Summaries of Benefits and related Amendments will govern. For more information, please call Member Services.
LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.
Life and Disability products underwritten by Anthem Life Insurance Company. 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 HealthKeepers, Inc. are 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 and Blue Shield Association.

Small Group product guide

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