Untitled

This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits in your plan, please refer to your Certificate of Insurance or Evidence of Coverage (EOC), which explains the full range of covered services, as well as any exclusions and limitations for your plan.
In addition to dollar and percentage copays, insured persons are responsible for deductibles, as described below. Please review the deductible information below to know if a deductible applies to a specific covered service. Certain Covered Services have maximum visit and/or day limits per year.
The number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether your Deductible has been met. Insured persons are also responsible for all costs over the plan maximums. Plan maximums & other important information appear in italics.
Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or coinsurance. PPO Providers—The rate the provider has agreed to accept as reimbursement for covered services. Members are not responsible for the difference between the provider's usual charges & the maximum allowed amount. Non-PPO Providers—For non-emergency care, reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider's usual charges & the maximum allowed amount. For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value.
When using Non-PPO and Other Health Care Providers, members are responsible for any difference between the covered expense & actual charges, as well as any deductible & percentage copay.
Calendar year deductible for all providers Calendar year deductible (Cross application applies) $250/member; maximum of three separate deductibles/family Deductible for non-Anthem Blue Cross PPO hospital or residen- $500/admission (waived for emergency admission) Deductible for non-Anthem Blue Cross PPO hospital or residential $500/admission (waived for emergency admission) Deductible for non-Anthem Blue Cross PPO hospital or residen- Deductible for non-Anthem Blue Cross PPO hospital or residential $500/admission (waived for emergency admission) $250/admission (waived for emergency admission) tial treatment center if utilization review not obtained treatment center if utilization review not obtained (in addition to $100/visit (waived if admitted directly from ER) PPO Providers & Other Health Care Provider $3,500/insured person/year; $7,000/insured family/year PPO Providers & Other Health Care Providers $10,000/insured person/year; $20,000/insured family/year o out-of-pocket maximums: deductibles listed above; non-covered expense. After an insured per pocket maximum, the insured person no longer pays percentage copays for the remainder of the year. However, insured person remains responsible for deductibles listed above; for non-PPO providers & other health care providers, costs in excess of the co The following do not apply to out-of-pocket maximums: deductibles listed above; non-covered expense.
After a member reaches the out-of-pocket maximum, the member remains responsible for deductibles listed above; for non-PPO providers & other health care providers, costs in excess of the covered expense; amounts related to a transplant unrelated donor search.
Adult Preventive Services (including mammograms, Pap Preventive Care Services including*, physical exams, preventive smears, prostate cancer screenings & colorectal cancer screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunizations, health education, intervention services, HIV testing), and additional preventive care for Well Baby & Well-Child Care for Dependent Children women provided for in the guidelines supported by the Health Resources and Services Administration. *This list is not exhaustive. This } Routine physical examinations (birth through age six) benefit includes all Preventive Care Services required by federal and Routine physical examinations (birth through age six) l Exams for Insured Persons Ages Seven & Older Routine physical exams, immunizations, diagnostic X-ray & lab for } Routine physical exams, immunizations, diagnostic X-ray & lab for routine physical exam (members 7 years old and older) £ Adult Preventive Services (including mammograms, pap smears, prostate cancer screenings & colorectal cancer screenings) } Hospital & skilled nursing facility visits } Surgeon & surgical assistant; anesthesiologis Hospital & skilled nursing facility visits £ Surgeon & surgical assistant; anesthesiologist or anesthetist Diabetes Education Programs (requires physician supervision) £ Teach members & their families about the disease process, the daily management of diabetic therapy & self-management training Physical Therapy, Physical Medicine & Occupational Therapy, including Chiropractic Services (limited to 24 visits/calendar year; additional visits may be authorized)Speech Therapy£ Outpatient speech therapy Acupuncture£ Services for the treatment of disease, illness or injury Diagnostic X-ray & Lab£ MRI, CT scan, PET scan & nuclear cardiac scan Emergency Care£ Emergency room services & supplies Hospital Medical Services (subject to utilization review for inpatient services; waived for emergency admissions)£ Semi-private room, meals & special diets, & ancillary services £ Outpatient medical care, surgical services & supplies (hospital care Skilled Nursing Facility (subject to utilization review) £ Semi-private room, services & supplies (medical conditions limited Related Outpatient Medical Services & Supplies£ Ground or air ambulance transportation, services & disposable supplies (air ambulance in a non-medical emergency is subject topre-service review and benefit limited to $50,000 for non-PPOprovider per trip) £ Blood transfusions, blood processing & the cost of unreplaced £ Autologous blood (self-donated blood collection, testing, processing & 30%§ Ambulatory Surgical Centers£ Outpatient surgery, services & supplies £ Prescription drug for elective abortion (mifepristone) Normal delivery, cesarean section, complications of pregnancy & Mental or Nervous Disorders and Substance Abuse £ Facility-based care (subject to utilization review; waived for £ Facility-based care (subject to utilization review; waived for £ Outpatient physician visits (pre-service review required after the £ Rental or purchase of DME including hearing aids, dialysis equipment & supplies (Hearing Aids benefit is available for onehearing aid per ear every three years; breast pump and supplies arecovered under preventive care at no charge for in-network) Home Health Care (subject to utilization review) £ Services & supplies from a home health agency (limited to 100 visits/calendar year, one visit by a home health aide equals fourhours or less; not covered while member receives hospice care) Home Infusion Therapy (subject to utilization review) £ Includes medication, ancillary services & supplies; caregiver training & visits by provider to monitor therapy; durable medicalequipment; lab services Hemodialysis£ Outpatient hemodialysis services & supplies Hospice Care£ Inpatient or outpatient services; family bereavement services Bariatric Surgery (subject to utilization review; medically necessary surgery for weight loss, only for morbid obesity, covered only when performed at a Centers of Medical Excellence [CME]) £ Inpatient services provided in connection with medically necessary surgery for weight loss, only for morbid obesity £ Travel expenses for an authorized, specified surgery (recipient &companion transportation limited to $3,000 per surgery) Organ & Tissue Transplants (subject to utilization review; specified organ transplants covered only when performed at Centers of Medical £ Inpatient services provided in connection with non-investigative £ Transplant travel expense for an authorized, specified transplant at CME (recipient & companion transportation limited to $10,000 pertransplant) Unrelated donor search, limited to $30,000 per transplantProsthetic Devices £ Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; thefirst pair of contact lenses or eyeglasses when required as a resultof eye surgery; & therapeutic shoes & inserts for members withdiabetes Temporomandibular Joint Disorders£ Splint therapy & surgical treatment This Summary of Benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the California Department of Insurance and the California Department of Managed The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., X-ray, lab, surgery), after Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.), or a dentist (D.D.S.).
These providers are not represented in the PPO network.
For California facilities, a discount applies if the facility has a contract with Anthem Blue Cross for fee-for-service business. For California facilities without a contract, covered expense for non-emergency hospital services and supplies is reduced by 25%, resulting in higher Exception: If service is performed at a Centers of Medical Excellence [CME], the services will be covered same as the PPO (in-network) benefit.
Sex Transformation. Procedures or treatments to change characteristics of the body to those of the Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Experimental or Investigative. Any experimental or investigative procedure or medication. But, if member is denied benefits because it is determined that the requested treatment is experimental or investigative, the member may request an independent medical review, as described in the Evidence of Coverage (EOC).
Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial insemination, in Outside the United States. Services or supplies furnished and billed by a provider outside the United vitro fertilization, sterilization reversal and gamete intrafallopian transfer.
States, unless such services or supplies are furnished in connection with urgent care or an emergency.
Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan Crime or Nuclear Energy. Conditions that result from (1) the member's commission of or attempt to in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another commit a felony, as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for the treatment of illness or injury arising from the release of nuclear energy.
Orthopedic Supplies. Orthopedic supplies, orthopedic shoes (other than shoes joined to braces), or non-custom molded and cast shoe inserts, except for therapeutic shoes and inserts for the prevention Not Covered. Services received before the member's effective date. Services received after the and treatment of diabetes-related feet complications, as specified as covered in the EOC.
member's coverage ends, except as specified as covered in the Evidence of Coverage (EOC).
Air Conditioners. Air purifiers, air conditioners or humidifiers.
Excess Amounts. Any amounts in excess of covered expense or any medical benefit maximum.
Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital stay Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by primarily for environmental change or physical therapy. Services provided by a rest home, a home for the adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or aged, a nursing home or any similar facility. Services provided by a skilled nursing facility or custodial occupational disease law, whether or not the member claims those benefits. If there is a dispute of care or rest cures, except as specified as covered in the EOC.
substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers' compensation, we will provide the benefits of this plan for such conditions, subject to a right of Chronic Pain. Treatment of chronic pain, except as specified as covered in the EOC.
recovery and reimbursement under California Labor Code Section 4903, as specified as covered in the Health Club Memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for Government Treatment. Any services the member actually received that were provided by a local, state developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to or federal government agency, except when payment under this plan is expressly required by federal or state law. We will not cover payment for these services if the member is not required to pay for them or they are given to the insured person for free.
Personal Items. Any supplies for comfort, hygiene or beautification. Education or Counseling. Educational services or nutritional counseling, except as specified as covered in the EOC. This exclusion does not Services of Relatives. Professional services received from a person living in the member's home or who is apply to counseling for the treatment of anorexia nervosa or bulimia nervosa.
related to the member by blood or marriage, except as specified as covered in the EOC.
Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or Voluntary Payment. Services for which the member has no legal obligation to pay, or for which no charge as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary would be made in the absence of insurance coverage or other health plan coverage, except services supplements that can be purchased over the counter, which by law do not require either a written received at a non-governmental charitable research hospital. Such a hospital must meet the following prescription or dispensing by a licensed pharmacist.
1. it must be internationally known as being devoted mainly to medical research; Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile 2. at least 10% of its yearly budget must be spent on research not directly related to patient care; 3. at least one-third of its gross income must come from donations or grants other than gifts or payments Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, 4. it must accept patients who are unable to pay; and injury or condition, including those required by employment or government authority, except as specified 5. two-thirds of its patients must have conditions directly related to the hospital's research.
Not Specifically Listed. Services not specifically listed in the plan as covered services.
Acupuncture. Acupuncture treatment, except as specified as covered in the EOC. Acupressure or massage to control pain, treat illness or promote health by applying pressure to one or more specific Private Contracts. Services or supplies provided pursuant to a private contract between the member and areas of the body based on dermatomes or acupuncture points.
a provider, for which reimbursement under Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.
Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay eyeglasses required as a result of this surgery.
primarily for diagnostic tests which could have been performed safely on an outpatient basis.
Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation. Mental or medicine, except when provided during a covered inpatient confinement or, as specified as covered in the nervous disorders and alcohol or drug dependence, including rehabilitative care in relation to these conditions, except as specified as covered in the EOC.
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs, medications and insulin, Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use. Smoking cessation except as specified as covered in the EOC. Any non-prescription, over-the-counter patent or proprietary drug or medicine. Cosmetics, health or beauty aids.
Orthodontia. Braces, other orthodontic appliances or orthodontic services.
Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, which are obtained from a retail pharmacy, are not covered by this plan.
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses, dental Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail implants, dental services, extraction of teeth, treatment to the teeth or gums, or treatment to or for any pharmacy that should have been obtained from the specialty pharmacy program.
disorders for the temporomandibular (jaw) joint, except as specified as covered in the EOC. Cosmetic dental surgery or other dental services for beautification.
Contraceptive Devices. Contraceptive devices prescribed for birth control, except as specified as Hearing Aids or Tests. Hearing aids, except as specified as covered in the EOC. Routine hearing tests.
Diabetic Supplies. Prescription and non-prescription diabetic supplies, except as specified as covered in Optometric Services or Supplies. Optometric services, eye exercises including orthoptics. Routine eye exams and routine eye refractions. Eyeglasses or contact lenses, except as specified as covered in the Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency, Lifestyle Programs. Programs to alter one's lifestyle which may include but are not limited to diet, hospice, or home infusion therapy provider, as specified as covered in the EOC.
exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered in the EOC.
Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to alter or reshape normal (including aged) structures or tissues of the body to improve appearance. This exclusion Pre-Existing Condition Exclusion - No payment will be made for services or supplies for the treatment of does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by a pre-existing condition during a period of six months following either: (a) the member's effective date or congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function (b) the first day of any waiting period required by the group, whichever is earlier. However, this limitation or symptomatology or to create a normal appearance), including surgery performed to restore symmetry does not apply to an insured person who is under age 19 or to conditions of pregnancy. Also if a member following mastectomy. Cosmetic surgery does not become reconstructive surgery because of was covered under creditable coverage, as outlined in the member's EOC, the time spent under the psychological or psychiatric reasons.
creditable coverage will be used to satisfy, or partially satisfy, the six-month period.
Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under Third Party Liability - Anthem Blue Cross is entitled to reimbursement of benefits paid if the member medical or physician supervision, unless specifically listed as covered in this plan. This exclusion includes, recovers damages from a legally liable third party.
but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid Coordination of Benefits - The benefits of this plan may be reduced if the member has any other group obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of health or dental coverage so that the services received from all group coverages do not exceed 100% of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross anthem.com/ca Anthem Blue Cross (P-NP) 2010-108/1 HCR Printed 03/2013 REEP 2013 PPO 5 Essential Premier PPo 250 15 -C RETAIL PRESCRIPTION PROGRAM
MAIL SERVICE PRESCRIPTION PROGRAM
GENERAL EXCLUSIONS AND LIMITATIONS
Prescription drug program benefits are not provided for The Express Scripts Retail Prescription Program allows The Express Scripts Mail Service Prescription Program you to go to an Express Scripts participating pharmacy is a convenient and cost-effective way to obtain your • Immunizing agents, biological sera, blood products or to have short-term prescriptions filled. maintenance medications through the mail. Maintenance drugs are those drugs taken for an • Hypodermic syringes and/or needles, except when • Simply present your Express Scripts ID card along ongoing or chronic condition such as high blood with your prescription to a participating pharmacy. pressure, heart disease or thyroid condition. • Contraceptive devices prescribed for birth control. Drugs and medications used to induce nonspontaneous abortions. Simply complete a mail service profile/order form. • Drugs and medications dispensed by or administered in an pharmacist will electronically verify eligibility, Enclose your written prescriptions along with your outpatient setting, including, but not limited to, outpatient early refills, drug-to-drug interactions and co-payment (if applicable) in the envelope hospital facilities and doctors’ offices. provided. You may pay by check or charge your • Drugs and medications dispensed by or while the member is confined in a hospital or skilled nursing facility, rest • If you go to a participating network pharmacy, you home, sanitarium, convalescent hospital or similar facility. will pay only your copayment amount and there Please allow up to 14 days from the date that you • Professional charges in connections with administering, mailed your prescription until you receive your injecting or dispensing of drugs. • A non-prescription patent or proprietary medicine, or Express Scripts
medication not requiring a prescription, except insulin. It is advisable for first time users of the mail order PARTICIPATING NETWORK PHARMACIES
Durable medical equipment, devices, appliances and pharmacy to have at least a 30-day supply of supplies, even if prescribed by a physician (refer to medical medication on hand when a request is placed with Express Scripts Mail Service Pharmacy. • Services or supplies for which the member is not charged. Orders are shipped in tamper-proof packaging by first class mail and are delivered by your normal Cosmetics, dietary supplements and health or beauty aids. carrier, unless the drug requires special handling • Any drug not approved for general use by the state of California Department of Health or the federal Food and Drug Administration. Express Scripts currently has over 50,000 pharmacies throughout the U.S. in our national pharmacy network. Any drug used for investigational purposes or labeled Express Scripts
All major chain pharmacies are included as well as
“Caution, Limited by Federal Law to Investigational Use.” MAIL SERVICE PHARMACY
many independent pharmacies. If you have questions
Any drug or medication prescribed for experimental on participating pharmacies in your area, you can indications (e.g., progesterone suppositories). access our pharmacy locator through the Express Non-medicinal substances or items Scripts web site at www.Express-Scripts.com. • Smoking Cessation products that require a prescription are covered. Smoking Cessation products that can be obtained You may also call Express Scripts Member Services at without a prescription (i.e. over the counter), are not 1-888-806-4969 for assistance in locating a pharmacy. Drugs used primarily for cosmetic purposes (e.g., Retin-A Non-Participating Pharmacies
for wrinkles, Rogaine for hair growth, Steroids for body If you choose to go to a pharmacy that is not in the • Drugs used primarily for the purpose of treating infertility network, you must pay for the prescription in full and (including but not limited to Clomid, Pergonal and file a claim with Express Scripts for reimbursement. You will still be responsible for the copayments as • Anorexiants (e.g., diet pills and appetite suppressants). outlined above and are reimbursed only 50% • Drugs obtained outside the United States. (reasonable & customary) of the total cost of the • Allergy desensitization products or allergy serum (refer to CUSTOMER SERVICE / QUESTIONS
Express Scripts Patient Care Contact Center representatives are able to assist you with various aspects of your prescription program. This includes inquiries on pharmacies, covered drugs, copayments and status of mail service prescriptions. PRESCRIPTION DRUG
Express Scripts Customer Service
1-888-806-4969
Open 24 hours per day, 7 days per week IVERSIDE
WEB SITE
EMPLOYER/EMPLOYEE
You may obtain information on Express Scripts PARTNERSHIP
through our web site. Features include a pharmacy locator, a mail service online refill option and a FOR BENEFITS
(REEP)
www.Express-Scripts.com
$10 / $50 / $100
PPO 3 Essentials
APPEALS
REEP provides a Prescription Drug Plan as Prescription Appeals must be mailed to: part of the medical benefit. This plan is administered by Express Scripts and consists of both a retail card program and a mail 6625 West 78th Street, Mail Route BL0390 The following guidelines provide general information on the program.

Source: http://www.valverde.edu/UserFiles/Servers/Server_88899/File/Staff/Benefits/1314-ABCPPOEssentials.pdf