| |
Anthem
Locations
l
Anthem Provider Finder
Anthem Health Insurance Colorado
Rocky Mountain Hospital and Medical Service,
Inc.
700
Broadway, 1st Floor Lobby, Denver, CO 80273
from Anthem
for individuals and families.
They also boast a
positive credit rating from the four largest
carrier ratings companies.
Rocky Mountain Hospital and
Medical Service, Inc. Executives
-
Larry C. Glasscock
Chairman, President & CEO
-
Marjorie Dorr President,
Anthem East
-
Thomas Snead President,
Anthem Southeast
Caroline S. Matthews COO
David R. Frick Executive
Vice President, Chief Administrative
Anthem Blue
Cross and Blue Shield RightPlan PPO 40 With Prescription
Drug Coverage
PART A: TYPE OF COVERAGE
|
 .
TYPE OF PLAN |
Preferred provider plan
|
|
.
OUT-OF-NETWORK CARE COVERED? |
Yes, but the patient pays more
for out-of-network care |
|
.
AREAS OF
COLORADO WHERE PLAN IS
AVAILABLE
|
Plan is available throughout
Colorado |
PART B: SUMMARY OF
BENEFITS
Important Note:
This form is not a contract,
it is only a summary. The contents of this form are subject
to the provisions of the policy, which contains all terms,
covenants and conditions of coverage.
Your plan may exclude coverage for certain treatments,
diagnoses, or services not noted below. The benefits shown
in this summary may only be available if required plan
procedures are followed (e.g., plans may require prior
authorization, a referral from your primary care physician,
or use of specified providers or facilities). Consult the
actual policy to determine the exact terms and conditions of
coverage. Coinsurance and co-payment options reflect the
amount the covered person will pay.
|
IN-NETWORK |
OUT-OF-NETWORK |
|
4. ANNUAL DEDUCTIBLE 2
a) Individual
b) Family
|
$0
Family coverage not provided
|
$0
Family coverage not provided
|
|
5. OUT-OF-POCKET
ANNUAL MAXIMUM3
a) Individual
b) Family
c) Is
deductible included in the out-of-pocket maximum?
|
$3,500
Family coverage not provided
No
The out-of-pocket annual maximum
does not include coinsurance for Other Mental Health
Care.
Copayment amounts do not apply to
out-of-pocket cost sharing requirements, except for
inpatient and outpatient hospital copayments (see
lines 12 and 13). |
$10,000
Family coverage not provided
No
The out-of-pocket annual maximum
does not include coinsurance for Other Mental Health
Care or member costs for not obtaining required
preauthorizations. Member cost sharing for visiting
a non-participating provider for physical,
occupational or speech therapies does not apply to
the out-of-pocket cost sharing requirements.
Copayment amounts do not apply to
out-of-pocket cost sharing requirements, except for
inpatient and outpatient hospital copayments (see
lines 12 and 13). |
|
6. LIFETIME OR
BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE
|
$5,000,000 per member in- and
out-of-network combined for all covered services.
Morbid obesity surgery has a lifetime maximum Anthem
payment of $7,500 for services received from a
Center of Excellence facility or a lifetime Anthem
maximum payment of $1,500 for services received from
a facility that has not been designated as a Center
of Excellence; total lifetime maximum payment by the
carrier shall not exceed $7,500 per member in- and
out-of-network combined. Major organ transplants
have a lifetime maximum Anthem payment of $1,000,000
per transplant in- and out-of-network combined.
|
$5,000,000 per member in- and
out-of-network combined for all covered services.
Morbid obesity surgery has a lifetime maximum Anthem
payment of $1,500 for services received from a
facility that has not been designated as a Center of
Excellence; total lifetime Anthem maximum payment
shall not exceed $7,500 in- and out-of-network
combined. Major organ transplants have a lifetime
maximum Anthem payment of $1,000,000 per transplant
in- and out-of-network combined. |
Independent licensees of the Blue Cross and
Blue Shield Association. Anthem Blue Cross and Blue Shield
is the trade name of Rocky Mountain Hospital and Medical
Service, Inc. ® Registered marks Blue Cross and Blue Shield
Association 05-73 CIM (4-06) v1 DL95 05-73 CIM (4-06) v1
DL95 2
IN-NETWORK OUT-OF-NETWORK
|
7A. COVERED PROVIDERS
|
Anthem Blue Cross and Blue Shield
PPO Provider Network. See provider directory for
complete list of current providers. |
All providers licensed or certified
to provide covered benefits. |
|
7B. With respect to network plans,
are all the providers listed in 7A accessible to me
through my primary care physician? |
Yes |
Yes |
|
8. ROUTINE
MEDICAL OFFICE VISITS4
a) Primary
Care Providers |
$40 co-payment per office visit plus
40% coinsurance for services other than an office
visit. |
50% coinsurance |
|
b) Specialists |
$40 co-payment per office visit plus
40% coinsurance for services other than an office
visit.
Only limited services are covered as
part of an office visit; all other covered services
are subject to applicable coinsurance or cost
sharing.
See line 9 for preventive services,
which are limited. |
50% coinsurance |
|
9. PREVENTIVE CARE
a) Children’s
services |
$40 co-payment for office visit plus
40% coinsurance for services other than an office
visit for age-appropriate visits and routine
immunizations. |
50% coinsurance, for age-appropriate
visits and routine immunizations. |
|
b) Adults’ services |
Not covered except for:
- One annual pap test. $40 co-payment for
office visit plus 40% coinsurance. Maximum $75
Anthem payment for laboratory test;
- Mammogram screening and prostate
screening, which are not subject to coinsurance.
|
Not covered except for:
- Mammogram screening and prostate
screening, which are not subject to coinsurance.
|
|
10. MATERNITY
a) Prenatal
care
b) Delivery &
inpatient well baby care 5 |
Not covered
Delivery not covered. 40%
coinsurance plus $500 co-payment per day up to 4
days for inpatient well baby care for up to 31-days
following birth, adoption or placement for adoption.
|
Not covered
Delivery not covered. 50%
coinsurance plus $500 hospital co-payment per day up
to 4 days for inpatient well baby care for up to
31-days following birth, adoption or placement for
adoption. |
|
See certificate for complications
of pregnancy coverage. |
05-73 CIM (4-06) v1 DL95 3
|
11. PRESCRIPTION DRUGS6
Level of
coverage and restrictions on prescriptions
a) Inpatient
care |
Included with inpatient hospital
(see line 12) |
Included with inpatient hospital
(see line 12) |
|
b) Outpatient care |
Tier 1 generic formulary $10
co-payment; Tier 2 brand formulary $30 co-payment;
Tier 3 non-formulary 50%
coinsurance;
Tier 4 30% coinsurance for
self-administered injectables;
At a participating pharmacy up to a
34-day supply. |
Not covered |
|
c) Prescription Mail Service |
Tier 1 generic formulary $20
co-payment; Tier 2 brand formulary $60 co-payment;
Tier 3 non-formulary 50%
coinsurance;
Tier 4 30% coinsurance for
self-administered injectables;
Through the mail order service up to
a 90-day supply.
All brand name prescription drugs
are subject to an annual $500 brand deductible. The
$500 brand deductible does not apply to the
out-of-pocket annual maximum.
In addition to the cost sharing
described above, if you purchase a brand-name drug
when there is a FDA rated equivalent drug available,
you are responsible for the Tier-2 or Tier-3
Co-payment for brand-name drugs and you will pay the
difference between the cost of the brand-name and
the cost of the generic.
For example: a Tier-3 brand-name
prescription costs $100; a generic Tier-1
substitution is available, the generic prescription
costs $60, you pay the $40 difference plus the
Tier-3 (50% coinsurance) for a total member cost of
$90. The $40 difference is not applied toward any
other cost-sharing requirement.
See certificate for details.
For drugs on our approved list,
contact Customer Service at 888-231-5046. Covered
only when received from a participating pharmacy.
|
Not covered |
05-73 CIM (4-06) v1 DL95 4
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12. INPATIENT HOSPITAL
|
$500 co-payment per day up to 4
days, plus 40% coinsurance. Hospital co-payment
amounts will be applied to out-of-pocket cost
sharing requirements. |
$500 co-payment per day up to 4 days
plus 50% coinsurance. Hospital co-payment amounts
will be applied to out-of-pocket cost sharing
requirements. |
|
13. OUTPATIENT/AMBULATORY SURGERY
|
$500 co-payment per surgical
admission, plus 40% coinsurance. Hospital co-payment
amounts will be applied to out-of-pocket cost
sharing requirements. |
$500 co-payment per surgical
admission plus 50% coinsurance. Hospital co-payment
amounts will be applied to out-of-pocket cost
sharing requirements. |
|
14. DIAGNOSTICS
a) Laboratory
& x-ray
b) MRI,
nuclear medicine and other high-tech services
|
40% coinsurance
40% coinsurance |
50% coinsurance
50% coinsurance |
|
15. EMERGENCY CARE7,8 |
$100 emergency room co-payment
(waived if admitted), plus 40% coinsurance
|
$100 emergency room co-payment
(waived if admitted), plus 50% coinsurance
|
|
16. AMBULANCE |
$100 co-payment |
$100 co-payment |
|
17. URGENT, NON-ROUTINE, AFTER HOURS CARE
|
$40 office visit co-payment plus 40%
coinsurance for services other than an office visit
See line 15 for emergency room care
|
50% coinsurance
See line 15 for emergency room care
|
|
18. BIOLOGICALLY-BASED MENTAL
ILLNESS CARE9 |
Biologically-Based Mental Illness
Care is paid as Other Mental Health Care, see line
19. |
Biologically-Based Mental Illness
Care is paid as Other Mental Health Care, see line
19. |
|
19. 0THER MENTAL
HEALTH CARE
a) Inpatient
care
b) Outpatient
care |
All charges except $175 per day.
Limited to 30 days in each benefit year in- and
out-of-network combined.
All charges except $25 per visit.
Limited to 20 visits in each benefit year, in-and
out-of-network combined. Maximum Anthem payment for
inpatient and outpatient care is limited to $10,000
per lifetime, in-and out-of-network combined.
|
All charges except $175 per day.
Limited to 30 days in each benefit year in- and
out-of-network combined.
All charges except $25 per visit.
Limited to 20 visits in each benefit year, in-and
out-of-network combined. Maximum Anthem payment for
inpatient and outpatient care is limited to $10,000
per lifetime, in-and out-of-network combined.
|
|
20. ALCOHOL &
SUBSTANCE ABUSE
a) Inpatient
Care
b) Outpatient
care |
Not covered
Not covered |
Not covered
Not covered |
05-73 CIM (4-06) v1 DL95 5
|
21. PHYSICAL,
OCCUPATIONAL, AND SPEECH THERAPY
a) Inpatient
|
40% coinsurance. Covered when
received as part of an inpatient hospital admission
for acute care and for rehabilitation therapy for up
to 30 days per illness or injury, in- and
out-of-network combined. |
50% coinsurance. Covered when
received as part of an inpatient hospital admission
for acute care and for rehabilitation therapy for up
to 30 days per illness or injury, in- and
out-of-network combined. |
|
b) Outpatient |
40% coinsurance
Physical and occupational therapy is
limited to a combination of 12 visits in each
benefit year in- and out-of-network combined, except
for children to age 5 (see certificate for details).
Speech therapy is limited to 50
visits in each benefit year, in- and out-of-network
combined, except for children to age 5 (see
certificate for details). |
Participating
Providers: 50% coinsurance
Non-Participating Providers: All
charges except $25 per visit
Physical and occupational therapy is
limited to a combination of 12 visits in each
benefit year in- and out-of-network combined, except
for children to age 5 (see certificate for details).
Speech therapy is limited to 50
visits in each benefit year, in- and out-of-network
combined, except for children to age 5 (see
certificate for details). |
|
22. DURABLE MEDICAL EQUIPMENT |
40% coinsurance. See certificate for
types and circumstances of coverage. For prosthetic
devices (arms and legs), benefits are provided with
the same deductible and coinsurance as provided by
Medicare.
Footwear is limited to a $400
maximum Anthem payment per member’s benefit year,
in- and out-of-network combined.
Wigs are limited to a $400 maximum
Anthem payment per member’s year, in- and
out-of-network combined. |
50% coinsurance. See certificate for
types and circumstances of coverage.
Footwear is limited to a $400
maximum Anthem payment per member’s benefit year,
in- and out-of-network combined.
Wigs are limited to a $400 maximum
Anthem payment per member’s benefit year, in- and
out-of-network combined. |
|
23. OXYGEN |
40% coinsurance |
50% coinsurance |
|
24. ORGAN TRANSPLANTS
|
40% coinsurance. See certificate for
details. |
50% coinsurance. See certificate for
details. |
|
25. HOME HEALTH CARE
|
40% coinsurance. Limited to 60
visits in each benefit year, in-and out-of-network
combined. |
50% coinsurance. Limited to 60
visits in each benefit year, in-and out-of-network
combined. |
|
26. HOSPICE CARE
a) Inpatient
Care
b) Outpatient
care |
40% coinsurance
40% coinsurance. Limited to $100
maximum Anthem payment per day with a maximum
benefit of 91 days in each benefit period, in-and
out-of-network combined.
See certificate for details.
|
50% coinsurance
50% coinsurance. Limited to $100
maximum Anthem payment per day with a maximum
benefit of 91 days in each benefit period, in-and
out-of-network combined.
See certificate for details.
|
05-73 CIM (4-06) v1 DL95 6
|
27. SKILLED NURSING FACILITY CARE
|
Not covered |
Not covered |
|
28. DENTAL CARE |
Not covered |
Not covered |
|
29. VISION CARE |
Not covered |
Not covered |
|
30. CHIROPRACTIC CARE
|
Not covered |
Not covered |
|
31. SIGNIFICANT ADDITIONAL COVERED
SERVICES (list up to 5) |
Dental injury – 40% coinsurance
Smoking cessation program – All
charges except $50 per lifetime, in-and
out-of-network combined.
When a member desires another
professional opinion, they may obtain a second
surgical opinion. |
Dental injury – 50% coinsurance
Smoking cessation program – All
charges except $50 per lifetime, in-and
out-of-network combined.
When a member desires another
professional opinion, they may obtain a second
surgical opinion. |
PART C: LIMITATIONS
AND EXCLUSIONS
|
32. PERIOD DURING WHICH PRE-EXISTING
CONDITIONS ARE NOT COVERED. 10 |
12 months for all pre-existing
conditions unless the covered person is a
HIPAA-eligible individual as defined under federal
and state law, in which case there are no
pre-existing condition exclusions. |
|
33. EXCLUSIONARY RIDERS. Can an
individual’s specific, pre-existing condition be
entirely excluded from the policy? |
No |
|
34. HOW DOES THE POLICY DEFINE A
"PRE-EXISTING CONDITION"? |
A pre-existing condition is an
injury, sickness, or pregnancy for which a person
incurred charges, received medical treatment,
consulted a health-care professional, or took
prescription drugs within 12 months immediately
preceding the effective date of coverage.
|
|
35. WHAT TREATMENTS AND CONDITIONS
ARE EXCLUDED UNDER THIS POLICY? |
Exclusions vary by policy. List of
exclusions is available immediately upon request
from your carrier, agent, or plan, sponsor (e.g.,
employer). Review them to see if a service or
treatment you may need is excluded from the policy.
|
PART D: USING THE PLAN
|
IN-NETWORK |
OUT-OF-NETWORK |
|
36. Does the enrollee have to obtain
a referral and/or prior authorization for specialty
care in most or all cases? |
No |
Yes, the member is responsible for
obtaining preauthorization unless the provider
participates with Anthem Blue Cross and Blue Shield.
|
|
37. Is prior authorization required
for surgical procedures and hospital care (except in
an emergency)? |
Yes |
Yes, the member is responsible for
obtaining pre-certification unless the provider
participates with Anthem Blue Cross and Blue Shield.
|
|
38. If the provider charges more for
a covered service than the plan normally pays, does
the enrollee have to pay the difference?
|
No |
Yes, unless the provider
participates with Anthem Blue Cross and Blue Shield.
|
|
39. What is the main customer
service number? |
888-231-5046 |
|
40. Whom do I write/call if I have a
complaint or want to file a grievance?11 |
Anthem Blue Cross and Blue Shield
Complaints and Appeals
700 Broadway, Denver, CO 80273
888-231-5046 |
|
41. Whom do I contact if I am not
satisfied with the resolution of my complaint or
grievance? |
Write to: Colorado Division of Insurance ICARE
Section
1560 Broadway, Suite 850, Denver, CO 80202
|
|
42. To assist in filing a grievance,
indicate the form number of this policy; whether it
is individual, small group, or large group; and if
it is a short-term policy. |
Policy form #’s 05-74, individual
|
|
43. Does the plan have a binding
arbitration clause? |
Yes |
05-73 CIM (4-06) v1 DL95 7
1 "Network"
refers to a specified group of physicians, hospitals,
medical clinics and other health care providers that your
plan may require you to use in order for you to get any
coverage at all under the plan, or that the plan may
encourage you to use because it may pay more of your bill if
you use their network providers (i.e., go in-network) than
if you don’t (i.e., go out-of-network).
2 "Deductible"
means the amount you will have to pay for allowable
covered expenses under a health plan during a specified time
period (e.g., a calendar year) before the carrier will cover
those expenses. The specific expenses that are subject to
deductible may vary by policy. Expenses that are subject to
deductible may be noted in boxes 8 through 31.
3 "Out-of-pocket
maximum" means the maximum amount you will have
to pay for allowable covered expenses under a health plan,
which may or may not include the deductibles or co-payments,
depending on the contract for that plan. The specific
deductibles or co-payments included in the out-of-pocket
maximum may vary by policy. Expenses that are applied toward
the out-of-pocket maximum may be noted in boxes 8 through
31.
4 Routine medical office visits include
physician, mid-level practitioner, and specialist visits.
5 Well baby care includes an in-hospital
newborn pediatric visit and newborn hearing screening. The
hospital co-payment applies to mother if complication of
pregnancy and well-baby together: there are not separate
co-payments.
6 Prescription drugs otherwise excluded are
not covered, regardless of whether preferred generic,
preferred brand name, or non-preferred.
7 "Emergency care"
means services delivered by an emergency care facility
which are necessary to screen and stabilize a covered
person. The plan must cover this care if a prudent lay
person having average knowledge of health services and
medicine and acting reasonably would have believed that an
emergency medical condition or life- or limb threatening
emergency existed.
8 Non-emergency care delivered in an
emergency room is covered only if the covered person
receiving such care was referred to emergency room by
his/her carrier or primary care physician. If emergency
departments are used by the plan or non-emergency
after-hours care, then urgent care co-payments apply.
9 "Biologically
based mental illnesses" means schizophrenia,
schizoaffective disorder, bipolar affective disorder, major
depressive disorder, specific obsessive-compulsive disorder,
and panic disorder.
10 Waiver of
pre-existing condition exclusions. State law
requires carriers to waive some or all of the pre-existing
condition exclusion period based on other coverage you
recently may have had. Ask your carrier or plan sponsor
(e.g., employer) for details.
11 Grievances.
Colorado law requires all plans to use consistent grievance
procedures. Write the Colorado Division of Insurance for a
copy of those procedures.
Anthem Blue Cross
and Blue Shield & HMO Colorado Health Plan Description Form
Disclosure Amendment
Colorado law requires carriers to make
available a Colorado Health Plan Description Form, which is
intended to facilitate comparison of health plans. The form
must be provided automatically within three (3) business
days to a potential policyholder who has expressed interest
in a particular plan. The carrier also must provide the
form, upon oral or written request, within three (3)
business days, to any person who is interested in coverage
under or who is covered by a health benefit plan of the
carrier.
Pursuant to Colorado law (C.R.S.
§10-16-107(7)(a), services or supplies for the treatment of
Intractable Pain and/or Chronic Pain are not covered.
Individual Health
Plans
This coverage is
renewable at your option, except for the following reasons:
-
1. Non-payment of the required premium;
-
2. Fraud or intentional misrepresentation of
material fact on the part of the plan sponsor;
-
3. The commissioner finds that the continuation of
the coverage would not be in the best interest of the
policyholders, the plan is obsolete, or would impair the
carrier’s ability to meet its contractual obligations;
-
4. The carrier elects to discontinue offering and
non-renew all of its individual plans delivered or
issued for delivery in Colorado.
Group Health Plans
Pursuant to Colorado law (C.R.S.
§10-16-105(5)(g)(I)), small employers purchasing any health
benefit plan other than a Basic Health Benefit Plan, must
pay for all benefits mandated by Colorado law, including
non-waivable coverages for: newborn, maternity, pregnancy,
childbirth, complications from pregnancy and childbirth,
therapies for congenital defects and birth abnormalities,
low-dose mammography, mental illness, biologically-based
mental illness, the availability of alcoholism treatment,
the availability of hospice care, prostate cancer screening,
child health supervision services, hospitalization and
general anesthesia for dental procedures for dependent
children, diabetes, and prosthetic devices.
Pursuant to Colorado law (C.R.S.
§10-16-105(5)(g)(II)), small employers purchasing a Basic
Health Benefit Plan is waiving coverage for low-dose
mammography screening, mental illness, prostate cancer
screening, hospitalization and general anesthesia for dental
procedures for children, the availability of treatment for
alcoholism, and the availability of hospice care. All other
state-mandated benefits are included in the Basic Health
Benefit Plan.
This coverage is
renewable at your option, except for the following reasons:
-
1. Non-payment of the required premium;
-
2. Fraud or intentional misrepresentation of
material fact on the part of the plan sponsor;
-
3. The policyholder fails to comply with
participation or contribution rules;
-
4. The carrier elects to discontinue offering and
non-renew all of its small group or large group plans
delivered or issued for delivery in Colorado;
-
5. An employer is no longer actively engaged in the
business in which it was engaged on the effective date
of the plan;
Independent licensees of the Blue Cross and Blue Shield
Association. Anthem Blue Cross and Blue Shield is the trade
name of Rocky Mountain Hospital and Medical Service, Inc. ®
Registered marks Blue Cross and Blue Shield Association
98868 (10-04) CO disclosure 8
-
6. With respect to group health benefit plans
offered through a managed care plan, there are no longer
any enrollees who live, reside or work in the service
area; or
-
7. With respect to coverage of an employer that is
made available only through one or more bona fide
associations, the membership of an employer ceases.
Important Information for Employers with 50
or Fewer Employees and Business Groups of One: Rates are
calculated based on allowable case characteristics – age
bands, geographic location, family size, health status, and
claims experience – and will be given within five working
days of request. Rates for a specific employer cannot be
adjusted due to the duration of coverage of employees or
dependents of the small employer. Rates may change based on
case characteristics, whenever benefits are changed, or upon
giving written notice to the employer not less than 31 days
prior to the effective date of the change. New applicants
may be subject to pre-existing condition clauses, based on
HIPAA requirements. Renewal of health insurance coverage in
this class is guaranteed, assuming compliance with
underwriting regulations. A Network Access Plan, which
describes Anthem Blue Cross and Blue Shield’s or HMO
Colorado’s network standards and evaluation procedures for
ensuring provider access is available by calling our
customer service department.
COLORADO INSURANCE
LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE
ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL
EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD
HEALTH BENEFIT PLAN, UPON REQUEST OF A SMALL EMPLOYER TO THE
ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY
OF THE INDIVIDUALS IN THE GROUP. BUSINESS GROUPS OF ONE
CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT
PLAN DURING OPEN ENROLLMENT PERIODS SPECIFIED BY LAW.
98868 (10-04) CO disclosure Independent licensees of the
Blue Cross and Blue Shield Association. Anthem Blue Cross
and Blue Shield is the trade name of Rocky Mountain Hospital
and Medical Service, Inc. ® Registered marks Blue Cross and
Blue Shield Association 98871 (7-04) v2 10
Cancer Screenings
At Anthem Blue Cross and Blue Shield and our
subsidiary company, HMO Colorado, Inc., we believe cancer
screenings provide important preventive care that supports
our mission: to improve the health of the people we serve.
We cover cancer screenings as described below.
Pap Tests
All plans except our BasicBlue PPO Plan
provide coverage for an annual Pap test and the related
office visit. The BasicBlue PPO Plan provides coverage for a
Pap test and the related office visit once every three
years. Payment for the Pap test is based on the plan’s
laboratory services provisions, and payment for the related
office visit is based on the plan’s preventive care
provisions. With our BluePreferred for Individuals PPO Plan,
laboratory services for a Pap test are limited to a maximum
payment of $75.00. With our Colorado HSA-Qualified Plans for
Individuals, all services related to a Pap test are subject
to the maximum benefit as described on the Health Plan
Description Form. Under most plans pap tests received out
of-network are not covered.
Mammogram Screenings
All plans except our HMO and PPO Basic
Health and BluePreferred for Individual Plans provide
mammogram screening coverage for women 35 years of age and
older. For BluePreferred for Individuals the following
frequency guidelines apply: For women between the ages of 35
years and 40 years, a single baseline screening mammogram is
covered. For women between 40 years of age and less than 50
years of age, a screening mammogram is covered once every
two years, or it is covered annually if the member’s
physician has determined that identified breast cancer risk
factors are present. For women between the ages of 50 years
and 65 years, a screening mammogram is covered annually.
Payment for the mammogram screening benefit is based on the
plan’s provisions for X-ray services. Our HMO and PPO Basic
Health Plans do not provide coverage for mammogram
screenings.
Prostate Cancer
Screenings
All plans except our HMO and PPO Basic
Health Plans provide prostate cancer screening coverage for
men 40 years of age and older. The following frequency
guidelines apply: For men between 40 years of age and less
than 50 years of age, a prostate cancer screening is covered
annually if the member’s physician has determined that
identified prostate cancer risk factors are present. For men
50 years of age and older, a prostate cancer screening is
covered annually. Payment for the prostate cancer screening
benefit is based on the plan’s provisions for X-ray
services. Our HMO and PPO Basic Health Plans do not provide
coverage for prostate cancer screenings.
Colorectal Cancer
Screenings
Several types of colorectal cancer screening
methods exist. All plans except BluePreferred for Individual
Plans provide coverage for colorectal cancer screenings,
such as colonoscopies, sigmoidoscopies and fecal occult
blood tests. Depending on the type of colorectal cancer
screening received, payment for the benefit is based on the
plan’s provisions for laboratory services, preventive care
office visit services, or other medical or surgical
services. Our plans do not provide coverage for preventive
colorectal cancer screenings involving invasive surgical
procedures and DNA analysis. Under most plans colorectal
cancer screenings received out of-network are not covered.
The information above is only a summary of
the benefits described. The certificate for each health plan
includes important additional information about limitations,
exclusions and covered benefits. The Health Plan Description
Form for each health plan includes additional information
about co-payments, deductibles and coinsurance. If you have
any questions, please call our customer service department
at the phone number on the Health Plan Description Form.
Which Anthem Colorado health plan Is right for
you?
RightPlan PPO 40 Brochure
Lumenos
Consumer Driven Health Plans - Brochure
Colorado
Plan Comparison
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In Colorado:
Rocky Mountain Hospital and Medical Service,
Inc.
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In Connecticut:
Anthem Health Plans, Inc.
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In Indiana:
Anthem Insurance Companies, Inc.
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In Kentucky:
Anthem Health Plans of Kentucky
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In Nevada:
Rocky Mountain Hospital and Medical Service,
Inc.
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In Ohio:
Community Insurance Company.
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In Wisconsin:
Blue Cross Blue Shield of Wisconsin BCBSWi and Compcare
Health Services Insurance Corporation Compcare.
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Independent licensees of the Blue Cross and Blue
Shield Association
Serving residents and businesses in Indiana,
Kentucky, Missouri, Ohio, Wisconsin, Colorado,
Nevada, Connecticut, Maine, New Hampshire and
Virginia (excluding the city of Fairfax,
the town of Vienna and the area east of State
Route 123)
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