Anthem Health Insurance HMO Blue New England

Anthem Health Insurance HMO Blue New England

A PLAN DESCRIPTION SUMMARY OF BENEFITS FOR ANTHEM HMO BLUE NEW ENGLAND

With Network Blue New England you have the comfort of knowing that you’re covered in sickness, in health, in the hospital, and in emergencies, anytime, anywhere. There are no waiting periods for benefits, no deductibles to meet, and claim forms to fill out. You’ll be recognized when you travel as a member of the Blue Cross Blue Shield Family.

These pages highlight some of the benefits of your Network Blue New England plan. The benefits described are covered when arranged by your primary care physician and coordinated by Network Blue New England. Your benefit description and riders define the terms and conditions of our plan. Should any questions arise, the benefit description and riders will govern. Some of the services not covered are: custodial care; cosmetic surgery; eyeglasses; contact lenses; most dental care (other than covered pediatric preventive dental care, provided care is received from a Blue Cross and Blue Shield participating dentist); chiropractor services; hearing aids; any services covered by workers’ compensation, other party liability; or coordination of benefits.

Please note: Blue Cross and Blue Shield of Massachusetts, Inc. administers claims payments only and does not assume financial risk for claims.

Administered by: Anthem Blue Cross and Blue Shield in Connecticut

Anthem Blue Cross and Blue Shield in Maine

Covered Services		Your Cost

Outpatient Care
Office visits		$5.00 per visit
Well-child care		$5.00 per visit
Routine checkups including one gyn exam per calendar year		$5.00 per visit
Maternity care		Nothing
X-rays, lab tests, and other imaging tests		Nothing
Preventive dental care for children underage 12 one visit each 6 months		Nothing
Hearing exams		$5.00 per visit
Eye exams one per 12 month period		$5.00 per visit
Emergency Room visits		$25 per visit (waived if admitted)
Allergy injections only		Nothing
Family planning		$5.00 per visit
Infertility services		$5.00 per visit
Short-term rehabilitative therapy-physical, speech/language, or occupational up to 60 visits per calendar year		$5.00 per visit
Home health care, including Hospice care		Nothing
Durable medical equipment such as wheelchairs, crutches, hospital beds covered up to a maximum of $1,500 per calendar year		All charges beyond the $1,500 calendar year benefit maximum
Oxygen and equipment for its administration		Nothing
Prosthetic devices		Nothing

Inpatient Care
Hospital care as many days as medically necessary		Nothing
Semiprivate room and board		Nothing
Special services		Nothing
Surgical services, X-rays and lab tests, and anesthesia		Nothing
Drugs and medication		Nothing
Physicians’ services		Nothing
Maternity care		Nothing
Care in a skilled nursing facility up to 100 days per calendar year		Nothing
Care in a rehabilitation facility up to 60 days per calendar year		Nothing

Prescription Drug Benefit
At designated retail pharmacies up to a 30-day supply for each prescription/refill or supply		$10 for generic $20 for preferred brand name $30 for non-preferred
Through mail-service drug program up to a 90-day supply for each prescription/refill or supply		$10 for generic $20 for preferred brand name $30 for non-preferred

Mental Health and Substance Abuse Treatment
Biologically-based conditions* Inpatient admission in a general hospital or mental hospital		Nothing
Outpatient visits		$5.00 per visit
Non-Biologically based mental conditions (includes drug addiction and alcoholism) Inpatient admissions in a general hospital		Nothing
Inpatient admissions in a mental hospital or substance abuse treatment facility up to 60 days per calendar year		Nothing
Outpatient visits up to 24 per calendar year		$.00 per visit

Alcoholism Treatment in addition to non-biologically-based mental conditions
Inpatient admissions in a general hospital		Nothing
Outpatient visits up to 8 visits in calendar year		$5.00 per visit
Treatment for rape-related mental or emotional disorders and treatment for children under the age of 19 is covered to the same extent as biologically-based conditions

Your Primary Care Physician: Your primary care physician (PCP) is the first person you call when you need medical care. If your PCP determines that you need to see a specialist, you’ll be referred to the appropriate specialist affiliated with your PCP’s network, which is also the network where you’ll receive inpatient care if needed.

Choosing a Primary Care Physician. When you join Network Blue New England, you may choose a PCP for you and each member of your family from any New England state. You’ll find a complete listing of PCP’s for each state in the state’s Provider Directory. In addition to PCP’s each directory lists specialists, hospitals, and health centers. If you need a copy of a directory from any New England state, or if you need help choosing a doctor, call the Physician Selection Service at 1 800-821-1388.

Urgent Care: If you need urgent medical care, call your PCP to arrange where you’ll receive treatment. Examples of urgent care are sprains, earaches, and high fever.

Urgent Care Away from Home: If you’re traveling outside of your plan service area (the state in which your PCP is located) and you need urgent care, go to the nearest appropriate medical facility. You or someone on your behalf must call your PCP within 48 hours and any follow-up care must be arranged by your PCP.

Emergency care—Wherever You Are: In an emergency, such as a suspected heart attack, stroke or poisoning, you should go directly to the nearest medical facility or call 911 or the local emergency phone number. There is a $25 co-payment for emergency room services, which is waived if you’re admitted to the hospital. You are someone on your behalf should notify your PCP within 48 hours. Any necessary follow-up care must be arranged by your PCP.

Dependent and Student Benefits: Network Blue Network Blue New England covers our unmarried dependent children until age 19 or full-time students until age 25. Student coverage ends when the student turns 25, or marries, or on November 1 following the date the student discontinues full-time classes or graduates, whichever comes first.

Living Healthy Program In addition to assuring you of access to appropriate medical care, your Network Blue New England membership helps you live as healthy a life as possible. For example, you’ll receive our booklet Living Healthy Programs, which outlines how to take advantage of many special programs, available to you—such as discounts on products and services that promise good health and a safer home environment.

Living Health Babies No Charge

A Fitness Benefit toward membership at any health club you choose You receive $150 per year per individual/family Discounts on eyewear, frames, lenses, supplies, safety helmets, and home safety items Discount varies BlueCare Line to answer your health care questions 24 hours a day No charge

Living Healthy Naturally—discounts for acupuncture, massage therapy, and nutritional counseling 20% discount