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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

&his is o$%" a su!!ar"( If you want more detail about your coverage and costs, you can get the completeterms in the policy or plan document at https://eoc.anthem.com/eocdps/for by calling 1-844-404-6843.

)!'orta$t *uestio$s A$s+ers Wh" this Matters:

What is the overalldeductible?

For in-network providers

,2-000individual/ ,.-000familyFor out-of-network providers

,-000individual/,10-000familyDoesnt apply to in-networkpreventive care and routine eyeexams.

ou must pay all the costs up to the deductible amountbefore thisplan begins to pay for covered services youuse. !heck your policy or plan document to see when thedeductible starts over "usually, but not always, #anuary$st%. &ee the chart starting on page 'for how much youpay for covered services after you meet the deductible.

Are there other

deductibles forspecic services?

es. For durable medical

e(uipment there is a ,20deductible.

ou must pay all of the costs for these services up to the

speci)c deductibleamount before this plan begins to payfor these services.

Is there an outofpocet li!it on !"e#penses?

For in-network providers

,6-600individual$,13-200family

For out-of-network providers

,10-000individual/,20-000family

*he out-of-pocet li!it is the most you could pay duringa coverage period "usually one year% for your share of thecost of covered services. *his limit helps you plan forhealth care expenses.

What is not included

in the outofpocetli!it?

+remiums, penalties for

non-compliance, balance-billedcharges, and health care thisplan doesnt cover.

ven though you pay these expenses, they dont counttoward the out-of-pocet li!it.

Is there an overallannual li!iton %hatthe plan pa"s?

o.*he chart starting on page 'describes any limits on whatthe plan will pay for specifccovered services, such asoice visits.

&uestions'!all 1-844-404-6843or visit us at%%%(anthe!(co!If you arent clear about any of the underlined terms used in this form, see the /lossary. ou can view the /lossaryat%%%(anthe!(co!or call 1-844-404-6843to re(uest a copy.

https://eoc.anthem.com/eocdps/fihttps://eoc.anthem.com/eocdps/fi

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

)oes this plan use anet%or ofproviders?

es. For a list of in-net%orproviders, seewww.anthem.com or call $-011-

121-3014

If you use an in-network doctor or other health careprovider, thisplan will pay some or all of the costs ofcovered services. 5e aware, your in-network doctor orhospital may use an out-of-network providerfor someservices. +lans use the term in-network, preferred, or

participatingfor providersin their net%or. &ee thechart starting on page 'for how this plan pays dierentkinds of providers.

)o I need a referralto see a specialist?

o.ou can see the specialistyou choose without permissionfrom this plan.

Are there servicesthis plan doesn*tcover?

es.&ome of the services thisplan doesnt cover are listed onpage 3. &ee your policy or plan document for additionalinformation about e#cluded services.

+opa"!entsare )xed dollar amounts "for example, 6$7% you pay for covered health care, usually when youreceive the service.

+oinsuranceisyour share of the costs of a covered service, calculated as a percent of the allo%ed

a!ountfor the service. For example, if the plans allo%ed a!ountfor an overnight hospital stay is6$,222, your coinsurancepayment of '28 would be 6'22. *his may change if you havent met yourdeductible.

*he amount the plan pays for covered services is based on the allo%ed a!ount. If an out-of-network

providercharges more than the allo%ed a!ount, you may have to pay the dierence. For example, if anout-of-network hospital charges 6$,722 for an overnight stay and the allo%ed a!ountis 6$,222, you mayhave to pay the 6722 dierence. "*his is called balance billin,.%

*his plan may encourage you to use in-network providersby charging you lower deductibles,

copa"!entsand coinsuranceamounts.

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

+rimary care visit to treat anin9ury or illness

6'7copay:visit

728coinsurance

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&uestions'!all 1-844-404-6843or visit us at%%%(anthe!(co!If you arent clear about any of the underlined terms used in this form, see the /lossary. ou can view the /lossaryat%%%(anthe!(co!or call 1-844-404-6843to re(uest a copy.

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

If "ou visit ahealth careprovider*soice or clinic

&pecialist visit612copay:visit

728coinsurance

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ail

ot !overed>aintenance >eds are re(uired to be)lled mail order after 4 )lls at retail"penalty applies%. If pre-auth re(uiredB not obtained, drug may not becovered. !ertain +reventive meds nocopay. If a generic e(uivalent isavailable B brand isprescribed:member will pay brandname cost dierence. +lan usespreferred drug list to identify coverage.

+referred brand drugs"?etail:42 day@>ail:A2 day%

612 ?etail:602>ail

ot !overed

on-preferred brand "?etail:42day@>ail:A2day%

632 ?etail:6$02>ail

ot !overed

&pecialty drugs

Cll &pecialtymeds process

throughCccredo at the

mail ordercosts.

ot !overed

*he mail order cost will be basedon the medication tier "generic,preferred, non-preferred%.&pecialty meds can not be )lled atretail pharmacies.

If "ou haveoutpatientsur,er"

Facility fee "e.g., ambulatorysurgery center%

o !harge728coinsurance

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&uestions'!all 1-844-404-6843or visit us at%%%(anthe!(co!If you arent clear about any of the underlined terms used in this form, see the /lossary. ou can view the /lossaryat%%%(anthe!(co!or call 1-844-404-6843to re(uest a copy.

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

If "ou needi!!ediate!edicalattention

mergency room services

6'22 copay :visitprofessionaland otherservicessub9ect todeductible

6'22 copay :visitprofessionaland otherservicessub9ect todeductible

6'22 copay is waived ifadmitted for inpatient stay.>embers may be balancebilled for out of networkservices.

mergency medicaltransportation

o !harge o !harge>embers may be balancebilled for out of networkservices

Ergent care 67 copay 67 copay

>embers may be balance

billed for out of networkservices

If "ou have ahospital sta"

Facility fee "e.g., hospital room% o !harge728coinsurance

+recerti)cation is re(uired forInpatient hospital admission. C6722 penalty is applied if an

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

If "ou have!ental health.behavioralhealth. orsubstanceabuse needs

>ental:5ehavioral healthoutpatient services

6'7copay:visit

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>ental:5ehavioral healthinpatient services

o !harge728coinsurance

+recerti)cation is re(uired forInpatient hospital admission. C6722 penalty is applied if an

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

If "ou needhelp recoverin,or have otherspecial healthneeds

Gome health care o !harge728coinsurance

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?ehabilitation services

612 copay foroutpatientservices. ocharge forinpatient care.

728coinsurance

Inpatient physical medicinerehabilitation is limited to $22days per member per calendar

year. Himited to 32 visitscombined physical therapy,speech therapy andoccupational therapy. Clltherapy limits are combined inand out of network.

Gabilitation services

612 copay foroutpatientservices. ocharge forinpatient care.

728coinsurance

Cll rehabilitation andhabilitation visits count toward

your rehabilitation visit limit.

&killed nursing care o !harge728coinsurance

Himited to $22 inpatientdaysper member per calendar

year. +recerti)cation isre(uired or 6722 penalty isapplied.

Durable medical e(uipment6'72Deductiblethen '28coinsurance

6'72Deductiblethen '28coinsurance

6'72 deductible combined inand out of network. >embermay be balance billed for out ofnetwork services.

Gospice service o !harge728coinsurance

+recerti)cation is re(uired forInpatient hospital admission. C6722 penalty is applied if an

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

Co!!o$Medica% Eve$t

ervices ou Ma" Need

our Cost )fou se a$)$$et+orProvider

our Cost )fou se a$

Outof$et+orProvider

4i!itatio$s 5 Ece'tio$s

If "our childneeds dental ore"e care

ye exam o !harge728coinsurance

Himited to one exam percalendar year for $0 and

younger. Himited to one examevery ' years for $A and older.

/lasses ot !overed ot !overed ;;;;;;;;;;;;none;;;;;;;;;;;;

Dental check-up ot !overed ot !overed ;;;;;;;;;;;;none;;;;;;;;;;;;

Ec%uded ervices 5 Other Covered ervices:

ervices our P%a$ 8oes NO& Cover /his isn*t a co!plete list( +hec "our polic" or plan docu!ent for othere#cluded services(

Ccupuncture

!osmetic surgery

Dental care "Cdult%

Hong-term care

on-emergency care when traveling

outside the E.&.

+rivate-duty nursing

?outine foot care

Jeight loss programs

Other Covered ervices/his isn*t a co!plete list( +hec "our polic" or plan docu!ent for other covered

services and "our costs for these services(

5ariatric surgery

!hiropractic care

Infertility treatment

!overage provided outside theEnited &tates.&ee www.5!5&.com:bluecardworldwide

Gearing aids "Himitations Cpply%

?outine eye care "Cdult -Himitations apply%

&uestions'!all 1-844-404-6843or visit us at%%%(anthe!(co!If you arent clear about any of the underlined terms used in this form, see the /lossary. ou can view the /lossaryat%%%(anthe!(co!or call 1-844-404-6843to re(uest a copy.

http://www.bcbs.com/bluecardworldwidehttp://www.bcbs.com/bluecardworldwidehttp://www.bcbs.com/bluecardworldwidehttp://www.bcbs.com/bluecardworldwide

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

our ights to Co$ti$ue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and &tate laws may provide

protections that allow you to keep health coverage. Cny such rights may be limited in duration and will re(uire you

to pay a pre!iu!, which may be signi)cantly higher than the premium you pay while covered under the plan.

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

our

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016u!!ar" of #e$efits a$d Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family |P%a$ &"'e: PPO

8oes this Coverage Provide Mi$i!u! Esse$tia% Coverage=

*he Cordable !are Cct re(uires most people to have health care coverage that (uali)es as Lminimum essential

coverage.M This plan or policy does provide minimum essential coverage.

8oes this Coverage Meet the Mi$i!u! >a%ue ta$dard=

*he Cordable !are Cct establishes a minimum value standard of bene)ts of a health plan. *he minimum value

standard is 328 "actuarial value%. This health coverage does meet the minimum value standard for the

benets it provides.

4a$guage Access ervices:

;;;;;;;;;;;;;;;;;;;;;;To see examples o how this plan might cover costs or a sample medical situation, see the nextpage.;;;;;;;;;;;

&uestions'!all 1-844-404-6843or visit us at%%%(anthe!(co!If you arent clear about any of the underlined terms used in this form, see the /lossary. ou can view the /lossaryat%%%(anthe!(co!or call 1-844-404-6843to re(uest a copy.

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?avi$g a @a@""normal delivery%

Ma$agi$g t"'e 2 dia@etes"routine maintenance of

a well-controlled condition%

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AWANE: Massachusetts PPO 2000 Coverage Period: 01/01/2016 12/31/2016Coverage Ea!'%es

Coverage for: Individual/Family |P%a$ &"'e: PPO

A@out these CoverageEa!'%es:

*hese examples show how this planmight cover medical care in givensituations. Ese these examples tosee, in general, how much )nancialprotection a sample patient mightget if they are covered underdierent plans.

A!ou$t o+ed to 'roviders:$7,540

P%a$ 'a"s$5,70

Patie$t 'a"s$!,"70

a!'%e care costs:

Gospital charges "mother%6',2

2

?outine obstetric care6',$2

2Gospital charges "baby% 6A22

Cnesthesia 6A22

Haboratory tests 6722

+rescriptions 6'22

?adiology 6'22

Naccines, other preventive 612

otal2.4

0

Patie$t 'a"s:Deductibles 6'222

!opays 6'2

!oinsurance 62

Himits or exclusions 6$2

otal25.1

0

A!ou$t o+ed to 'roviders:$5,400

P%a$ 'a"s$!,!#0

Patie$t 'a"s$,""0

a!'%e care costs:

+rescriptions6',A2

2>edical (uipment and&upplies

6$,422

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*uestio$s a$d a$s+ers a@out the Coverage Ea!'%es:

What are so!e of theassu!'tio$s @ehi$d theCoverage Ea!'%es=

!osts dont include pre!iu!s.

&ample care costs are based onnational averages supplied bythe E.&. Department of Gealthand Guman &ervices, andarent speci)c to a particulargeographic area or health plan.

*he patientscondition was notan excluded or preexisting

condition. Cll services and treatments

started and ended in the samecoverage period.

*here are no other medicalexpenses for any membercovered under this plan.

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costs, such as copa"!ents,deductibles, and coinsurance.

ou should also considercontributions to accounts suchas health savings accounts"G&Cs%, Oexible spendingarrangements "F&Cs% or health

reimbursement accounts "G?Cs%that help you pay out-of-pocketexpenses.