Anthem Blue Cross Avondale Represented EPO

Huntington Ingalls Industries, Inc.
Benefits Summary - Plan Year 7/1/10 - 6/30/11
Plan Facts
Anthem Avondale Rep EPO
Web site
www.anthem.com/ca
Member services 1-800-948-3648
Domestic partner benefits
No
Additional comments
See SPD or check with Plan for details
Cost
Anthem Avondale Rep EPO
Health Reimbursement Arrangement--Account Information
You only
Not applicable
You and spouse
Not applicable
You and Child
Not applicable
You and Family
Not applicable
Eligible expenses for reimbursement
Not applicable
General Medical Expenses
Annual deductible
$250 Individual; $500 Family; applies only to
durable medical equipment, appliances, and
ambulance services
Primary doctor office visit
$15 copay
Specialist office visit
$15 copay
Out-of-pocket maximum
$0 Individual; $0 Family
Lifetime coverage limit
Limit does not apply
Inpatient Hospital Care
Hospital copay
100% covered; preauthorization required
Hospital semi-private room
100% covered; preauthorization required
Inpatient lab and X-ray
100% covered; preauthorization required
Inpatient surgery
100% covered; preauthorization required
Inpatient physician and surgeon services 100% covered; preauthorization required
Outpatient Care
Outpatient surgery
100% covered
Outpatient laboratory services
100% covered
Outpatient X-ray
100% covered
Emergency room (not followed by admission) $50 copay; limited to emergencies only
Urgent care clinic visit
Outpatient cardiac rehabilitation
100% covered; $15 office visit copay may apply
$15 copay; limited to Phase 1 and Phase 2 care;
copay applies to office visit setting only
Prescription Drug Expenses
Prescription drug vendor
Express Scripts
Prescription drug Web site
www.express-scripts.com
Prescription drug member services 1-877-498-4161

Annual prescription deductible
Annual Rx out-of-pocket maximum
Retail generic
Retail formulary brand
Retail nonformulary brand
Mail order generic
Mail order formulary brand
Mail order nonformulary brand
Oral contraceptives
Fertility drugs
Injectables
Coverage
Adult Preventive Care
Annual physical exam
Well-woman exam (includes pap)
$250 Individual; $500 Family; two family
members must meet the individual deductible
before family deductible is satisfied
$0 Individual; $0 Family
90% covered; 30 day supply
80% covered; 30 day supply
80% covered; 30 day supply
90% covered; 90 day supply
80% covered; 90 day supply
80% covered; 90 day supply
Retail and mail order available
Not covered
Applicable medical or prescription drug
coinsurance or copays apply; check with Anthem
or Express Scripts for details
Anthem Avondale Rep EPO
Not covered
$15 copay; limited to two routine gynecological
exams and Pap tests per benefit plan year; no
limit for medically necessary services
Mammogram 100% covered; for members after age 35;
maximum benefit of $150
Colonoscopy
100% covered; limited to one per benefit plan
year after age 50
Cancer screenings
Applicable copays apply; prostate exams limited
to one screening after age 50
Cardiovascular screenings
Not covered
Allergy tests and treatments
100% covered after office visit copay
Family Planning
Fertility services
Not covered
In vitro fertilization
Not covered
Artificial insemination
Not covered
Female tubal ligation
Applicable copays apply
Male vasectomy
Applicable copays apply
Maternity Care
Office visit: Pre/postnatal
$15 copay
In-hospital delivery services
100% covered; preauthorization required
Newborn nursery services
100% covered; preauthorization required
Well-Baby/Well-Child Preventive Care
Pediatric exams
Immunizations (child)
Mental Health Care
Not covered; applicable copays apply for
newborn nursery charges and circumcision only
Not covered

Mental Health: Combined with substance abuse Yes; outpatient only
Mental Health: Outpatient coverage
Mental Health: Inpatient coverage
Behavioral health member services
Behavioral health vendor
Behavioral health Web site
Substance Abuse Care
Detox: Outpatient coverage
Detox: Inpatient coverage
Rehab: Outpatient coverage
Rehab: Inpatient coverage
Dental
Dental implants
Accidental injury to teeth
Surgical removal of tumors, cysts, and
impacted teeth
Vision Care
Routine vision exams
Regular lenses and frames
Contact lenses
Hearing Care
Hearing evaluations
Hearing aids
Medical Therapy
Acupuncture
Chiropractic
Outpatient physical therapy
Outpatient speech therapy
Outpatient occupational therapy
Care at Alternate Sites
Noncustodial home health care
Prescribed care in noncustodial skilled nursing
facility
Hospice care
Other Services
80% covered; limited to 24 hour crisis
intervention and evaluation/outpatient
counseling; limited to 50 visits per year
100% covered; limited to 30 days per year
Same as medical plan
Same as medical plan
Same as medical plan
80% covered; limited to 24 hour crisis
intervention and evaluation/outpatient
counseling; limited to 50 visits per year
100% covered; limited to 2 episodes per
lifetime; dependents not covered
80% covered; limited to 24 hour crisis
intervention and evaluation/outpatient
counseling; limited to 50 visits per year
Not covered
Not covered
$15 copay
Applicable copays apply; limited to surgical
removal of tumors and cysts; removal of
impacted teeth not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
50% covered; limited to $500 per benefit plan
year; including x-rays
$15 copay; limited to 60 visits per benefit plan
year
$15 copay; limited to 60 visits per benefit plan
year
$15 copay; limited to 60 visits per benefit plan
year
100% covered; limited to 30 days;
preauthorization required
100% covered; limited to 50 days;
preauthorization required
100% covered

Ambulance services
Durable medical equipment
Prosthetic devices
Access
Out-of-area dependent coverage
Out-of-area participant coverage
Domestic partner benefits
Ease of Use
Ability to self-refer to OB/GYN
Ability to self-refer to specialists
Member Satisfaction
80% covered after deductible is met; limited to
nearest hospital and emergencies only
80% covered after deductible is met;
preauthorization required
80% covered after deductible is met;
preauthorization required
Anthem Avondale Rep EPO
Yes
Yes
No
Anthem Avondale Rep EPO
Yes
Yes
Anthem Avondale Rep EPO
% satisfied with plan overall
Health plan average
Not available
National average 88%
% satisfied with quality of care provided
Health plan average
Not available
National average 94%
% satisfied with plan's convenience/ease of use
Health plan average
Not available
National average 90%
% satisfied with types of services covered
Health plan average
Not available
National average 89%
Care Management: Education
and Assistance
Asthma care management
Cancer care management
Diabetes care management
Heart disease care management
Hypertension care management
Smoking cessation program
Weight control program
Prenatal care management
Anthem Avondale Rep EPO
No
No
No
No
No
No
No
No

The comparison charts are compiled using information that applies to a large number of health plan users and
is commonly reported by the health plans. Depending on the chart type, such as charts for dental and vision
plans, certain information and/or sections won't appear because the necessary data isn't available. If you have
questions about a topic that isn't covered in the charts, refer to the plan's SPD or contact the health provider's
member services department for additional information. Also, keep in mind that the information on access and
quality of care is provided by the health plans. Neither Huntington Ingalls Industries nor Hewitt Associates is
responsible for the accuracy of this information. If there is a discrepancy between the information displayed on
these charts and the official plan documents, the official plan documents will control. Huntington Ingalls
Industries reserves the right to amend, suspend, or terminate the plan(s) or program(s) at any time.