SBC - HMO L18 Anthem Blue Cross - My Benefit Choices

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.anthem.com/ca or by calling 1-800-227-3771.Important Questions Answers Why this Matters:What is the overalldeductible?Are there otherdeductibles for specificservices?$ 0No.See the chart starting on page 2 for your costs for services this plan covers.You don’t have to meet deductibles for specific services, but see the chart starting on page2 for other costs for services this plan covers.Is there an out–of–pocket limit on myexpenses?What is not included inthe out–of–pocketlimit?Is there an overallannual limit on whatthe plan pays?Does this plan use anetwork of providers?Do I need a referral tosee a specialist?Are there services thisplan doesn’t cover?$500 Individual$1,000 Two Party$1,500 FamilyPremiums, infertility servicesand Prescription drug copays.No.Yes. Seewww.anthem.com/ca or call1-800-227-3771 for a list of innetworkproviders.Yes. The Primary CarePhysician (PCP) makes thereferralYes.The out-of-pocket limit is the most you could pay during a coverage period (usually oneyear) for your share of the cost of covered services. This limit helps you plan for healthcare expenses.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.The chart starting on page 2 describes any limits on what the plan will pay for specificcovered services, such as office visits.If you use an in-network doctor or other health care provider, this plan will pay some or allof the costs of covered services. Be aware, your in-network doctor or hospital may use anout-of-network provider for some services. Plans use the term in-network, preferred, orparticipating for providers in their network. See the chart starting on page 2 for how thisplan pays different kinds of providers.This plan will pay some or all of the costs to see a specialist for covered services but onlyif you have the plan’s permission before you see the specialist.Some of the services this plan doesn’t cover are listed on page 5. See your policy or plandocument for additional information about excluded services.Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.1 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMO• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven’t met your deductible.• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testServices You May NeedYour Cost IfYou Use anIn-networkProviderYour Cost IfYou Use anOut-of-networkProviderLimitations & ExceptionsPrimary care visit to treat an injury or illness No Charges Not Covered –––––––––––none–––––––––––Specialist visit No Charges Not Covered –––––––––––none–––––––––––Physical, Occupational, SpeechTherapy and Chiropractic is limited to60 days after injury or illness.Additional visits available whenOther practitioner office visit- must beapproved by the medical group.No Charges Not Coveredordered by primary care physicianAdditional Chiropractic andAcupuncture Rider: $10 copay/visitand 30 visits/calendar year(chiropractic and acupuncture visitscombined)Preventive care/screening/immunization No Charges Not Covered –––––––––––none–––––––––––Diagnostic test (x-ray, blood work) No Charges Not Covered –––––––––––none–––––––––––Imaging (CT/PET scans, MRIs) No Charges Not Covered –––––––––––none–––––––––––Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.2 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMOCommonMedical EventIf you need drugs totreat your illness orconditionMore informationabout prescriptiondrug coverage isavailable atwww.anthem.com/ca.If you haveoutpatient surgeryIf you needimmediate medicalattentionIf you have ahospital stayServices You May NeedGeneric drugsBrand drugsYour Cost IfYou Use anIn-networkProviderRetail:$5/copayprescriptionMail:$10/copayprescriptionRetail:$10/copayprescriptionMail:$20/copayprescriptionYour Cost IfYou Use anOut-of-networkProviderRetail:$5/copayprescriptionRetail:$10/copayprescriptionLimitations & ExceptionsOut-of-Network: Generic or Branddrug copay plus 50% of the maximumallowed amount & costs in excess ofthe prescription drug maximumallowed amount.Limited to a 30-day supply for retail.Limited to a 90-day supply for mailorder.Mail order is not available Out-of-Network. Other limits may apply.Please see your Evidence of Coveragefor details.Female oral contraceptives (genericand single source brand) are covered atno charge if you use a ParticipatingProvider.Facility fee (e.g., ambulatory surgery center) No Charges Not Covered –––––––––––none–––––––––––Physician/surgeon fees No Charges Not Covered –––––––––––none–––––––––––If you are 20 or more miles from theEmergency room services No Charges No Chargesnearest in-network provider and havean emergency, there is no copay. Seeevidence of coverage for details.Emergency medical transportation No Charges No Charges –––––––––––none–––––––––––You can get urgent care from an outofUrgent care No Charges No Chargesnetwork provider if you are morethan 20 miles away from your primarycare doctor or medical group.Facility fee (e.g., hospital room) No Charges Not Covered –––––––––––none–––––––––––Physician/surgeon fee No Charges Not Covered –––––––––––none–––––––––––Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.3 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMOCommonMedical EventIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careServices You May NeedYour Cost IfYou Use anIn-networkProviderMental/Behavioral health outpatient services No ChargesYour Cost IfYou Use anOut-of-networkProviderNot CoveredMental/Behavioral health inpatient services No Charges Not CoveredSubstance use disorder outpatient services No Charges Not CoveredSubstance use disorder inpatient services No Charges Not CoveredLimitations & Exceptions–––––––––––none––––––––––––––––––––––none––––––––––––––––––––––none––––––––––––––––––––––none–––––––––––Prenatal and postnatal care No Charges Not Covered –––––––––––none–––––––––––Delivery and all inpatient services No Charges Not Covered –––––––––––none–––––––––––Limited to 100 visits/calendar year;Home health care No Charges Not Covered one visit by a home health aide equalsfour hours or less.Rehabilitation services No Charges Not CoveredHabilitation services No Charges Not Covered –––––––––––none–––––––––––Skilled nursing care No Charges Not Covered Limited to 100 days/calendar year.Durable medical equipment No Charges Not Covered –––––––––––none–––––––––––Hospice service No Charges Not Covered –––––––––––none–––––––––––Eye exam Provided by VSP Provided by VSP–––––––––––none–––––––––––Glasses Provided by VSP Provided by VSP–––––––––––none–––––––––––Dental check-up Not Covered Not Covered –––––––––––none–––––––––––Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.4 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMOExcluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)• Cosmetic Surgery• Dental Care• Non-emergency care when traveling outsidethe U.S.• Long-term Care• Private-duty Nursing• Routine eye care• Routine foot care• Weight loss programsOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)• Acupuncture• Bariatric surgery• Chiropractic care (requires authorization)• Hearing aids (one hearing aid per ear everythree years)• Infertility diagnosis and testing (limitationsapply)• Special footwear (limitations apply)Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-800-227-3771. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.5 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 07/01/2013 – 06/30/2014Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: HMOYour Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact:Anthem Blue Cross21555 Oxnard Street-attn: Customer Service, Woodland Hills, CA 91367Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-227-3771Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-227-3771Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助 , 请 拨 打 这 个 号 码 1-800-227-3771Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-227-3771––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.6 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 01/01/2013 – 12/31/2013Coverage Examples Coverage for: Individual/Family | Plan Type: HMOAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Having a baby(normal delivery) Amount owed to providers: $7,540 Plan pays $7,370 Patient pays $170Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540Patient pays:Deductibles $10Copays $10Coinsurance $0Limits or exclusions $150Total $170Managing type 2 diabetes(routine maintenance ofa well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,710 Patient pays $690Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays:Deductibles $10Copays $600Coinsurance $0Limits or exclusions $80Total $690Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.7 of 8

Anthem: IBEW Local 18-HMO Coverage Period: 01/01/2013 – 12/31/2013Coverage Examples Coverage for: Individual/Family | Plan Type: HMOQuestions and answers about the Coverage Examples:What are some of theassumptions behind theCoverage Examples?• Costs don’t include premiums.• Sample care costs are based on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren’t specific to aparticular geographic area or health plan.• The patient’s condition was not anexcluded or preexisting condition.• All services and treatments started andended in the same coverage period.• There are no other medical expenses forany member covered under this plan.• Out-of-pocket expenses are based onlyon treating the condition in the example.• The patient received all care from innetworkproviders. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.What does a Coverage Exampleshow?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.Does the Coverage Examplepredict my own care needs? No. Treatments shown are just examples.The care you would receive for thiscondition could be different based on yourdoctor’s advice, your age, how serious yourcondition is, and many other factors.Does the Coverage Examplepredict my future expenses?No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.Can I use Coverage Examplesto compare plans?Yes. When you look at the Summary ofBenefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.Are there other costs I shouldconsider when comparingplans?Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you’ll pay in out-ofpocketcosts, such as copayments,deductibles, and coinsurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.Questions: Call 1-800-227-3771 or visit us at www.anthem.com/ca.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.anthem.com/ca or call 1-800-227-3771 to request a copy.8 of 8