Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Chapter 1
Administrative information
The basics
This Summary Plan Description (SPD) covers the
provisions of the Anthem Blue Cross Blue Shield
(BCBS) PPO Plan (the Plan)�
While reading this material, be aware that:
• The Plan is a welfare benefts plan provided as a
beneft to eligible team members and their eligible
dependents� Participation in the Plan does not
constitute a guarantee or contract of employment
with Wells Fargo & Company or its subsidiaries� Plan
benefts depend on continued eligibility�
• The name “Wells Fargo,” as used throughout this
document, refers to Wells Fargo & Company�
In case of any confict between the SPD, any other
information provided, and the ofcial Plan document,
the Plan document governs Plan administration and
benefts decisions� You may request a copy of the ofcial
Plan document by submitting a written request to the
address below, or you may view the document on-site
during regular business hours by prior arrangement:
Compensation and Benefts Department
Wells Fargo
MAC N9311-170
625 Marquette Avenue
Minneapolis, MN 55479
Wells Fargo contracts with third-party administrators
to provide claims administrative services� These
third-party administrators are referred to as claims
administrators�
While the Plan’s provisions determine what services
and supplies are eligible for benefts, you and your
health care provider have ultimate responsibility for
determining the treatment and care you receive�
Responsibilities of covered persons
Each covered team member and covered dependent
is responsible for reading this SPD and related
materials completely and complying with all rules and
Plan provisions�
Defnition of a Summary Plan Description (SPD)
An SPD explains your benefts and rights under the
Plan� The SPD includes this booklet, the frst chapter
and the appendixes of your Benefts Book� The Benefts
Book and SPDs are available on Teamworks at work
and at home� Every attempt has been made to make
the Benefts Book and SPDs easy to understand,
informative, and as accurate as possible� However, an
SPD cannot replace or change any provision of the
actual Plan documents�
As a participant in the Plan, you are entitled to certain
rights and protection under the Employee Retirement
Income Security Act of 1974 as amended (ERISA)� For
a list of specifc rights, review the section “Your rights
under ERISA” in “Appendix B: Legal notifcations” of
your Benefts Book�
Who’s eligible
Each team member who satisfes the Plan’s eligibility
requirements may enroll� Your employment
classifcation determines eligibility to participate in
the Plan� For more information regarding employment
classifcation and eligibility, refer to “Chapter 1: An
introduction to your benefts” in your Benefts Book�
Plan information
Claims administrator
Anthem Blue Cross and Blue Shield (“Anthem
BCBS”) is the organization designated by the plan
administrator to receive, process, and administer claims
for benefts described in Chapter 2 of this SPD and
make claim payments for such benefts on behalf of the
Plan� Anthem BCBS is the claims fduciary for claims
for benefts described in Chapter 2 of this SPD�
CVS Caremark is the organization designated by the
plan administrator to receive, process, and administer
claims for prescription drug benefts described in
Chapter 3 of this SPD and make claim payments for
such benefts on behalf of the Plan� CVS Caremark is
the claims fduciary for claims for prescription drug
benefts described in Chapter 3 of this SPD�
Anthem Behavioral Health is the organization
designated by the plan administrator to receive,
process, and administer claims for mental health and
substance abuse benefts described in Chapter 4 of
this SPD and make claim payments for such benefts
on behalf of the Plan� Anthem Behavioral Health is
the claims fduciary for claims for mental health and
substance abuse benefts described in Chapter 4 of
this SPD�
Anthem Blue Cross Blue Shield PPO Plan 3