Anthem ClearProtection CoreGuard CA 2011

8/7/2019 Anthem ClearProtection CoreGuard CA 2011

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•ClearProtectionSM

•CoreGuard

SM

CABR0015818CGP (4/10)

Individual and Family Health Care Plan

or Caliorn

Our plans ft your plans



Our plans ft the

way you live.In a world that’s constantly changing, one thing’s or

certain. You can benet rom the reliability and protectio

o health coverage. Whether you’re sel-employed, need

coverage or your amily, just let group coverage, or you

job doesn’t provide it, Anthem Blue Cross and Anthem

Blue Cross Lie and Health Insurance Company oer

dependable individual health care plans that save you

time and make sense or the way you live.

You’re in charge o your health and budget, and our

plans help keep it that way. Check out our wide range

o benet options and i you have any questions,

we are here to help. Dependable, valuable protection

that ts the way you live. Sounds like a plan.

Experience you can rely onAs one o the most trusted names in health coverage,

Anthem Blue Cross has been providing health care

coverage and security to Caliornians or over 70 years.

We’re committed to simpliying your lie and improving

your health. In addition, we oer:

• One o the largest provider networks in Caliornia.

With nearly 60,000 PPO doctors and more than 350

hospitals throughout the state, chances are your docto

is one o ours. For a complete listing o all doctors in

our network, go to anthem.com/ca and click on “Find

a Doctor”.

• A choice o plans to it your budget and liestyle.

No matter where you are in lie, we’ve got a plan

designed to it your health coverage needs,

as well as your budget.• Optional dental and term lie insurance.

To enhance your health and your amily’s inancial utur

we also oer dental and term lie coverage and make it

easy to enroll.

• Coverage that travels with you.

No matter where lie takes you, your health coverage go

with you. And the BlueCard® program makes it easy to

access network providers across the country.

1

Why do you need healthcare coverage?

These days, a single day in the hospital can cost

thousands o dollars. Not only does health coverage

help you stay healthy, it also gives you added

security, because you know you’re protected

against the high cost o unexpected medical bills.

Apply online at www.GetMyMedical.com

http://www.getmymedical.com/




Network Discounts: With Anthem Blue Cross you

have access to one o the largest provider networks in

the state. These network (or participating) providers haveagreed to accept lower costs or their covered services to

Anthem members — similar to volume discounts. These

negotiated costs help reduce the overall cost o covered

medical services, including your share o those costs.

This is true whether you are paying the entire cost or

covered services (such as while you are meeting your

deductible), or whether we are sharing the cost. With

nearly 60,000 doctors and specialists and more than 350

hospitals and other acilities, chances are your provider

already participates. Just visit a network provider to take

advantage o the savings.

With our PPO plans, you can always choose to receive

services outside the network, but your share o the cost

will be greater.

Cost-Sharing: The costs o medical care today can be

staggering. Health care coverage rom Anthem can help

protect you against these high costs. With most health

care coverage, you pay a monthly premium, then you

share some o the cost o covered medical care with the

company that provides your health care coverage. The

level o cost-sharing you choose directly impacts your

premium amount. The more you are willing to share in

the costs, the lower your premium. With Anthem you

can choose your level o protection and the level o

cost-sharing that works best or your health care needs

and budget.

Deductible is the amount you have to pay each

calendar year (annually) or covered services beore your

health care plan starts paying. For some services, the

plan will even begin to pay beore the deductible is met.

Usually, the higher a plan’s deductible, the lower the

premium. In some cases, you may also have a separate

deductible or certain services such as prescription drugs.

Coinsurance is the percentage o the cost o covered

services that you will be responsible or, ater your annual

deductible is met. With some plans, you have a choice o

coinsurance levels. Much like your deductible, selecting

a higher coinsurance typically lowers your monthly

premium because it increases your share o the cost.

Some defnitions so we’re all on the same page

Copayment (or Copay) is a specic dollar amount you

have to pay or certain covered services.

Out-O-Pocket Maximum is the most that you would

pay in a calendar year or deductible and coinsurance or

network covered services. Once you reach this maximum,

the plan pays at 100% or most services or the rest o

the calendar year.

Lietime Maximum is the lietime benet amount

that will be paid under the policy or each member.

This includes network and non-network covered

services combined.

Prescription Drugsare medications that must be

authorized or use by your doctor. Anthem oers varying

levels o prescription drug coverage. Depending on the

plan, you may have coverage or generic drugs or generic

and brand name drugs.

Generic Drugs are prescription drugs that typically

have been in use or some time and can be manuactured

and distributed by numerous companies, so their cost

is usually much lower. Generic drugs must, by law,

contain the same active ingredients as their brand name

equivalent and have the same clinical benet.

Brand Name Drugs are prescription drugs that are

manuactured and marketed under a registered name.

They are usually patented and may be exclusively oered

by certain manuacturers.

Specialty Drugs are typically high cost, scientically

engineered drugs used to treat complex, chronic

conditions. They require special handling and usually

must be shipped directly to the user.

Formulary is a list o prescription drugs our health

care plans cover. They include generic, brand name,

and specialty drugs that have been rigorously reviewedand selected by a committee o practicing doctors and

clinical pharmacists or their quality and eectiveness.

We’ve negotiated lower prices on these ormulary drugs,

so you’ll save when your doctor prescribes medication

rom our ormularies. There can be dierent ormularies

or dierent health care plans.






How ClearProtection Works

ClearProtection has two deductibles:1. INPATIENT/SURGICAL SERVICES

This is the lower o the two deductibles to help youaccess benefts aster or these higher-cost services.

2. OUTPATIENT/PROFESSIONAL ANDDIAGNOSTIC SERVICES

This deductible is equal to your out-o-pocket maximum.So even i you only use outpatient services, once youmeet this deductible, you will have also met yourout-o-pocket maximum.

These two deductibles work together to help youreach your total out-o-pocket maximum. Depending

on your health care needs, you can satisy your totalout-o-pocket maximum in any o the ollowing ways:

ClearProtectionSM

Is this the right plan or you?

ClearProtection Plan Highlights This plan oers a valuable combination o aordable

coverage with some immediate benets, plus abroad range o benets once the out-o-pocketmaximum is met.

Features:• Someofourlowestmonthlyratesandimmediate

coverage or rst two doctors’ oce visits.

• AccesstodiscountsonALLcoveredservices rom network providers while meeting yourout-o-pocket maximum.

• 100%coverageformostnetworkcoveredservices once your out-o-pocket maximum is met.

• Coverageforprescriptiondrugs.• $4millionpermemberinlifetimebenets.

You should know:• Thisplanfeaturestwodeductiblesthatworktogether

to help you meet your total out-o-pocket maximum.

• ThisplanhasitsownDrugFormulary.

• Maternitybenetsarenotincludedwiththisplan.

ClearProtection is one o our lower-priced plans with aninnovative plan design that helps limit your share o thecosts or major medical expenses, such as surgery and

hospitalizations. In addition:•You’llhaveimmediatebenetsforyourrsttwo

doctors’ oce visits.

•Therearetwodeductiblesthatworktogethertohelpyou meet your out-o-pocket maximum.

•Onceyourout-of-pocketmaximumismet,theplanpays 100% o the costs or most network covered services.

3

ClearProtection Preventive CareWith ClearProtection, certain basic preventive careand immunizations or adults and children are covered(deductible waived), ater you’ve been on the planor six months. You also have the option o going to aHealthyCheckSM Center which provides immediate coverageor annual preventive screenings. For more inormation aboutHealthyCheckSM, go to anthem.com/healthycheck.

Prescription Drug Coverage The ClearProtection plan covers both generic and brand-nameprescription drugs. This plan also uses a special Formularywhich is posted at www.wellpointnextrx.com/Formulary1.

The TotalOut-O-Pocket Maximum Equals:

$4,500 (for$1,000deductibleplan)



Once this amount is satisfed, the plan pays 100%o the costs or most network covered services.

Meet the Inpatient/Surgicaldeductible plus coinsurance(such as surgeries,hospitalizations and emergency room services)

Meet the Outpatient/Proessional and DiagnosticServices deductible (such asdoctors’ ofce visits and lab work)

or Any combination o #1 and #2

or

#1 #2

Note: Deductibles and Out-o-Pocket Maximums arebased on a calendar year (January 1 - December 31).






Benefts

Calendar Year Deductible

Individual

Family

Network Coinsurance Options

Calendar Year Out-o-PocketMaximum

IndividualNETWORK:

orNON-NETWORK:

FamilyNETWORK:

orNON-NETWORK:

How amily deductibles and amilyout-o-pocket maximums work

Plan Lietime Maximum

Covered Services

Doctors’ Oce Visits

Proessional and DiagnosticServices(X-ray, lab, anesthesia, surgeon, etc.)

Inpatient Services(overnight hospital/acility stays)

Outpatient Services(without overnight hospital/acility stays)

Emergency Room Services

Preventive Care Services

Maternity

Optional Coverage (at additional cost)

Prescription Drug Coverage

Retail Drugs (and Mail OrderDrugs when available)

Optional Drug Coverage (when available)

Other Covered Benetsinclude but are not limited to:

IMPORTANT: This Benet Guide isintended to be a brie outline o coverageand is not intended to be a legal contract.

The entire provisions o benets,limitations and exclusions are containedin the Policy. In the event o a confictbetween the Policy and this Benet Guide,the terms o the Policy will prevail.

ClearProtectionSM

ALL COVERED NETWORK AND NON-NETWORK SERVICES APPLY TOWARD THE DEDUCTIBLES BELOW*

$1,000or

$4,500

$3,300or

$6,800

$5,000or

$8,500

For Inpatient/Surgical and Emergency Room Servicesor

For Outpatient/Proessional and Diagnostic Services

$2,000or

$9,000

$6,600or

$13,600

$10,000or

$17,000

For Inpatient/Surgical and Emergency Room Servicesor

For Outpatient/Proessional and Diagnostic Services

40%0%

40%0%

40%0%

For Inpatient/Surgical and Emergency Room ServicesFor Outpatient/Proessional and Diagnostic Services

ALL COVERED SERVICES, IN ANY COMBINATION, APPLY TOWARD YOUR OUT-OF-POCKET MAXIMUM BELOW*This is the maximum you’ll pay or most network covered services each calendar year; then the plan pays 100%

$4,500 $6,800 $8,500 (these amounts include the deductibles)

$9,000 $13,600 $17,000 (these amounts include the deductibles)

Once one amily member reaches their individual deductible or out-o-pocket maximum, the remaining amount o the amily deductible or out-o-pockemaximum needs to be met by one or more other amily members. The amily deductible or out-o-pocket maximum can be met by the amily combined.

Planpaysupto:$4millionpermember,networkandnon-networkservicescombined

Your Share o Costs (ater deductible, i applicable)

NETWORK: First 2 Ofce Visits (per member): $40 copay, deductible waived Additional Ofce Visits: 100% o negotiated ee; then 0% Coinsurance ater out-o-pocket maximum is met

NON-NETWORK: 100% Coinsurance; then 50% Coinsurance ater out-o-pocket maximum is met

NETWORK: Inpatient: 40% Coinsurance

Outpatient: 100% o negotiated ee; then 0% Coinsurance ater out-o-pocket maximum is met

NON-NETWORK: Inpatient: 50% Coinsurance

Outpatient: 100% Coinsurance; then 50% Coinsurance ater out-o-pocket maximum is met

NETWORK: 40% Coinsurance

NON-NETWORK: Allchargesexcept$650perday

NETWORK: Surgery: 40% Coinsurance Other Services: 100% o negotiated ee; then 0% Coinsurance ater out-o-pocket maximum is met

NON-NETWORK: Allchargesexcept$380perday

NETWORK: 40% Coinsuranceplus$100EmergencyRoomcopay(copaywaivedifadmitted)

NON-NETWORK: 40% Coinsuranceplus$100EmergencyRoomcopay(copaywaivedifadmitted)

NETWORK: HealthyCheckSM

Centers (deductible waived): $25 or $75 Copay or basic or premium screening (or ages 7 and older) For members covered more than 6 months1 (deductible waived):

Routine mammogram, Pap and PSA tests: 40% Coinsurance Childhood immunizations through age 6: 40% Coinsurance

NON-NETWORK: For members covered more than 6 months1 (deductible waived):Routine mammogram, Pap and PSA tests: 50% CoinsuranceChildhood immunizations through age 6: 50% Coinsurance

Not Covered

Dental, Lie

ClearProtection2

NETWORK: Tier 1 (Generic drugs): $15 Copay $2,000annualPrescriptionDrugdeductiblepermemberforTier2/Specialtydrugsappliesbeforethefollowing:

• Tier 2 (Formulary Brand name drugs): $35 Copay • Specialty: 25% Coinsuranceuptoa$2,500annualPrescriptionDrugout-of-pocketmaximum(themostyou’llhavetopay),fornetworkonlyandin

additionto$2,000annual deductible.• For Drugs Not on Formulary: Not covered, discounts apply.

NON-NETWORK: Not Covered

Not Available

Ambulance, Home Health Care, Physical/Occupational Therapy, Urgent Care

*Network and non-network deductible are combined and accumulate toward each other. Network and non-network out-o-pocket maximums are alsocombined and accumulate toward each other.

1 Members covered less than 6 months will pay 100% o negotiated ee or network covered services; then 0% coinsurance ater out-o-pocket maximumis met (plus all charges in excess o allowable amount i non-network).

2 ClearProtection has its own Plan Formulary.

NOTES: Discounted network rates apply or network covered services. For non-network services, member is responsible or the coinsurance plus charge

in excess o the allowable amount. Copays/Coinsurance to network and non-network providers apply to annual out-o-pocket maximum except wherespecically noted in the Policy.

ClearProtection is oered by Anthem Blue Cross Lie and Health Insurance Company.

Beneft Guide or Californi



Prescription Drug Coverage The CoreGuard plan covers both generic and brand nameprescription drugs. This plan also uses a special Formularywhich is posted at www.wellpointnextrx.com/Formulary1.

How to Customize yourCoreGuard PlanWith CoreGuard, you have some choice and fexibility tochange the plan to better meet your needs. CoreGuard oers

a choice o:

Deductible: CoreGuardplandeductiblesrangefrom$75to$10,000.Youcanusuallyloweryourpremiumbychoosinga higher deductible. Simply choose the deductible andpremium combination that works best or you.

Coinsurance: CoreGuard oers a choice o coinsurancelevels, depending on the deductible you choose. Choosingthe$10,000deductiblecantakeyourcoinsuranceforcovered services to zero i you’d like to pay more toward yourcalendar year deductible rst.

Other Optional Coverage: You can add more

protection or you and your amily by purchasing optionaldental or lie insurance. See the ollowing pages or details.

CoreGuardSM

Is this the right plan or you?

CoreGuard Plan Highlights This plan can be ideal or individuals whowant aordable protection against signicantmedical expenses.

Features:• Asimpleplandesignwithsomeofourlowest

monthly rates.

• Higherpercentageofmembercost-sharinginexchange or lower premiums.

• Forplanswithdeductiblesupto$7,500,oncethedeductible is met we’ll share 50% o the costs atournegotiatedratesupto$3,500,thenwe’llcoverthe rest or most covered services.

• Forthe$10,000deductibleplan,oncethedeductible is met we’ll pay 100% o the costs or

most covered services.

• Coverage or prescription drugs.

• $4millionpermemberinlifetimebenets.

You should know:• The$750,$1,500and$2,500deductibleplans

have a acility copay that continues to apply, evenater the deductible or out-o-pocket maximum hasbeen met.

• ThisplanhasitsownDrugFormulary.

• Maternitybenetsarenotincludedwiththisplan.

I you’re looking or a simple plan design with some o ourlowest rates, CoreGuard, rom Anthem Blue Cross Lie andHealth Insurance Company, could be the plan that’s rightor you. CoreGuard oers a wide range o deductibles (rom$750–$10,000)andhighercost-sharinghelpsloweryourmonthly premiums.

CoreGuard Preventive CareWith CoreGuard, certain basic preventive care screeningsare covered ater you meet your deductible. You also havethe option o going to a HealthyCheckSM Center or annualpreventive screenings without rst needing to meet yourdeductible. For more inormation about HealthyCheck

SM, go

to anthem.com/healthycheck.

5






Beneft Guide or Californi

Benefts

Calendar Year Deductible

IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:

Network Coinsurance OptionsCalendar Year Out-o-PocketMaximum

IndividualNETWORK:

NON-NETWORK:

FamilyNETWORK:

NON-NETWORK:

How amily deductibles and amilyout-o-pocket maximums work

Plan Lietime Maximum

Covered Services

Doctors’ Oce Visits

Proessional and DiagnosticServices(X-ray, lab, anesthesia, surgeon, etc.)

Inpatient Services(overnight hospital/acility stays)

Outpatient Services(without overnight hospital/acility stays)

Emergency Room Services

Preventive Care Services

Maternity

Optional Coverage(at additional cost)

Prescription Drug Coverage

Retail Drugs (and Mail OrderDrugs when available)

Optional Drug Coverage (when available)

Other Covered Benetsinclude but are not limited to:

IMPORTANT: This Benet Guide is intendedto be a brie outline o coverage and is notintended to be a legal contract. The entireprovisions o benets, limitations andexclusions are contained in the Policy. Inthe event o a confict between the Policyand this Benet Guide, the terms o thePolicy will prevail.

CoreGuardSM

Your Choices

$750 $1,500 $2,500 $3,500 $5,000 $7,500 $10

$750 $1,500 $2,500 $3,500 $5,000 $7,500 $10

$1,500 $3,000 $5,000 $7,000 $10,000 $15,000 $20

$1,500 $3,000 $5,000 $7,000 $10,000 $15,000 $20

50% 50% 50% 50% 50% 50%

Add Your Chosen Deductible to the Amount Below1

$3,500 $3,500 $3,500 $3,500 $3,500 $3,500

$7,500 $7,500 $7,500 $7,500 $7,500 $7,500 $7

$7,000 $7,000 $7,000 $7,000 $7,000 $7,000

$15,000 $15,000 $15,000 $15,000 $15,000 $15,000 $15

Once one amily member reaches their individual deductible or out-o-pocket maximum, the remaining amount o the amily deductible or out-o-pocketmaximum needs to be met by one or more other amily members. The amily deductible or out-o-pocket maximum can be met by the amily combined.

Planpaysupto:$4millionpermember,networkandnon-networkservicescombined

Your Share o Costs (ater deductible)

NETWORK: 50% Coinsurance (or 0% Coinsurance with$10,000plan)

NON-NETWORK: 70% Coinsurance (or 30% Coinsurance with$10,000plan)

NETWORK: 50% Coinsurance (or 0% Coinsurance with$10,000plan)

NON-NETWORK: 70% Coinsurance (or 30% Coinsurance with$10,000plan)

NETWORK: 50% CoinsurancePLUS$500FacilityCopay 1perdayuptotherst3days(with$750,$1,500,$2,500) 50% Coinsurance(with$3,500,$5,000,$7,500) 0% Coinsurance(with$10,000)

NON-NETWORK: 70% CoinsurancePLUS$500FacilityCopay 1perdayuptotherst3days(with$750,$1,500,$2,500) 70% Coinsurance(with$3,500,$5,000,$7,500) 30% Coinsurance(with$10,000)

NETWORK: 50% CoinsurancePLUS$200FacilityCopay 1peradmission(with$750,$1,500,$2,500) 50% Coinsurance(with$3,500,$5,000,$7,500) 0% Coinsurance(with$10,000)

NON-NETWORK: 70% CoinsurancePLUS$200FacilityCopay 1peradmission(with$750,$1,500,$2,500) 70% Coinsurance(with$3,500,$5,000,$7,500) 30% Coinsurance(with$10,000)

NETWORK: 50% Coinsurance (or 0% Coinsurance with$10,000plan)NON-NETWORK: 50% Coinsurance (or 0% Coinsurance with$10,000plan)

NETWORK: Routine mammogram, Pap and PSA tests: 50% Coinsurance (or 0% Coinsurancewith$10,000plan) HealthyCheckSM Centers: $25 or $75 Copay or basic or premium screening, deductible waived (or ages 7 and older)

NON-NETWORK: Routine mammogram, Pap and PSA tests: 70% Coinsurance (or 30% Coinsurancewith$10,000plan)

Not Covered

Dental, Lie

CoreGuard2

NETWORK: Tier 1 (Generic drugs): $15 Copay

$2,000annualPrescriptionDrugdeductiblepermemberforTier2/Specialtydrugsappliesbeforethefollowing:• Tier 2 (Formulary Brand name drugs): $35 Copay

• Specialty: 25% Coinsuranceuptoa$2,500annualPrescriptionDrugout-of-pocketmaximum(themostyou’llhavetopay),fornetworkonlyandinadditto$2,000annualdeductible.

• For Drugs Not on Formulary: Not covered, discounts apply.

NON-NETWORK: Not Covered

Not Available

Ambulance, Chiropractic Services, Home Health Care, Mental Health, Physical/Occupational Therapy, Urgent Care

1FacilityCopayonlyappliesto$750,$1,500and$2,500deductibleplans.FacilityCopay does not accumulate toward the deductible or out-of-pocketmaximum. Facility Copay is still required even if out-of-pocket maximum has been met. Balance of covered charges subject to deductible and coinsurancNo additional Facility Copay if readmitted to the same facility within 72 hours of the initial admission.2 CoreGuard has its own Plan Formulary.

NOTES: Discounted network rates apply or network covered services. Network and non-network deductibles are separate and do not accumulate towardother. Network and non-network out-o-pocket maximums are also separate and do not accumulate toward each other. For non-network services, memberesponsible or the coinsurance plus charges in excess o the allowable amount. Copays/Coinsurance to network and non-network providers apply to annout-o-pocket maximum except where specically noted in the Policy.

CoreGuard is oered by Anthem Blue Cross Lie and Health Insurance Company.



Aordable Dental Blue® PPO solutions designed tomeet your dental needsDental Blue Basic oers:•Lowplanpremiums

• Coverageformanydiagnosticservicesandpreventivecaresuch as cleanings, exams and X-rays with no waiting period

• Coverageforcertainbasicservices(llings)withasix-month waiting period

•Anannualmaximumbenetof$500

Dental Blue Enhanced oers:•Coverageformanydiagnosticservicesandpreventivecare

such as cleanings, exams and X-rays with no waiting period• Coverageforcertainbasicservices(llings)witha

six-month waiting period

• Coverageforcertainmajorserviceslikerootcanals,periodontal procedures and crowns ater a 12-monthwaiting period

•Anannualmaximumbenetof$1,250

•Orthodonticcoverageforchildrenaftera12-monthwaiting period

Save money by using our dental network

As a Dental Blue member, you can see any dentist youwant; however, you do have the potential or lower costswhen you choose a dentist in the Dental Blue 100 network.

This is because network dentists have agreed to accept ournegotiated rates or services they provide to you. I youchoose to go to a provider outside o the Dental Blue 100network, you can be billed the dierence between ournetwork negotiated rates and what your chosen dentistwishestocharge.But,withmorethan18,000Californiadentists in our Dental Blue 100 network, it’s likely yourdentist is part o our network!

Plus, network dentists have agreed to pass along ournegotiated rates to you during waiting periods, i youexceed your annual maximum benet -- and even orcertain non-covered services such as veneers, dentalimplants and TMJ!

You will also have access to emergency dental care romour worldwide listing o credentialed dentists whiletraveling or working nearly anywhere in the world.

Preer a Dental HMO?I so, our Dental SelectHMO plan may be the rightchoice or you. For more inormation about theDental SelectHMO plan — or our Dental Blue plans —ask your agent.

Dental Care Coverage Dental Blue Basic Dental Blue Enhanced

Benefits Network Non-Network Network Non-Network

Annual Deductible $25permember $50permember;$150maximumperfamily

Waived or Diagnostic & Preventive Yes No Yes No

Annual Maximum $500 $1,250

Diagnostic and Preventive Network Non-Network Network Non-Network

Cleanings, exams and X-rays 100% 80% 100% 80%

Basic Services Network Non-Network Network Non-Network

Fillings 80% 60%80% 60%

Other Minor Restorative Not covered

Major Services Network Non-Network Network Non-Network

Oral Surgery Not covered 50%

Endodontics 50%; pulpotomies on primary teeth only 50%

Periodontics Not covered 50%

Prosthodontics 50%; stainless steel crowns on primary teeth only 50%

Orthodontics Not covered Childrenonly:50%;$100deductible; $500peryear;$1,000lifetimemaximum

Waiting Periods None or cleanings, exams and X-rays;6 months or all other covered services

None or cleanings, exams and X-rays;6 months or basic services;

12 months or major services/orthodontics

7

Note: Amounts shown below are paid by the plan, ater the deductible.

Dental Blue PPO is oered by Anthem Blue Cross Lie and Health Insurance Company and Dental SelectHMO is oered by Anthem Blue Cross.



Term Lie InsuranceLosing a loved one is painul enough without having toworry about nances. Give your amily extra support withterm lie insurance rom Anthem Blue Cross Lie andHealth Insurance Company.

I you’re accepted or coverage on one o our health careplans, you’ll automatically be approved or our term lieinsurance. Plus, there are no medical exams or additional

enrollment orms to worry about. It’s that simple.

Term lie monthly rates

Age$15,000

Beneit$30,000

Beneit$50,000

Beneit$75,000

Beneit$100,000

Beneit

1-18 $1.50 $3.00 N/A N/A N/A

19-29 $2.80 $5.60 $9.30 $11.25 $13.00

30-39 $3.25 $6.50 $10.80 $13.50 $16.00

40-49 $7.50 $15.00 $25.00 $33.75 $42.00

50-59 $20.90 $41.80 $69.60 $97.50 $125.00

60-64 $29.40 $58.80 $98.00 $142.50 $185.00

Up to $100,000 in lieinsurance with no medica

exams and no blood workrequired. Just check a boxon our application.

It’s that simple.



Additional inormationSave time with automatic premiumpayment

Hate writing checks? Ater your initial payment, ourElectronic Fund Transer (EFT) program will automaticallywithdraw unds rom your bank account each month to payor your health care plan premium. You’ll not only save onpostage, you won’t have to worry about a lapse in coveragebecause you orgot to mail in your payment. To sign up, justll out the billing section o the enrollment application.

“No Obligation” review period

Ater you enroll in a plan oered by Anthem Blue Cross orAnthem Blue Cross Lie and Health Insurance Company,you will receive a Policy/EOC booklet that explains the

exact terms and conditions o coverage, including theplan’s exclusions and limitations. You will have 10 days toexamine your plan’s eatures. During that time, i you arenot ully satised, you may decline by returning your Policy/EOC booklet along with a letter notiying us that you wish todiscontinue coverage. Policy/EOC booklets are availableor you to examine prior to enrolling. Ask your agent orAnthem Blue Cross.



Ready to choose a plan?•Ater reviewing all the materials included with this

brochure, contact your Anthem Blue Cross agent.

•Ask questions. I you aren’t sure about how a plan works

or have additional questions, your agent will help you.

•Fill out an application. The quickest and easiest way

to complete an application is online and your agent

can assist you. Or your agent can provide you with

instructions or mailing or axing your application.

I you have questions or want more details about youroptions, call your Anthem Blue Cross agent today!



Ready to enroll?

ClearProtection, CoreGuard, Dental Blue PPO and Term Lie are oered by Anthem Blue Cross Lie andHealth Insurance Company. Dental SelectHMO is oered by Anthem Blue Cross. Anthem Blue Crossis the trade name o Blue Cross o Caliornia. Anthem Blue Cross and Anthem Blue Cross Lieand Health Insurance Company are independent licensees o the Blue Cross Association.® ANTHEM is a registered trademark o Anthem Insurance Companies, Inc. ® The Blue Cross

name and symbol are registered marks o the Blue Cross Association.

For internal purposes o

CA14 BRO (4/

Individual health coverage.Your plans. Your choices.

Make sure you have all the acts This brochure is only one piece o your plan inormation. Please make sure you have all theacts about the benets oered by the plan(s) described — including what’s covered, and whatisn’t. For additional inormation about exclusions, limitations, and terms o this coverage,please see the enclosed Coverage Details. This document should be included with yourinormation kit, or i you have printed this rom your computer, it should be at the end o thisdocument. I you don’t have this document, be sure to contact your Anthem Blue Cross agent.

This brochure is intended as a brie summary o beneits and services; it is not yourPolicy. I there is any dierence between this brochure and your Policy, the provisions o

the Policy will prevail. Beneits and premiums are subject to change.

Individual and Family Health Care Planor Caliorn

Apply Online Today!

Get a Quote

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http://www.getmymedical.com/ca_anthem_apply

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CoreGuard,SM

ClearProtection,SM

Premier, SmartSense,® Basic PPO, 3500 Deductible PPO, PPO 3500 HSA Compatible,Lumenos® HSA, RightPlan PPO 40, PPO Share, Select HMO, HMO Saver, Individual HMO*

To Enroll, You And Your Dependents Must Be:• Age 643

⁄ 4 or younger

• A permanent legal resident of California

• A U.S. resident for at least the last 3 months

• The applicant’s spouse or domestic partner, age 643 ⁄ 4 or younger

• The applicant’s children (under 19 years of age), or the children(under 19 years of age) of the applicant’s enrolling spouse orqualied domestic partner

• The applicant’s unmarried dependent children between theages of 19 through 22 (“dependent” as dened by the InternalRevenue Service)

• The applicant’s child (of any age) who is incapable of self-sustainingemployment by reason of a physically or mentally disabling injury,illness or condition and is chiey dependent upon the applicant forsupport and maintenance

Medical Underwriting Requirement

We believe that the cost of our plans should be consistent with yourexpected health care needs and risk factors. That’s why Anthemoffers various levels of coverage. To determine individual medicalrisk factors, all applications are subject to medical underwriting.Depending on the results of the underwriting review, a number of things may happen:

• You may be offered coverage at the standard premium charge

• You may be offered the plan you selected at a higher rate

• You may not qualify for the plan listed in this brochure

• You may be offered an alternate plan

If you have a signicant medical condition and do not qualify forthe plan you’ve chosen or if you have discontinued group coverage,please contact your Anthem representative for informationregarding other Individual coverage options.

Incurred Medical Care RatioAs required by law, we are advising you that Anthem Blue Cross’ incurredmedical care ratio for 2009 was 83.44 percent. The 2009 medical careratio for Anthem Blue Cross Life and Health Insurance Company was78.4 percent. These ratios were calculated after provider discounts wereapplied and based on regulatory rules and regulations.

Waiting Periods There is a specic six-month waiting period for coverage of anycondition, disease or ailment for which medical advice or treatmenwas recommended or received within six months preceding theeffective date of coverage. If you apply for coverage within 63 daysof terminating your membership with another “creditable” healthcare plan, then you can use your prior coverage for credit towardthe six-month waiting period. Anthem will credit the time you wereenrolled on the previous plan.

Access To The Medical Information Bureau (MIB)Information regarding your insurability will be treated as condential.Anthem Blue Cross and Anthem Blue Cross Life and Health InsuranceCompany or its reinsurers may, however, make a brief report thereonto the MIB, a not-for-prot membership organization of insurancecompanies, which operates an information exchange on behalf of its

Members. If you apply to another MIB Member company for life orhealth insurance coverage, or a claim for benets is submitted to sucha company, MIB, upon request, will supply such company with theinformation in its le.

Upon receipt of a request from you, MIB will arrange disclosureof any information it may have in your le. Please contact MIB at866-692-6901 (TTY 866-346-3642). If you question the accuracyof information in MIB’s le, you may contact MIB and seek acorrection in accordance with the procedures set forth in thefederal Fair Credit Reporting Act.

The address of MIB’s Information Ofce is50 Braintree Hill Park, Suite 400Braintree, MA 02184-8734.

Information for consumers about MIB may be obtained on itswebsite at www.mib.com.

Anthem Blue Cross and Anthem Blue Cross Life and Health InsuranceCompany, or its reinsurers, may also release information in its le toother insurance companies to whom you may apply for life or healthinsurance, or to whom a claim for benets may be submitted.

What Individual Health Care Plans Do Not Cover The following overview will help you understand what your healthcare plan does not include before you enroll. For a comprehensivelist of the plans’ exclusions and limitations, you can request a copyof the Policy/Evidence of Coverage (EOC).

Medical Exclusions And Limitations• Maternity or pregnancy care, unless the plan selected specically

includes maternity care (not applicable to HMO plans)

• Conditions covered by workers’ compensation or similar law

• Experimental or investigative services

• Services provided by a local, state or federal government, unlessyou have to pay for them

• Durable Medical Equipment, except as specically stated inthe policy

CADD0015827 (4/10)

Before choosing a health care plan,

please review the following information,

along with the other materials enclosed.

California Coverage Details Things you need to know before you buy...



2 – CoreGuard,SM ClearProtection,SM Premier, SmartSense,® Basic PPO, 3500 Deductible PPO,PPO 3500 HSA Compatible, Lumenos® HSA, RightPlan PPO 40, PPO Share, Select HMO,HMO Saver, Individual HMO*

• Services or supplies not specically listed as covered under thePolicy/EOC

• Services received before your effective date or aftercoverage ends

• Services you wouldn’t have to pay for without insurance• Services from relatives

• Any services received by Medicare benets without payment of additional premium

• Services or supplies that are not medically necessary

• Routine physical exams, except for preventive care services(e.g., physical exams for insurance, employment, licenses orschool are not covered), except as specically stated in thePolicy/EOC

• Any amounts in excess of the maximum amounts listed in thePolicy/EOC

• Sex changes

• Cosmetic surgery

• Services primarily for weight reduction except medicallynecessary treatment of morbid obesity

• Dental care, dental implants or treatment to the teeth, except asspecically stated in the Policy/EOC

• Orthodontic services, braces, and other orthodontic appliances

• Hearing aids

• Infertility services

• Private duty nursing

• Eyeglasses or contact lenses, except as specically stated in thePolicy/EOC

• Vision care including certain eye surgeries to replace glasses,except as specically stated in the Policy/EOC

• Specialty drugs from a pharmacy other than our specialtydrug provider

• Certain orthopedic shoes or shoe inserts, except as specicallystated in the Policy/EOC

• Services or supplies related to a pre-existing condition

• Outdoor treatment programs

• Telephone or facsimile machine consultations

• Educational services except as specically provided or arrangedby Anthem

• Nutritional counseling, food or dietary supplements, except forformulas and special food products to prevent complications of phenylketonuria (PKU)

• Care or treatment furnished in a non-contracting hospital, exceptas specically stated in the Policy/EOC

• Personal comfort items

• Custodial care

• Outpatient speech therapy, except as specically stated in thePolicy/EOC

• Outpatient drugs, medications or other substances dispensed oradministered in any outpatient setting

• Certain genetic testing

• Services or supplies provided to any person not covered underthe Agreement in connection with a surrogate pregnancy

ClearProtection also does not cover:

• Mental and ner vous disorders and substance abuse exceptas specically stated in the Policy/EOC. Except severe mentalillnesses and serious emotional disturbances of a child

• Chiropractic care

In addition the Select HMO, HMO Saver and Individual HMO plansdo not cover:

• Care not authorized by your Primary Medical Group orIndependent Practice Association

• Amounts in excess of customary and reasonable charges for carerendered by a non-participating provider without a referral fromyour PMG or IPA

• Chiropractic services

• Immunizations for foreign travel

• Treatment for chronic alcoholism or other substance abuseexcept as specically stated in the Evidence of Coverage

• Inpatient mental care, including acute alcoholism and drugaddiction benets, except detoxication

• Treatment of mental and nervous disorders, except as specicallystated in the Evidence of Coverage

• Rehabilitative care specically stated in the Evidence of Coverage

• Reconstructive surgery, purchase or replacement of articiallimbs or prosthesis except as specically stated in the Evidenceof Coverage

• Medical, surgical and/or psychological treatment of a sexualdysfunction, except when a sexual dysfunction is a result of aphysical abnormality, defect or disease

• Medical, surgical services, supplies or treatment to the joint of the jaw (temporomandibular joint), upper jaw (maxilla) or lower

jaw (mandible), unless related to a tumor or accident occurringwhile covered

• Routine physical examinations or tests that do not directly treat anacute illness, injury or condition unless authorized by your PrimaryCare Physician, except in no event will any physical examinationor test required by employment or government authority, or at therequest of a third party, such as a school, camp or sports-afliatedorganization, be covered unless medically necessary

• Care or treatment of a pregnancy, or any condition related topregnancy (except treatment of complications of pregnancy orCesarean-section deliveries) when conception has occurredbefore the effective date of the plan agreement. However, if you were covered under Creditable Coverage within 63 days of becoming pregnant, the time spent under Creditable Coverage

will be used to satisfy, or partially satisfy, the six (6) month period

Dental Blue® PPO Limitations And Exclusions

Limitations

This is a partial list of plan limitations. Please see the IndividualDental Plan Contract for a complete list.

• Oral Evaluations: Limited to two per calendar year

• Routine Cleaning or Periodontal Cleaning: Limited to twotreatments per calendar year

• Fluoride: Fluoride treatment limited to two per calendar year forchildren up to age 19




• X-rays: Limited to one set of full-mouth X-rays or its equivalent ina ve-year period

• Periapical X-rays: Limited to four lms per year

• Bitewing X-rays: Limited to one set of up to four lms twice per

calendar year• Sealants: Limited to children under 16 years of age for

permanent unrestored rst and second molars

• Treatment is limited to one application per tooth per lifetime

• Space Maintainers: Limited to once per quadrant per lifetime forchildren up to age 16. Includes all adjustments within six monthsof placement

• Restorations: Limited to once per surface per tooth every24 months

• Periodontal Scaling: Limited to once per quadrant every24 months

• Periodontal Surgery: Limited to one time per quadrant in a36-month period

• Root Canal Therapy: Limited to one treatment per tooth forinitial treatment and one retreatment per tooth — for permanentteeth only

• Stainless Steel Crowns: Limited to baby teeth only. Once pertooth in any ve years

• Crowns: Limited to once per tooth in any ve years

• Removable, Partial and Complete Dentures: Limited to once inve years. Benets are payable for either complete or immediatedentures, but not both

• General Anesthesia: Covered only when used in conjunction withcovered oral surgical procedures

Exclusions This is a partial listing of plan exclusions. Please see the IndividualDental Plan Contract for a complete list.

• Prescribed drugs, pre-medication or analgesia including chargesfor nitrous oxide or any similar local anesthetic when the chargeis made separately

• Occlusal guards

• Bleaching of non-vital discolored teeth

• Crown buildups on the same tooth as an amalgam or compositerestoration that was done within the same calendar year

• Procedures to alter, restore or maintain occlusion, changevertical dimension, and replace or stabilize tooth structure lostby attrition, abrasion, erosion or bruxism

• Harmful habit appliances

• Services related to diagnosis or treatment related to thetemporomandibular joint (TMJ)

• Dental implants and all adjunctive services performed inconjunction with the placement or removal of implantsincluding but not limited to surgery, cleanings, maintenanceand prosthetics placed on implants

• Infection control procedures, if billed separately

• Precision attachments

• Prefabricated resin crown or stainless steel crown withresin window

• Pulpotomy on permanent teeth

• Replacement of a prosthodontic appliance (xed or removable)

more often than once in any ve-year period, whether under thiscontract or under any prior dental coverage

• Root canal therapy on baby teeth

• Sealants on restored teeth (occlusal surface)

• Temporary/interim prosthodontia or appliances (temporarycrowns, bridges, partials, dentures, etc.)

• Biopsies

• Services or supplies not specically listed in the covered servicessection of the Individual Dental Plan Contract

Dental SelectHMO Limitations And Exclusions

This is a partial listing of plan limitations and exclusions. Please see

the Contract for a complete list.• Experimental or investigative care or therapy

• Any condition for which benets of any nature are recovered orfound to be recoverable, whether by adjudication, settlement orotherwise, under any workers’ compensation or occupationaldisease law, even if you do not claim these benets. If thereis a dispute or substantial uncertainty as to whether benetsmay be recovered for those conditions pursuant to workers’compensation, Anthem Blue Cross Life and Health InsuranceCompany will provide the plan benets for such conditionssubject to its right of recovery and reimbursement underCalifornia Labor Code Section 4903

• Any services for which you are entitled to receive Medicarebenets, whether or not Medicare benets are actually paid

• Any services provided by a local, state, county or federalgovernment agency, including any foreign government, exceptwhen payment under the plan is expressly required by federal orstate law

• Services or supplies for which no charge is made, or for whichno charge would be made if you had no insurance coverage, orservices for which you are not legally obligated to pay

• Services received before your effective date or during an inpatienstay that began before your effective date

• Services rendered before coverage begins or after coverage ends

• Prescribed drugs, pre-medication or analgesia (includingnitrous oxide)

• No benets are provided for hospital or associated physiciancharges for any dental treatment that cannot be performed in thedentist’s ofce because of your general health, mental, emotionalbehavioral or physical limitations

• Unless an exception is specically authorized by Anthem BlueCross in writing, dental services must be received from yourparticipating dentist or participating specialty dentist

• A dental treatment plan, which in the opinion of the participatingdentist and/or Anthem Blue Cross is not dentally necessary fordental health or will not produce benecial results




• Conditions caused by the inadvertent release of nuclear energy

when government funds are available for treatment of illness orinjury arising from such release of nuclear energy

• Treatment of fractures or dislocations

• Any treatment to correct a dental condition that resultedfrom dental services performed by a non-participating dentistwhile coverage is in effect and any dental services started bya non-participating dentist will not be the responsibility of theparticipating dentist or Anthem Blue Cross for completion

• Histopathological exams and/or the removal of tumors,cysts, neoplasms and foreign bodies not covered under themedical plan

• Teeth with questionable, guarded or poor prognosis are notcovered for endodontic treatment, periodontal surgery or crownand bridge. Plan will allow for observation or extraction and

prosthetic replacement

• Services received after the benet limit under this agreementis reached

• Orthodontic services must be received from a participatingorthodontist. In the event of loss of coverage for any reason, andat the time of loss of coverage you are still receiving orthodontictreatment, you will be responsible for the remainder of the costfor that treatment

• Replacement of lost or stolen or thodontic appliances or repairof orthodontic appliances that were broken due to negligence

• Myofunctional therapy and related services

• Surgical procedures incidental to orthodontic treatment,including but not limited to extraction of teeth solely fororthodontic reasons, exposure of impacted teeth, correction of micrognathia or macrognathia, or repair of cleft palate

• Changes in treatment necessitated by an accident of any kind• Treatment related to the joint of the jaw (temporomandibular joint, TMJ) and/or hormonal imbalance

This document provides a brief summary of provisions, exclusionsand limitations. If there is any difference between this documentand the Policy, the Policy will prevail.

Dental SelectHMO Limitations And Exclusions(continued)

*The following plans are offered by Anthem Blue Cross: PPO Share 3500/7500, Select HMO, HMO Saver, Individual HMO and Dental Blue PPO. The following plans are

offered by Anthem Blue Cross Life and Health Insurance Company: ClearProtection, CoreGuard, SmartSense, Premier, Basic PPO, PPO Share 5000, RightPlan PPO 40,

3500 Deductible PPO, PPO 3500 (HSA-Compatible) and Lumenos HSA. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem

Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM and LUMENOS are registered trademarks of Anthem

Insurance Companies, Inc. ® Dental Blue, SmartSense and the Blue Cross name and symbol are registered marks of the Blue Cross Association.

Selecting health coverageis an important decision.

To assist you, we are also providing you with the Brochureand Enrollment Application. If you did not receive one ormore of these materials, please contact your Anthem BlueCross agent to request them.

The Policy/Evidence of Coverage booklets are alsoavailable for you to examine before enrolling. Ask youragent or Anthem Blue Cross.

Documents

Anthem ClearProtection CoreGuard CA 2011