-
Benefits
-
PC
A L
ow
PC
A L
ow
PC
A L
ow
PC
A L
ow
-
TYPE O
F S
ER
VIC
E
Netw
ork
Lim
ited
to
UofL
Ph
ysic
ian
s,
Ken
tuckyO
ne
Pro
vid
ers
(th
at
are
als
o i
n t
he A
nth
em
Blu
e A
ccess P
PO
Netw
ork
) &
Kosair
Ch
ild
ren
's H
osp
ital
Ou
t-o
f-n
etw
ork
(Lim
ited
ON
LY
to
An
them
Blu
e
Access P
PO
Netw
ork
)
Netw
ork
(Anth
em
Blu
e
Access P
PO
Netw
ork
)
Ou
t-o
f-
netw
ork
Netw
ork
(Anth
em
Blu
e
Access P
PO
Netw
ork
)
Ou
t-o
f-n
etw
ork
Netw
ork
(Anth
em
Blu
e
Access P
PO
Netw
ork
)
Ou
t-o
f-n
etw
ork
Netw
ork
(Anth
em
Blu
e
Access P
PO
Netw
ork
)
Ou
t-o
f-n
etw
ork
$5
00
Indiv
idual
$5
00
Indiv
idual
$1,0
00 E
mplo
yee+
Spouse
$1,0
00 E
mplo
yee+
Spouse
$2,0
00 E
mplo
yee+
Child(r
en)
$2,0
00 E
mplo
yee+
Child(r
en)
$2
,00
0 F
am
ily
$2
,00
0 F
am
ily
None
None
None
$2
50
per
pers
on
$5
00
per
pers
on
$1
,00
0 p
er
pers
on
$2
,00
0 p
er
pers
on
$2
,00
0 p
er
pers
on
$4
,00
0 p
er
pers
on
None
None
None
$7
50
per
fam
ily
$1
,50
0 p
er
fam
ily
$3
,00
0 p
er
fam
ily
$6
,00
0 p
er
fam
ily
$4
,00
0 p
er
fam
ily
$8
,00
0 p
er
fam
ily
$2
,00
0 p
er
pers
on
$4
,00
0 p
er
pers
on
$2
,00
0 p
er
pers
on
$2
,25
0 p
er
pers
on
$4
,50
0 p
er
pers
on
$4
,00
0 p
er
pers
on
$8
,00
0 p
er
pers
on
$5
,00
0 p
er
pers
on
$1
0,0
00
per
pers
on
$4
,00
0 p
er
fam
ily
$8
,00
0 p
er
fam
ily
$4
,00
0 p
er
fam
ily
$4
,75
0 p
er
fam
ily
$1
3,5
00
per
fam
ily
$9
,00
0 p
er
fam
ily
$1
8,0
00
per
fam
ily
$1
0,0
00
per
fam
ily
$2
0,0
00
per
fam
ily
$
0 P
CP
$2
0 P
CP;
$0
PC
P U
ofL
Physic
ians
Not
Covere
d
$1
5 P
CP;
$0
PC
P U
ofL
Physic
ians
$3
5 S
pecia
list,
UofL
Physic
ians
$3
5 S
pecia
list
Not
Covere
d$
30
Specia
list
Pre
ven
tive C
are
Routi
ne p
hysic
als
, W
ell-child
check-ups a
nd r
outi
ne
imm
uniz
ati
ons
10
0%
Pla
n p
ays 6
0%
1
00
%N
ot
Covere
d1
00
%6
0%
aft
er
deducti
ble
10
0%
60
% a
fter
deducti
ble
10
0%
50
% a
fter
deducti
ble
Mam
mogra
phy s
cre
enin
gs
Routi
ne G
YN
exam
s1
00
%Pla
n p
ays 6
0%
1
00
%N
ot
Covere
d1
00
%6
0%
aft
er
deducti
ble
10
0%
60
% a
fter
deducti
ble
10
0%
50
% a
fter
deducti
ble
Lab,
X-ra
y o
r oth
er
pre
venti
ve
tests
10
0%
Pla
n p
ays 6
0%
1
00
%N
ot
Covere
d1
00
%6
0%
aft
er
deducti
ble
10
0%
60
% a
fter
deducti
ble
10
0%
50
% a
fter
deducti
ble
Inp
ati
en
t H
osp
ital
Inpati
ent
care
10
0%
aft
er
$5
00
copay p
er
adm
issio
n
Pla
n p
ays 6
0%
Pla
n p
ays 9
0%
Not
Covere
d9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
Physic
ian Inpati
ent
care
10
0%
Pla
n p
ays 6
0%
Pla
n p
ays 9
0%
Not
Covere
d9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
EPO
Does n
ot
apply
Does n
ot
apply
None
Does n
ot
apply
Does n
ot
apply
Physic
ian o
ffic
e (
OBG
YN
vis
its
covere
d a
s P
rim
ary
Care
) P
CP=
Pri
mary
Care
Physic
ian
60
% a
fter
deducti
ble
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
; U
ofL
PC
P w
ill apply
a
$2
0 d
iscount
off
the n
orm
al
netw
ork
dis
count
Does n
ot
apply
Does n
ot
apply
N /
A
80
% a
fter
deducti
ble
; U
ofL
PC
P w
ill apply
a
$2
0 d
iscount
off
the n
orm
al
netw
ork
dis
count
Pla
n p
ays 6
0%
20
16
Hea
lth
Pla
ns
PC
A H
IGH
PPO
Annual A
llow
ance
Annual M
edic
al O
ut-
of-
pocket
Maxim
um
(C
opays a
nd
deducti
ble
s a
ccum
ula
te t
ow
ard
the o
ut-
of-
pocket
maxim
um
)
PC
A L
OW Does n
ot
apply
Annual D
educti
ble
50
% a
fter
deducti
ble
Card
inal
Care
- C
losed
to
new
en
rollees
Does n
ot
apply
-
TYPE O
F S
ER
VIC
E
Ou
tpati
en
t N
etw
ork
Ou
t-o
f-n
etw
ork
N
etw
ork
Ou
t-o
f-
netw
ork
N
etw
ork
Ou
t-o
f-n
etw
ork
N
etw
ork
Ou
t-o
f-n
etw
ork
N
etw
ork
Ou
t-o
f-n
etw
ork
Outp
ati
ent
surg
ery
- f
acilit
yPla
n p
ays 1
00
%Pla
n p
ays 6
0%
1
00
% a
fter
$1
00
copay
Not
Covere
d9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
Lab S
erv
ices
10
0%
10
0%
10
0%
Not
Covere
d1
00
%6
0%
aft
er
deducti
ble
10
0%
60
% a
fter
deducti
ble
10
0%
50
% a
fter
deducti
ble
X-R
ay a
nd M
ajo
r D
iagnosti
cs
10
0%
Pla
n p
ays 6
0%
Pla
n p
ays 9
0%
Not
Covere
d9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
10
0%
60
% a
fter
deducti
ble
10
0%
50
% a
fter
deducti
ble
Em
erg
en
cy R
oo
m
10
0%
aft
er
$7
5
copay
10
0%
aft
er
$7
5
copay
10
0%
aft
er
$1
00
copay
10
0%
aft
er
$1
00
copay
10
0%
aft
er
$1
00
copay
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
90
% a
fter
deducti
ble
. 6
0%
non-em
erg
ency
80
% a
fter
deducti
ble
80
% a
fter
deducti
ble
. 6
0%
non-em
erg
ency
Men
tal
Healt
h &
Su
bsta
nce A
bu
se
Inpati
ent
care
10
0%
aft
er
$5
00
copay p
er
inpati
ent
sta
y
60
% a
fter
$5
00
copay p
er
inpati
ent
sta
y
Pla
n p
ays 9
0%
Not
Covere
d9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
Outp
ati
ent
care
- p
er
vis
it$
0
copay
10
0%
$2
0 c
opay o
r $
0
copay if
UofL
Physic
ian
Not
Covere
d
$1
5 c
opay o
r $
0
copay if
UofL
Physic
ian
60
% a
fter
deducti
ble
90
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
Vis
ion
Vis
ion
Exam
(o
ne r
outi
ne e
xam
per
year)
10
0%
aft
er
$3
5
copay
10
0%
aft
er
$3
5
copay
10
0%
aft
er
$2
0
copay
Not
Covere
d
100%
aft
er
copays
ULP $
0 c
opay
Anth
em
Netw
ork
$15 c
opay
$30
Specia
list
60
%9
0%
aft
er
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble
50
% a
fter
deducti
ble
Pre
scri
pti
on
Dru
gs
Reta
il
Pre
scri
pti
on D
rug G
eneri
c R
eta
il
Pre
scri
pti
on D
rug B
rand F
orm
ula
ry
Reta
il
Pre
scri
pti
on D
rug N
on F
orm
ula
ry
Reta
il
Mail O
rder
(90
day s
up
ply
)
Pre
scri
pti
on D
rug G
eneri
c M
ail
Ord
er
Pre
scri
pti
on D
rug B
rand F
orm
ula
ry
Mail O
rder
Pre
scri
pti
on D
rug N
on-Form
ula
ry
Mail O
rder
Bra
nd
wit
h G
en
eri
c A
vailab
le
Pre
scri
pti
on D
rug B
rand f
or
whic
h a
Generi
c e
quiv
ale
nt
is a
vailable
- r
eta
il
or
mail o
rder
$4
,35
0 p
er
pers
on
$4
,60
0 p
er
pers
on
$4
,60
0 p
er
pers
on
$2
,60
0 p
er
pers
on
$1
,60
0 p
er
pers
on
$8
,45
0 p
er
fam
ily
$9
,20
0 p
er
fam
ily
$9
,20
0 p
er
fam
ily
$4
,20
0 p
er
fam
ily
$3
,20
0 p
er
fam
ily
Pla
n p
ays 6
0%
Card
inal
Care
PC
A L
ow
Non-Form
ula
ry M
ail O
rder
- Y
ou
Pay 3
5%
, up t
o $
20
0 m
axim
um
Non-Form
ula
ry M
ail O
rder
- Y
ou
Pay 3
5%
, up t
o $
20
0 m
axim
um
Non-Form
ula
ry M
ail O
rder
- Y
ou
Pay 3
5%
, up t
o $
20
0 m
axim
um
Generi
c M
ail O
rder
- $
7.5
0G
eneri
c M
ail O
rder
- $
16
.00
Generi
c M
ail O
rder
- $
16
.00
Bra
nd F
orm
ula
ry M
ail O
rder
- Y
ou
Pay 2
0%
, up t
o $
75
maxim
um
Bra
nd F
orm
ula
ry M
ail O
rder
- Y
ou
Pay 1
5%
, up t
o $
12
0 m
axim
um
Bra
nd F
orm
ula
ry M
ail O
rder
- Y
ou
Pay 1
5%
, up t
o $
12
0 m
axim
um
Non-Form
ula
ry R
eta
il -
You p
ay
40
%,
up t
o $
10
0 m
axim
um
Non- F
orm
ula
ry R
eta
il -
You P
ay
40
%,
up t
o $
10
0 m
axim
um
Non- F
orm
ula
ry R
eta
il -
You P
ay
40
%,
up t
o $
10
0 m
axim
um
Non- F
orm
ula
ry R
eta
il -
You P
ay
40
%,
up t
o $
10
0 m
axim
um
Generi
c R
eta
il -
$8
.00
Generi
c R
eta
il -
$5
.00
Generi
c R
eta
il -
$8
.00
Generi
c R
eta
il -
$8
.00
Card
inal
Care
EPO
90
% a
fter
deducti
ble P
CA
HIG
H
EPO
PPO
PC
A H
igh
60
% a
fter
deducti
ble
PPO
Bra
nd F
orm
ula
ry R
eta
il -
You P
ay
20
%,
up t
o $
50
maxim
um
90
%Physic
ian O
utp
ati
ent
serv
ices
(oth
er
than
off
ice v
isit
)
100%
aft
er
copays
ULP $
0 c
opay
Anth
em
Netw
ork
$15 c
opay
$30
Specia
list
Bra
nd F
orm
ula
ry R
eta
il -
You P
ay
25
%,
up t
o $
60
maxim
um
Bra
nd F
orm
ula
ry R
eta
il -
You P
ay
25
%,
up t
o $
60
maxim
um
Bra
nd F
orm
ula
ry R
eta
il -
You P
ay
25
%,
up t
o $
60
maxim
um
Not
Covere
d
Generi
c M
ail O
rder
- $
16
.00
Generi
c M
ail O
rder
- $
16
.00
Bra
nd F
orm
ula
ry M
ail O
rder
- Y
ou
Pay 1
5%
, up t
o $
12
0 m
axim
um
Pla
n P
ays C
ost
of
Generi
c D
rug-
You P
ay r
em
ain
der,
no m
axim
um
Pla
n P
ays C
ost
of
Generi
c D
rug-
You P
ay r
em
ain
der,
no m
axim
um
Pla
n P
ays C
ost
of
Generi
c D
rug- Y
ou
Pay r
em
ain
der,
no m
axim
um
Pla
n P
ays C
ost
of
Generi
c D
rug- Y
ou
Pay r
em
ain
der,
no m
axim
um
N /
AN
/ A
10
0%
Annual Pre
scri
pti
on O
ut-
of-
pocket
Maxim
um
N
/ A
N /
AN
/ A
50
% a
fter
deducti
ble
60
% a
fter
deducti
ble
80
% a
fter
deducti
ble P
CA
LO
W
Pla
n P
ays C
ost
of
Generi
c D
rug- Y
ou
Pay r
em
ain
der,
no m
axim
um
Bra
nd F
orm
ula
ry R
eta
il -
You P
ay
25
%,
up t
o $
60
maxim
um
Generi
c R
eta
il -
$8
.00
Non- F
orm
ula
ry R
eta
il -
You P
ay
40
%,
up t
o $
10
0 m
axim
um
Bra
nd F
orm
ula
ry M
ail O
rder
- Y
ou
Pay 1
5%
, up t
o $
12
0 m
axim
um
Non-Form
ula
ry M
ail O
rder
- Y
ou P
ay
35
%,
up t
o $
20
0 m
axim
um
Non-Form
ula
ry M
ail O
rder
- Y
ou P
ay
35
%,
up t
o $
20
0 m
axim
um
-
Un
ive
rsit
y o
f L
ou
isville
20
16
Hea
lth
Pla
n R
ate
sM
on
thly
Rate
s10
-Mo
nth
FT
Acti
ve E
mp
loyee
FT
Ac
tive
Wit
h G
HN
Dis
co
un
tC
ard
inal C
are
EP
OP
PO
PC
A H
igh
PC
A L
ow
FT
Ac
tive
Wit
h G
HN
Dis
co
un
tC
ard
inal C
are
EP
OP
PO
PC
A H
igh
PC
A L
ow
Em
plo
ye
e C
ove
rag
e15
5.00
$
96.1
2$
78
.58
$
27.1
2$
25.0
0$
E
mp
loye
e C
ove
rag
e18
6.00
$
11
5.34
$
94
.30
$
32.5
4$
3
0.0
0$
Em
plo
ye
e +
Sp
ou
se
/QA
355.
00$
45
5.04
$
41
6.46
$
30
3.24
$
17
1.64
$
Em
plo
ye
e +
Sp
ou
se
/QA
426.
00$
546.
05$
499.
75$
363.
89$
20
5.9
7$
Em
plo
ye
e +
Ch
ildre
n22
2.00
$
228.
21$
196.
63$
104.
01$
25.0
0$
E
mp
loye
e +
Ch
ildre
n26
6.40
$
27
3.85
$
23
5.96
$
12
4.81
$
3
0.0
0$
Em
plo
ye
e +
Fa
mily
38
0.00
$
513.
24$
460.
62$
306.
24$
126.
78$
E
mp
loye
e +
Fa
mily
45
6.00
$
61
5.89
$
55
2.74
$
36
7.49
$
1
52
.14
$
Tw
o E
mp
loye
e F
am
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Rate
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PC
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-
Types of Coverage
Network Benefits Annual Deductible
Individual Deductible Family Deductible
No deductible No deductible
Out‐of‐Pocket Maximum (Member copayments (excluding Pharmacy) accumulate toward the OOP maximum)
Individual Out‐of‐Pocket Maximum Family Out‐of‐Pocket Maximum
$2,000 per year $4,000 per year
Benefit Plan Coinsurance (The amount the Plan pays)
90% coverage
Lifetime Maximum
There is no dollar limit to the amount the Plan will pay for essential benefits during the entire period you are enrolled in this Plan.
No lifetime maximum benefit
Prescription Drug Benefits
Prescription drug benefits are shown under separate cover.
Information of Precertification
Precertification is required for certain services. Please refer to your Benefit Plan Document.
Information on Benefit Limits
Out‐of‐pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any combination of network and non‐
network benefits unless specifically stated in the benefit category.
Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:
•
Anthem.com – Take advantage of easy, time‐saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.
•
24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24‐hours a day, 7‐days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.
•
Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.
The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage. Plan Highlights
Your Summary of BenefitsEPO
-
Benefits
Types of Coverage
Network Benefits
Ambulance Services (Emergency and non‐emergency)
100% after you pay a $100 copayment per trip
Dental Services (Accident only)
90% coverage
Durable Medical Equipment (DME)
100% coverage
Emergency Health Services ‐ Outpatient
100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a network hospital directly from the emergency room, you will not have to pay this copayment. The benefits for an
inpatient stay in a network hospital will apply instead.
Hearing Aids
One per year every 36 months
100% coverage
Home Health Care
Benefits are limited to 100 visits per year
100% coverage
Hospice Care
100% coverage
Hospital Inpatient Stay
90% coverage
Lab, X‐Ray and Major Diagnostics – Outpatient
Lab X‐Ray and Diagnostics
100% coverage 90% coverage
Lab, X‐Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine) Lab
X‐Ray and Diagnostics 100% coverage 90% coverage
Mental Health Services
Inpatient ‐ 90% coverage
Outpatient ‐ 100% after you pay a $20 copayment per visit ULP Providers – covered in full
Neurobiological Disorders ‐ Mental Health Services for Autism Spectrum Disorders
Inpatient ‐ 90% coverage
Outpatient ‐ 100% after you pay a $20 copayment per visit ULP Providers – covered in full
Pharmaceutical Products ‐ Outpatient
This includes medications administered in an outpatient setting, in the physician’s office and by a home health agency.
Physician’s office – 100% coverage All other place of service – 100% after you pay a $35 copay
Physician Fees for Surgical and Medical Services
90% coverage
Physician’s Office Services – Sickness and Injury
Primary Physician 100% ‐
copay waived if ULP Provider$20 Copayment per visit for Anthem PCP
Specialist Physician
100% after you pay a $35 Copayment per visit for Anthem PCP
-
Types of Coverage
Pregnancy – Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service
category in this Benefit Summary.
For services provided in the physician’s office, a copayment will only apply to the initial office visit
Infertility treatment (Limited to $5,000 per lifetime)
Preventive Care Services
(Covered health services include but not limited to:)
Primary Physician Office Visit
100% coverage
Specialist Physician Office Visit
100% coverage
Lab, X‐Ray or other preventive tests
100% coverage
Prosthetic Devices
100% coverage
Reconstructive Procedures
Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary.
Rehabilitation Services – Outpatient Therapy and Manipulative Treatment
Benefits are limited as follows:
50 visits combined of physical and occupational therapy 25 visits combined of speech and cognitive therapy
30 visits of manipulative treatment 25 visits combined of respiratory and pulmonary therapy
PT/OT 100% copay waived for ULP Providers $20 Copayment per visit for Anthem PCP
Manipulative and all other therapies ‐ 100% after you pay a $35 copayment per visit
Scopic Procedures – Outpatient Diagnostic and Therapeutic
Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.
For Preventive Scopic Procedures, refer to the
Preventive Care Services category.
90% coverage
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services
Benefits are limited as follows: 120 days per year
100% coverage
Substance Use Disorder Services
Inpatient ‐ 90% coverage
Outpatient ‐ 100% after you pay a $20 copayment per visit ULP Providers – covered in full
Surgery – Outpatient
$100 coverage after you pay $100 copayment
Transplantation Services
90% coverage
For network benefits, services must be received at a Blue Distinction
Center for Transplant.
Urgent Care Center Services
100% coverage after you pay a $35 copayment per visit
Vision Examinations
Benefits are limited as follows: 1 routine exam every year
100% coverage after you pay a $20 copayment per visit
-
Medical Notes
It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.
Dependent Age: to the end of the calendar year the child attains age 26.
When choosing a non‐network provider, the member is responsible for any balance due after the plan
payment.
Benefit Period: Equals calendar year
Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with
the Federal Mental Health Parity.
Precertification: Members are encouraged to always obtain prior approval when using non network
providers. Precertification will help avoid any unnecessary reduction in benefits for non‐covered or non‐medically necessary services.
Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice, internal medicine and pediatrics.
Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Thi
s is
onl
y a
sum
mar
y. If
you
wan
t mor
e de
tail
abou
t you
r cov
erag
e an
d co
sts,
you
can
get t
he c
ompl
ete
term
s in
the
polic
y or
pla
n do
cum
ent a
t ww
w.a
nthe
m.c
om o
r by
calli
ng 1
-855
-747
-113
7.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
$0.
See
the
char
t sta
rting
on
page
2 fo
r you
r cos
ts fo
r ser
vice
s thi
s pla
n co
vers
.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
don
’t ha
ve to
mee
t ded
uctib
les
for s
peci
fic se
rvic
es, b
ut se
e th
e ch
art s
tarti
ng o
n pa
ge
2 fo
r oth
er c
osts
for s
ervi
ces t
his p
lan
cove
rs
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. $2,
000
Indi
vidu
al/
$4,0
00 F
amily
for N
etw
ork
Prov
ider
s. Ph
arm
acy
Max
Out
of
Poc
ket;
In-N
etw
ork
$4,6
00 In
divi
dual
/ $9
,200
Fam
ily. N
on-
Net
wor
k; U
nlim
ited
Indi
vidu
al/F
amily
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
ye
ar) f
or y
our s
hare
of t
he c
ost o
f cov
ered
serv
ices
. Thi
s lim
it he
lps y
ou p
lan
for h
ealth
ca
re e
xpen
ses.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Prem
ium
s, Ba
lanc
e-bi
lled
char
ges a
nd H
ealth
car
e th
is pl
an d
oesn
’t co
ver.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-poc
ket l
imit.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t th
e pl
an p
ays?
N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan
will
pay
for s
pecif
ic co
vere
d se
rvic
es, s
uch
as o
ffic
e vi
sits.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. See
ww
w.a
nthe
m.c
omor
ca
ll 1-
855-
747-
1137
for a
list
of
Net
wor
k pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s pla
n w
ill p
ay so
me
or a
ll of
the
cost
s of c
over
ed se
rvic
es. B
e aw
are,
you
r in-
netw
ork
doct
or o
r hos
pita
l may
use
an
out-o
f-ne
twor
k pr
ovid
er fo
r som
e se
rvic
es. P
lans
use
the
term
in-n
etw
ork,
pre
ferr
ed, o
r pa
rtici
patin
g fo
r pro
vide
rs in
thei
r net
wor
k. S
ee th
e ch
art s
tarti
ng o
n pa
ge E
rror
! B
ookm
ark
not d
efin
ed. f
or h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
ders
.
Do
I ne
ed a
refe
rral
to
No.
You
don
’t ne
ed a
refe
rral
to
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Pag
e 1
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
see
a sp
ecia
list?
se
e a
spec
ialis
t.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvic
es th
is pl
an d
oesn
’t co
ver a
re li
sted
on
page
6. S
ee y
our p
olic
y or
pla
n do
cum
ent f
or a
dditi
onal
info
rmat
ion
abou
t exc
lude
d se
rvic
es.
• C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $
15) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usu
ally
whe
n yo
u re
ceiv
e th
e se
rvic
e.
• C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice,
cal
cula
ted
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice.
For
exa
mpl
e, if
th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r Coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Thi
s may
cha
nge
if yo
u ha
ven’
t met
you
r ded
uctib
le.
• Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices
is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-
netw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffer
ence
. For
exa
mpl
e, if
an
out-o
f-ne
twor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
ount
is $
1,00
0, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.) •
This
plan
may
enc
oura
ge y
ou to
use
Net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, c
opay
men
ts a
nd C
oins
uran
ce a
mou
nts.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
a
Net
wor
k Pr
ovid
er
Your
Cos
t If
You
Use
a
Non
-Net
wor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
U o
f L P
hysic
ian
- 100
% C
over
age;
A
nthe
m B
lue
Acc
ess P
PO
Net
wor
k $2
0 C
opay
/Visi
t
Not
Cov
ered
––
––––
––––
––no
ne––
––––
––––
––
Spec
ialis
t visi
t $3
5 C
opay
/Visi
t N
ot C
over
ed
––––
––––
––––
none
––––
––––
––––
Oth
er p
ract
ition
er o
ffic
e vi
sit
$35
Cop
ay/V
isit
for M
anip
ulat
ive
Trea
tmen
t N
ot C
over
ed
Cov
erag
e is
limite
d to
30
visit
s for
M
anip
ulat
ive
treat
men
t. A
cupu
nctu
re is
Not
Cov
ered
. Pr
even
tive
care
/scr
eeni
ng/i
mm
uniz
atio
n 10
0% C
over
age
Not
Cov
ered
––
––––
––––
––no
ne––
––––
––––
––
Pag
e 2
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
a
Net
wor
k Pr
ovid
er
Your
Cos
t If
You
Use
a
Non
-Net
wor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
a te
st
Dia
gnos
tic te
st (l
ab, b
lood
wor
k)
100%
cov
erag
e N
ot C
over
ed
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit
for b
elow
serv
ices
. D
iagn
osis
of S
leep
Diso
rder
s, G
ene
Exp
ress
ion
Prof
iling
for M
anag
ing
Brea
st
Can
cer T
reat
men
t and
Gen
etic
Tes
ting
for C
ance
r Sus
cept
ibili
ty.
Imag
ing
(X-r
ay, C
T/PE
T sc
ans,
MR
Is)
10%
Coi
nsur
ance
N
ot C
over
ed
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit
for b
elow
serv
ice.
M
RI G
uide
d H
igh
Inte
nsity
Foc
used
U
ltras
ound
Abl
atio
n of
Ute
rine
Fibr
oids
. If
you
nee
d dr
ugs
to
trea
t you
r illn
ess
or
cond
ition
M
ore
info
rmat
ion
abou
t pre
scrip
tion
drug
cov
erag
e is
avai
labl
e at
w
ww
.
Typi
cally
Gen
eric
dru
gs
$8 C
opay
men
t $8
Cop
aym
ent
Typi
cally
Pre
ferr
ed b
rand
dru
gs
25%
Coi
nsur
ance
25
% C
oins
uran
ce
A m
axim
um c
oins
uran
ce a
mou
nt o
f $6
0 ap
plie
s to
each
pre
scrip
tion.
Typi
cally
Non
-pre
ferr
ed b
rand
dru
gs
40%
Coi
nsur
ance
40
% C
oins
uran
ce
A m
axim
um c
oins
uran
ce a
mou
nt o
f $10
0 ap
plie
s to
each
pre
scrip
tion.
Typi
cally
Spe
cial
ty d
rugs
Fo
llow
s abo
ve.
Follo
ws a
bove
.
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bula
tory
surg
ery
cent
er)
$100
C
opay
/Sur
gery
N
ot C
over
ed
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit
for b
elow
surg
ery.
Gen
der R
eass
ignm
ent
Surg
ery:
Hum
an O
rgan
and
Bon
e M
arro
w/S
tem
Cel
l Tra
nspl
ants
. Ple
ase
call
the
plan
for e
xclu
ded
deta
ils.
Phys
icia
n/su
rgeo
n fe
es
100%
Cov
erag
e N
ot C
over
ed
––––
––––
––––
none
––––
––––
––––
Pag
e 3
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
http://www.%5Binsert%5D/
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
a
Net
wor
k Pr
ovid
er
Your
Cos
t If
You
Use
a
Non
-Net
wor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
$1
00 C
opay
/Visi
t $1
00 C
opay
/Visi
t
If a
dmitt
ed, t
he E
R c
opay
is w
aive
d.
Failu
re to
obt
ain
pre-
auth
oriz
atio
n if
requ
ire n
otifi
catio
n no
late
r tha
n 2
busin
ess d
ays a
fter a
dmiss
ion
may
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit.
Em
erge
ncy
med
ical
tran
spor
tatio
n $1
00 C
opay
/ Tr
ip
$100
Cop
ay/
Trip
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit
for A
ir A
mbu
lanc
e (e
xclu
des 9
11 in
itiat
ed
emer
genc
y tra
nspo
rt).
Urg
ent c
are
$35
Cop
ay/V
isit
Not
Cov
ered
––
––––
––––
––no
ne––
––––
––––
––
If y
ou h
ave
a ho
spita
l sta
y Fa
cilit
y fe
e (e
.g.,
hosp
ital r
oom
) 10
% C
oins
uran
ce
Not
Cov
ered
Fa
ilure
to o
btai
n pr
e-au
thor
izat
ion
may
re
sult
in n
on-c
over
age
or re
duce
d be
nefit
. Ph
ysic
ian/
surg
eon
fee
10%
Coi
nsur
ance
N
ot C
over
ed
––––
––––
––––
none
––––
––––
––––
Pag
e 4
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
a
Net
wor
k Pr
ovid
er
Your
Cos
t If
You
Use
a
Non
-Net
wor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al h
ealth
out
patie
nt se
rvic
es
U o
f L P
hysic
ian
- 100
% C
over
age;
A
nthe
m B
lue
Acc
ess P
PO
Net
wor
k $2
0 C
opay
/Visi
t
Not
Cov
ered
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fits f
or In
tens
ive
Out
patie
nt
ther
apy(
IOP)
.
Men
tal/
Beha
vior
al h
ealth
inpa
tient
serv
ices
10
% C
oins
uran
ce
Not
Cov
ered
Fa
ilure
to o
btai
n pr
e-au
thor
izat
ion
may
re
sult
in n
on-c
over
age
or re
duce
d be
nefit
.
Subs
tanc
e ab
use
diso
rder
out
patie
nt se
rvic
es
U o
f L P
hysic
ian
- 100
% C
over
age;
A
nthe
m B
lue
Acc
ess P
PO
Net
wor
k $2
0 C
opay
/Visi
t
Not
Cov
ered
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fits f
or In
tens
ive
Out
patie
nt
ther
apy(
IOP)
.
Subs
tanc
e ab
use
diso
rder
inpa
tient
serv
ices
10
% C
oins
uran
ce
Not
Cov
ered
Fa
ilure
to o
btai
n pr
e-au
thor
izat
ion
may
re
sult
in n
on-c
over
age
or re
duce
d be
nefit
.
If y
ou a
re p
regn
ant
Pren
atal
and
pos
tnat
al c
are
U o
f L P
hysic
ian
- 100
% C
over
age;
A
nthe
m B
lue
Acc
ess P
PO
Net
wor
k $2
0 C
opay
/Visi
t
Not
Cov
ered
In-N
etw
ork
bene
fit a
pplie
s for
firs
t ini
tial
visit
onl
y. T
here
may
be
othe
r lev
els o
f co
st sh
are
that
are
con
tinge
nt o
n ho
w
serv
ices
are
pro
vide
d, p
leas
e se
e yo
ur
form
al c
ontra
ct o
f cov
erag
e fo
r a
com
plet
e ex
plan
atio
n.
Del
iver
y an
d al
l inp
atie
nt se
rvic
es
10%
Coi
nsur
ance
N
ot C
over
ed
App
lies t
o In
patie
nt fa
cilit
y. O
ther
cos
t sh
ares
may
app
ly d
epen
ding
on
the
serv
ice
prov
ided
. Fa
ilure
to o
btai
n pr
e-au
thor
izat
ion
may
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit.
Pag
e 5
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Your
Cos
t If
You
Use
a
Net
wor
k Pr
ovid
er
Your
Cos
t If
You
Use
a
Non
-Net
wor
k Pr
ovid
er
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
car
e 10
0% C
over
age
Not
Cov
ered
C
over
age
is lim
ited
to 1
00 v
isits
per
ca
lend
ar y
ear.
Reh
abili
tatio
n se
rvic
es
• Ph
ysic
al T
hera
py/O
ccup
atio
nal
Ther
apy
•
Pulm
onar
y Th
erap
y/Sp
eech
The
rapy
U o
f L P
hysic
ian
- 100
% C
over
age;
A
nthe
m B
lue
Acc
ess P
PO
Net
wor
k $2
0 C
opay
/Visi
t $3
5 C
opay
/Visi
t
Not
Cov
ered
Cov
erag
e is
limite
d to
50
visit
s per
ca
lend
ar y
ear c
ombi
ned
for O
ccup
atio
nal
and
Phys
ical
ther
apy
com
bine
d N
etw
ork
and
Non
-Net
wor
k.
Cov
erag
e is
limite
d to
25
visit
s for
eac
h Pu
lmon
ary
and
Spee
ch th
erap
y co
mbi
ned
Net
wor
k an
d N
on-N
etw
ork.
Pr
e-au
thor
izat
ion
may
be
requ
ired
afte
r th
e in
itial
twel
ve (1
2) v
isits
. Pl
ease
cal
l th
e pl
an fo
r acc
ount
-spe
cific
det
ails.
Hab
ilita
tion
serv
ices
Sa
me
as
Reh
abili
tatio
n N
ot C
over
ed
All
Reh
abili
tatio
n an
d H
abili
tatio
n vi
sits
coun
t tow
ard
your
Reh
abili
tatio
n vi
sit
limit.
Pre
-aut
horiz
atio
n m
ay b
e re
quire
d af
ter t
he in
itial
twel
ve (1
2) v
isits
. Pl
ease
ca
ll th
e pl
an fo
r acc
ount
-spe
cific
det
ails.
Skill
ed n
ursin
g ca
re
100%
Cov
erag
e N
ot C
over
ed
Cov
erag
e is
limite
d to
120
day
s per
ca
lend
ar y
ear.
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit.
Dur
able
med
ical
equ
ipm
ent
100%
Cov
erag
e N
ot C
over
ed
Failu
re to
obt
ain
pre-
auth
oriz
atio
n m
ay
resu
lt in
non
-cov
erag
e or
redu
ced
bene
fit.
Hos
pice
serv
ice
100%
Cov
erag
e N
ot C
over
ed
––––
––––
––––
none
––––
––––
––––
If y
ou n
eed
dent
al o
r ey
e ca
re
Eye
exa
m
$20
Cop
ay/V
isit
Not
Cov
ered
1
rout
ine
exam
eve
ry y
ear;
G
lass
es
Not
Cov
ered
N
ot C
over
ed
––––
––––
––––
none
––––
––––
––––
D
enta
l che
ck-u
p N
ot C
over
ed
Not
Cov
ered
––
––––
––––
––no
ne––
––––
––––
––
Pag
e 6
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
• A
cupu
nctu
re
• C
osm
etic
surg
ery
• D
enta
l car
e (A
dult)
• Lo
ng-te
rm c
are
• Pr
ivat
e-du
ty n
ursin
g
• R
outin
e fo
ot c
are
• W
eigh
t los
s pro
gram
s O
ther
Cov
ered
Ser
vice
s (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
cov
ered
ser
vice
s an
d yo
ur c
osts
for t
hese
se
rvic
es.)
• Ba
riatri
c su
rger
y (O
nly
for M
orbi
d O
besit
y)
• C
hiro
prac
tic c
are
(Man
ipul
ativ
e Tr
eatm
ent)
• In
ferti
lity
treat
men
t (Li
mite
d to
$5,
000
per l
ifetim
e)
• H
earin
g ai
ds
• R
outin
e E
ye C
are
• M
ost C
over
age
prov
ided
out
side
the
Uni
ted
Stat
es.
See
ww
w.b
cbs.c
om/b
luec
ardw
orld
wid
e Yo
ur R
ight
s to
Con
tinue
Cov
erag
e:
If y
ou lo
se c
over
age
unde
r the
pla
n, th
en, d
epen
ding
upo
n th
e ci
rcum
stan
ces,
Fede
ral a
nd S
tate
law
s may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay
whi
le c
over
ed u
nder
the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply
. Fo
r mor
e in
form
atio
n on
you
r rig
hts t
o co
ntin
ue c
over
age,
con
tact
the
plan
at 1
-855
-747
-113
7. Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, o
r the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.c
ciio
.cm
s.gov
. Yo
ur G
rieva
nce
and
App
eals
Rig
hts:
Pag
e 7
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
http://www.bcbs.com/bluecardworldwidehttp://www.dol.gov/ebsahttp://www.cciio.cms.gov/
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
If y
ou h
ave
a co
mpl
aint
or a
re d
issat
isfie
d w
ith a
den
ial o
f cov
erag
e fo
r cla
ims u
nder
you
r pla
n, y
ou m
ay b
e ab
le to
app
eal o
r file
a g
rieva
nce.
For
qu
estio
ns a
bout
you
r rig
hts,
this
notic
e, o
r ass
istan
ce, y
ou c
an c
onta
ct: 1
-855
-747
-113
7.
anth
em.c
om
Lang
uage
Acc
ess
Serv
ices
:
Pag
e 8
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
opy.
-
Ant
hem
Blu
eCro
ss B
lueS
hiel
d U
nive
rsity
of L
ouis
ville
-EPO
Med
ical
Pla
n
C
over
age
Perio
d: 0
1/01
/201
6 –
12/3
1/20
16
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
C
over
age
for:
Indi
vidu
al/F
amily
| Pl
an T
ype:
EP
O
––––
––––
––––
––––
––––
––To
see e
xamp
les of
how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medi
cal s
ituat
ion, s
ee th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
Pag
e 9
of 1
1 Q
uest
ions
: Cal
l 1-8
55-7
47-1
137
or v
isit u
s at w
ww
.ant
hem
.com
.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.a
nthe
m.c
om o
r cal
l 1-8
55-7
47-1
137
to re
ques
t a c
