Ear, Nose & Throat Gastroenterology. General. Dental

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1 You can save money on outpatient surgery and other procedures through Anthem s Site of Service benefit option. When your employer chooses the Site of Service benefit option, use one of these ambulatory surgery centers (ASC) to help lower your out-of-pocket costs. Facility Dental Ear, Nose & Throat Gastroenterology General Gynecology Neurology Ophthalmology Oral & Maxillofacial Orthopedic Pain Management Plastic Podiatry Urology Vascular Androscoggin Valley Hospital Berlin, NH avhnh.org Atlantic Plastic Surgery Center Portsmouth, NH atlanticplasticsurg.com Barrington Surgical Care Barrington, NH nhpain.com Bedford Ambulatory Surgery Center Bedford, NH bedfordsurgical.com Capital Orthopedic Surgery Center LLC Concord, NH concordortho.com Capital Orthopedic Surgery Center LLC Derry, NH concordortho.com Cataract and Laser Center Andover, MA CLCandover.comcastbiz.net Center for Pain Solutions Nashua, NH painsolutionsusa.com 12227NHMENABS 04_26_2017 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, 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.

2 You can save money on outpatient surgery and other procedures through Anthem s Site of Service benefit option. When your employer chooses the Site of Service benefit option, use one of these ambulatory surgery centers (ASC) to help lower your out-of-pocket costs. Facility Concord ASC at Horseshoe Pond Concord, NH concordasc.com Concord Endoscopy Center LLC Concord, NH giaofnh.com Concord Eye Surgery LLC Concord, NH Dartmouth Hitchcock Clinic Manchester, NH dartmouth-hitchcock.org Dartmouth Hitchcock Clinic Nashua, NH dartmouth-hitchcock.org Dental Ear, Nose & Throat Gastroenterology General Gynecology Neurology Ophthalmology Oral & Maxillofacial Orthopedic Pain Management Plastic Podiatry Urology Vascular Elliot One Day Surgery Center Manchester, NH elliot1-day.com Franklin Regional Hospital ASC Franklin, NH lrgh.org Hillside Surgery Center Gilford, NH hillsidesurgerycenter.com Laconia Clinic ASC Laconia, NH laconiaclinic.com 12227NHMENABS 04_26_2017 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, 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.

3 You can save money on outpatient surgery and other procedures through Anthem s Site of Service benefit option. When your employer chooses the Site of Service benefit option, use one of these ambulatory surgery centers (ASC) to help lower your out-of-pocket costs. Facility Dental Ear, Nose & Throat Gastroenterology General Gynecology Neurology Ophthalmology Oral & Maxillofacial Orthopedic Pain Management Plastic Podiatry Urology Vascular Lakes Region General Hospital ASC Laconia, NH lrgh.org Lakes Region Urology ASC Laconia, NH lrgh.org Merrimack Valley Endoscopy Center Haverhill, MA pmaonline.com Nashua Ambulatory Surgery Center Nashua, NH nashuasurgical.com Northeast Surgical Care Newington, NH northeastsurgicalcare.com Novamed Surgery Center of Bedford LLC Bedford, NH nheyesurgicenter.com Novamed Surgery Center of Nashua LLC Nashua, NH novamedsurgeryofnashua.com Orchard Surgical Center LLC Salem, NH orchardsurgical.com PMC Surgical Center, LLC Merrimack, NH painmd.com 12227NHMENABS 04_26_2017 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, 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.

4 You can save money on outpatient surgery and other procedures through Anthem s Site of Service benefit option. When your employer chooses the Site of Service benefit option, use one of these ambulatory surgery centers (ASC) to help lower your out-of-pocket costs. Facility Dental Ear, Nose & Throat Gastroenterology General Gynecology Neurology Ophthalmology Oral & Maxillofacial Orthopedic Pain Management Plastic Podiatry Urology Vascular PMC Surgical Center, LLC Somersworth, NH painmd.com Portsmouth Regional ASC Portsmouth, NH prasc.com Rye Surgical Center Rye, NH nhpain.com Skyhaven Surgery Center, LLC Rochester, NH skyhavensurgery.com Stratham ASC Stratham, NH strathamasc.com The Surgery Center of Greater Nashua Nashua, NH surgerycenternashua.org Upper Connecticut Valley Hospital Colebrook, NH ucvh.org Wentworth Surgery Center Somersworth, NH wentworthsurgerycenter.com 12227NHMENABS 04_26_2017 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, 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.

5 You can save money on outpatient surgery and other procedures through Anthem s Site of Service benefit option. When your employer chooses the Site of Service benefit option, use one of these ambulatory surgery centers (ASC) to help lower your out-of-pocket costs. Facility Dental Ear, Nose & Throat Gastroenterology List of facilities and services provided is intended as a guide to the types of surgical procedures that may be provided at the Site of Service facilities. Coverage for procedures offered at facilities varies based on the actual procedure performed and the services covered under your health benefit plan. Contact Anthem customer service for additional information regarding plan coverage prior to services being rendered. This information is provided as a guide only and is subject to change. The list of facilities can also be found on Anthem s Find a Doctor tool on anthem.com. General Gynecology Neurology Ophthalmology Oral & Maxillofacial Orthopedic Pain Management Plastic Podiatry Urology Vascular 12227NHMENABS 04_26_2017 Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, 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.

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9 Not using Site of Service? Then you re paying too much for care. Find the right place for care and avoid paying extra out of your own pocket. Here s how using Site of Service works to cut costs for you on lab tests and outpatient surgeries. 1 Lab tests When your doctor wants you to get a lab test, use a Site of Service preferred lab and you won t pay anything for services. Whether you need a blood, urine or strep test, you have no out-of-pocket costs. That means you won t have to pay a deductible or even your percentage of the costs. All independent labs in New Hampshire, including Quest Diagnostics, LabCorp and NorDx, are part of Anthem s Site of Service program, as well as some hospital-based labs. How to find a Site of Service preferred lab or ambulatory surgery center To find a Site of Service preferred lab or a Site of Service preferred ASC, visit healthtrustnh.org and select the Medical icon. Scroll down to Medical Plan Provider Directories and choose the orange button that says Access Blue New England Site of Service (HMO). Outpatient surgery When your doctor recommends a common same-day surgery, like a knee arthroscopy, use a Site of Service ambulatory surgery center (ASC). It could save you thousands. For example, a typical arthroscopic knee surgery could cost more than $9,100, 2 but with Site of Service, you ll have a $0 copay. See your plan details in your Cost Sharing Schedule for the exact amount. Remind your doctor that you have the Site of Service program to save on lab work and outpatient surgeries. Visit healthtrustnh.org to find the right place for you NHMENABS Rev. 10/17

10 Site of Service FAQ How does Anthem s Site of Service program help lower costs? When you use Anthem s Site of Service preferred labs, which include all independent labs in New Hampshire and some hospital labs, you won t have a copay for your lab services. This cuts down on how much you pay out of your own pocket, and your overall health care costs. How do I find a zero-cost lab through the Site of Service program? To find a Site of Service preferred lab, visit healthtrustnh.org and select the Medical icon. Scroll down to Medical Plan Provider Directories and choose the orange button that says Access Blue New England Site of Service (HMO). What if I don t use an Anthem Site of Service preferred lab? You may use any lab you d like. But if you choose a lab that s not listed in the Access Blue New England Site of Service directory on the HealthTrust website, your share of the costs may be higher. Does an independent lab provide the same type of quality and service as a hospital-based lab? Yes, independent labs specialize in these types of services. They have the same level of quality and offer the same services as hospital-based labs. While the account is being set up, your doctor can still order your lab work at an independent lab by giving you the laboratory order form. You ll need to take the form to the lab. Once your doctor has an account with the lab, the lab will automatically pick up your samples from your doctor s office. My doctor says he or she doesn t want to use one of the labs that I ve requested under the Site of Service program. What can I do? Remind your doctor that under New Hampshire law, you have the right to choose where you want to get services, including lab services. Your doctor is required to give you a laboratory order form to take to the lab you want to use. What are ambulatory surgery centers? Ambulatory surgery centers (ASCs) provide a wide range of same-day surgical services, such as tonsillectomies (surgery to remove one or both of the tonsils) or knee arthroscopies. How can I find an ASC? To find a Site of Service ASC, visit healthtrustnh.org and select the Medical icon. Scroll down to Medical Plan Provider Directories and choose the orange button that says Access Blue New England Site of Service (HMO). Or call the Member Services number on your Anthem member ID card. Can my doctor use an independent lab for my lab work? Yes, when your doctor orders lab work, ask him or her to order your lab work at an independent lab. Even if your doctor usually uses another hospital lab not found on the list of Site of Service preferred labs at healthtrustnh.org, he or she can order your lab work at an independent lab that is in the Site of Service program. My doctor doesn t have a contract with any independent labs. How can he or she get one? Your doctor can easily set up an account with independent labs such as LabCorp, Quest Diagnostics or NorDx through their websites. I m going to have surgery. How can I find out whether it can be done at an ASC? Ask your doctor to recommend a surgeon who may be able to perform your surgery at an ASC. How much will I have to pay if I use an ASC? If you use a Site of Service ASC for same-day surgery, you ll have a $0 copay. See your plan details in your Cost Sharing Schedule for the exact amount. 1 Site of Service is not available on Anthem s health reimbursement accounts and health savings account plans. 2 Cost is based on Anthem claims data for the average paid amount for knee arthroscopy at New Hampshire hospitals in If you need more care as part of the surgery or procedure, you may have to pay coinsurance and/or a deductible (the amount you pay before the plan pays). For example, you may pay more for pathology or lab work if it is not sent to one of the labs found on Anthem s Find a Doctor tool. Make sure your doctor at the ASC knows you have Anthem s Site of Service program Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. Independent licensees 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.

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