The road to better health starts with a plan

Transcription

1 The road to better health starts with a plan Know where you re going with our health plans for New Hampshire small businesses Available through the Health Insurance Marketplace (the exchange) for 2017 We can help you steer your course After more than 70 years, we ve gotten pretty good at navigating the twists and turns of health insurance. You can count on us to be right by your side on this journey with the right products, information and services to give you what you need on your terms NHEENABS Rev. 08/16

2 A healthy business needs healthy employees to keep things moving Keeping things running smoothly at your business, starts with getting the answers to the questions that matter most to you. So we re here with the information and tools you need to help you better understand how choosing a plan works. First, let s get down to the basics. The Health Insurance Marketplace (also known as the exchange ) is run by the state or federal government. It gives you another way to compare and buy health coverage. All plans in the marketplace are run by health insurance companies and offer a core set of benefits called essential health benefits. At Anthem, we re happy to offer you six plans through the Health Insurance Marketplace. Our plans cover all essential health benefits, including: Preventive care at $0 Maternity (pregnancy) and newborn care Prescription drugs Pediatric vision Outpatient (ambulatory) care Emergency services, including emergency room and walk-in center Inpatient care (hospital stays) Laboratory services Rehabilitative and habilitative services and devices (habilitative services help people learn, keep or improve skills they not be developing normally) Chronic disease management services Health and wellness tools and resources Mental health and substance abuse services 1

3 We ve put some careful thought into the design of our exchange plans because we know you need to keep your costs down while offering your employees the benefits they need to take control of their health. It s a delicate balance. We get that. So let s figure out what works best for you, together. 2

4 Your employees health comes first. Our 2017 health plans were designed with that in mind. Product type HMO HMO HMO-HSA HMO-HSA HMO-HSA HMO-HSA Plan name Anthem Gold Pathway X HMO 1500/20%/3000 Anthem Silver Pathway X HMO 3500/10%/6000 Anthem Gold Pathway X HMO 1500/10%/3000 w/hsa Anthem Silver Pathway X HMO 3000/0%/6550 w/hsa Anthem Bronze Pathway X HMO 5250/30%/6550 w/hsa Anthem Bronze Pathway X HMO 6550/0%/6550 w/hsa Network name Contract code Deductible (indivudal/ family) Deductible type 1 Pathway X 204T $1,500/$3,000 Embedded 20% Pathway X 204W $3,500/$7,000 Embedded 10% Pathway X 205L $1,500/$3,000 Non embedded Coinsurance Pathway X 205J $3,000/$6,000 Embedded 0% Deductible 10% Pathway X 205H $5,250/$10,500 Embedded 30% Office visits (PCP/specialist) $20 for first 3 visits, then deductible and 20% coinsurance $35 for first 3 visits, then deductible and 10% coinsurance 10% coinsurance 30% coinsurance Pathway X 205P $6,550/$13,100 Embedded 0% Deductible 1 Here s an overview of non-embedded versus embedded deductible products: Non-embedded Accumulation: All family members have a shared deductible and out-of-pocket (OOP) maximum, regardless of the number of family members. The entire deductible must be satisfied before any one member of the family can begin receiving benefits. The entire OOP must be satisfied before the family has satisfied the OOP maximum. Embedded Accumulation: Each member has an individual deductible/oop amount. Any deductible amount contributed by an individual family member will apply to the family deductible amount, but no individual family member is required to contribute more to the family deductible than their individual deductible amount. The OOP accumulates on an embedded basis also. Why choose Anthem over other exchange plans? With Anthem, your employees will have a full range of health benefits, as well as the latest health and wellness tools and resources right at their fingertips. That makes it a whole lot easier for them to stay on top of their health. Take a look at what you get: Stability: We ve got years of experience providing health care to millions of Americans. In fact, we ve been providing health care benefits to the people of New Hampshire for more than 70 years. That s experience you can count on. 3 Pharmacy benefits designed to save money: The Anthem Select Drug List includes preferred generic and brand-name drugs approved by the Food and Drug Administration (FDA). The list is designed to save money and is split into five 1 tiers. On our plans that don t include a health savings account (HSA), tier 1 drugs have the lowest cost share. Tiers 2 and 3 have higher copays over time. Tier 4 drugs have a coinsurance (percentage of the costs) up to a maximum dollar amount per prescription.

5 Coverage is generally available only from doctors and hospitals in the plan, except for urgent or emergency care. All cost share and coverage information in this brochure assumes your employees get covered services by doctors or hospitals in the plan. Urgent care facility Emergency room facility 2 Outpatient surgery Hospital inpatient admission Out-of-pocket maximum (individual/family) Prescription drugs - retail 3 : 30-day supply 20% coinsurance $300 20% coinsurance 20% coinsurance $3,000/$6,000 $10/$25/$50 or 30%, whichever is greater, up to $300/$80 or 30%, whichever is greater, up to $300/30% up to $500 per script 10% coinsurance $300 10% coinsurance 10% coinsurance $6,000/$12,000 $10/$25/$50 or 30%, whichever is greater, up to $300/$80 or 30%, whichever is greater, up to $300/30% up to $500 per script 10% coinsurance 10% coinsurance 10% coinsurance 10% coinsurance $3,000/$6,000 10% coinsurance Deductible Deductible Deductible Deductible $6,550/$13,100 20% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance 30% coinsurance $6,550/$13,100 30% coinsurance Deductible Deductible Deductible Deductible $6,550/$13,100 Deductible 2 Services received in an urgent care and emergency room setting are subject to deductible and applicable coinsurance. 3 Home delivery (90-day supply): 2.5x for tiers 1a and 1b/3x/3x/30%. Most retail locations (90-day supply): 3x for tiers 1a and 1b/3x/3x/30%. Excludes HSA plans. Prescription drug coverage on our HSA plans is subject to the medical deductible and applicable coinsurance. To see the Anthem Select Drug List, visit anthem.com/pharmacyinformation. Total health care: We offer your employees a total health solution so they can live healthier, feel better and save money doing it. That includes: 100% COVERAGE for preventive care 24/7 NurseLine The value of seeing a doctor in the plan: Give your employees access to the best doctors in the area. We re well-known for our network strength and the well-respected providers who ve chosen to be a part of our plans. Our Pathway networks also include: Lab, durable medical equipment and behavioral health services statewide. Urgent and emergency services nationwide. Health coaching Clinical and wellness programs 4

6 What else do you and your employees need on the go? Great ways to stay connected, of course. No matter where you are. Connect to care anywhere You and your employees can visit anthem.com for 24/7 information. Use the tools and resources on the website to: Learn more about topics like nutrition, weight loss and quitting tobacco. Find a doctor or hospital in your plan and in your neighborhood. Compare cost and quality for different hospitals. Get a new member ID card or print a temporary one. See benefits or check on a claim. Submit benefit questions. LiveHealth Online stay in touch Your employees can connect to a doctor or licensed psychologist or therapist through a face-to-face video visit on their computer or mobile device. Doctors are available in minutes and therapists within four days, depending on the particular therapist s schedule. Doctors can: Don t forget to tell your employees about our free mobile app, Anthem Anywhere, to manage health care on the go! Answer questions. Make a diagnosis. Prescribe basic medications. 2 5 It s a cool innovation designed with your employees in mind so they don t have to leave work for hours to see a doctor. Now that s a win-win for both you and your employees!

7 Programs to keep your employees healthy and on their toes for any roadblocks ahead Your employees are your most valuable asset. Of course you want them to be healthy, but there s more to it than that. When your employees are healthy, there s a healthy chance that: Productivity increases. Total medical spending is reduced. That s why you re getting one of the most complete suites of wellness and clinic care in the industry. Just take a look: Program What is it about? How does it help? 24/7 NurseLine A toll-free number any member can call anytime to talk to a registered nurse. Nurses are trained to answer general health questions. They also help members choose the right level of care. Cancer Care Quality Program A new program that allows oncologists to compare planned cancer treatments against evidence-based clinical criteria and potentially get enhanced reimbursement. The goal of this program is to promote access to quality, evidence-based, affordable health care for members and to provide the framework to begin changing the cancer care paradigm. This program also allows our members to be identified earlier for our Case Management program. Case Management After a major hospital stay or procedure due to illness or injury, members can get phone or video support from our nurses. Cancer, NICU and transplant services are included. It helps members get the most out of their medical benefits, arrange care after hospital discharge as well as community health services. ConditionCare Teams up members with nurse coaches and other health professionals to help manage chronic conditions like asthma, COPD, diabetes or heart disease. It provides targeted information, guidance and support with 24/7 access to health professionals. This helps members better understand and manage their condition so they make healthier choices for optimal wellness. Future Moms Provides moms-to-be (and dads-to-be) with personalized support and guidance. This program helps pregnant women achieve healthier pregnancies and deliveries. We work with their own team of obstetric specialists to give them access to expert information and direction before, during and after pregnancy. MyHealth Advantage Analyzes a member s overall health information. It helps by suggesting ways members can be healthier and reduce out-of-pocket costs. MyHealth Advantage aims to lower costs by increasing member compliance with medical best practices and improving health care quality. Both members and providers are contacted if the system is alerted to potential issues or gaps in care. Online Wellness Kit Helps members set and achieve personalized health goals. Through a health assessment, members learn about their health risks and how to improve their health. Uses personalized trackers and activities to improve their well-being. Preventive Plus Rewards members for taking positive steps toward better health. Members get $100 for completing both a wellness exam and the flu shot; $50 for a tobacco-free certification and $50 for completing the Health Assessment. 6

8 Exclusions and limitations What s not covered In this section you will find a review of items that are not covered by your Plan. Excluded items will not be covered even if the service, supply, or equipment is Medically Necessary. This section is only meant to be an aid to point out certain items that may be misunderstood as Covered Services. This section is not meant to be a complete list of all the items that are excluded by your Plan. Anthem determines whether services or supplies are Medically Necessary based on the definition of Medical Necessity found in the Definitions section Administrative charges: Charges to complete claim forms Charges to get medical records or reports Membership, administrative, or access fees charged by Doctors or other Providers. Examples include, but are not limited to, fees for educational brochures or calling you to give you test results 2. Alternative/Complementary medicine Services or supplies for alternative or complementary medicine. This includes, but is not limited to: a) Acupuncture. b) Holistic medicine. c) Homeopathic medicine. d) Hypnosis. e) Aroma therapy. f) Massage and massage therapy. g) Reiki therapy. h) Herbal, vitamin or dietary products or therapies. i) Naturopathy. j) Thermography. k) Orthomolecular therapy. l) Contact reflex analysis. m) Bioenergetic synchronization technique (BEST). n) Iridology study of the iris. o) Auditory integration therapy (AIT). p) Colonic irrigation. q) Magnetic innervation therapy. r) Electromagnetic therapy. s) Neurofeedback/Biofeedback. 3. Before effective date or after termination date Charges for care you get before your effective date or after your coverage ends, except as written in this plan. 4. Certain providers Services you get from Providers that are not licensed by law to provide Covered Services as defined in this Booklet. Examples include, but are not limited to, masseurs or masseuses (massage therapists), physical therapist technicians, and athletic trainers. 5. Charges over the maximum allowed amount Charges over the maximum allowed amount for covered services. 6. Charges not supported by medical records Charges for services not described in your medical records. 7. Clinically-equivalent alternatives Certain Prescription Drugs may not be covered if you could use a clinically equivalent Drug, unless required by law. Clinically equivalent means Drugs that for most Members, will give you similar results for a disease or condition. If you have questions about whether a certain Drug is covered and which Drugs fall into this group, please call Member Services at [ ] or visit our website at If you or your Doctor believes you need to use a different Prescription Drug, please have your Doctor or pharmacist get in touch with us. We will cover the other Prescription Drug only if we agree that it is Medically Necessary and appropriate over the clinically equivalent Drug. We will review benefits for the Prescription Drug from time to time to make sure the Drug is still Medically Necessary. 8. Complications of noncovered services Care for problems directly related to a service that is not covered by this plan. Directly related means that the care took place as a direct result of the noncovered service and would not have taken place without the noncovered service. 9. Cosmetic services Treatments, services, prescription drugs, equipment, or supplies given for cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or are given for psychiatric, psychological, or social reasons. No benefits are available for surgery or treatments to change the texture or look of your skin or to change the size, shape or look of facial or body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts). This exclusion does not apply to Reconstructive Surgery as stated under Surgery in the What s Covered section. 10. Custodial care Custodial Care, convalescent care or rest cures. This exclusion does not apply to hospice services. 11. Delivery charges Charges for delivery of Prescription Drugs. 12. Dental treatment Excluded treatment includes but is not limited to preventive care and fluoride treatments; dental X-rays, supplies, appliances and all associated costs; and diagnosis and treatment for the teeth, jaw or gums such as: Removing, restoring, or replacing teeth. Medical care or surgery for dental problems (unless listed as a covered service in this booklet). Services to help dental clinical outcomes. Dental treatment for injuries that are a result of biting or chewing is also excluded unless the biting or chewing results from a medical or mental condition. This Exclusion does not apply to services that we must cover by law or to the Dental Services described in the What s Covered section of this booklet. 13. Disease or injury sustained as a result of war or participation in riot or insurrection No Benefits are available for care required to diagnose or treat any illness or injury that is a result of war or participation in a riot or an insurrection. 14. Drugs over quantity limits Drugs in quantities which are over the limits set by the plan. 15. Drugs over the quantity prescribed or refills after one year Drugs in amounts over the quantity prescribed, or for any refill given more than one year after the date of the original Prescription Order. 16. Drugs that do not need a prescription Drugs that do not need a

9 prescription by federal law (including drugs that need a prescription by state law, but not by federal law), except for injectable insulin. 17. Drugs prescribed by providers lacking qualifications/certifications Prescription drugs prescribed by a provider that does not have the necessary qualifications including certifications, as determined by Anthem. 18. Educational services Services or supplies for teaching, vocational, or self-training purposes, except as listed in this booklet. 19. Emergency room services for nonemergency care Services provided in an emergency room for conditions that do not meet the definition of emergency. This includes services such as suture removal in an emergency room. 20. Experimental or investigational services Services or supplies that are experimental/investigational as defined in the Definitions section of this booklet. Except as stated under Clinical Trials in the What s Covered section, this exclusion also applies to services related to experimental/ Investigational services, whether you get them before, during, or after you get the experimental/investigational service or supply. The fact that a service or supply is the only available treatment will not make it Covered Service if it is experimental/investigational. 21. Eyeglasses and contact lenses Eyeglasses and contact lenses to correct your eyesight unless listed as covered in this booklet. This Exclusion does not apply to lenses needed after a covered eye surgery. 22. Eye exercises Orthoptics and vision therapy. 23. Eye surgery Eye surgery to fix errors of refraction, such as nearsightedness. This includes, but is not limited to, LASIK, radial keratotomy or keratomileusis, and excimer laser refractive keratectomy. 24. Family members Services prescribed, ordered, referred by or given by a member of your immediate family, including your spouse, child, brother, sister, parent, in-law, or self. 25. Foot care Routine foot care unless Medically Necessary. This Exclusion applies to cutting or removing corns and calluses; trimming nails; cleaning and preventive foot care, including, but not limited to: Cleaning and soaking the feet. Applying skin creams to care for skin tone. Other services that are given when there is not an illness, injury or symptom involving the foot. 26. Foot orthotics Foot orthotics, orthopedic shoes or footwear or support items unless used for an illness affecting the lower limbs, such as severe diabetes. 27. Foot surgery Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet; tarsalgia; metatarsalgia; hyperkeratoses. 28. Free care Services you would not have to pay for if you didn t have this Plan. This includes, but is not limited to government programs, services during a jail or prison sentence, services you get from workers compensation, and services from free clinics. If Workers Compensation benefits are not available to you, for whatever reason, this Exclusion does not apply. This exclusion will apply if you get the benefits in whole or in part. This exclusion also applies whether or not you claim the benefits or compensation, and whether or not you get payments from any third party. 29. Gene therapy Gene therapy as well as any Drugs, procedures, health care services related to it that introduce or is related to the introduction of genetic material into a person intended to replace or correct faulty or missing genetic material. 30. Health club memberships and fitness services Health club memberships, workout equipment, charges from a physical fitness or personal trainer, or any other charges for activities, equipment, or facilities used for physical fitness, even if ordered by a Doctor. This Exclusion also applies to health spas. 31. Home care: Services given by registered nurses and other health workers who are not employees of or working under an approved arrangement with a home health care provider. Private duty nursing. Food, housing, and home delivered meals. Homemaker services, except for the homemaker visits described in the What s Covered section under Home Care (prenatal and postpartum visits) and under Hospice. 32. Infertility treatment Infertility testing, treatment or procedures not specified in this booklet. 33. Maintenance therapy Rehabilitative treatment given when no further gains are clear or likely to occur. Maintenance therapy includes care that helps you keep your current level of function and prevents loss of that function, but does not result in any change for the better. This Exclusion does not apply to Habilitative Services as described in the What s Covered section. 34. Medical equipment and supplies: Replacement or repair of purchased or rental equipment because of misuse, abuse, or loss/theft. Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury. Nonmedically Necessary enhancements to standard equipment and devices. Supplies, equipment and appliances that include comfort, luxury, or convenience items or features that exceed what is Medically Necessary in your situation. Reimbursement will be based on the Maximum Allowable Amount for a standard item that is a Covered Service, serves the same purpose, and is Medically Necessary. Any expense that exceeds the Maximum Allowable Amount for the standard item which is a Covered Service is your responsibility. 35. Missed or canceled appointments Charges for missed or canceled appointments. 36. Nonmedically necessary services Services that are not medically necessary as defined in the Definitions section of this booklet. 37. Nutritional or dietary supplements Nutritional and/or dietary supplements, except as described in this booklet or that we must cover by law. This Exclusion includes, but is not limited to, nutritional formulas and dietary supplements that you can buy over the counter and those you can get without a written prescription or from a licensed pharmacist. 38. Out-of-network care Services from a provider or facility that is not in Anthem s network. This does not apply to emergency care or authorized services. 8

10 39. Personal care and convenience: Items for personal comfort, convenience, protection, cleanliness such as air conditioners, humidifiers, water purifiers, sports helmets, raised toilet seats, and shower chairs First aid supplies and other items kept in the home for general use (bandages, cotton-tipped applicators, thermometers, petroleum jelly, tape, nonsterile gloves, heating pads) Home work out or therapy equipment, including treadmills and home gyms Pools, whirlpools, spas, or hydrotherapy equipment Hypoallergenic pillows, mattresses, or waterbeds Residential, auto, or place of business structural changes (ramps, lifts, elevator chairs, escalators, elevators, stair glides, emergency alert equipment, handrails) 40. Private duty nursing Private duty nursing services. 41. Prosthetics Prosthetics for sports or cosmetic purposes. This includes wigs and scalp hair prosthetics except as required by law. 42. Residential accommodations Residential accommodations to treat medical or behavioral health conditions, except when provided in a hospital, hospice, skilled nursing facility, or residential treatment center. 43. Services received outside of the service area Services received from a provider outside of the service area. This does not apply to: a) Emergency or Urgent Care; or b) Covered Services approved in advance by Anthem. 44. Services Received Outside of the United States Services rendered by Providers located outside the United States, unless the services are for emergency care, urgent care, emergency ambulance or covered services approved in advance by Anthem. 45. Sexual dysfunction Services or supplies for male or female sexual problems. 46. Smoking cessation programs Programs to help you stop smoking. Please note: Preventive screenings, counseling and other Preventive Care services for tobacco use and tobacco cessation are covered as required by law under the Preventive Care benefit in the What s Covered section and in the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section. 47. Stand-by charges Stand-by charges of a doctor or other provider. 48. Reversal of elective sterilization 49. Surrogate mother services Services or supplies for a person not covered under this plan for a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). 50. Temporomandibular joint treatment Fixed or removable appliances which move or reposition the teeth, fillings, or prosthetics (crowns, bridges, dentures). 51. Travel costs Mileage, lodging, meals, and other member-related travel costs except as described under Ambulance Services in the What s Covered section of this booklet. 52. Vein treatment Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) for cosmetic purposes. 53. Vision services We will not pay for services incurred for, or in connection with, any of the items below: Vision services for Members age 19 or older, unless listed as covered in this booklet. Eyeglass lenses, frames, or contact lenses for Members age 19 and older, unless listed as covered in this booklet. For safety glasses and accompanying frames. For two pairs of glasses in lieu of bifocals. For plano lenses (lenses that have no refractive power) Blended lenses Lost or broken lenses or frames, unless the Member has reached the Member s normal interval for service when seeking replacements Vision services not listed as covered in this booklet. Cosmetic lenses or options unless specifically listed in this booklet. For services or supplies combined with any other offer, coupon or in-store advertisement. Certain frames in which the manufacturer imposes a no-discount policy. For members through age 18, no benefit is available for frames or contact lenses purchased outside of Anthem s formulary. For any condition, disease, defect, ailment or injury arising out of and in the course of employment if benefits are available under the Workers Compensation Act or any similar law. This exclusion applies if a member receives the benefits in whole or in part. This exclusion also applies whether or not the member claims the benefits or compensation. It also applies whether or not the member recovers from any third party. To the extent that they are provided as benefits by any governmental unit, unless otherwise required by law or regulation. For which the member has no legal obligation to pay in the absence of this or like coverage. For services or supplies prescribed, ordered or referred by, or received from a member of the Member s immediate family, including the Member s spouse or Domestic Partner, child, brother, sister or parent. For completion of claim forms or charges for medical records or reports. For missed or cancelled appointments. Visual therapy, such as orthoptics or vision training and any associated supplemental testing, unless covered by the medical benefits of this booklet. For medical or surgical treatment of the eyes, including inpatient or outpatient hospital vision care, except as covered under the medical benefits of this plan. Services and materials not meeting accepted standards of optometric practice or services that are not performed by a licensed provider. For vision care received out of network. 54. Weight-loss programs Programs, whether or not under medical supervision, unless listed as covered in this booklet. This Exclusion includes, but is not limited to, commercial weight-loss programs (Weight Watchers, Jenny Craig, LA Weight Loss ) and fasting programs. This Exclusion does not apply to the Diabetes Management or Preventive Care benefits or to Surgery for conditions caused by obesity under Surgery in the What s Covered section. 9

11 What s not covered under your prescription drug retail or home delivery (Mail Order) pharmacy benefit In addition to the above Exclusions, certain items are not covered under the prescription drug retail or home delivery (mail order) pharmacy benefit: 1. Administration charges Charges for the administration of any drug except for covered immunizations as approved by Anthem or the PBM. 2. Clinically-equivalent alternatives Certain prescription drugs may not be covered if you could use a clinically equivalent drug, unless required by law. Clinically equivalent means drugs that for most members, will give you similar results for a disease or condition. If you have questions about whether a certain drug is covered and which drugs fall into this group, please call Member Services at or visit our website at anthem.com. If you or your doctor believes you need to use a different prescription drug, please have your Doctor or pharmacist get in touch with Anthem to request prior authorization. The prior authorization process is stated under Additional Features of Your Prescription Drug Pharmacy Benefit in the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy section. 3. Compound drugs Compound drugs unless all of the ingredients are FDA-approved and require a prescription to dispense, and the compound medication is not essentially the same as an FDA-approved product from a drug manufacturer. Exceptions to non-fda-approved compound ingredients may include multi-source, nonproprietary vehicles and/or pharmaceutical adjuvants. 4. Contrary to approved medical and professional standards Drugs given to you or prescribed in a way that is against approved medical and professional standards of practice. 5. Cosmetic drugs agents or medications used for cosmetic purposes 6. Delivery charges Charges for delivery of prescription drugs. 7. Drugs given at the provider s office/facility Drugs you take at the time and place where you are given them or where the prescription order is issued. This includes samples given by a doctor. This exclusion does not apply to drugs used with a diagnostic service, Drugs given during chemotherapy in the office as described in the Prescription Drugs Administered by a Medical Provider section, or Drugs covered under the Medical and Surgical Supplies benefit in the What s Covered section they are Covered Services. 8. Drugs not on the Anthem prescription drug list (formulary) You can get a copy of the list by calling us at or visiting our website at [anthem.com]. If you or your doctor believes you need a certain prescription drug not on the list, please refer to Prior Authorization in the section Prescription Drug Benefit at a retail or home delivery (mail order) pharmacy for details on requesting an exception. 9. Drugs over quantity limits Drugs in quantities which are over the limits set by the plan. 10. Drugs over the quantity prescribed or refills after one year Drugs in amounts over the quantity prescribed, or for any refill given more than one year after the date of the original prescription order. 11. Drugs prescribed by providers lacking qualifications/certifications prescription drugs Prescribed by a provider that does not have the necessary qualifications and including certifications, as determined by Anthem. 12. Drugs that do not need a prescription Drugs that do not need a prescription by federal law (including Drugs that need a prescription by state law, but not by federal law), except for injectable insulin. Please see Over-the-Counter Items below for information about coverage required by law for over-the-counter items purchased at an In-Network Pharmacy with a Prescription from your Doctor. 13. Gene Therapy Gene therapy as well as any drugs, procedures, health care services related to it that introduce or is related to the introduction of genetic material into a person intended to replace or correct faulty or missing genetic material. 14. Infertility hormones and infertility drugs. 15. Items covered as durable medical equipment (DME) Therapeutic DME, devices and supplies except peak flow meters, spacers, blood glucose monitors and contraceptive devices. Items not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy may be covered under the Durable Medical Equipment and Medical Supplies benefit in the What s Covered section. Please see that section for details. 16. Items covered under the Allergy Services benefit Allergy desensitization products or allergy serum. While not covered under the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy benefit, these items may be covered under the Allergy Services benefit in the What s Covered section. Please see that section for details. 17. Lost or stolen drugs Refills of lost or stolen drugs. 18. Mail order providers other than the pbm s home delivery mail order provider Prescription drugs dispensed by any mail order provider other than the PBM s home delivery provider, unless we must cover them by law. 19. Nonapproved drugs Drugs not approved by the FDA. 20. Onychomycosis drugs Drugs for Onychomycosis (toenail fungus) except when we allow it to treat Members who are immunocompromised or diabetic. 21. Over-the-counter items Drugs, devices and products, or prescription legend drugs with over-the-counter equivalents and any drugs, devices or products that are therapeutically comparable to an over-the-counter drug, device or product. This includes prescription legend drugs when any version or strength becomes available over the counter. This Exclusion does not apply to over-the-counter products that we must cover by law under Preventive Care in the What s Covered section when you purchase them from an in-network pharmacy with a prescription from your doctor. These include over-the-counter contraceptive products for women and over-the-counter smoking cessation/nicotine replacement products (limited to nicotine patches and gum), low-dose aspirin and colonoscopy prep medications. 22. Sexual dysfunction drugs Drugs to treat sexual or erectile problems. 23. Syringes Hypodermic syringes except when given for use with insulin and other covered self-injectable drugs and medicine. 24. Weight-loss drugs Any drug mainly used for weight loss. 10

12 The road to better health doesn t have to be bumpy And we re here to make sure it s a smooth ride. Call your producer of Anthem Sales representative today to learn more about exchange plans for your small business. This document is only a brief summary of benefits and services. For more complete details, including what s covered and what isn t: See your Certificate booklet. Call your producer or Anthem Sales representative. Visit healthcare.gov. To view a Summary of Benefits and Coverage, please visit sbc.anthem.com. Available through the Health Insurance Marketplace 1 Health savings account plans only have a four-tier drug list and no split generic copay in tier 1. 2 Prescription availability is defined by physician judgment and state regulations. LiveHealth Online is available in most states and is expected to expand to more in the near future. Visit the home page of livehealthonline.com to view the service map by state. LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. 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.