Summary f Benefits fr Lumens Health Savings Accunt (HSA-Cmpatible) Plan n Pathway PPO Netwrk This is a general benefit summary fr this health plan. A cmplete listing and descriptin f benefits, limitatins, and exclusins are fund in the Certificate. Cpayment ptins reflect the amunt the member will pay, cinsurance ptins reflect the amunt that Anthem will pay. In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Annual Deductible Deductibles are per calendar year. Individual: $3,000 Family: $6,000 aggregate One member may nt cntribute any mre than the individual tward the family. Individual: $3,000 Family: $6,000 aggregate One member may nt cntribute any mre than the individual tward the family. Anthem Blue Crss and Blue Shield is the trade name f Rcky Muntain Hspital and Medical Service, Inc. HMO prducts underwritten by HMO Clrad, Inc. dba HMO Nevada. Independent licensees f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. Si usted necesita ayuda en españl para entender éste dcument, puede slicitarla gratis llamand al númer de servici al cliente que aparece en su tarjeta de identificación en su fllet de inscripción. 06-00224 (Rev. 1/16) v1 1 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Out-f-Pcket Annual Maximum All cpayments, cinsurance and cntribute twards the ut-f-pcket annual maximum. Sme cvered services have a maximum number f days, visits r dllar amunts. These maximums apply even if the applicable ut-f-pcket annual maximum is satisfied. Lifetime Maximum Benefit Other Applicable Maximums Individual: $4,000 Family: $8,000 aggregate One member may nt cntribute any mre than the individual ut-fpcket annual maximum tward the family ut-fpcket annual maximum. Individual: $8,000 Family: $16,000 aggregate One member may nt cntribute any mre than the individual ut-fpcket annual maximum tward the family ut-fpcket annual maximum. N lifetime maximum Applied behavir analysis treatment fr autism spectrum disrder is limited t a maximum benefit f 500 hurs per year fr members under 18 years f age r, if enrlled in high schl, until the member reaches 22 years f age. Services In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Additinal Infrmatin 1. Physician Visits a) Physician ffice visits and physician cnsultatins b) Services related t physician ffice visit including but nt limited t, allergy testing, allergy injectins, r ffice surgeries Physician visits include diabetic management and limited family planning services (see certificate fr cvered services). c) Inpatient physician visits d) Online Care Visit nt cvered 2. Retail Health Clinic 3. Preventive Care Preventive care services that meet the requirements f federal and state law including screenings, immunizatins and ffice visits. N charge 06-00224 (Rev. 1/16) v1 2 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
Services In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Additinal Infrmatin 4. Diagnstic Services, Labratry, Pathlgy, and X-ray a) Labratry, Pathlgy, and X-ray b) MRI/MRA, PET, CT scans, nuclear medicine and ther high tech services 5. Maternity Care In patient services billed by a hspital are included in the hspital inpatient benefits. a) Prenatal care b) Delivery & inpatient baby care Limited t ne rutine ultrasund per pregnancy. 6. Outpatient Therapies: Physical therapy, ccupatinal therapy, speech therapy, cardiac rehabilitatin and spinal manipulatins/ acupuncture a) Outpatient physical therapy, ccupatinal therapy, speech therapy and cardiac rehabilitatin Limited t 20 visits each f physical, ccupatinal and speech therapy per member per year. Benefits are paid up t 36 visits fr cardiac rehabilitatin. b) Outpatient spinal manipulatins and acupuncture Limited t 12 visits per member per year 7. Hspital Care/Other Facility Services a) Inpatient b) Inpatient - acute rehabilitatin therapy c) Outpatient Surgery Inpatient acute rehabilitatin therapy Limited t 30 inpatient days per member per year. 06-00224 (Rev. 1/16) v1 3 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
Services In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Additinal Infrmatin 8. Emergency Care 9. Urgent Care 10. Ambulance Services Member cst share respnsibility fr Outf-Netwrk services will be the same as In-Netwrk services. a) Grund Services b) Air and Water Services 11. Mental Health and Substance Abuse Services a) Inpatient b) Outpatient 12. Medical Supplies and Equipment Includes diabetic supplies and equipment, medical supplies, durable medical equipment, xygen and equipment, rthpedic appliances, prsthetic devices and ther appliances. Wigs fr alpecia resulting frm chemtherapy and radiatin therapy are limited t a maximum benefit f $500 per member per year. 13. Hme Health Care 14. Chemtherapy, Hemdialysis, and Radiatin Therapy Limited t 100 visits per member per year. a) Inpatient b) Outpatient 15. Skilled Nursing Facility Limited t 100 inpatient days per member per year. 06-00224 (Rev. 1/16) v1 4 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
Services In-Netwrk (Pathway PPO Netwrk Participating Prvider) Out-f-Netwrk (Nn-Participating Prvider) Additinal Infrmatin 16. Hspice Care 17. Human Organ and Tissue Transplants a) Inpatient b) Outpatient 18. Temprmandibular Jint Syndrme See the certificate fr details n cvered transplants. Transprtatin and ldging services are limited t a maximum benefit f $10,000 per transplant; unrelated dnr searches are limited t a maximum benefit f $30,000 per transplant. a) Inpatient Surgery b) Outpatient Surgery c) Outpatient Physician Visits 19. Enteral Frmula and Special Fds Special fd prducts that are prescribed r rdered by a physician as medically necessary is allwed. 06-00224 (Rev. 1/16) v1 5 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
Services 20. Prescriptin Drugs a) Outpatient Retail Pharmacy Drugs b) Hme Delivery (Mail Order) Pharmacy Drugs c) Specialty Pharmacy Drugs After is satisfied yu pay a Tier 1 $15 cpayment per prescriptin, Tier 2 $45 cpayment per prescriptin, Tier 3 $75 cpayment per prescriptin, Tier 4 30% cpayment per prescriptin when received frm a cntracted pharmacy r when received frm a nn-cntracted pharmacy After is satisfied yu pay a Tier 1 $37.50 cpayment per prescriptin, Tier 2 $135 cpayment per prescriptin, Tier 3 $225 cpayment per prescriptin, Tier 4 30% cpayment per prescriptin when received frm a cntracted pharmacy r when received frm a nn-cntracted pharmacy After is satisfied yu pay a Tier 1 $15 cpayment per prescriptin, Tier 2 $45 cpayment per prescriptin, Tier 3 $75 cpayment per prescriptin, Tier 4 30% cpayment per prescriptin when received frm a cntracted pharmacy r when received frm a nn-cntracted pharmacy The fllwing applies t a), b) and c) abve: Fr the Tier 4 utpatient retail pharmacy drugs r specialty pharmacy drugs, the maximum member cpayment per prescriptin is $500 per 30-day supply at a cntracted pharmacy r frm a cntracted specialty pharmacy r a maximum member cpayment per prescriptin f $1,000 per 30-day supply at a nn-cntracted pharmacy. Fr the Tier 4 nn-specialty utpatient hme delivery (mail rder) pharmacy drugs, the maximum member cpayment per prescriptin is $1,000 per 90-day supply via cntracted hme delivery (mail rder) service. Prescriptin drugs will always be dispensed as rdered by yur prvider and by applicable state pharmacy regulatins, hwever yu may have higher ut-f-pcket expenses. Yu may request, r yur prvider may rder, the brand-name drug. Hwever, if a generic drug is available, yu will be respnsible fr the cst difference between the generic and brand-name drug, in additin t yur tier cpayment f the generic drug. This cst difference des nt cntribute t the r ut-f-pcket annual maximum. By law, generic and brand-name drugs must meet the same standards fr safety, strength, and effectiveness. Using generics generally saves mney, yet gives the same quality. Fr certain higher cst generic drugs, Anthem reserves the right, in ur sle discretin, t make an exceptin and nt require the member t pay the difference in cst between the generic and brand name drug. Fr drugs n ur apprved list, call the custmer service phne number n the back f the member s ID card. Additinal Infrmatin Orally administered cancer chemtherapy drugs are cvered accrding t state law. Available up t a 30-day supply. Tier 1, Tier 2, and Tier 3 nn specialty maintenance drugs may be filled up t a 90 day supply at mst retail pharmacy lcatins. A member is required t pay the retail pharmacy cpayment fr each 30 day supply. Available thrugh the Pharmacy Benefits Manager (PBM) hme delivery (mail rder) service up t a 90-day supply. Available up t a 30-day supply. Specialty pharmacy drugs are high-cst, injectable, infused, ral r inhaled medicatins that generally require clse supervisin and mnitring f their effect n the patient by a medical prfessinal. They are ften unavailable at an utpatient retail pharmacy r hme delivery (mail rder) pharmacy since these drugs may require special handling such as temperature cntrlled packaging and vernight delivery. These specialty pharmacy drugs are available n an in-netwrk basis frm the PBM r ut-f-netwrk at ther specialty pharmacy lcatins. If specialty pharmacy drugs are purchased frm a retail pharmacy they are cnsidered ut-f-netwrk fr benefits since they are nt cnsider services frm the in-netwrk PBM. 06-00224 (Rev. 1/16) v1 6 (PW) NV Lumens NGF HSA 22AE $3000_100% Rx.s0116v2 NV Lumens Summary
Anthem Blue Crss and Blue Shield Benefit Summary Disclsure Infrmatin Lumens Plans 700 Bradway, Denver, CO 80273 866-837-4596 This disclsure statement prvides nly a brief descriptin f sme imprtant features and limitatins f yur plicy. The certificate itself sets frth in the detail the rights and bligatins f bth yu and the insurance cmpany. It is imprtant that yu review the certificate nce yu are enrlled. Cverage fr treatment as part f a clinical trial: Includes cverage fr medical treatment prvided in a Phase I, Phase II, Phase III r Phase IV clinical trial fr the treatment f cancer r in a Phase II, Phase III r Phase IV study r clinical trial fr the treatment f chrnic fatigue syndrme cnducted in the state f Nevada. Cverage fr medical treatment is limited t: Any drug r device apprved fr sale by the Fd and Drug Administratin. The cst f any reasnably necessary health care services required frm the medical treatment r cmplicatins theref arising ut f the medical treatment prvided in the clinical trial. The initial cnsultatin t determine whether the persn is eligible t participate in a clinical trial. Health care services required fr the clinically apprpriate mnitring f the persn during the clinical trial. Cverage fr the management and treatment f diabetes Includes cverage fr medicatin, equipment, supplies, and appliances that are medically necessary fr the treatment f diabetes type I, type II, and gestatinal diabetes. Cverage fr self-management f diabetes, including: The training and educatin prvided t a persn cvered under the cntract after initial diagnsis f diabetes which is medically necessary fr the care and management f diabetes, including, withut limitatin, cunseling in nutritin and the prper use f equipment and supplies fr the treatment f diabetes. Training and educatin which is medically necessary as a result f a subsequent diagnsis that indicates a significant change in the symptms r cnditin f the prgram f self-management f diabetes. Training and educatin which is medically necessary because f the develpment f new techniques and treatment fr diabetes. Medically Necessary An interventin that is r will be prvided fr the diagnsis, evaluatin and treatment f a cnditin, illness, disease r injury and that Anthem, subject t a member s right t appeal, slely determines t be: Medically apprpriate fr and cnsistent with the symptms and prper diagnsis r treatment f the cnditin, illness, disease r injury. Obtained frm a physician and/r licensed, certified r registered prvider. Prvided in accrdance with applicable medical and/r prfessinal standards. Knwn t be effective, as prven by scientific evidence, in materially imprving health utcmes. The mst apprpriate supply, setting r level f service that can safely be prvided t the member and which cannt be mitted cnsistent with recgnized prfessinal standards f care (which, in the case f hspitalizatin, als means that safe and adequate care culd nt be btained as an utpatient). Cst-effective cmpared t alternative interventins, including n interventin ( cst effective des nt mean lwest cst). It des mean that as t the diagnsis r treatment f the member s illness, injury r disease, the service is: (1) nt mre cstly than an alternative service r sequence f services that is medically apprpriate, r (2) the service is perfrmed in the least cstly setting that is medically apprpriate. CDHP Disclsure (1/16) v2 1
Nt experimental/investigatinal. Nt primarily fr the cnvenience f the member, the member s family r the prvider. Nt therwise subject t an exclusin under the Certificate. The fact that a physician and/r prvider may prescribe, rder, recmmend r apprve care, treatment, services r supplies des nt, f itself, make such care, treatment, services r supplies medically necessary. Maximum allwed amunt Reimbursement fr services rendered by participating and nn-participating prviders is based n this health benefits plan maximum allwed amunt fr the cvered service that the member receives. NOTE: Anthem will apply the in netwrk level f benefits and the member will nt be required t pay mre fr the services than if the services had been received frm a participating prvider in the fllwing circumstances: Emergency care (where rendered either within r utside the State f Nevada) Where in-patient hspital care at a nn-participating hspital is necessary due t the nature f the treatment Where in-patient hspital care at a nn-participating hspital is necessary due t participating prvider hspital capacity When a member has received a preauthrized netwrk exceptin Emergency Emergency means a sudden nset f a medical cnditin manifesting itself by acute symptms f sufficient severity that a prudent persn wuld believe that the absence f immediate medical attentin culd result in: Serius jepardy t the health f the member, r Serius jepardy t the health f an unbrn child, r Serius impairment t bdily functins, r Serius and permanent dysfunctin f any bdily rgan r part. Maximum Benefits Sme services r supplies may have an annual r lifetime maximum benefit, be sure t review yu summary f benefits fr further details n what services may have a maximum benefit. Limitatins and Exclusins This plan des nt cver sme services. The plan includes limitatins and exclusins t prtect against duplicate r unnecessary services that culd unfairly ffset the cst f health care cverage fr the entire plan. Fllwing are examples f the plan s limitatins and exclusins (please cnsult yur Summary f Benefits and the certificate fr an exhaustive listing f exclusins and limitatins): Benefits prvided under any lcal, state, r federal laws, including Wrkers Cmpensatin and Medicare Csmetic surgery Services by a family member Weight-reductin services and medicatins Cmplicatins frm nn-cvered services Our payment allwance will be reduced r denied frm what wuld have been paid if pre-certificatin is nt btained prir t receiving inpatient hspital services and utpatient surgeries. Mst services, such as nn-emergency hspital admissins r surgical prcedures require prir authrizatin. Alternative r cmplementary medicine. Services in this categry include, but are nt limited t, hlistic medicine, hmepathy, hypnsis, armatherapy, massage therapy, reike therapy, herbal medicine, vitamin r dietary prducts r therapies, naturpathy, thermgraphy, rthmlecular therapy, cntact reflex analysis, bienergial synchrnizatin technique (BEST), clnics r iridlgy. CDHP Disclsure (1/16) v2 2
Artificial cnceptin Services received befre the effective date f cverage. Bifeedback. Chelating agents except fr prviding treatment fr heavy metal pisning. Services r supplies prvided as part f clinical research, except where required by law r allwed by Anthem. Cnvalescent care Cnvenience, luxury, deluxe services r equipment. Such services and supplies include but are nt limited t, guest trays, beauty r barber shp services, gift shp purchases, telephne charges, televisin, admissin kits, persnal laundry services, and ht and/r cld packs, equipment r appliances, which include cmfrt, luxury, r cnvenience items (e.g. wheelchair sidecars, fashin eyeglass frames, r crycuff unit). Equipment r appliances the member requests that include mre features than needed fr the medical cnditin are cnsidered luxury, deluxe and cnvenience items (e.g., mtrized equipment when manually perated equipment can be used such as electric wheelchairs r electric scters). Curt rdered services unless thse services are therwise cvered under the certificate. Custdial care. Dental services except fr accident related dental services, dental anesthesia fr children, temprmandibular jint therapy r surgery. Inpatient care received after the date Anthem, using managed care guidelines, determines discharge is apprpriate. Hspital care if the member leaves a hspital against the medical advice f the physician, charges which are a direct result f the member s knwing and vluntary nn-cmpliance f medically necessary care with prescribed medical treatment are nt eligible fr cverage. Dmiciliary care such as care prvided in residential, nn-treatment institutin, halfway huse r schl. Services and supplies already cvered by ther valid cverage. Experimental/Investigative prcedures. Genetic cunseling. Gvernment perated facility such as a military medical facility r veteran s administratin facility unless authrized by Anthem. Hair lss, drugs, wigs, hairpieces, artificial hairpieces, hair r cranial prsthesis, hair transplants r implants even if there is a physician prescriptin, and a medical reasn fr the hair lss. Hearing aids r rutine hearing tests. Hypnsis, whether fr medical r anesthesia purpses. This cverage des nt cver any lss t which a cntributing cause was the member s cmmissin f r attempt t cmmit a felny which they are cnvicted f. Therapies fr learning deficiencies and/r behaviral prblems. Maintenance therapy. Services and supplies that are nt medically necessary. Charges fr failure t keep a scheduled appintment. Neurpsychiatric testing. Nn-cvered prviders wh include but are nt limited t: Health spa r health fitness centers (whether r nt services are prvided by a licensed r registered prvider). Schl infirmary. CDHP Disclsure (1/16) v2 3
Halfway huse. Massage therapist. Nursing hme. Dental r medical services spnsred by r fr an emplyer, mutual benefit assciatin, labr unin, trustee, r any similar persn r grup. Nn-medical expenses, including but nt limited t: Adptin expenses. Educatinal classes and supplies nt prvided by the member s prvider unless specifically allwed as a benefit under this certificate. Vcatinal training services and supplies. Mailing and/r shipping and handling expenses. Interest expenses and delinquent payment fees. Mdificatins t hme, vehicle, r wrkplace regardless f medical cnditin r disability. Membership fees fr spas, health clubs, persnal trainers, r ther such facilities even if medically recmmended, regardless f any therapeutic value. Persnal cnvenience items such as air cnditiners, humidifiers, r exercise equipment. Persnal services such as haircuts, shamps, guest meals, and radi r televisins. Vice synthesizers r ther cmmunicatin devices, except as specifically allwed by Anthem s medical plicy. Upper r lwer jaw augmentatin r reductins (rthgnathic surgery) even if the cnditin is due t a genetic cngenital imperfectin r acquired characteristic. Any items available withut a prescriptin such as ver the cunter items and items usually stcked in the hme fr general use including but nt limited t bandages, gauze, tape, cttn swabs, dressing, thermmeters, heating pads, and petrleum jelly. This cverage des nt cver labratry test kits fr hme use. These include but are nt limited t, hme pregnancy tests and hme HIV tests. Benefits are nt prvided fr care received after cverage is terminated. Private duty nursing services. Private rms are nt cvered. Charges fr services and supplies when the member has received a prfessinal r curtesy discunt frm a prvider r where the member s prtin f the payment is waived due r prfessinal curtesy r discunt. Peripheral bne density testing. This cverage des nt cver the fllwing except as described by medical plicy screening r as prvided in the certificate, whle bdy CT scan, rutine screening, r mre than ne rutine ultrasund per pregnancy. Charges fr the preparatin f medical reprts r itemized bills r charges fr duplicatin f medical recrds frm the prvider when requested by the member. Services r supplies necessitated by injuries which a member intentinally self-inflicted, except where the law prhibits such an exclusin. Treatment f sexual dysfunctin r imptence including all services, supplies r prescriptin drugs used fr the treatment. Services and supplies which may be reimbursed by a third party Travel r ldging expenses fr the member, member s family r the physician except as travel r ldging expenses related t human rgan and tissue transplants. Rutine eye examinatins, rutine refractive examinatins, eyeglasses, cntact lenses (even if there is a medical diagnsis which requires the use f cntact lenses), r prescriptins fr such services and supplies. Surgical, medical, CDHP Disclsure (1/16) v2 4
r hspital service and/r supply rendered in cnnectin with any prcedure designed t crrect farsightedness, nearsightedness, r astigmatism. Visin therapy, including but nt limited t, treatment such as visin training, rthptics, eye training r training fr eye exercises. Services r supplies necessary t treat disease r injury resulting frm war, civil war, insurrectin, rebellin, r revlutin. Acupuncture except fr pain management and chirpractic services except fr spinal manipulatin. Limited t a cmbined maximum f 12 visits per calendar year. Whle bld, bld plasma and bld derivatives received frm cmmunity surces r replaced thrugh dnr credit. Bariatric surgery services. Treatment f varicse veins r telangiectatic dermal veins (spider veins) by any methd (including sclertherapy r ther surgeries) when services are rendered fr csmetic purpses. Waived cst shares ut-f-netwrk. This cverage des nt cver any service fr which the member is respnsible fr under the terms f this certificate t pay a cpayment, cinsurance r, and the cpayment, cinsurance r is waived by an ut-f-netwrk prvider. Rate determinatins Rates are calculated based n allwable case characteristics f member age, gegraphic rating area, dependent enrllment, and tbacc use status. Prvider Directries Cpies f prvider directries fr all prducts ffered by Anthem may be btained by calling the custmer service department r accessing the infrmatin n ur Internet site at www.anthem.cm. Prvider Netwrk Under Anthem PPO plans, members chse physicians, hspitals and ther health care prviders frm the Anthem Pathway preferred prvider rganizatin (PPO) netwrk. Using the PPO netwrk can mean substantial savings. If care is received utside the Pathway PPO netwrk, the member will pay a higher and cinsurance and charges ver the Maximum Allwed Amunt. Brker Name, Address and Telephne Number (If applicable): CDHP Disclsure (1/16) v2 5