Awane: Sanel 2000 HMO Blue

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-800-634-8638. Important Questions Answers For in-network providers $2,000 individual / $6,000 family Doesnt apply to in-network preventive care and routine eye exams. No. Yes. For in-network providers $6,350 individual / $12,700 family Premiums, balance-billed charges, penalties for noncompliance, pharmacy claims and health care this plan doesnt cover. No. Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. You dont have to meet deductibles for specific services, but see the chart starting on page 3 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses

What is the overall deductible?

Are there other deductibles for specific services? Is there an outof pocket limit on my expenses?

What is not included in the outofpocket limit? Is there an overall annual limit on what the plan pays?

Even though you pay these expenses, they dont count toward the out-of-pocket limit. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services, such as office visits.

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 1 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan Type: HMO If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of Yes. For a list of preferred covered services. Be aware, your in-network doctor or Does this plan use a providers, see hospital may use an out-of-network provider for some network of www.anthem.com or services. Plans use the term in-network, preferred, or providers? call 1-800-870-3122. participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist Do I need a referral Yes. for covered services but only if you have the plans to see a specialist? permission before you see the specialist from this plan. Are there services Some of the services this plan doesnt cover are listed on this plan doesnt Yes. page 5. See your policy or plan document for additional cover? information about excluded services.

Awane: Sanel 2000 HMO Blue

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you

receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you havent met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 2 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan Type: HMO Your Cost If Common You Use an Services You May Need Limitations & Exceptions Medical Event In-network Provider Primary care visit to treat an injury or illness $30 copay /visit none If you visit a Specialist visit $50 copay /visit none health care providers Other practitioner office visit $50 copay /visit none office or clinic Preventive care/screening/immunization No Charge none If you have a test Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.medco.com Generic drugs (Retail/30 day: Mail/90 day)
Preferred brand drugs (Retail/30 day: Mail/90 day)

Awane: Sanel 2000 HMO Blue

No Charge No Charge
$10 Retail/$20 Mail
$35 Retail/$87.5 Mail

Lab services performed in an office or independent lab are paid at 100%, no deductible. none
Maintenance Meds are required to be filled mail order after 3 fills at retail (penalty applies). If pre-auth required & not obtained, drug may not be covered. Certain Preventive meds no copay. If a generic equivalent is available & brand is prescribed/member will pay brand name cost difference. Plan uses preferred drug list to identify coverage.

Non-preferred brand (Retail/30day: Mail/90day)

$60 Retail/$150 Mail

Specialty drugs

All Specialty meds process through Accredo at the mail order costs.

The mail order cost will be based on the medication tier (generic, preferred, non-preferred). Specialty meds can not be filled at retail pharmacies.

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 3 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan Type: HMO Your Cost If Common You Use an Services You May Need Limitations & Exceptions Medical Event In-network Provider $75/copay visit This copay applies to free standing Facility fee (e.g., ambulatory surgery ambulatory none center) surgical center If you have only; other outpatient providers subject to surgery deductible. Deductible waived if services Physician/surgeon fees No Charge are provided at a free standing ambulatory surgical center. $250 copay /visit; professional and other services subject to deductible. No Charge $50 copay /visit; professional and other services subject to deductible No Charge No Charge $250 copay is waived if admitted for inpatient stay. Members may be balance billed for out of network services. Members may be balance billed for out of network services. none

Awane: Sanel 2000 HMO Blue

Emergency room services If you need immediate medical attention

Emergency medical transportation

Urgent care

If you have a hospital stay

Facility fee (e.g., hospital room) Physician/surgeon fee

Precertification is required for any out of network Inpatient hospital admission or $500 penalty is applied. none

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 4 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan Type: HMO Your Cost If Common You Use an Services You May Need Limitations & Exceptions Medical Event In-network Provider Mental/Behavioral health outpatient $30 copay /visit none services Precertification is required for If you have any out of network Inpatient Mental/Behavioral health inpatient services No Charge mental health, hospital admission or $500 behavioral penalty is applied.. health, or Substance use disorder outpatient services $30 copay /visit none substance Precertification is required for abuse needs any out of network Inpatient Substance use disorder inpatient services No Charge hospital admission or $500 penalty is applied. Office visits not subject to Prenatal and postnatal care No Charge If you are deductible pregnant Delivery and all inpatient services No Charge none If you need Home health care No Charge none help recovering Inpatient physical medicine or have other rehabilitation is limited to 60 special health $50 copay/visit for days per member per calendar needs outpatient visit; year. Limited to 20 visits each Rehabilitation services inpatient services therapy physical therapy, subject to speech therapy and deductible. occupational therapy. All therapy limits are combined in and out of network Habilitation services $50 copay/visit for All rehabilitation and habilitation outpatient visit; visits count toward your inpatient services rehabilitation visit limit. subject to deductible. Questions: Call 1-800-870-3122 or visit us at www.anthem.com 5 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue

Coverage Period: 01/01/2014 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan Type: HMO Your Cost If Common You Use an Services You May Need Limitations & Exceptions Medical Event In-network Provider Limited to 100 days per Skilled nursing care No Charge calendar year Durable medical equipment Hospice service Eye exam If your child needs dental or Glasses eye care Dental check-up No Charge No Charge No Charge Not Covered Not Covered none none One vision exam every 2 years. none none

Awane: Sanel 2000 HMO Blue

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.) Acupuncture Cosmetic surgery Dental care (Adult) Long-term care Private-duty nursing

Non-emergency care when traveling Routine foot care outside the U.S. Weight loss programs

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery (Limitations may apply) Coverage provided outside the United States. Hearing aids (Limitations may apply)

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 6 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Chiropractic care Infertility treatment (Limitations may apply)

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

See www.BCBS.com/bluecardworldwi Routine eye care (Adult de Limitations may apply)

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-258-5318. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 7 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem Blue Cross & Blue Shield P.O. Box 518 North Haven, Connecticut 06473-0518 For grievances and/or appeals regarding you prescription drug coverage, call the number listed on the back of prescription member ID card or visit www.express-scripts.com. For ERISA information contact: Department of Labors Employee Benefits Security Administration 1-866-444-EBSA (3272) www.dol.gov/ebsa/healthreform Additionally, a consumer assistance program can help you file your appeal. Contact: New Hampshire Department of Insurance 21 South Fruit Street, Suite 14 Concord, NH 03301 (800) 852-3416 www.nh.gov/insurance consumerservices@ins.nh.gov

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 8 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services:

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 9 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue with SOS

Coverage Examples

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Having a baby
(normal delivery)

Managing type 2 diabetes

(routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $440 Patient pays $4,960 Sample care costs: $2,70 0 $2,10 0 $900 $900 $500 $200 $200 $40 $7,54 0 $2,00 0 $0 $0 $150 $2,15 0 Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $2,00 0 $30 $0 $2,93 0 $4,96 0 $2,90 0 $1,30 0 $700 $300 $100 $100 $5,40 0

This is not a cost Amount owed to providers: $7,540 estimator. Plan pays $5,390
Patient pays $2,150 Dont use these examples to estimate Sample care costs: your actual costs under Hospital (mother) this plan.charges The actual care you receive will be Routine obstetric care different from these examples, and the cost Hospital charges (baby) of that care will also be Anesthesia different. Laboratory tests Prescriptions See the next page for Radiology important information Vaccines, other preventive about these examples. Total Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 10 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Awane: Sanel 2000 HMO Blue with SOS

Coverage Examples

Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual / Family| Plan Type: HMO

Questions: Call 1-800-870-3122 or visit us at www.anthem.com 11 of 13 If you arent clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.anhem.com or call 1-800-870-3122 to request a copy.

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?
Costs dont include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and arent specific to a particular geographic area or health plan. The patients condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isnt covered or payment is limited.

No. Coverage Examples are not

cost estimators. You cant use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Does the Coverage Example predict my own care needs?

Can I use Coverage Examples to compare plans?

No. Treatments shown are just

examples. The care you would receive for this condition could be different based on your doctors advice, your age, how serious your condition is, and many other factors.

Yes. When you look at the

Summary of Benefits and Coverage for other plans, youll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides.

Does the Coverage Example predict my future expenses?

Are there other costs I should consider when comparing plans?

Yes. An important cost is the

premium you pay. Generally, the lower your premium, the more youll pay in out-of-pocket

costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.