HMO Colorado/Anthem Blue Cross and Blue Shield
Colorado Higher Education Insurance Benefits Al iance Trust
Effective January 1, 2017
PART A: TYPE OF COVERAGE
Blue Advantage HMO/Point-of-Service (POS) Plan PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
TYPE OF PLAN
Point of Service
Preferred Provider Plan
Health Maintenance Organization (HMO)
Preferred Provider Plan
OUT-OF-NETWORK CARE COVERED?1
Yes, but patient pays more for out-of-network care.
Yes, but the patient pays more for out-of- network care
Only for Emergency and Urgent Care
Yes, but patient pays more for out-of- network care
AREAS OF COLORADO WHERE PLAN IS AVAILABLE
Plan is available throughout Colorado
Blue Priority Designated providers are available in Adams, Arapahoe, Plan is available in Adams, Arapahoe, Boulder,
Plan is available throughout Colorado
Boulder, Denver, Douglas, El Paso, Elbert, Fremont, Jefferson, La
Broomfield, Denver, Douglas, El Paso, Elbert,
Plata, Montezuma, Pueblo, Summit and Teller counties.
Fremont, Jefferson, La Plata, Montezuma, Pueblo,
Participating Providers are available throughout Colorado.
Summit and Teller counties.
Grandfathered Health Plan
No
No
No
No
PART B: SUMMARY OF BENEFITS
Important Note: This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the policy, which contains al terms, covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses, or services not noted below. The benefits shown in
this summary may only be available if required plan procedures are fol owed (e.g., plans may require prior authorization, a referral from your primary care physician, or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage. Coinsurance and Copayment
options reflect the amount the covered person wil pay.
BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
Deductible Type 2
Calendar Year
Calendar Year
Calendar Year
Calendar Year
ANNUAL DEDUCTIBLE2a
a) Individual (Single)2b
No Deductible
$500
$400, excludes Copayments
$1,000
$2,000
$2,500
$2,500
b) Family2c (Non-Single)
No Deductible
$1,000
$800, excludes Copayments
$2,000
$6,000
$5,000
$5,000
Some covered services have a maximum benefit of
One Member may not contribute any more than the individual
Plus separate $200 Deductible per individual or $400 If you select non-single membership, no single Deductible applies
days, visits or dol ar amounts . When the deductible is
Deductible towards the family Deductible.
per family for outpatient tier 2 and tier 3 Prescription and the non-single Deductible must be met before we reimburse for
applied to a covered service which has a maximum
Drugs.
Covered Services. The non-single Deductible amount is met as
number of days or visits, those maximum benefits wil
fol ows: when one family Member has satisfied the non-single
be reduced by the amount applied toward the
One Member may not contribute any more than the Deductible, that family Member and all other family Members are
deductible, whether or not the covered service is
individual Deductible towards the family Deductible. eligible for benefits. When no one family Member meets the non-
paid.
single Deductible, but the family Members col ectively meet the
entire non-single Deductible, then al family Members wil be eligible
for benefits.
The family Deductible is also applicable for newborn and adopted
children (and for all other family Members) for the first 31-day
period fol owing birth or adoption if the child is enrol ed or not
enrol ed.
The In-Network Deductible
The Out-Network Deductible
cannot be applied toward
cannot be applied toward
meeting the Out-Network
meeting the In-Network
Deductible.
Deductible.
An independent licensee of the Blue Cross and Blue Shield Association. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. ® Registered marks Blue Cross and Blue Shield Association.
Si usted necesita ayuda en español para entender éste documento, puede solicitarla gratis llamando al número de servicio al cliente que aparece en su tarjeta de identificación o en su fol eto de inscripción.
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
OUT-OF-POCKET ANNUAL MAXIMUM3
a) Individual (Single)
$2,000
$3,000
$2,000
$4,000
$4,000
$2,500
$5,000
b) Family (Non-Single)
$4,000
$6,000
$4,000
$8,000
$10,000
$5,000
$10,000
One Member may not contribute any more than the individual Out- One Member may not contribute any more than the If you select Family (Non-single) membership, no single Out-of-
of-Pocket Annual Maximum towards the family Out-of-Pocket
individual Out-of-Pocket Annual Maximum towards
Pocket Annual Maximum applies and the non-single Out-of-Pocket
Annual Maximum.
the family Out-of-Pocket Annual Maximum.
Annual Maximum must be met as fol ows: when one family (non-
single) Member has satisfied the non-single Out-of-Pocket Annual
Maximum, that non-single Member and all other family Members
wil be treated as having satisfied the Out-of-Pocket Annual
Maximum. When no one family Member meets the non-single Out-
of-Pocket Annual Maximum, but the family Members col ectively
meet the entire non-single Out-of-Pocket Annual Maximum, then al
family Members wil be treated as having satisfied the Out-of-Pocket
Annual Maximum.
The non-single Out-of-Pocket Annual Maximum is also applicable for
newborn and adopted children (and for al other family Members)
for the first 31-day period fol owing birth or adoption if the child is
enrol ed or not enrol ed.
c) What is included in the Out-of-Pocket Maximum? Al Copayments, including
Annual Deductible, Coinsurance Al copayments, including
Annual Deductible and
Al Copayments, including prescription drug
Annual Deductible and
Annual Deductible and
Some covered services have a maximum number of prescription drug copayments are and any Copayments are included prescription drug copayments,
Coinsurance are included in the copayments, Deductibles (Annual Deductible and
Coinsurance are included in the Coinsurance are included in the
days, visits or dol ar amounts al owed during a
included in the Out-of-Pocket
in the Out-of-Pocket Maximum.
Annual Deductible and
Out-of-Pocket Maximum.
Prescription Drug Tier 2 and 3 Deductible) and
Out-of-Pocket Maximum.
Out-of-Pocket Maximum.
calendar year. These maximums apply even if the
Maximum.
Coinsurance are included in the
Coinsurance are included in the Out-of-Pocket Annual
applicable out-of-pocket annual maximum is satisfied.
Out-of-Pocket Maximum.
Maximum.
The difference between bil ed charges and the
maximum allowed amount for non- participating
providers does not count toward the out- of-pocket
annual maximum. Even once the out-of- pocket
annual maximum is satisfied, the member wil stil be
responsible for paying the difference between the
maximum al owed amount and the non- participating
providers bil ed charges (sometimes cal ed “balance
bil ing”).
The amounts you pay for Out-of-Network Covered
Services are in addition to your balance bil ing costs.
LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN No lifetime maximum for most covered services. Bariatric surgery has a per occurrence maximum payment of $15,000 per member for
No lifetime maximum for most Covered Services.
No lifetime maximum for most Covered Services.
FOR ALL CARE
services received from a designated facility (and $1,500 per member from a facility that is not a designated facility) with a total per
occurrence maximum that shal not exceed $15,000 per member for designated and non- designated facilities combined.
COVERED PROVIDERS
HMO Colorado Managed Care
Al providers licensed or certified Anthem Blue Cross and Blue
Al Providers licensed or certified Blue Priority network, which does not include al
Anthem Blue Cross and Blue
Al Providers licensed or certified
Network.
to provide covered benefits.
Shield Blue Priority PPO
to provide Covered Services.
Providers in the HMO Colorado managed care
Shield PPO Provider network. See to provide Covered Services.
Designated Participating
network. See Provider directory for complete list of
Provider directory for complete
Providers and Participating
current Providers.
list of current Providers.
Provider network. See Provider
directory for complete list of
current Providers.
WITH RESPECT TO NETWORK PLANS, ARE ALL THE
Yes
Yes
Yes
Yes
Yes
Yes
PROVIDERS LISTED ACCESSIBLE TO ME THROUGH MY
PRIMARY CARE PHYSICIAN?
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
MEDICAL OFFICE VISITS4
a) Primary Care Providers
$20 per visit Copayment
Covered person pays 30% after
Designated Participating
Covered person pays 35% after
$20 Copayment per visit.
Covered person pays no
Covered person pays 30% after
deductible
Providers: $10 Copayment per
deductible
coinsurance after deductible
deductible
office visit. Covered person pays
15% after Deductible for non-
laboratory and non-x-ray services.
Participating Providers: 15% after
Deductible per office visit.
Covered person 15% after
Deductible for non-laboratory
and non-x-ray services.
b) Specialists
$40 per visit Copayment
Covered person pays 30% after
Designated Participating
Covered person pays 35% after
$60 Copayment per visit.
Covered person pays no
Covered person pays 30% after
deductible
Providers: $10 Copayment per
deductible
coinsurance after deductible
deductible
office visit. Covered person pays
15% after Deductible for non-
laboratory and non-x-ray services.
Participating Providers: 15% after
Deductible per office visit.
Covered person 15% after
Deductible for non-laboratory
and non-x-ray services.
PREVENTIVE CARE
a) Children’s services
No Copayment (100% covered)
Up to age 13, covered person
Designated Participating
Up to age 13, covered person
Up to age 13, No Copayment (100% covered)
Covered person pays no
$80 Copayment per office visit
pays $30 Copayment per visit.
Providers: No Copayment (100% pays no deductible or
deductible or coinsurance
Copayment includes services
covered)
coinsurance.
provided as preventive care.
Participating Providers: No
Copayment (100% covered)
b) Adult’s services
No Copayment (100% covered)
$30 Copayment per visit.
Designated Participating
Covered person pays no
No Copayment (100% covered)
Covered person pays no
$80 Copayment per office visit.
Covered preventive care services include those that
Copayment includes services
Providers: No Copayment (100% deductible or coinsurance. For
deductible or coinsurance
For covered preventive facility
meet the requirements of federal and state law
provided as preventive care.
covered)
covered preventive facility
services, covered person pays a
including certain screenings, immunizations,
Participating Providers: No
services, covered person pays
$500 Copayment.
contraceptives and office visits; and are not subject to
For covered preventive facility
Copayment (100% covered)
$500 Copayment.
Coinsurance or Deductible.
services, covered person pays
$500 Copayment.
For covered preventive facility
services, covered person pays no
Copayment, however
professional services related to
the facility visit are subject to the
Copayments listed above.
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
MATERNITY
a) Prenatal care
One time $20 Copayment for first Covered person pays 30% after
Designated Participating
Covered person pays 35% after
$200 global Copayment for prenatal care office
Covered person pays no
Covered person pays 30% after
prenatal care visit office visit and deductible
Providers: $150 Copayment for deductible
visit/delivery from the Doctor.
coinsurance after deductible
deductible
delivery from the physician.
prenatal care office visit/delivery
from the Doctor. Covered person
pays 15% after Deductible for non-
laboratory and non-x-ray services.
Participating Providers: 15% after
Deductible for prenatal care
office visit/delivery from the
Doctor. Covered person pays 15%
after Deductible for non-
laboratory and non-x-ray services.
b) Delivery & inpatient well baby care5
$600 per admission Copayment Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
$250 Copayment per admission then covered person Covered person pays no
Covered person pays 30% after
for facility services.
deductible
deductible
deductible
pays 20% after Deductible
coinsurance after deductible
deductible
INPATIENT HOSPITAL
$600 per admission Copayment
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
$250 Copayment per admission then covered person Covered person pays no
Covered person pays 30% after
deductible
deductible
deductible
pays 20% after Deductible
coinsurance after deductible
deductible
OUTPATIENT AMBULATORY SURGERY
$60 Copayment per date of
Covered person pays 30% after
Covered person pays 10% after
Covered person pays 35% after
$250 Copayment per admission at an ambulatory
Covered person pays no
Covered person pays 30% after
service at an ambulatory surgery deductible
deductible per date of service at deductible
surgery center.
coinsurance after deductible
deductible
center.
an ambulatory surgery center.
$250 Copayment per admission then covered person
$125 Copayment per date of
Covered person pays 15% after
pays 20% after Deductible at a Hospital.
service at a Hospital or Hospital
deductible at a Hospital or
based facility.
Hospital based facility.
DIAGNOSTICS
a) Laboratory & x-ray
Covered person pays no
Covered person pays 30% after
Covered person pays 10% after
Covered person pays 35% after
No Copayment (100% covered) for laboratory services Covered person pays no
Covered person pays 30% after
Copayment (100% covered)
deductible
deductible per procedure except deductible
except those services received from either a Hospital coinsurance after deductible
deductible
those services received from
or Hospital-based Provider.
either a Hospital or Hospital-
based Provider.
Covered member pays a $60 Copayment per visit for x-
ray services except those services received from
Covered person pays 15% after
either a Hospital or Hospital-based Provider.
deductible for services received
from either a Hospital or Hospital-
$250 Copayment per visit then covered person pays
based Provider.
20% after Deductible for laboratory and x-ray services
received from either a Hospital or Hospital-based
Provider.
b) MRI, nuclear medicine, and other high- tech
$60 Copayment per procedure
Covered person pays 30% after
Covered person pays 10% after
Covered person pays 35% after
$250 Copayment per procedure for MRI/MRA/CT/PET Covered person pays no
Covered person pays 30% after
services
except those services received
deductible
deductible per procedure except deductible
scans except those services received from either a
coinsurance after deductible
deductible
from either a Hospital or Hospital-
those services received from
Hospital or Hospital-based Provider.
based Provider.
either a Hospital or Hospital-
based Provider.
$250 Copayment per procedure then covered person
$120 Copayment per procedure
pays 20% after Deductible for MRI/MRA/CT/PET scans
for services received from either a
Covered person pays 15% after
received from either a Hospital or Hospital-based
Hospital or Hospital-based
deductible for services received
Provider.
Provider.
from either a Hospital or Hospital-
based Provider.
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
EMERGENCY CARE 7
$150 Copayment per emergency Out-of-network care is paid as in Covered person pays 15% after
Out-of-network care is paid as in- $250 Copayment per Emergency room visit.
Covered person pays no
Covered person pays no
room visit. Copayment waived if network
deductible. Copayment is waived network
Copayment is waived if admitted. Care is covered In coinsurance after deductible
coinsurance after deductible
admitted to hospital.
if admitted.
or Out-of-Network.
AMBULANCE
$100 per trip Copayment (waived Out-of-network care is paid as in Covered person pays 15% after
Out-of-network care is paid as in- Covered person pays 20% after Deductible. Care is
Covered person pays no
Covered person pays no
if admitted)
network
deductible
network
covered In or Out-of-Network.
coinsurance after deductible
coinsurance after deductible.
Non-emergency ambulance
services are limited to a
maximum benefit of $50,000 per
trip.
URGENT, NON-ROUTINE, AFTER HOURS CARE
$50 per urgent care visit
$50 per urgent care visit
Covered person pays 15% after
Covered person pays 35% after
$60 Copayment per visit. Urgent care may be received Covered person pays no
Covered person pays 30% after
Copayment. Urgent care may be Copayment. Urgent care may be deductible
deductible
from your PCP or from an Urgent Care center. Care is coinsurance after deductible
deductible
received from your PCP or from received from your PCP or from
covered In or Out-of-Network.
an urgent care center.
an urgent care center.
MENTAL HEALTH CARE, ALCOHOL & SUBSTANCE
ABUSE CARE




a) Inpatient care
$600 per admission Copayment
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
$250 Copayment per admission then covered person Covered person pays no
Covered person pays 30% after
deductible
deductible
deductible
pays 20% after deductible
coinsurance after deductible
deductible
b) Outpatient care
For outpatient facility services
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
For outpatient facility services, covered person pays Covered person pays no
Covered person pays 30% after
covered person pays no
deductible
deductible
deductible
20% after Deductible. For outpatient office visits and coinsurance after deductible
deductible
Copayment (100% covered); for
professional services, covered person pays $20
outpatient office visits and
Copayment per visit.
professional services $40
Copayment per visit.
PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY
From birth until the sixth birthday benefits are
provided as required by applicable law.
a) Inpatient
$600 Copayment per admission. Covered person pays 30% after
Included with the Inpatient
Included with the Inpatient
$250 Copayment per admission then covered person Included with Inpatient Hospital benefit (Covered person pays no
deductible.
Hospital benefit.
Hospital benefit.
pays 20% after Deductible.
coinsurance after deductible)
Limited to 30 non-acute inpatient days per calendar year in and out Limited to 30 non-acute inpatient days per calendar year in and out Limited to 30 inpatient rehab days per calendar year. Limited to 30 non-acute inpatient days per calendar year in and out
of network combined.
of network combined.
of network combined.
b) Outpatient
$40 Copayment per visit.
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
$20 Copayment per visit.
Covered person pays no
Covered person pays 30% after
deductible.
deductible
deductible
coinsurance after deductible
deductible
Limited to 30 visits per calendar year each for physical, occupational Limited to 60 visits per calendar year combined for physical, speech Up to 20 visits each for physical, occupational or
Up to 20 visits each for physical, occupational or speech therapy per
and speech therapy in and out-of-network combined.
and occupational therapies in and out-of-network combined.
speech therapy per calendar year.
calendar year in and out-of-network combined.
DURABLE MEDICAL EQUIPMENT & OXYGEN
No Copayment (100% covered)
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
Covered person pays 50% after Deductible
Covered person pays no
Not covered
deductible.
deductible
deductible
coinsurance after deductible.
Wigs for alopecia resulting from
chemotherapy and radiation
therapy up to a maximum benefit
by Anthem of $500 per Member
per calendar year.
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
ORGAN TRANSPLANT
$600 per admission Copayment Covered by HMO Colorado when Inpatient Care - Covered person Inpatient Care or Outpatient Care - Inpatient care - $250 Copayment per admission then Covered person pays no
Not covered
Transportation and lodging services are limited to a
for inpatient services.
preauthorized and delivered at a 15% after Deductible.
Covered person 35% after
covered person pays 20% after Deductible.
coinsurance after deductible.
maximum benefit of $10,000 per Transplant Benefit $40 per office visit Copayment
Center of Excel ence. Covered
Outpatient Care –
Deductible. See Policy for details. Outpatient care - $20 Copayment per visit for PCP,
Period; unrelated donor searches are limited to a
See Policy for details.
person pays 30% after deductible. Designated Participating
$60 Copayment per visit for Specialist.
maximum benefit of $30,000 per Transplant Benefit
See Policy for details.
Providers: $10 Copayment for
Period.
Primary Care Provider or $20
Copayment for Specialist per
office per visit. Covered person
pays 15% after Deductible for non-
laboratory and non-x-ray services.
Participating Providers: Covered
person pays 15% after Deductible
for Primary Care Provider or for
Specialist per office visit. Covered
person pays 15% after Deductible
for non-laboratory and non-x-ray
services.
See Policy for details.
HOME HEALTH CARE
No Copayment (100% covered)
Covered person pays 30% after
No coinsurance (100% covered). Covered person pays 35% after
Covered person pays 20% after Deductible.
Covered person pays no
Not covered
deductible
deductible.
coinsurance after deductible.
Up to 60 visits per calendar year in and out of network combined.
Up to 100 visits per calendar year.
Up to 100 visits per calendar year.
HOSPICE CARE
No Copayment (100% covered)
Covered person pays 30% after
No coinsurance (100% covered). Covered person pays 35% after
No Copayment (100% covered)
Covered person pays no
Covered person pays 30% after
deductible
deductible
coinsurance after deductible
deductible
SKILLED NURSING FACILITY CARE
No Copayment (100% covered).
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
Covered person pays 20% after Deductible.
Covered person pays no
Covered person pays 30% after
deductible.
deductible
deductible
coinsurance after deductible
deductible
Limited to 60 days per calendar year combined in and out of
Limited to 60 days per calendar year combined in and out of
Up to 100 days per calendar year.
Up to 100 days per calendar year In and Out-of-Network combined.
network.
network.
DENTAL CARE
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
VISION CARE
Vision benefits can be found on Vision benefits can be found on Vision benefits can be found on Vision benefits can be found on Vision benefits can be found on the separate Anthem Vision benefits can be found on Vision benefits can be found on
the separate Anthem Vision
the separate Anthem Vision
the separate Anthem Vision
the separate Anthem Vision
Vision summary and Benefit Booklet.
the separate Anthem Vision
the separate Anthem Vision
summary and Benefit Booklet.
summary and Benefit Booklet
summary and Benefit Booklet
summary and Benefit Booklet
summary and Benefit Booklet
summary and Benefit Booklet
CHIROPRACTIC THERAPY
$20 per visit Copayment.
Covered person pays 30% after
Covered person pays 15% after
Covered person pays 35% after
$25 Copayment per visit.
Covered person pays no
Not covered
deductible.
deductible
deductible
coinsurance after deductible
Limited to 20 visits per calendar year combined with out-of-network Limited to 20 visits per calendar year combined with out-of-network 20 visits per calendar year
20 visits per calendar year
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
Massage Therapy/ Acupuncture Care
$20 Copayment per visit.
Not covered
Covered person pays 15% after
Not covered
$25 Copayment per visit
Covered person pays no
Not covered
deductible
coinsurance after deductible
Limited to 20 visits per calendar year combined
Limited to 20 visits per calendar year combined.
Limited to 20 visits per calendar year
Limited to 20 visits per calendar
year
HEARING AIDS
No Copayment (100% covered).
No Copayment (100% covered).
Benefit level determined by place of service.
Benefit level determined by place of service.
Benefit level determined by place of service.
Benefits are covered up to age 18 and are supplied
every 5 years, except as required by law.
SECOND OPINIONS
When a member desires another professional opinion, they may obtain a second opinion.
TREATMENT OF AUTISM SPECTRUM DISORDERS
Benefit level determined by type of service provided.
SIGNIFICANT ADDITIONAL COVERED SERVICES
BlueCares for You Program
Point of Service Rider
Retail Health Clinic -Covered person pays 15% after deductible
Retail Health Clinic: $40 Copayment per visit.
Retail Health Clinic: Covered
Retail Health Clinic: Not covered
For services covered under this
Nutritional Counseling (other than for eating disorders and Diabetes Nutritional (other than for eating disorders and
person pays no Coinsurance
Nutritional Counseling (other
rider, a member is not required to Management) - Covered person pays 15% after deductible per visit Diabetes Management) - $25 Copayment per visit for (100% covered) after Deductible. than for eating disorders and
get a PCP referral. A member may for Specialist. Up to 4 visits per calendar year.
Specialist. Up to 4 visits per calendar year.
Nutritional Counseling (other
Diabetes Management) - Not
also choose to receive covered
Nutritional Counseling for eating disorders - Covered under Mental Osteopathic manipulative therapy (OMT) – subject to than for eating disorders and
covered
services from a provider who is
Health Care.
office visit Copayment, up to a maximum of 6
Diabetes Management) - Covered Nutritional Counseling for eating
not in the HMO Colorado
Nutritional Counseling for Diabetes Management - Benefit level
outpatient visits per calendar year.
person pays no Coinsurance
disorders – Covered under Mental
network.
determined by place of service.
Nutritional Counseling for eating disorder – covered (100% covered) after Deductible. Health care.
under Mental Health Care.
Up to 4 visits per calendar year.
Nutritional Counseling for
General Information - For outpatient Covered Service not elsewhere Nutritional Counseling for Diabetes Management –
Nutritional Counseling for eating Diabetes Management – Benefit
listed, Covered person pays Coinsurance after Deductible. For
Benefit level determined by place of service.
disorders – Covered under Mental level determined by place of
example, this includes chemotherapy and outpatient non-surgical
General Information -
Health care.
service.
facility services. However, some covered services may require a
For any outpatient Covered Service not elsewhere
Nutritional Counseling for
Copayment prior to and in addition to the Coinsurance.
listed, covered person pays Coinsurance after
Diabetes Management – Benefit
Deductible. For example this includes chemotherapy level determined by place of
and outpatient non-surgical facility services.
service.
However, some outpatient Covered Services received
from a Hospital may require a $250 Copayment prior
to and in addition to the Deductible and Coinsurance.
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BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
In Network Only (Out-of-Network care is not
In Network (HMO)
Out of Network (POS)
In Network
Out of Network
In Network
Out of Network
covered except as noted)
PRESCRIPTION DRUGS
Level of coverage and restrictions on prescriptions6
a) Inpatient care
Included with the inpatient
Included with the inpatient
Included with the inpatient Hospital benefit
Included with the inpatient Hospital benefit
Included with the inpatient Hospital benefit
hospital benefit
hospital benefit
b) Outpatient care
Retail Pharmacy Drugs - Tier 1
Not covered
Retail Pharmacy Drugs - Tier 1
Not covered
Tier 2 and tier 3 outpatient Retail Pharmacy,
Retail Pharmacy Drugs - Covered Retail Pharmacy Drugs - Covered
$10 Copayment, tier 2 $40
$10 Copayment, tier 2 $40
Specialty Pharmacy and/or Home Delivery
person pays no coinsurance after person pays 30% after deductible
Copayment, tier 3 $60
Copayment, tier 3 $60
Prescription Drugs are first subject to a $200
deductible for up to a 30-day
for up to a 30-day supply.
Copayment, tier 4 30%
Copayment, tier 4 30%
Individual / $400 Family Deductible, once satisfied
supply.
Copayment, per prescription at a
Copayment, per prescription at a
then services are subject to the Copayment per
participating pharmacy up to a 30-
participating pharmacy up to a 30-
prescription.
day supply. For tier 4 retail
day supply. For tier 4 retail
Retail Pharmacy Drugs - Tier 1 $15 Copayment, tier 2
pharmacy drugs, the maximum
pharmacy drugs, the maximum
$40 Copayment, tier 3 $60 Copayment, tier 4 30%
Copayment per prescription is
Copayment per prescription is
Copayment, per prescription at a participating
$125 per 30-day supply.
$125 per 30-day supply.
pharmacy up to a 30-day supply. For tier 4 Retail
Pharmacy drugs, the maximum Copayment per
prescription is $250 per 30-day supply.
Specialty Pharmacy Drugs - Tier 1 Not covered
Specialty Pharmacy Drugs - Tier 1 Not covered
Specialty Pharmacy Drugs - Tier 1 $15 Copayment,
Specialty Pharmacy Drugs -
Specialty Pharmacy Drugs - Not
$10 Copayment, tier 2 $40
$10 Copayment, tier 2 $40
tier 2 $40 Copayment, tier 3 $60 Copayment, tier 4
Covered person pays no
covered
Copayment, tier 3 $60
Copayment, tier 3 $60
30% Copayment, per prescription from Our Specialty coinsurance after Deductible per
Copayment, tier 4 30%
Copayment, tier 4 30%
Pharmacy up to a 30-day supply. For tier 4 Specialty 30-day supply from Anthem
Copayment, per prescription from
Copayment, per prescription up
Pharmacy Drugs the maximum Copayment per
Specialty Pharmacy. Specialty
our Specialty Pharmacy up to a 30-
to a 30-day supply. For tier 4
prescription is $250 per 30-day supply from Our
Pharmacy Drugs are not available
day supply. For tier 4 Specialty
Specialty Pharmacy Drugs the
Specialty Pharmacy. Specialty Pharmacy Drugs are not at a Retail Pharmacy or from a
Pharmacy Drugs the maximum
maximum Copayment per
available at a Retail Pharmacy or from a Home
Home Delivery Pharmacy.
Copayment per prescription is
prescription is $125 per 30-day
Delivery Pharmacy.
$125 per 30-day supply from our
supply. Specialty Pharmacy Drugs
Specialty Pharmacy. Specialty
are not available at a retail
Pharmacy Drugs are not available
pharmacy or from a home
at a retail pharmacy or from a
delivery pharmacy. Specialty
mail-order pharmacy. Specialty
pharmacy drugs are only available
pharmacy drugs are only available
through The Pharmacy Benefit
through The Pharmacy Benefit
Manager (PBM).
Manager (PBM).
c) Prescription Mail Service
Home Delivery Pharmacy Drugs - Not covered
Home Delivery Pharmacy Drugs - Not covered
Home Delivery Pharmacy Drugs - Tier 1 $15
Home Delivery Pharmacy Drugs - Not covered
Tier 1 $10 Copayment, tier 2 $80
Tier 1 $10 Copayment, tier 2 $80
Copayment, tier 2 $80 Copayment, tier 3 $120
Covered person pays no
Copayment, tier 3 $120
Copayment, tier 3 $120
Copayment, tier 4 30% Copayment, per prescription coinsurance after Deductible for
Copayment, tier 4 30%
Copayment, tier 4 30%
through the Home Delivery Pharmacy up to a 90-day up to a 90 day supply. Specialty
Copayment, per prescription
Copayment, per prescription
supply. For the tier 4 Home Delivery Pharmacy drugs, Pharmacy Drugs are not available
through the mail-order service up
through the mail-order service up
the maximum Copayment per prescription is $250 per through the Home Delivery
to a 90-day supply. For the tier 4
to a 90-day supply. For tier 4 mail-
30-day supply or $500 per 90-day supply. Specialty
Pharmacy.
mail-order drugs, the maximum
order drugs, the maximum
Pharmacy Drugs are not available through the Home
Copayment per prescription is
Copayment per prescription is
Delivery Pharmacy.
$125 per 30-day supply or $250
$125 per 30-day supply or $250
per 90-day supply. Specialty
per 90-day supply. Specialty
pharmacy drugs are only available
pharmacy drugs are only available
through the Pharmacy Benefit
through the Pharmacy Benefit
Manager (PBM).
Manager (PBM).
Prescription Drugs will always be dispensed as ordered by your provider and by applicable State Pharmacy Regulations, however you may have higher out-of-pocket expenses. You may request, or your provider may order, the brand-name drug. However, if a generic drug is available, you will be
responsible for the cost difference between the generic and brand-name drug, in addition to your tier 1 generic Copayment. The cost difference between the generic and brand-name drug does not contribute to the out-of-pocket annual maximum.
Asthma & Diabetic Prescription Drugs & Supplies
100% covered from a retail pharmacy or mail-order pharmacy
By law, generic and brand-name drugs must meet the same standards for safety, strength, and effectiveness. HMO Colorado reserves the right, at our
We reserve the right, at Our discretion, to remove certain
We reserve the right, at Our discretion, to remove certain higher cost Generic
discretion, to remove certain higher cost generic drugs from this policy. For drugs on our approved list, call customer service at 800-542-9402.
higher cost Generic Drugs from this coverage. For drugs on Drugs from this policy. For drugs on Our approved list, call member services
Our approved list, call member services at 877-811-3106.
at 866-837-4596.
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PART C: LIMITATIONS AND EXCLUSIONS
BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
Period during which pre-existing conditions are not Not applicable. Plan does not impose limitation periods for pre-existing conditions. For late enrol ees, individual must wait until next open enrol ment.
covered
EXCLUSIONARY RIDERS. Can an individual’s specific, No
pre-existing condition be entirely excluded from the
policy?
How does the policy define a “pre-existing
Not applicable. Plan does not exclude coverage for pre-existing conditions.
condition?”
What treatments and conditions are excluded under Exclusions vary by policy. List of exclusions is available immediately upon request from your carrier, agent, or plan sponsor (e.g., employer). Review them to see if a service or treatment you may need is excluded from the policy.
this policy?
PART D: USING THE PLAN
BlueAdvantage HMO/Point-of-Service (POS)
PRIME Blue Priority PPO Plan
Blue Priority HMO Plan
Lumenos HDHP-PPO Plan
Does the enrol ee have to obtain a referral and/or
No
No
Yes except for care from an OB/GYN, certified nurse No
prior authorization for specialty care in most or al
midwife, optometrist or ophthalmologist, Autism
cases?
Services Provider, perinatologists, retail health clinics
or Professional Providers for the treatment of Alcohol
Dependency, Mental Health Conditions or Substance
Dependency. Care from these Providers, if they are
participating Providers within the Blue Priority
network, may be obtained without a referral.
Is prior authorization required for surgical
Yes, the member is responsible for obtaining pre-certification unless Yes, the member is responsible for obtaining pre-certification unless Yes, the Doctor who schedules the procedure or
Yes, the Doctor who schedules
Yes, you are responsible for
procedures and hospital care (except in an
the provider participates with Anthem Blue Cross and Blue Shield. If the provider participates with Anthem Blue Cross and Blue Shield. If Hospital care is responsible for obtaining the
the procedure or hospital care is obtaining Preauthorization unless
emergency)?
the provider is in- network, the physician who schedules the
the provider is in- network, the physician who schedules the
Preauthorization.
responsible for obtaining the
the Provider participates with
procedure or hospital care is responsible for obtaining the pre-
procedure or hospital care is responsible for obtaining the pre-
Preauthorization.
Anthem Blue Cross and Blue
certification.
certification.
Shield.
If the provider charges more for a covered service
Yes, unless the provider participates with HMO Colorado or Anthem In Network-No
No
No
Yes, you wil be responsible for
than the plan normal y pays, does the enrol ee have Blue Cross and Blue Shield or is a PPO Provider
Out of Network-Yes, you wil be responsible for paying the difference
paying the difference between
to pay the difference?
between the Maximum Al owed Amount and the nonparticipating
the Maximum Al owed Amount
Provider’s Bil ed Charges (sometimes cal ed “balance bil ing”). The
and the nonparticipating
amounts you pay for Out-of-Network covered services are in
Provider’s Bil ed Charges
addition to your balance bil ing costs.
(sometimes cal ed “balance
bil ing”).
What is the main customer service number?
800-542-9402
800-542-9402
800-542-9402
800-542-9402
Whom do I write/cal if I have a complaint or want to HMO Colorado Complaints and Appeals
Anthem BCBS Complaints and Appeals
HMO Colorado, Complaints and Appeals
Anthem Blue Cross and Blue Shield
file a grievance?8
700 Broadway
700 Broadway
700 Broadway
Complaints and Appeals
CAT0430
Denver, CO 80273
Denver, CO 80273
700 Broadway, Denver, CO 80273
Denver, CO 80273
800-542-9402
877-811-3106
866-837-4596
800-542-9402
Whom do I contact if I am not satisfied with the
Write to: Colorado Division of Insurance, ICARE Section,
Write to: Colorado Division of Insurance, ICARE Section,
Write to: Colorado Division of Insurance
Write to: Colorado Division of Insurance
resolution of my complaint or grievance?
1560 Broadway, Suite 850
1560 Broadway, Suite 850
ICARE Section
ICARE Section
Denver, CO 80202
Denver, CO 80202
1560 Broadway, Suite 850
1560 Broadway, Suite 850,
Denver, CO 80202
Denver, CO 80202
Does the plan have a binding arbitration clause?
Yes
Yes
Yes
Yes
To assist in filing a grievance, indicate the form
Policy form #’s 98898_GF
Policy form #'s COLGPPONGF
Policy form #’s COLGHMONGF
Policy form # COLGCDHPNGF
number of this Large Group policy.
Large Group
Large Group
Large Group
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1 “Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at al under the plan, or that the plan may encourage you to use because it may pay more of your bil if you use their network
providers (i.e., go in-network) than if you don’t (i.e., go out-of-network).
2. “Deductible Type” indicates whether the deductible period is “Calendar Year” (January 1 through December 31) or “Benefit Year” (i.e., based on a benefit year beginning on the policy’s anniversary date) or if the deductible is based on other requirements such as a “Per Accident or Injury” or Per Confinement”.
2a “Annual Deductible ” means the amount you wil have to pay for al owable covered expenses under a health plan during a specified time period (e.g., a calendar year or benefit year) before the carrier wil cover those expenses. The specific expenses that are subject to deductible should vary by policy. Expenses that
are subject to deductible may be noted.
2b “Individual” means the deductible amount you and each individual covered by a non-HSA qualified policy wil have to pay for the al owable covered expenses before the carrier wil cover those expenses. “Single” means the deductible amount you wil have to pay for al owable covered expenses under an HSA-
qualified health plan when you are the only individual covered by the plan.
2c “Family” is the maximum deductible amount that is required to be met for al family members covered by a non-HSA qualified policy and it may be an aggregated amount (e.g., “$3,000 per family”) or specified as the number of individual deductibles that must be met (e.g., “3 deductibles per family”). “Non-single” is
the deductible amount that must be met by one or more family members covered by an HSA-qualified plan before any covered expenses are paid.
3 “Out-of-pocket maximum ” Means the maximum amount you wil have to pay for al owable covered expenses under a health plan, which may or may not include the deductible or Copayments, depending on the contract for that plan. The specific deductibles or Copayments included in the out-of-pocket maximum
may vary by policy. Expenses that are applied toward the out-of-pocket maximum may be noted.
4 Medical office visits include physician, mid-level practitioner, and specialist visits.
5 Well baby care includes an in-hospital newborn pediatric visit and newborn hearing screening. The hospital Copayment applies to mother and well-baby together: there are not separate Copayments.
6 Prescription drugs otherwise excluded are not covered, regardless of whether preferred generic, preferred brand name, or non-preferred.
7 “Emergency care ” means al services delivered in an emergency care facility which is necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency
medical condition or life- or limb threatening emergency existed.
8 Grievances. Colorado law requires al plans to use consistent grievance procedures. Write the Colorado Division of Insurance for a copy of those procedures.
Cancer Screenings
At Anthem Blue Cross and Blue Shield and Our subsidiary company, HMO Colorado, Inc., We believe cancer screenings provide important preventive care that supports Our mission: to improve the lives of the people We serve and the health of Our communities. We cover cancer screenings as described below.
Pap Tests
Al plans provide coverage under the preventive care benefits for a routine annual pap test and the related office visit. Payment for the routine pap test is based on the plan’s provisions for preventive care. Payment for the related office visit is based on the plan’s preventive care provisions.
Mammogram Screenings
Al plans provide coverage under the preventive care benefits for routine screening or diagnostic mammogram regardless of age. Payment for the mammogram screening benefit is based on the plan’s provisions for preventive care and is normal y not subject to the deductible or coinsurance.
Prostate Cancer Screenings
Al plans provide coverage under the preventive care benefits for routine prostate cancer screening for men. Payment for the prostate cancer screening is based on the plan’s provisions for preventive care and is normal y not subject to the deductible or coinsurance.
Colorectal Cancer Screenings
Several types of colorectal cancer screening methods exist. Al plans provide coverage for routine colorectal cancer screenings, such as fecal occult blood tests, barium enema, sigmoidoscopies and colonoscopies. Depending on the type of colorectal cancer screening received, payment for the benefit is based on where
the services are rendered and if rendered as a screening or medical procedure. Colorectal cancer screenings are covered under preventive care as long as the services provided are for a preventive screening. Payment for preventive colorectal cancer screenings is based on the plan’s provisions for preventive care and is
not subject to deductible or coinsurance.
The information above is only a summary of the benefits described. The Booklet includes important additional information about limitations, exclusions and covered benefits. The Schedule of Benefits (Who Pays What) includes additional information about Copayments, Deductibles and Coinsurance. If you have any
questions, please cal Our member services department at the phone number on the Schedule of Benefits (Who Pays What) form.
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