PPO Plan
Summary of Benefits and Coverage
Page 59
Aflac: PPO
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:
PPO
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 1-888-893-6366.
Important Questions
Answers
Why this Matters:
What is the overall
deductible
?
•
$500
Individual/
$1,000
Family for
In Network providers.
•
$1,000
Individual/
$2,000
Family for
Out of Network providers.
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 2 for how
much you pay for covered services after you meet the
deductible.
Are there other
deductibles
for specific services?
No.
You don’t have to meet
deductibles
for specific services, but see the chart starting on
page 2 for others cost for services this plan covers.
Is there an
out–of–pocket
limit
on my expenses?
• Yes.
$2,000
Individual/
$4,000
Family
for In Network providers.
•
$4,000
Individual/
$8,000
Family
for Out of Network providers.
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 not included in the
out–of–pocket
l
imit
?
Copayments, Non-Covered Services,
Services deemed not medically
necessary by medical Management
and/or Anthem, Penalties for non-
compliance, Charges over the allowed
amount, Pharmacy claims, Deductible.
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit
.
Is there an overall annual limit
on what the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Does this plan use a
Yes. See
www.anthem.com
or
If you use an in-network doctor or other health care
provider
, this plan will pay some or all.
Questions
: Call 1-888-893-6366 or visit us at www.anthem.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary.
You can view the Glossary at www.anthem.com or call 1-888-893-6366 to request a copy.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Corrected on May 11, 2012
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