PPO Plan
Summary of Benefits and Coverage
Page 60
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
Network
of
providers
?
Call
1-888-893-6366
for a list of
In Network providers.
Of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network
provider
for some services. Plans use the term in-network,
preferred,
or
participating for
providers
in their
network
. See the chart starting on page 2 for how this
plan pays different kinds of
providers
.
Do I need a referral to
see a
specialist
?
No. You don’t need a referral to see
a specialist.
You can see the
specialist
you choose without permission from this plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 7. See your policy or plan
document for additional information about
excluded services.
•
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 plan’s
allowed amount
for
an overnight hospital stay is $1,000, your
coinsurance
payment of 20% would be $200. This may change if you haven’t 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.
Common
Medical Event
Services You May Need
Your Cost If
You Use an
In Network
Provider
Your Cost If
You Use an
Out of Network
Provider
Limitations & Exceptions
If you visit a health
care
provider’s
office or clinic
Primary care visit to treat an injury
or illness
$25
Copay/Visit
40%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
Specialist visit
$35
Copay/Visit
40%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
Other practitioner office visit
$35
Copay/Visit
40%
Coinsurance
Coverage is limited to 30 visits per calendar year for
Chiropractor and 30 visits for Acupuncture combined In
Network and Out of Network.
Preventive care/screening/
immunization
$25/$35
Copay
Not Covered
––––––––––––––––––––none––––––––––––––––––––
If you have a test
Diagnostic test (x-ray, blood work)
No Charges
40%
Coinsurance
––––––––––––––––––––none––––––––––––––––––––
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.
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