Anthem® Blue Cross

Your Plan: Snap, Inc: Custom Classic PPO 500/20/20

Your Network: Prudent Buyer PPO

Cost if you use a

Cost if you use an In-
Covered Medical Benefits Non-Network
Network Provider
Provider

Overall Deductible $500 person /

$1,500 family

Out-of-Pocket Limit $4,000 person / $7,000 person /

$8,000 family $14,000 family

The family deductible and out-of-pocket maximum are embedded, meaning the cost shares of one family member will be
applied to both per person deductible and per person out-of-pocket maximum; in addition, amounts for all covered family
members apply to both the family deductible and family out-of-pocket maximum. No one member will pay more than the per
person deductible or per person out-of-pocket maximum.
Your copays, coinsurance and deductible count toward your out of pocket amount(s).
In-network and out-of-network deductibles are combined and accumulate toward each other; however, in-network and out-of-
network out-of-pocket maximum amounts accumulate separately and do not accumulate toward each other.

Preventive Care / Screening / Immunization No charge 40% coinsurance after

deductible is met

Preventive Care for Chronic Conditions per IRS guidelines No charge 40% coinsurance after
deductible is met

Virtual Care (Telemedicine / Telehealth Visits)

Virtual Visits - Online visits with Doctors who also provide services in
person

Primary Care (PCP) including Mental Health and Substance Abuse care by $20 copay per visit 40% coinsurance after
a PCP deductible does not deductible is met
apply

Mental Health and Substance Abuse care by Providers other than a PCP $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply

Specialist $20 copay per visit 40% coinsurance after

deductible does not deductible is met
apply

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 Cost if you use a
Cost if you use an In-
Covered Medical Benefits Non-Network
Network Provider
Provider

Virtual Visits from Online Provider LiveHealth Online via

www.livehealthonline.com; our mobile app, website or Anthem-enabled
device

Primary Care (PCP) and Mental Health and Substance Use Disorder $10 copay per visit deductible does not apply

Specialist Care $20 copay per visit deductible does not apply

Visits in an Office

Primary Care (PCP) $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply

Specialist Care $20 copay per visit 40% coinsurance after

deductible does not deductible is met
apply

Other Practitioner Visits

Routine Maternity Care (Prenatal and Postnatal) $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply

Retail Health Clinic $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply
Manipulation Therapy $20 copay per visit 40% coinsurance after
Coverage is limited to 30 visits per benefit period. Visit limit is combined deductible does not deductible is met
with in-network and non-network providers. apply
Acupuncture $20 copay per visit 40% coinsurance after
Coverage is limited to 20 visits per benefit period. Visit limit is combined deductible does not deductible is met
with in-network and non-network providers. apply
Other Services in an Office
Allergy Testing 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Chemo/Radiation Therapy 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Dialysis/Hemodialysis 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Prescription Drugs 20% coinsurance after 40% coinsurance after

Dispensed in the office thru infusion/injection deductible is met deductible is met

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 Cost if you use a
Cost if you use an In-
Covered Medical Benefits Non-Network
Network Provider
Provider
Surgery 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Diagnostic Services
Lab
Office 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Freestanding Lab 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Outpatient Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

X-Ray

Office 20% coinsurance after 40% coinsurance after

deductible is met deductible is met
Freestanding Radiology Center 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Outpatient Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Advanced Diagnostic Imaging for example: MRI, PET and CAT scans

Office 20% coinsurance after 40% coinsurance after

deductible is met deductible is met
Freestanding Radiology Center 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Outpatient Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Emergency and Urgent Care

Urgent Care $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply
Emergency Room Facility Services $150 copay per Covered at the in-
Copay waived if admitted. admission and then network allowable
20% coinsurance after amount
deductible is met

Emergency Room Doctor and Other Services 20% coinsurance after Covered at the in-
deductible is met network allowable
amount

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 Cost if you use a
Cost if you use an In-
Covered Medical Benefits Non-Network
Network Provider
Provider

Ambulance 20% coinsurance after Covered at the in-

deductible is met network allowable
amount

Outpatient Mental Health and Substance Use Disorder

Doctor Office Visit $20 copay per visit 40% coinsurance after
deductible does not deductible is met
apply
Facility Visit
Facility Fees 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Doctor Services 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Outpatient Surgery
Facility Fees
Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Freestanding Surgical Center 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Doctor and Other Services
Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Hospital (Including Maternity, Mental Health and Substance Use

Disorder)
Member is responsible for an additional $500 copay if prior authorization is
not obtained from Anthem for non-emergency Inpatient admissions to non-
network providers. Anthem’s maximum payment is up to $1,000 per day
for non-emergency Inpatient admissions to non-network providers.
Facility Fees 20% coinsurance after 40% coinsurance after
deductible is met deductible is met
Doctor and other services 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Recovery & Rehabilitation

Home Health Care 20% coinsurance after 40% coinsurance after
Coverage is limited to 100 visits per benefit period. Visit limit is combined deductible is met deductible is met
with in-network and non-network providers.

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 Cost if you use a
Cost if you use an In-
Covered Medical Benefits Non-Network
Network Provider
Provider

Rehabilitation services

Office 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Outpatient Hospital 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Cardiac rehabilitation

Office 20% coinsurance after 40% coinsurance after

deductible is met deductible is met
Outpatient Hospital 20% coinsurance after 40% coinsurance after
deductible is met deductible is met

Skilled Nursing Care (facility) 20% coinsurance after 40% coinsurance after
Coverage is limited to 100 days per benefit period. Visit limit is combined deductible is met deductible is met
with in-network and non-network providers.

Inpatient Hospice No charge 40% coinsurance after

deductible is met

Durable Medical Equipment 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Prosthetic Devices 20% coinsurance after 40% coinsurance after

deductible is met deductible is met

Hearing Aids 20% coinsurance after 40% coinsurance after

Coverage is limited to 1 per ear every 2 years. deductible is met deductible is met

Infertility Services 0% coinsurance after 0% coinsurance after

Coverage is limited to a lifetime maximum of $20,000. See Notes for deductible is met deductible is met
further limitations and coverage.

Wigs and Cranial Prosthesis 20% coinsurance after 40% coinsurance after
Coverage is limited to 1 per benefit period for cancer diagnosis only. deductible is met deductible is met

Transgender Benefits 20% coinsurance after 40% coinsurance after

No coverage limitations, utilization management prior authorization deductible is met deductible is met
required. For details on the travel expense benefits, please refer to your
benefit booklet.

Nutritional Counseling 20% coinsurance after 20% coinsurance after

Coverage is limited to 12 visits per benefit period, covers both medical deductible is met deductible is met
doctor and nutritionist.

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 Cost if you use a
Cost if you use an In-
Covered Prescription Drug Benefits Non-Network
Network Pharmacy
Pharmacy

Pharmacy Deductible Not applicable Not applicable

Pharmacy Out-of-Pocket Limit Combined with In- Combined with Non-

Network medical out- Network medical out-
of-pocket limit of-pocket limit

Prescription Drug Coverage Cost shares for drugs included on the National drug list appear below. Your plan uses the Base
Network. If you select a brand name drug when a generic drug is available, additional cost sharing amounts may apply.

Home Delivery Pharmacy Maintenance medication are available through IngenioRx Home Delivery Pharmacy. You will need
to call us on the number on your ID card to sign up when you first use the service.

Tier 1 - Typically Generic $5 copay per 50% coinsurance

Per 30 day supply (retail pharmacy). Per 90 day supply (home delivery). prescription (retail and (retail) and Not covered
home delivery) (home delivery)

Tier 2 – Typically Preferred Brand $25 copay per 50% coinsurance

Per 30 day supply (retail pharmacy). Per 90 day supply (home delivery). prescription(retail) and (retail) and Not covered
$50 copay per (home delivery)
prescription (home
delivery)

Tier 3 - Typically Non-Preferred Brand $40 copay per 50% coinsurance

Per 30 day supply (retail pharmacy). Per 90 day supply (home delivery). prescription (retail) and (retail) and Not covered
$80 copay per (home delivery)
prescription (home
delivery)

Tier 4 - Typically Specialty (brand and generic) $50 copay per 50% coinsurance
Per 30 day supply (retail pharmacy). Per 30 day supply (home delivery). prescription (retail and (retail) and Not covered
home delivery) (home delivery)

Infertility Drugs Applicable tier copay 47% of the prescription

Limited to a lifetime maximum of $3,000. applies depending on drug maximum allowed
drug classification amount (maximum
$100 copay per fill)

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Notes:
• If you have an office visit with your Primary Care Physician or Specialist at an Outpatient Facility (e.g., Hospital or
Ambulatory Surgical Facility), benefits for Covered Services will be paid under “Outpatient Facility Services”.
• Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your
Certificate of Coverage for details.
• Outpatient Facility tests and treatments are limited to $350 per visit for Non-Network Providers. Includes Diagnostic
Services, X-ray, Surgery, Rehabilitation, Habilitation, and Cardiac Therapy. This also includes Surgery at Freestanding
Facilities. Advanced Diagnostic Imaging is limited to $800 per service for Non-Network Providers.
• Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000 per trip.
• Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to,
injections, cryopreservation and storage for both male and female members when a medically necessary treatment
may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and
service rendered.
• Infertility coverage to include artificial insemination, in-vitro, GIFT and ZIFT. Benefits are subject to medical necessity.
Testing and treatment in connection with an underlying medical condition will not be subject to any of the maximums.

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary
does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details,
important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference
between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail.

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Get help in your language
Language Assistance Services

Curious to know what all this says? We would be too. Here’s the English version:
IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this
letter written in your language. For free help, please call right away at 1-888-254-2721. (TTY/TDD: 711)

Separate from our language assistance program, we make documents

available in alternate formats for members with visual impairments. If you
need a copy of this document in an alternate format, please call the customer
service telephone number on the back of your ID card.

Spanish
IMPORTANTE: ¿Puede leer esta carta? De lo contrario, podemos hacer que alguien lo ayude a leerla. También puede
recibir esta carta escrita en su idioma. Para obtener ayuda gratuita, llame de inmediato al 1-888-254-2721. (TTY/TDD: 711)

Arabic

Armenian
ՈՒՇԱԴՐՈՒԹՅՈՒՆ. Կարողանո՞ւմ եք ընթերցել այս նամակը: Եթե ոչ, մենք կարող ենք տրամադրել ինչ-որ մեկին, ով
կօգնի Ձեզ՝ կարդալ այն: Կարող ենք նաև այս նամակը Ձեզ գրավոր տարբերակով տրամադրել: Անվճար օգնություն
ստանալու համար կարող եք անհապաղ զանգահարել 1-888-254-2721 հեռախոսահամարով: (TTY/TDD: 711)

Chinese
重要事項：您能看懂這封信函嗎？如果您看不懂，我們能夠找人協助您。您有可能可以獲得以您的語言而寫的本信函。如需免
費協助，請立即撥打1-888-254-2721。(TTY/TDD: 711)

Farsi

Hindi

Hmong
TSEEM CEEB: Koj puas muaj peev xwm nyeem tau daim ntawv no? Yog hais tias koj nyeem tsis tau, peb muaj peev xwm cia lwm tus
pab nyeem rau koj mloog. Tsis tas li ntawd tej zaum koj kuj tseem yuav tau txais daim ntawv no sau ua koj hom lus thiab. Txog rau kev
pab dawb, thov hu tam sim no rau tus xov tooj 1-888-254-2721. (TTY/TDD: 711)

Japanese

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark
of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

MCASH4644CML 06/16 DMHC3 DMHCW #CA-DMHC-001#

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重要：この書簡を読めますか？もし読めない場合には、内容を理解するための支援を受けることができます。また、この書
簡を希望する言語で書いたものを入手することもできます。次の番号にいますぐ電話して、無料支援を受けてください。
1-888-254-2721 (TTY/TDD: 711)

Khmer

Korean
중요: 이 서신을 읽으실 수 있으십니까? 읽으실 수 없을 경우 도움을 드릴 사람이 있습니다. 귀하가 사용하는 언어로 쓰여진
서신을 받으실 수도 있습니다. 무료 도움을 받으시려면 즉시 1-888-254-2721로 전화하십시오. (TTY/TDD: 711)

Punjabi
ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁ ਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤ ਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁ ਹ ਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲ ਸਕਦ ਹ ਾਂ ਤੁ ਸ􁶣 ਸ਼ ਇਦ ਪੱਤਰ
ਨੂੂੰ ਆਪਣੀ ਭ ਸ਼ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਪ ੍ ਪ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਮਦਦ ਲਈ, ਿ ਕਰਪ ਕਰਕੇ ਫੌਰਨ 1-888-254-2721 ਤੇ ਕ ਲ ਕਰੋ।
(TTY/TDD: 711)

Russian
ВАЖНО. Можете ли вы прочитать данное письмо? Если нет, наш специалист поможет вам в этом. Вы также можете
получить данное письмо на вашем языке. Для получения бесплатной помощи звоните по номеру 1-888-254-2721.
(TTY/TDD: 711)

Tagalog
MAHALAGA: Nababasa ba ninyo ang liham na ito? Kung hindi, may taong maaaring tumulong sa inyo sa pagbasa nito.
Maaari ninyo ring makuha ang liham na ito nang nakasulat sa ginagamit ninyong wika. Para sa libreng tulong, mangyaring
tumawag kaagad sa 1-888-254-2721. (TTY/TDD: 711)

Thai
หมายเหตุสาคัญ: ท่านสามารถอ่านจดหมายฉบับนีห ้ รือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้
เราสามารถจัดหาเจ ้าหน ้าทีม ่ ว่ ยเขียนจดหมายในภาษาของท่านอีกด ้วย
่ าอ่านให ้ท่านฟั งได ้ ท่านยังอาจให ้เจ ้าหน ้าทีช
หากต ้องการความช่วยเหลือโดยไม่มค ี า่ ใช ้จ่าย โปรดโทรติดต่อทีห ่ มายเลข 1-888-254-2721 (TTY/TDD: 711)

Vietnamese
QUAN TRỌNG: Quý vị có thể đọc thư này hay không? Nếu không, chúng tôi có thể bố trí người giúp quý vị đọc thư này.
Quý vị cũng có thể nhận thư này bằng ngôn ngữ của quý vị. Để được giúp đỡ miễn phí, vui lòng gọi ngay số 1-888-254-
2721. (TTY/TDD: 711)

It’s important we treat you fairly

That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or
treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer
free aids and services. For people whose primary language isn’t English, we offer free language assistance services through
interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for
help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age,
disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance
Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you
can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence
Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or
online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark
of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

MCASH4644CML 06/16 DMHC3 DMHCW #CA-DMHC-001#

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