Your summary of benefits

Anthem® Blue Cross

Your 2024 Contract Code: 9B1J
Your Plan: Anthem Silver Priority Select HMO 60/2500/45%
Your Network: Priority Select HMO

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. Unless stated otherwise, services
received in an office, Ambulatory Surgical Center, or outpatient facility are combined across all outpatient settings. 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 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.
Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized
by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's
medical group/IPA, and services for mental health and substance use disorders. Benefits are subject to all terms, conditions, limitations, and
exclusions of the EOC.

Visits with Virtual Care-Only Providers Cost through our mobile app and website

Primary Care, and medical services for urgent/acute No charge

care
Mental Health & Substance Use Disorder Services No charge
Specialist care $95 copay per visit medical deductible does not apply

Cost if you use an Cost if you use a

Covered Medical Benefits In-Network Non-Network
Provider Provider

Overall Deductible $2,500 person / Not covered

$5,000 family
Your plan applies a separate Pharmacy Deductible to prescription drugs
obtained at a pharmacy. See the Covered Prescription Drug Benefits section.

Overall Out-of-Pocket Limit $9,100 person / Not covered

When you meet your out-of-pocket limit, you will no longer have to pay cost- $18,200 family
shares during the remainder of your benefit period.

The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per
member deductible and per member out-of-pocket limit; in addition, amounts for all covered family members apply to both the family
deductible and family out-of-pocket limit. No one member will pay more than the per member deductible or per member out-of-pocket
limit.
Your copays, coinsurance and deductible count toward your out-of-pocket limit. However, member cost sharing for the following service(s)
do not apply toward the out-of-pocket limit: adult vision.

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

Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). A referral from your
Primary Care Physician (PCP) is required for Specialist care and most other providers for select covered services.

Primary Care (PCP) and Mental Health and Substance Use $60 copay per visit Not covered
Disorder Services virtual and office medical deductible
does not apply

Specialist Care virtual and office $95 copay per visit Not covered
medical deductible
does not apply

Other Practitioner Visits

Routine Maternity Care

Prenatal No charge Not covered

Postnatal $60 copay per visit Not covered

medical deductible
does not apply

Retail Health Clinic Visit $60 copay per visit Not covered
medical deductible
does not apply
Chiropractic/Manipulation Therapy $15 copay per visit Not covered
Coverage is limited to 30 visits per year. medical deductible
does not apply
Acupuncture $60 copay per visit Not covered
medical deductible
does not apply
Other Services in an Office
Allergy Testing $60 copay per visit Not covered
medical deductible
does not apply
Prescription Drugs - Dispensed in the office 45% coinsurance Not covered
For the drugs itself dispensed in the office through infusion/injection. medical deductible
does not apply
Surgery $95 copay per surgery Not covered
medical deductible
does not apply

Preventive care/screenings/immunizations No charge Not covered

Preventive care for Chronic Conditions per IRS guidelines No charge Not covered

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

Diagnostic Services
Lab
Office $20 copay per visit Not covered
Office Cost Share applies only when Freestanding/Reference Labs are medical deductible
not used. does not apply
Freestanding Lab/Reference Lab No charge Not covered

Outpatient Hospital 45% coinsurance Not covered

after medical
deductible is met

X-Ray

Office $20 copay per visit Not covered

medical deductible
does not apply
Freestanding Radiology Center $20 copay per visit Not covered
medical deductible
does not apply
Outpatient Hospital 45% coinsurance Not covered
after medical
deductible is met

Advanced Diagnostic Imaging - for example: MRI, PET

and CAT scans

Office $200 copay per visit Not covered

medical deductible
does not apply
Freestanding Radiology Center $200 copay per visit Not covered
medical deductible
does not apply
Outpatient Hospital $350 copay per visit Not covered
after medical
deductible is met

Emergency and Urgent Care

Urgent Care (Office Setting) $60 copay per visit Covered as In-
medical deductible Network
does not apply
Emergency Room Facility Services $350 copay per visit Covered as In-
Your copay will be waived if admitted. and 45% coinsurance Network

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

after medical
deductible is met

Emergency Room Doctor and Other Services No charge Covered as In-

Network

Ambulance Transportation 45% coinsurance Covered as In-

Authorized Non-Network non-emergency ambulance services are limited to an after medical Network
Anthem maximum payment of $50,000 per trip. deductible is met

Outpatient Mental Health and Substance Use Disorder

Services at a Facility
Facility Fees No charge Not covered

Doctor Services No charge Not covered

Outpatient Surgery
Facility Fees
Hospital 45% coinsurance Not covered
after medical
deductible is met
Ambulatory Surgical Center $600 copay per visit Not covered
after medical
deductible is met
Physician and other services including surgeon fees
Hospital No charge Not covered

Ambulatory Surgical Center No charge Not covered

Hospital Stay (all Inpatient stays including Maternity, Mental

Health and Substance Use Disorder Services)

Facility fees (for example, room & board) 45% coinsurance Not covered
after medical
deductible is met
Physician and other services including surgeon fees No charge Not covered

Home Health Care $95 copay per visit Not covered

medical deductible
does not apply

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

Home health visits are limited to 100 visits per benefit period. Limits are
combined for home health care and private duty nursing. Benefit limit and cost
share applies to physical, occupational, speech, respiratory, cardiac and
pulmonary therapy when performed as part of Home Health.

Rehabilitation services (for example,

physical/speech/occupational therapy)

Office $60 copay per visit Not covered

medical deductible
does not apply

Outpatient Hospital 45% coinsurance Not covered

after medical
deductible is met
Habilitation services (for example,
physical/speech/occupational therapy)

Office $60 copay per visit Not covered

medical deductible
does not apply
Outpatient Hospital 45% coinsurance Not covered
after medical
deductible is met

Pulmonary rehabilitation

Office $60 copay per visit Not covered

medical deductible
does not apply

Outpatient Hospital 45% coinsurance Not covered

after medical
deductible is met

Cardiac rehabilitation

Office $60 copay per visit Not covered

medical deductible
does not apply
Outpatient Hospital 45% coinsurance Not covered
after medical
deductible is met

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

Office 45% coinsurance Not covered

medical deductible
does not apply
Outpatient Hospital 45% coinsurance Not covered
after medical
deductible is met

Chemo/Radiation Therapy

Office 45% coinsurance Not covered

medical deductible
does not apply

Outpatient Hospital 45% coinsurance Not covered

after medical
deductible is met

Skilled Nursing Care (in a facility) 45% coinsurance Not covered

Coverage is limited to 100 days per benefit period. after medical
deductible is met

Inpatient Hospice No charge after Not covered

medical deductible is
met

Durable Medical Equipment 50% coinsurance Not covered

after medical
deductible is met

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

Pharmacy Deductible $200 person / $200 person / Not covered

$400 family (does $400 family (does
not apply to Tier 1 not apply to Tier 1
drugs) drugs)

Pharmacy Out of Pocket Limit Combined with In- Combined with In- Not covered
Network medical Network medical
out of pocket limit out of pocket limit

Prescription Drug Coverage

Network: Rx Choice Tiered Network
Drug List: Select Drugs not included on the Select drug list will not be covered. Prescription Drugs that we are required to cover by
federal law under the “Preventive Care” benefit will be covered with no deductible, copayments or coinsurance when you use an In-Network
Pharmacy.

Day Supply Limits:

Retail Pharmacy 30 day supply (cost shares noted below)
Retail 90 Pharmacy 90 day supply (cost shares noted below)
Home Delivery Pharmacy 90 day supply (maximum cost shares noted below). Maintenance medications are available through
CarelonRx Pharmacy. You will need to call us on the number on your ID card to sign up when you first use the service.
Specialty Pharmacy 30 day supply (cost shares noted below for retail and home delivery apply). We may require certain drugs with
special handling, provider coordination or patient education be filled by our designated specialty pharmacy.

Tier 1 - Typically Generic $10 copay per $20 copay per Not covered (retail
Each 90 day supply script filled at Retail 90 prescription, prescription, and home delivery)
pharmacies is subject to 3 times the 30 day supply cost Pharmacy Pharmacy
share(s) charged at Preferred Network and In-Network deductible does not deductible does not
Retail Pharmacies. apply (retail) and apply (retail) and
$20 copay per Not covered (home
prescription, delivery)
Pharmacy
deductible does not
apply (home
delivery)

Tier 2 - Typically Preferred Brand $70 copay per $80 copay per Not covered (retail
Each 90 day supply script filled at Retail 90 prescription after prescription after and home delivery)
pharmacies is subject to 3 times the 30 day supply cost Pharmacy Pharmacy
share(s) charged at Preferred Network and In-Network deductible is met deductible is met
Retail Pharmacies. (retail) and $175 (retail) and Not
copay per covered (home
prescription after delivery)
Pharmacy
deductible is met
(home delivery)

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

Tier 3 - Typically Non-Preferred Brand $110 copay per $120 copay per Not covered (retail
Each 90 day supply script filled at Retail 90 prescription after prescription after and home delivery)
pharmacies is subject to 3 times the 30 day supply cost Pharmacy Pharmacy
share(s) charged at Preferred Network and In-Network deductible is met deductible is met
Retail Pharmacies. (retail) and $275 (retail) and Not
copay per covered (home
prescription after delivery)
Pharmacy
deductible is met
(home delivery)

Tier 4 - Typically Specialty (brand and 30% coinsurance 40% coinsurance Not covered (retail
generic) up to $250 per up to $250 per and home delivery)
prescription after prescription after
Pharmacy Pharmacy
deductible is met deductible is met
(retail and home (retail) and Not
delivery) covered (home
delivery)

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

This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. Benefits include coverage for member’s
choice of eyeglass lenses or contact lenses, but not both. For a full list, including benefits, exclusions and limitations, see the combined
Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure
form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail.
Only children's vision services count towards your out of pocket limit.

Children's Vision Essential Health Benefits (up to age 19)

Child Vision Deductible Not Applicable Not Applicable
Vision exam No charge Not covered
Coverage for In-Network Providers is limited to 1 exam per benefit period.

Frames No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Single Vision Lenses No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Bifocal Vision Lenses No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Trifocal Vision Lenses No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Elective contact lenses No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Non-Elective Contact Lenses No charge Not covered

Coverage for In-Network Providers is limited to 1 unit per benefit period.

Adult Vision (age 19 and older)

Adult Vision Deductible Not Applicable Not Applicable
Vision exam $20 copay Not covered
Coverage for In-Network Providers is limited to 1 exam per benefit period.

Frames Not covered Not covered

Single Vision Lenses Not covered Not covered

Bifocal Vision Lenses Not covered Not covered

Trifocal Vision Lenses Not covered Not covered

Elective contact lenses Not covered Not covered

Non-Elective Contact Lenses Not covered Not covered

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

This is a brief outline of your dental coverage. Not all cost shares for covered services are shown below. For a full list, including benefits,
exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this summary
and either Evidence of Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail.
Only children's dental services count towards your out of pocket limit.

Children's Dental Essential Health Benefits

Diagnostic and preventive No charge Not covered
Coverage for In-Network Providers is limited to 1 visit per 6 months.

Basic services 20% coinsurance Not covered

dental deductible
does not apply

Major services 50% coinsurance Not covered

dental deductible
does not apply

Medically Necessary Orthodontia services 50% coinsurance Not covered

dental deductible
does not apply

Cosmetic Orthodontia services Not covered Not covered

Deductible $0 $0

Adult Dental

Diagnostic and preventive Not covered Not covered

Basic services Not covered Not covered

Major services Not covered Not covered

Deductible Not covered Not covered

Annual maximum Not covered Not covered

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Notes:
• Benefit period refers to calendar year.
• For additional information on this plan, please visit www.sbc.anthem.com to obtain a “Summary of Benefits and
Coverage”.
• If services are rendered by a non-participating provider and your plan includes out of network benefits, you may be
responsible for any difference between the covered plan payment and the actual non-participating provider’s
charge.
• For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may apply
for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible.
• The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as
part of the Mental Health and Substance Use Disorder benefit.
• Certain services are subject to the utilization review program or precertification. Before scheduling services, the
member must make sure utilization or precertification review is obtained. If utilization or precertification review is
not obtained, benefits may be reduced or not paid according to the plan.
• 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.
• This health plan includes an Employee Assistance Program (EAP) to support your emotional health and wellness
with work life resources including one-on-one counseling by phone, in person and online. Virtual visits are
available through LiveHealth Online and Talkspace. Three visits are provided at no charge and 24/7, 365 days of
support on the go.
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.
Questions: (833) 913-2234 or visit us at www.anthem.com/ca
CA/SG/Anthem Silver Priority Select HMO 60/2500/45%/9B1J/01-01-2024

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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 서
신을 받으실 수도 있습니다. 무료 도움을 받으시려면 즉시 1-888-254-2721로 전화하십시오. (TTY/TDD: 711)

Punjabi
ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁਸ� ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ�, ਤਾਂ ਅਸ� ਇਸ ਨੂੰ ਪੜਹ੍ ਿਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿਕਸੇ ਨੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ� ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੰ
ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਿਲਿਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ਾਪ ੍ਾਪ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਮਦਦ ਲਈ, ਿਕਰਪਾ ਕਰਕੇ ਫੌਰਨ 1-888-254-2721 ਤੇ ਕਾਲ 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
หมายเหตุสำคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ้าหน้าที่มาอ่านให้ท่านฟังได้
ท่านยังอาจให้เจ้าหน้าที่ช่วยเขียนจดหมายในภาษาของท่านอีกด้วย หากต้องการความช่วยเหลือโดยไม่มีค่าใช้จ่าย โปรดโทรติดต่อที่หมายเลข 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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