202 1 RAM Plan Administered by Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products are underwritten by HMO Colorado, Inc. and HMO Colorado, Inc. dba HMO Nevada. Life and disability products underwritten by Anthem Life Insurance Company. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the 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 folleto de inscripción. Schedule of Benefits Colorado State University RAM Plan Effective January 1, 2021 PART A: TYPE OF COVERAGE1 IN-NETWORK: PARTICIPATING PROVIDERS: You will have access to a National Blue Cross and Blue Shield PPO Network. Your benefit will be the highest level when you receive covered services from a participating provider. (You are responsible for any applicable copayments, deductible and coinsurance). Anthem Blue Cross and Blue Shield will pay the participating provider directly. OUT-OF-NETWORK: NON-PARTICIPATING PROVIDERS: Non-participating facilities or providers have not entered into any agreement with Anthem Blue Cross and Blue Shield. They may bill Anthem Blue Cross and Blue Shield or the patient. Anthem Blue Cross and Blue Shield will pay you. It is your responsibility to pay the non-participating providers. PART B: SUMMARY OF BENEFITS Important Note: This and the following pages contain a limited description of the coverage available through this group plan. Coverage is governed at all times by the complete terms of the Master Group Insurance Policy issued to Colorado State University. This Benefit Booklet is available online at https://hr.colostate.edu/wp-content/uploads/sites/25/2020/10/fap-insplans- 2.pdf. This group major medical plan is self-insured by Colorado State University and is administered by Anthem Blue Cross and Blue Shield. PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS (in-network) (out-of-network) 1. ANNUAL DEDUCTIBLE a) Individual $1,500 b) Family $3,000 If you select family membership, no single Deductible applies and the family Deductible must be met before we reimburse for Covered Services. The family Deductible amount is met as follows: when one family Member has satisfied the family Deductible, that family Member and all other family Members are eligible for benefit. When no one family Member meets the family Deductible, but the family Members collectively meet the entire family Deductible, then all family Members will be eligible for benefits. Some Covered Services have a maximum benefit of days, visits or dollar amounts allowed. When the Deductible is applied to a Covered Service which has a maximum benefit of days or visits, those maximum benefits will be reduced by the amount applied toward the Deductible, whether or not the Covered Service is paid. The family Deductible is also applicable for newborn and adopted children (and for all other family Members) for the first 31-day period following birth or adoption if the child is enrolled or not enrolled. 2. COINSURANCE / Coinsurance: COPAYMENTS You pay 20% after deductible. Coinsurance is required up to the out-of-pocket annual maximum. Subject to certain exclusions as identified below. Copayments: Does not apply. Coinsurance options reflect the amount the You will pay. For non-participating providers you also pay the difference between Anthem’s maximum allowed amount and the amount billed by the non-participating provider. 2 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS (in-network) (out-of-network) 3. OUT-OF-POCKET ANNUAL MAXIMUM2 a) Individual $6,550 in coinsurance, includes deductible, plus Charges for non-participating providers that are above Anthem’s maximum allowed amount. b) Family $13,100 in coinsurance, includes deductible, plus Charges for non-participating providers that are above Anthem’s maximum allowed amount. If you select family membership when one family Member has satisfied their individual Out-of-Pocket Annual Maximum, that family Member is eligible for benefits. The enrolled remaining family Members are eligible for benefits when they individually satisfy their individual Out-of-Pocket Annual Maximum or collectively satisfy the balance of the family Out-of-Pocket Annual Maximum. When no family Member meets the individual Out-of-Pocket Annual Maximum, but the family Members collectively meet the entire family Out-of-Pocket Annual Maximum, then all family Members will be eligible for benefits. The family Out-of-Pocket Annual Maximum is also applicable for newborn and adopted children (and for all other family Members) for the first 31-day period following birth or adoption if the child is enrolled or not enrolled. Some Covered Services have a maximum benefit of days, visits or dollar amounts allowed. These maximums apply even if the applicable Out-of-Pocket Annual Maximum is satisfied. 4. LIFETIME OR BENEFIT No lifetime maximum MAXIMUM PAID BY THE PLAN FOR ALL CARE 5. COVERED PROVIDERS Anthem Blue Cross and Blue Shield PPO Provider All providers licensed or certified to provide Network. See provider directory for complete list covered benefits. or refer to www.anthem.com or refer to www.bluecares.com for providers outside the state of Colorado. 6. ROUTINE MEDICAL You pay 20% after deductible You pay 20% after deductible OFFICE VISITS 7. PREVENTIVE CARE a) Children’s services Covered in full, not subject to deductible; includes You pay 20% not subject to deductible; includes routine physicals, associated laboratory, X-rays routine physicals, associated laboratory, X-rays and immunizations. and immunizations. b) Adults’ services Covered in full, not subject to deductible; (includes You pay 20% not subject to deductible; (includes routine physicals, associated laboratory, X-rays, routine physicals, associated laboratory, X-rays, mammogram screening, colorectal cancer mammogram screening, colorectal cancer screening (includes preventive colonoscopies) screening (includes preventive colonoscopies) and immunizations. and immunizations. 8. MATERNITY a) Prenatal care You pay 20% after deductible You pay 20% after deductible b) Delivery & inpatient You pay 20% after deductible You pay 20% after deductible well baby care 3 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS (in-network) (out-of-network) 9. PRESCRIPTION DRUGS You pay 20% after deductible Retail Pharmacy or Mail Order Service: Participating pharmacy (34 to 90 day supply), specialty pharmacy (34-day supply) or mail order service (90-day supply): Specialty Pharmacy: Participating pharmacy (34-day supply). Specialty pharmacy drugs often require special handling such as temperature controlled packaging and overnight delivery and are often unavailable at a retail pharmacy. Benefits are only provided when you receive services from a specialty pharmacy as determined by Anthem for those specialty pharmacy drugs included on Anthem’s specialty drug list. Birth Control: Oral injection and contraceptive devices obtained by a physician’s prescription are covered. 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 Deductible and Coinsurance. The cost difference between the Generic and Brand Name Drug does not go towards your Deductible or Out-of-Pocket Annual Maximum. By law, Generic and Brand Name Drugs must meet the same standards for safety, strength, and effectiveness. We reserve the right, at Our discretion, to remove certain higher cost Generic Drugs from this policy. For drugs on Our approved list, call Member Services at 866-837-4596. Prescription Drugs are covered only when received from a participating pharmacy, participating specialty pharmacy or participating mail order service. 10. INPATIENT HOSPITAL You pay 20% after deductible You pay 20% after deductible Precertification from Anthem Blue Cross and Blue Precertification from Anthem Blue Cross and Blue Shield must be received before a hospital Shield must be received before a hospital admission or within 5 days after an emergency admission or within 5 days after an emergency admission for full benefits to be payable. admission for full benefits to be payable If you use a non-participating provider, you are responsible for making sure this precertification has been obtained. 11. OUTPATIENT / You pay 20% after deductible. You pay 20% after deductible. AMBULATORY SURGERY This includes colonoscopies with a medical This includes colonoscopies with a medical diagnosis. diagnosis. 12. LABORATORY AND You pay 20% after deductible You pay 20% after deductible X-RAY 13. EMERGENCY CARE3 You pay 20% after deductible Out-of-Network care is paid as In-Network 14. AMBULANCE You pay 20% after deductible Out-of-Network care is paid as In-Network 15. URGENT, NON-ROUTINE, You pay 20% after deductible You pay 20% after deductible AFTER HOURS CARE 16. MENTAL HEALTH CARE a) Inpatient care You pay 20% after deductible You pay 20% after deductible b) Outpatient care You pay 20% after deductible You pay 20% after deductible Contact the behavioral health administrator at 1- Contact the behavioral health administrator at 1- 800-424-4014 for information on how to locate a 800-424-4014 for information on how to locate a provider and your benefits. provider and your benefits. 17. ALCOHOL & SUBSTANCE ABUSE a) Inpatient Care You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible You pay 20% after deductible b) Outpatient care Contact the behavioral health administrator at 1- Contact the behavioral health administrator at 1- 800-424-4014 for information on how to locate a 800-424-4014 for information on how to locate a provider and your benefits.