1 Combined Evidence of Coverage and Disclosure Form Anthem Bronze 60 D HMO 49ZT A Health Maintenance Organization (HMO) Plan Anthem Blue Cross P.O. Box 9051 Oxnard, CA 93031-9051 1-855-383-7247 RIGHT TO EXAMINE IF THIS AGREEMENT IS PROVIDED TO YOU AS A NEW SUBSCRIBER, YOU HAVE THE RIGHT TO VIEW THE AGREEMENT PRIOR TO ENROLLMENT. IF THIS AGREEMENT IS PROVIDED TO YOU AS A NEW SUBSCRIBER, ONCE ENROLLED, YOU HAVE THIRTY (30) DAYS FROM THE DATE OF DELIVERY TO EXAMINE THIS AGREEMENT. IF YOU ARE NOT SATISFIED, FOR ANY REASON WITH THE TERMS OF THIS AGREEMENT, YOU MAY RETURN THE AGREEMENT TO US WITHIN THOSE THIRTY (30) DAYS. YOU, CONSISTENT WITH CALIFORNIA LAW, WILL BE REQUIRED TO PAY FOR ANY SERVICES ANTHEM BLUE CROSS PAID ON YOUR BEHALF DURING THE THIRTY (30) DAY PERIOD AND ANTHEM BLUE CROSS WILL REFUND ANY PREMIUM PAID BY YOU, LESS YOUR MEDICAL AND PHARMACY EXPENSES THAT ANTHEM BLUE CROSS PAID. IF NO SERVICES WERE RENDERED, YOU WILL BE ENTITLED TO RECEIVE A FULL REFUND OF ANY PREMIUMS PAID. THIS AGREEMENT WILL THEN BE NULL AND VOID. 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. 2 Welcome to Anthem! We are pleased that You have become a Member of Our health plan, where it is Our mission to improve the health of the people We serve. We have designed this Evidence of Coverage and Disclosure Form (EOC) (also called Agreement or Plan) to give a clear description of Your benefits, as well as Our rules and procedures. This EOC explains many of the rights and duties between You and Us. It also describes how to get health care, what services are covered and what part of the costs You will need to pay. Many parts of this EOC are related. Therefore, reading just one (1) or two (2) sections may not give You a full understanding of Your coverage. You should read the whole EOC to know the terms of Your coverage. This EOC, the application and any endorsements attached shall constitute the entire Agreement under which Covered Services and supplies are provided by Us. Many words used in the EOC have special meanings (e.g., Covered Services and Medical Necessity). These words are capitalized and are defined in the “Definitions” section. See these definitions for the best understanding of what is being stated. Throughout this EOC You will also see references to “We,” “Us,” “Our,” “You” and “Your.” The words “We,” “Us,” and “Our” mean Anthem Blue Cross (Anthem). The words “You” and “Your” mean the Member, Subscriber and each covered Dependent. Should You have a complaint, problem or question about Your health Plan or any services received, a Member Services representative will assist You. Contact Member Services by calling the number on the back of Your Member Identification Card. Also be sure to check Our web site, www.anthem.com/ca for details on how to find a Provider, get answers to questions and access valuable health and wellness tips. Thank You again for enrolling in the Plan! J. Brian Ternan President Anthem Blue Cross How to Obtain Language Assistance Anthem Blue Cross (Anthem) is committed to communicating with Our Members about their health Plan, no matter what their language is. Interpretation services are available through all of Our Member Services call centers. Simply call the Member Services phone number on the back of Your Identification Card and a representative will be able to help You. Translation of written materials about Your benefits can also be asked for by contacting Member Services. Teletypewriter/Telecommunications Device for the Deaf (TTY/TDD) services are also available by dialing 711. A special operator will get in touch with Us to help with Your needs. You may provide Your preferred written and spoken language directly to Anthem and directly to Your Provider. If You provide Your language preferences to Anthem, this information will be maintained by Anthem and will be shared with Your Provider when the Provider calls to check eligibility or upon request. If Your preferred written language is one of Your health plan’s threshold languages, You may receive some Plan information in Your preferred written language. You may update Your preferred written and spoken languages to Your health plan by calling 1-855-383-7247. Si necesita ayuda en español para entender este documento, puede solicitarla sin costo adicional, llamando al número de servicio al cliente. (If You need Spanish-language assistance to understand this document, You may request it at no additional cost by calling the Member Services number.) CA_DMHC_OFF_SEP_HMO_01-20 49ZT 3 Oral interpretation services are available in fifteen (15) languages. Auxiliary aids and services are also available for Members with disabilities as well as information in alternate formats. These aids and services are free of charge and will be provided in a timely manner when they are necessary to ensure an equal opportunity for Members with disabilities to participate. Contact Us Member Services is available to explain policies and procedures, and answer questions regarding the availability of benefits. For information and assistance, a Member may call or write Anthem. The telephone number for Member Services is 1-855-383-7247. The address is: P. O. Box 9051 Oxnard, CA 93031-9051 Visit Us on-line www.anthem.com/ca Hours of operation Monday - Thursday 8:00 a.m. to 6:00 p.m. Pacific Time Friday 8:00 a.m. to 5:00 p.m. Pacific Time Conformity with Law This Agreement is subject to the laws of the State of California. Any provision of this Agreement which, on its Effective Date, is in conflict with any law is amended to confirm to the minimum requirements of such law. This coverage is A Health Maintenance Organization (HMO) Plan regulated by the California Department of Managed Health Care pursuant to the Health and Safety Code. Acknowledgement of Understanding Subscriber hereby expressly acknowledges their understanding that this Agreement constitutes a contract solely between Subscriber and Anthem Blue Cross, which is an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, (the “Association”) permitting Anthem Blue Cross to use the Blue Cross Service Mark in the State of California, and that Anthem Blue Cross is not contracting as the agent of the Association. Subscriber further acknowledges and agrees that it has not entered into this Agreement based upon representations by any person other than Anthem Blue Cross and that no person, entity or organization other than Anthem Blue Cross shall be held accountable or liable to Subscriber for any of Anthem Blue Cross’s obligations to Subscriber created under this Agreement. This paragraph shall not create any additional obligations whatsoever on the part of Anthem Blue Cross other than those obligations created under other provisions of this Agreement. Some Hospitals and other Providers do not provide one or more of the following services that may be covered under Your Plan contract and that You or Your family member might need: family planning; contraceptive services, including Emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments or abortion. You should obtain more information before You enroll. Call Your prospective doctor, medical group, independent practice association, or clinic or call the health plan at 1-855-383-7247 to ensure that You can obtain the health care services that You need. CA_DMHC_OFF_SEP_HMO_01-20 49ZT 4 Delivery of Documents We will provide an Identification Card (ID Card) and Evidence of Coverage and Disclosure Form for each Subscriber. CA_DMHC_OFF_SEP_HMO_01-20 49ZT 5 TABLE OF CONTENTS LANGUAGE ASSISTANCE SERVICES...................................................................................................... 8 SCHEDULE OF COST SHARE AND BENEFITS...................................................................................... 11 Medical Services..................................................................................................................................... 15 Prescription Drugs................................................................................................................................... 21 Child Dental Services.............................................................................................................................. 24 Child Vision Services...............................................................................................................................25 HOW YOUR COVERAGE WORKS........................................................................................................... 27 This is a Health Maintenance Organization (HMO) Plan.........................................................................27 Choice of Doctors and Providers.............................................................................................................27 In Network Services ............................................................................................................................... 27 Out of Network Services..........................................................................................................................28 How to Find a Provider in the Network.................................................................................................... 28 Primary Care Physician (PCP)...............................................................................................................