1 of 16

Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015

Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
"$i! i! only a !ummary% If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-855-271-4549.
&m#oran 'ue!ion! (n!)er! *$y $i! +aer!:
What is the
overall
deductible?
For in-network
providers,
,5-0.0 Individual /
,10-160 Family
Doesnt apply to in-
network preventive care
exams.
ou must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. !heck your policy or
plan document to see when the deductible starts over "usually, but
not always, #anuary $st%. &ee the chart starting on page ' for how
much you pay for covered services after you meet the deductible.
Are there other
deductibles for
seci!c services?
es
ou dont have to meet deductibles for speci(c services, but see the
chart starting on page ' for other costs for services this plan covers.
"s there an out#
of#oc$et limit
on m% e&enses?
es. For in-network
providers
,5-0.0 individual )
,10-160 family
*his plan has a separate
+ut of
,ocket -aximum of
,1-2/0
Individual/,2-500 per
family for in and out of
network
prescription drugs
*he out-of-oc$et limit is the most you could pay during a coverage
period "usually one year% for your share of the cost of covered
services. *his limit helps you plan for health care expenses.
What is not
included in the
out#of#oc$et
limit?
.alance-.illed charges,
/ealth !are this plan
doesnt cover, and
,remiums
0ven though you pay these expenses, they dont count toward the
out-of-oc$et limit.
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
2 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
"s there an
overall annual
limit on what the
lan a%s?
3o.
*he chart starting on page ' describes any limits on what the plan
will pay for specifc covered services, such as o4ice visits.
)oes this lan
use a networ$ of
roviders?
es. For a list of in-
networ$ roviders, see
www.anthem.com or call
$-566-78$-969:.
If you use an in-network doctor or other health care rovider, this
plan will pay some or all of the costs of covered services. .e aware,
your in-network doctor or hospital may use an out-of-network
rovider for some services. ,lans use the term in-network,
referred, or participating for roviders in their networ$. &ee the
chart starting on page ' for how this plan pays di4erent kinds of
roviders.
)o " need a
referral to see a
secialist?
3o.
ou can see the secialist you choose without permission from this
plan.
Are there
services this lan
doesn*t cover?
es.
&ome of the services this plan doesnt cover are listed on page ;. &ee
your policy or plan document for additional information about
e&cluded services.
+oa%ments are (xed dollar amounts "for example, <$6% you pay for covered health care, usually when you
receive the service.
+oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed
amount for the service. For example, if the plans allowed amount for an overnight hospital stay is
<$,===, your coinsurance payment of 7=> would be <7==. *his may change if you havent met your
deductible.
*he amount the plan pays for covered services is based on the allowed amount. If an out-of-network
rovider charges more than the allowed amount, you may have to pay the di4erence. For example, if an
out-of-network hospital charges <$,6== for an overnight stay and the allowed amount is <$,===, you may
have to pay the <6== di4erence. "*his is called balance billin,.%
*his plan may encourage you to use in-network roviders by charging you lower deductibles,
coa%ments and coinsurance amounts.
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
3 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
"f %ou visit a
health care
rovider*s
o-ice or clinic
,rimary care visit to treat an
in?ury or illness
<'6 copay)visit 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
&pecialist visit <;= copay)visit 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
+ther practitioner o4ice visit
!hiropractor
<6= copay)visit
Acupuncturist
3ot covered
!hiropractor
3ot !overed
Acupuncturist
3ot covered
@@@@@@@@@@@@@
none@@@@@@@@@@@@
,reventive
care)screening)immuniBation
3o !harge 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
"f %ou have a
test
Diagnostic test "x-ray, blood
work%
3o cost share
for labs in
o4ice or
independent
labC other
services =>
coinsurance
3ot !overed
Deductible waived when lab
services performed in o4ice
or independent lab. !osts
may vary by site of service.
Imaging "!*),0* scans, -DIs%
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
"f %ou need
dru,s to treat
%our illness or
condition
1eneric drugs "Detail)'= dayE -ail):=
day%
<$6 Detail)<'=
-ail
3ot !overed
-aintenance -eds are re2uired to be
(lled mail order after ' (lls at retail
"penalty applies%. If pre-auth re2uired F
not obtained, drug may not be covered.
!ertain ,reventive meds no copay. If a
generic e2uivalent is available F brand is
prescribed)member will pay brand name
cost di4erence. ,lan uses preferred drug
list to identify coverage.
,referred brand drugs "Detail)'= dayE
-ail):= day%
<'6 Detail)<58.6
-ail
3ot !overed
3on-preferred brand "Detail)'=dayE
-ail):=day%
<8= Detail)<$86
-ail
3ot !overed
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
0 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
-ore
information
about
rescrition
&pecialty drugs
All &pecialty
meds process
through
Accredo at the
mail order
costs.
3ot !overed
*he mail order cost will be
based on the medication tier
"generic, preferred, non-
preferred%. &pecialty meds
can not be (lled at retail
pharmacies.
"f %ou have
outatient
sur,er%
Facility fee "e.g., ambulatory
surgery center%
<$76
copay)visit for
ambulatory
surgical
centerC other
sites of service
=>
coinsurance
3ot !overed
!osts may vary by site of
service.
,hysician)surgeon fees
=>
coinsurance
3ot !overed
Deductible waived when
performed in an ambulatory
surgical center.
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
5 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
"f %ou need
immediate
medical
attention
0mergency room services
<76= copay
)visitC
professional
and other
services
sub?ect to
deductible
<76=
copay)visitC
professional
and other
services
sub?ect to
deductible
<76= copay waived if
admitted. -ember may be
balance billed for out of
network services.
0mergency medical
transportation
=>
coinsurance
=>
coinsurance
-ember may be balance
billed for out of network
services.
Grgent care
<;= copay
)visit
3ot !overed @@@@@@@@@@@@none@@@@@@@@@@@@
"f %ou have a
hosital sta%
Facility fee "e.g., hospital room%
=>
coinsurance
3ot !overed
,hysical -edicine and
Dehabilitation limited to ;=
days per member per
calendar year.
,hysician)surgeon fee
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
6 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
"f %ou have
mental health.
behavioral
health. or
substance
abuse needs
-ental).ehavioral health
outpatient services
-ental).ehavi
oral /ealth
+4ice
Hisit
<'6 copay)visit
-ental).ehavi
oral /ealth
Facility
Hisit
=>
coinsurance
-ental).ehavi
oral/ealth
+4ice
Hisit
3ot
!overed
-ental).ehavi
oral /ealth
Facility
Hisit
3ot
!overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
-ental).ehavioral health
inpatient services
=>
coinsurance
3ot !overed @@@@@@@@@@@@@
none@@@@@@@@@@@@
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
/ of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
&ubstance use disorder
outpatient services
-ental).ehavi
oral /ealth
+4ice
Hisit
<'6 copay)visit
-ental).ehavi
oral /ealth
Facility
Hisit
=>
coinsurance
-ental).ehavi
oral/ealth
+4ice
Hisit
3ot
!overed
-ental).ehavi
oral /ealth
Facility
Hisit
3ot
!overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
&ubstance use disorder inpatient
services
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
"f %ou are
re,nant
,renatal and ,ostnatal care
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
Delivery and all inpatient services
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
. of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
Common
+edi1al Even
Servi1e! 2ou +ay 3eed
2our Co! &f
2ou 4!e an
&n-ne)or5
Provider
2our Co! &f
2ou 4!e an
Ou-of-ne)or5
Provider
6imiaion! 7 E81e#ion!
"f %ou need
hel recoverin,
or have other
secial health
needs
/ome health care
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
Dehabilitation services
<;= copay)visit
for outpatient
services.
Inpatient
services
sub?ect to
deductible.
3ot !overed
+utpatient services limited
to ;= visits per member per
calendar year for physical
therapy, occupational
therapy, and speech therapy
combined.
/abilitation services
<;= copay)visit
for outpatient
services.
Inpatient
services
sub?ect to
deductible.
3ot !overed
All rehabilitation and
habilitation visits count
toward your rehabilitation
visit limit.
&killed nursing care
=>
coinsurance
3ot !overed
Iimited to $== days per
calendar year.
Durable medical e2uipment
=>
coinsurance
3ot !overed
*-# Appliances are not
covered.
/ospice service
=>
coinsurance
3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
"f %our child
needs dental or
e%e care
0ye exam 3ot !overed 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
1lasses 3ot !overed 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
Dental check-up 3ot !overed 3ot !overed
@@@@@@@@@@@@@
none@@@@@@@@@@@@
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
9 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
E81luded Servi1e! 7 O$er Covered Servi1e!:
Servi1e! 2our Plan :oe! 3O" Cover /0his isn*t a comlete list. +hec$ %our olic% or lan document for other
e&cluded services.1
J Acupuncture
J !osmetic surgery
J Dental care "Adult%
J /earing aids
J Infertility treament
J Iong-term care
J ,rivate-duty nursing
J Doutine foot care
J Doutine eye care
J Keight loss programs
O$er Covered Servi1e! /0his isn*t a comlete list. +hec$ %our olic% or lan document for other covered
services and %our costs for these services.1
J .ariatric surgery "Iimitations -ay
Apply%
J !hiropractic care "Iimitations -ay
Apply%
-ost coverage provided outside
the Gnited &tates. &ee
www..!.&.com)bluecardworldwid
e
2our Rig$! o Coninue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and &tate laws may provide
protections that allow you to keep health coverage. Any such rights may be limited in duration and will re2uire you
to pay a remium, which may be signi(cantly higher than the premium you pay while covered under the plan.
+ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at $-5==-765-6'$5. ou may also contact
your state insurance department, the G.&. Department of Iabor, 0mployee .ene(ts &ecurity Administration at $-5;;-
999-'787 or www.dol.gov)ebsa, or the G.&. Department of /ealth and /uman &ervices at $-588-7;8-7'7' x;$6;6 or
www.cciio.cms.gov.
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
10 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
2our ;rievan1e and (##eal! Rig$!:
If you have a complaint or are dissatis(ed with a denial of coverage for claims under your plan, you may be able to
aeal or (le a ,rievance. For 2uestions about your rights, this notice, or assistance, you can contactE
Anthem .lue !ross .lue &hield
!linical AppealsE ,.+. .ox $=66;5 Atlanta, 1A '='95
For grievances and)or appeals regarding you prescription drug coverage, call the number listed on the back of
prescription member ID card or visit www.express-scripts.com.
For 0DI&A information contactE
Department of Iabors 0mployee .ene(ts &ecurity Administration
$-5;;-999-0.&A "'787%
www.dol.gov)ebsa)healthreform
Additionally, a consumer assistance program can help you (le your appeal. !ontactE
3ew /ampshire Department of Insurance
7$ &outh Fruit &treet, &uite $9
!oncord, 3/ =''=$
"5==% 567-'9$;
www.nh.gov)insurance
consumerservicesLins.nh.gov
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
11 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
:oe! $i! Coverage Provide +inimum E!!enial Coverage<
*he A4ordable !are Act re2uires most people to have health care coverage that 2uali(es as Mminimum essential
coverage.N This plan or policy does
provide minimum essential coverage.
:oe! $i! Coverage +ee $e +inimum =alue Sandard<
*he A4ordable !are Act establishes a minimum value standard of bene(ts of a health plan. *he minimum value
standard is ;=> "actuarial value%. This health coverage does meet the minimum value standard for the
benefts it provides.
6anguage (11e!! Servi1e!:
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
12 of 16
Sanel: CORE EPO Coverage Period: 01/01/2015- 12/31/2015
Summary of Benefi! and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan "y#e: EPO
@@@@@@@@@@@@@@@@@@@@@@To see examples of how this plan might cover costs for a sample medical situation, see the next
page.@@@@@@@@@@@
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
>aving a ?a?y
"normal delivery%
+anaging y#e 2 dia?ee!
"routine maintenance of
a well-controlled condition%
13 of 16
Sanel : CORE EPO Coverage Period: 01/01/2015 - 12/31/2015
Coverage E8am#le!
Coverage for: Individual/Family | Plan "y#e: EPO
(?ou $e!e Coverage
E8am#le!:
*hese examples show how this plan
might cover medical care in given
situations. Gse these examples to
see, in general, how much (nancial
protection a sample patient might
get if they are covered under
di4erent plans.
(moun o)ed o #rovider!: $7,54
Plan #ay! $!,"#
Paien #ay! $5,!"
Sam#le 1are 1o!!:
/ospital charges "mother%
<7,8=
=
Doutine obstetric care
<7,$=
=
/ospital charges "baby% <:==
Anesthesia <:==
Iaboratory tests <6==
,rescriptions <7==
Dadiology <7==
Haccines, other preventive <9=
0otal
27.54
3
Paien #ay!:
Deductibles
<6,=5
=
!opays <=
!oinsurance <=
Iimits or exclusions <$6=
0otal
25.24
3
(moun o)ed o #rovider!: $5,4
Plan #ay! $!,"4
Paien #ay! $",$
Sam#le 1are 1o!!:
,rescriptions
<7,:=
=
-edical 02uipment and
&upplies
<$,'=
=
+4ice Hisits and ,rocedures <8==
0ducation <'==
Iaboratory tests <$==
Haccines, other preventive <$==
0otal
25.43
3
Paien #ay!:
Deductibles
<7,'5
=
!opays <;==
!oinsurance <=
Iimits or exclusions <5=
0otal
24.35
3
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.

"$i! i!
no a 1o!
e!imaor%
Dont use these
examples to estimate
your actual costs under
this plan. *he actual
care you receive will be
di4erent from these
examples, and the cost
of that care will also be
di4erent.
&ee the next page for
important information
about these examples.
10 of 16
Sanel : CORE EPO Coverage Period: 01/01/2015 - 12/31/2015
Coverage E8am#le!
Coverage for: Individual/Family | Plan "y#e: EPO
'uestions( !all 1-855-271-4549 or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 1lossary. ou can view the 1lossary
at www.anthem.com or call 1-855-271-4549 to re2uest a copy.
'ue!ion! and an!)er! a?ou $e Coverage E8am#le!:
*$a are !ome of $e
a!!um#ion! ?e$ind $e
Coverage E8am#le!<
!osts dont include remiums.
&ample care costs are based on
national averages supplied by
the G.&. Department of /ealth
and /uman &ervices, and
arent speci(c to a particular
geographic area or health plan.
*he patients condition was not
an excluded or preexisting
condition.
All services and treatments
started and ended in the same
coverage period.
*here are no other medical
expenses for any member
covered under this plan.
+ut-of-pocket expenses are
based only on treating the
condition in the example.
*he patient received all care
from in-network roviders. If
the patient had received care
from out-of-network roviders,
costs would have been higher.
*$a doe! a Coverage E8am#le
!$o)<
For each treatment situation, the
!overage 0xample helps you see
how deductibles, coa%ments,
and coinsurance can add up. It
also helps you see what expenses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
:oe! $e Coverage E8am#le
#redi1 my o)n 1are need!<
6o. *reatments shown are ?ust
examples. *he care you would
receive for this condition could
be di4erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
:oe! $e Coverage E8am#le
#redi1 my fuure e8#en!e!<
6o. !overage 0xamples are not
cost estimators. ou cant use
the examples to estimate costs
for an actual condition. *hey are
for comparative purposes only.
our own costs will be di4erent
depending on the care you
receive, the prices your
roviders charge, and the
reimbursement your health plan
allows.
Can & u!e Coverage E8am#le!
o 1om#are #lan!<
7es. Khen you look at the
&ummary of .ene(ts and
!overage for other plans, youll
(nd the same !overage
0xamples. Khen you compare
plans, check the M,atient ,aysN
box in each example. *he
smaller that number, the more
coverage the plan provides.
(re $ere o$er 1o!! & !$ould
1on!ider )$en 1om#aring
#lan!<
7es. An important cost is the
remium you pay. 1enerally,
the lower your remium, the
more youll pay in out-of-pocket
costs, such as coa%ments,
deductibles, and coinsurance.
ou should also consider
contributions to accounts such
as health savings accounts
"/&As%, Oexible spending
arrangements "F&As% or health
reimbursement accounts "/DAs%
that help you pay out-of-pocket
expenses.