Loading...
HomeMy WebLinkAboutAgreement A-21-513 with SJVIA.pdf- 1 - SJVIA PARTICIPATION AGREEMENT THIS AGREEMENT (“Agreement”) is made and entered into this 13th day of December 2021, by and between COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter referred to as "COUNTY OF FRESNO," and the SAN JOAQUIN VALLEY INSURANCE AUTHORITY, a joint powers agency, hereinafter referred to as “SJVIA.” W I T N E S S E T H: WHEREAS, the purpose of the SJVIA is to develop and provide various health insurance programs for health, pharmacy, vision, dental, mental health and life insurance, including related administrative services for such programs to be provided by the insurance provider(s) and the SJVIA and its agents and consultants (collectively, “Various Benefits”), for the benefit of participating entities; and WHEREAS, the COUNTY OF FRESNO wishes to participate in the SJVIA Various Benefits for the purpose of purchasing health insurance programs, and/or other benefits in a cost-effective manner for its participating employees; and WHEREAS, the COUNTY OF FRESNO elects to participate in the selected SJVIA health insurance programs as referenced in Exhibit “A” (collectively, “SELECTED PROGRAMS”); and WHEREAS, a true and correct copy of a summary of applicable SJVIA health insurance programs is attached hereto and incorporated herein by reference as Exhibit “A”; and WHEREAS, the SJVIA represents that it will contract with Insurance Providers which will provide its Various Benefits under the terms and conditions of a written contract between the SJVIA and the Insurance Provider (the “Insurance Contract”) for each of the COUNTY OF FRESNO’s participating employees; and WHEREAS, the SJVIA represents that the rates for the Various Benefits under the SELECTED PROGRAMS to be provided under the Insurance Contract and by the SJVIA, including the costs of its agents and consultants, are set forth in Exhibit “B” which is attached hereto and incorporated herein by reference; and WHEREAS, the COUNTY OF FRESNO and the SJVIA now desire to enter into this Agreement to secure the COUNTY OF FRESNO’s commitment to remit premium payments to the SJVIA for the Various Benefits to be provided under the Insurance Contract, and the COUNTY OF FRESNO’s portion of the costs of the SJVIA’s agents and consultants, as provided herein. NOW THEREFORE, in consideration of their mutual promises, covenants and conditions, the parties agree as follows: 1.COUNTY OF FRESNO’s OBLIGATIONS: The COUNTY OF FRESNO acknowledges that this agreement requires a commitment to participate in SJVIA Various Benefits effective December 13, 2021 through December 11, 2022. Within ten business days of the date that SJVIA is required under the Insurance Contract to pay any insurance premium and/or similar charge to the Insurance Provider, the COUNTY OF FRESNO shall remit to SJVIA the amount necessary to pay the required premium payment based on the intervals of such payments under the Insurance Contract. Agreement No. 21-513 - 2 - The COUNTY OF FRESNO may also participate in SELECTED PROGRAMS as referenced in Exhibit “A” and shall comply with all applicable terms and provisions of the Insurance Contract and this Agreement, effective December 13, 2021. The attached rates in Exhibit “B” reference only the SELECTED PROGRAMS the COUNTY OF FRESNO is electing. Exhibit “B” also references the effective term such rates apply to the COUNTY OF FRESNO which are effective December 13, 2021 through December 11, 2022. The COUNTY OF FRESNO agrees that it may only elect to participate in additional health insurance programs, or elect to make changes to the SELECTED PROGRAMS, through subsequent amendment to this agreement or separate agreement. Subsequent renewals are based on the SJVIA underwriting guidelines. The SJVIA uses actuarially based underwriting standards. 2. SJVIA’S OBLIGATIONS: The SJVIA shall approve and execute related Insurance Contracts. Following execution of the Insurance Contracts, (i) SJVIA shall make available the fully- executed copy of the Insurance Contract to COUNTY OF FRESNO, (ii) SJVIA shall enforce SJVIA’s rights under the Insurance Contract for the benefit of COUNTY OF FRESNO, and (iii) SJVIA shall perform SJVIA’s obligations under the terms and conditions of the Insurance Contracts, including making timely payment of premium payments, and/or any similar charges, necessary to keep the Insurance Contracts in full force and effect. 3.MODIFICATION: Any matters of this Agreement may be modified from time to time but only by the written consent of all the parties hereto without, in any way, affecting the remainder hereof. 4.NON-ASSIGNMENT: Neither party hereto shall assign, transfer, or subcontract this Agreement nor their rights or duties under this Agreement without the prior written consent of the other party hereto. 5.AUDITS AND INSPECTIONS: The SJVIA shall at any time during usual SJVIA business hours, upon request by the COUNTY OF FRESNO, and as often as the COUNTY OF FRESNO may deem necessary, make available to the COUNTY OF FRESNO for examination all SJVIA records and data for inspection, examination, and audit by the COUNTY OF FRESNO with respect to the matters covered by this Agreement. SJVIA shall be subject to the examination and audit of the State Auditor General for a period of three (3) years after final payment under contract (Government Code section 8546.7). 6. NOTICES: The persons having authority to give and receive notices under this Agreement and their addresses include the following: COUNTY OF FRESNO SJVIA Any and all notices between the COUNTY OF FRESNO and the SJVIA provided for or permitted under this Agreement shall be in writing and delivered either by person service, by first- class United States mail, by an overnight commercial courier service, or by telephonic facsimile transmission. A notice delivered by personal service is effective upon service to the recipient. A notice delivered by first-class United States mail is effective three business days after deposit in the United States mail, postage prepaid, addressed to the recipient. A notice delivered by an overnight commercial courier service is effective one business day after deposit with the overnight commercial Hollis Magill Director of Human Resources 2220 Tulare St, 16th Floor Fresno, CA 93721 hmagill@fresnocountyca.gov Lupe Garza SJVIA Assistant Manager 2500 West Burrel Visalia, CA 93291 lugarza@co.tulare.ca.us - 3 - courier service, delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the recipient. A notice delivered by telephonic facsimile is effective when transmission to the recipient is completed (but, if such transmission is completed outside of COUNTY OF FRESNO business hours, then such delivery shall be deemed to be effective at the next beginning of a COUNTY OF FRESNO business day), provided that the sender maintains a machine record of the completed transmission. For all claims arising out of or related to this Agreement, nothing in this section establishes, waives, or modifies any claims presentation requirements or procedures provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of the Government Code, beginning with section 810). 7. GOVERNING LAW: The parties agree that for the purposes of venue, performance under this Agreement is to be in Fresno County, California. The rights and obligations of the parties and all interpretation and performance of this Agreement shall be governed in all respects by the laws of the State of California. 8. TERM: This Agreement shall become effective beginning at 12:01 a.m. on December 13, 2021 and shall terminate on December 11, 2022. 9.TERMINATION: a.The terms of this Agreement, and the health insurance programs, administrative services, and/or SJVIA staff costs to be provided hereunder, are contingent on the approval of funds by the COUNTY OF FRESNO. Should sufficient funds not be allocated, the services provided may be modified, or this Agreement terminated at any time by giving SJVIA 120 days advance written notice. b.Notwithstanding any other provision of this Article, if the COUNTY OF FRESNO fails to make in full any payment when due pursuant to Article 1, the SJVIA shall have the right, in its sole discretion, to terminate this Agreement, without notice, effective at the expiration of the last period for which full premium payment was made. Notwithstanding such termination or suspension, the SJVIA, in its sole discretion, may accept late payment or delinquent amounts and, upon acceptance, this Agreement may be reinstated retroactively to the last date for which full premium payment was made. Any such acceptance of a delinquent payment by the SJVIA shall not be deemed a waiver of this provision for termination of this Agreement in the event of any future failure of the COUNTY OF FRESNO to make timely payments of any amounts due under this Agreement. 10. SEVERABILITY: In the event any provisions of this Agreement are held by a court of competent jurisdiction to be invalid, void, or unenforceable, the parties will use their best efforts to meet and confer to determine how to mutually amend such provisions with valid and enforceable provisions, and the remaining provisions of this Agreement will nevertheless continue in full force and effect without being impaired or invalidated in any way. 11. DISPUTE RESOLUTION: Any controversy or dispute between the parties arising out of this agreement shall be submitted to mediation. The mediator will be selected by mutual agreement. If the matter cannot be resolved through mediation or if the parties cannot agree upon a mediator the matter shall be submitted to arbitration and such arbitration shall comply with and be governed by the provisions of the California Arbitration Act, of the California Code of Civil Procedure. - 4 - 12. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement between the SJVIA and COUNTY OF FRESNO with respect to the subject matter hereof and supersedes all previous agreement negotiations, proposals, commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless expressly included in this Agreement. 13. COUNTERPARTS: This Agreement may be executed in one or more original counterparts, all of which together will constitute one and the same agreement. /// /// /// (Go to next page for signatures) AGREEMENT BETWEEN COUNTY OF FRESNO AND THE SAN JOAQUIN VALLEY INSURANCE AUTHORITY SANJ AUT By :__,__ __________ _ Pe e Vander Poe! SJVIA Board President Date : ___________ _ REVIEWED & RECOMMENDED FOR APPROVAL By~iiJr< ~ Garza SJVIA Assistant Manager :~UNTY Jt: Steve 13randau Chairman of the Board of Supervisors of the County of Fresno Date : ~ ,q.chl-\ ATTEST: Bernice E. Se idel C lerk of the Board of Supervisors County of Fresno , State of California By ~L..&,~ BOARD OF DIRECTORS STEVE BRANDAU NATHAN MAGSIG BUDDY MENDES LARRY MICARI BRIAN PACHECO AMY SHUKLIAN PETE VANDER POEL Exhibit A County of Fresno Plan Year 2022 Benefit Summaries •Anthem Blue Cross EPO •Anthem Blue Cross EPO 500 •Anthem Blue Cross EPO 1000 •Anthem Blue Cross PPO 250 •Anthem Blue Cross HDHP PPO 1500 (Retirees only) •Anthem Blue Cross HDHP PPO 3000 •EmpiRx Health Prescription Benefit •Kaiser Permanente HMO •Delta Dental PPO •Delta Dental DHMO •VSP Vision Benefit 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: (855) 333-5730 or visit us at www.anthem.com/ca CA/LG/San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO/706G/01-01-2022 Page 1 of 8 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO 0 Your Network: EPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $0 person Not covered Out-of-Pocket Limit $1,000 person / $2,000 family Not covered 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). Preventive Care / Screening / Immunization No charge Not covered Preventive Care for Chronic Conditions per IRS guidelines No charge Not covered Virtual Care (Telemedicine / Telehealth Visits) Virtual Visits - Online visits with Doctors who also provide services in person Primary Care (PCP) $15 copay per visit Not covered Mental Health and Substance Use Disorder care $15 copay per visit Not covered Specialist $15 copay per visit Not covered 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 $15 copay per visit Not covered Specialist Care $15 copay per visit Not covered Visits in an Office Primary Care (PCP) $15 copay per visit Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Specialist Care $15 copay per visit Not covered Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge Not covered Retail Health Clinic $15 copay per visit Not covered Manipulation Therapy Coverage is limited to 40 visits per benefit period. $10 copay per visit Not covered Acupuncture $15 copay per visit Not covered Other Services in an Office Allergy Testing No charge Not covered Chemo/Radiation Therapy No charge Not covered Dialysis/Hemodialysis No charge Not covered Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. No charge Not covered Surgery 0% coinsurance after deductible is met Not covered Diagnostic Services Lab Office No charge Not covered Freestanding Lab No charge Not covered Outpatient Hospital No charge Not covered X-Ray Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Emergency and Urgent Care Urgent Care $15 copay per visit Not covered Emergency Room Facility Services Copay waived if admitted. $100 copay per visit Covered as In-Network Emergency Room Doctor and Other Services No charge Covered as In-Network Ambulance No charge Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit $15 copay per visit Not covered Facility Visit Facility Fees No charge Not covered Doctor Services No charge Not covered Outpatient Surgery Facility Fees Hospital No charge Not covered Freestanding Surgical Center No charge Not covered Doctor and Other Services Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees No charge Not covered Doctor and other services No charge Not covered Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. $15 copay per visit Not covered Rehabilitation services Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 days combined per benefit period. Office $15 copay per visit Not covered Outpatient Hospital No charge Not covered Cardiac rehabilitation Office $15 copay per visit Not covered Outpatient Hospital No charge Not covered Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. No charge Not covered Inpatient Hospice No charge Not covered Durable Medical Equipment No charge Not covered Prosthetic Devices No charge Not covered 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. • 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 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. 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# Page 6 of 8 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 i mpairments. 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# Page 7 of 8 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 หมายเหตุส าคัญ: 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) 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# Page 8 of 8 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 thro ugh 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, a ge, 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. Questions: (855) 333-5730 or visit us at www.anthem.com/ca CA/LG/San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO//01-01-2022 Page 1 of 8 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO 500 Your Network: EPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $0 person Not covered Out-of-Pocket Limit $3,000 person / $6,000 family Not covered 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). Preventive Care / Screening / Immunization No charge Not covered Preventive Care for Chronic Conditions per IRS guidelines No charge Not covered Virtual Care (Telemedicine / Telehealth Visits) Virtual Visits - Online visits with Doctors who also provide services in person Primary Care (PCP) $35 copay per visit Not covered Mental Health and Substance Use Disorder care $35 copay per visit Not covered Specialist $35 copay per visit Not covered 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 $35 copay per visit Not covered Specialist Care $35 copay per visit Not covered Visits in an Office Primary Care (PCP) $35 copay per visit Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Specialist Care $35 copay per visit Not covered Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No Charge Not covered Retail Health Clinic $35 copay per visit Not covered Manipulation Therapy Coverage is limited to 40 visits per benefit period. $35 copay per visit Not covered Acupuncture $35 copay per visit Not covered Other Services in an Office Allergy Testing No charge Not covered Chemo/Radiation Therapy No charge Not covered Dialysis/Hemodialysis No charge Not covered Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. No charge Not covered Surgery No charge Not covered Diagnostic Services Lab Office No charge Not covered Freestanding Lab No charge Not covered Outpatient Hospital No charge Not covered X-Ray Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Emergency and Urgent Care Urgent Care $35 copay per visit Not covered Emergency Room Facility Services Copay waived if admitted. $250 copay per visit Covered as In-Network Emergency Room Doctor and Other Services No charge Covered as In-Network Ambulance No charge Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit $35 copay per visit Not covered Facility Visit Facility Fees No charge Not covered Doctor Services No charge Not covered Outpatient Surgery Facility Fees Hospital No charge Not covered Freestanding Surgical Center No charge Not covered Doctor and Other Services Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees $500 copay per admission Not covered Doctor and other services No charge Not covered Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. $35 copay per visit Not covered Rehabilitation services Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 days combined per benefit period. Office $35 copay per visit Not covered Outpatient Hospital No charge Not covered Cardiac rehabilitation Office $35 copay per visit Not covered Outpatient Hospital No charge Not covered Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. No charge Not covered Inpatient Hospice No charge Not covered Durable Medical Equipment No charge Not covered Prosthetic Devices No charge Not covered 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. • 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 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. 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# Page 6 of 8 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# Page 7 of 8 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 หมายเหตุส าคัญ: 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) 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# Page 8 of 8 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, a ge, disability, or sex, you can file a complaint, also known as a gr ievance. 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. Questions: (855) 333-5730 or visit us at www.anthem.com/ca CA/LG/San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO//01-01-2022 Page 1 of 8 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) - County of Fresno: Custom EPO 1000 Your Network: EPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $0 person Not covered Out-of-Pocket Limit $4,000 person / $8,000 family Not covered 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). Preventive Care / Screening / Immunization No charge Not covered Preventive Care for Chronic Conditions per IRS guidelines No charge Not covered Virtual Care (Telemedicine / Telehealth Visits) Virtual Visits - Online visits with Doctors who also provide services in person Primary Care (PCP) $35 copay per visit Not covered Mental Health and Substance Use Disorder care $35 copay per visit Not covered Specialist $35 copay per visit Not covered 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 $35 copay per visit Not covered Specialist Care $35 copay per visit Not covered Visits in an Office Primary Care (PCP) $35 copay per visit Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Specialist Care $35 copay per visit Not covered Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No Charge Not covered Retail Health Clinic $35 copay per visit Not covered Manipulation Therapy Coverage is limited to 40 visits per benefit period. $35 copay per visit Not covered Acupuncture $35 copay per visit Not covered Other Services in an Office Allergy Testing No charge Not covered Chemo/Radiation Therapy No charge Not covered Dialysis/Hemodialysis No charge Not covered Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. No charge Not covered Surgery No charge Not covered Diagnostic Services Lab Office No charge Not covered Freestanding Lab No charge Not covered Outpatient Hospital No charge Not covered X-Ray Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Not covered Freestanding Radiology Center No charge Not covered Outpatient Hospital No charge Not covered Emergency and Urgent Care Urgent Care $35 copay per visit Not covered Emergency Room Facility Services Copay waived if admitted. $300 copay per visit Covered as In-Network Emergency Room Doctor and Other Services No charge Covered as In-Network Ambulance No charge Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit $35 copay per visit Not covered Facility Visit Facility Fees No charge Not covered Doctor Services No charge Not covered Outpatient Surgery Facility Fees Hospital No charge Not covered Freestanding Surgical Center No charge Not covered Doctor and Other Services Hospital No charge Not covered Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees $1,000 copay per admission Not covered Doctor and other services No charge Not covered Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. $35 copay per visit Not covered Rehabilitation services Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 days combined per benefit period. Office $35 copay per visit Not covered Outpatient Hospital No charge Not covered Cardiac rehabilitation Office $35 copay per visit Not covered Outpatient Hospital No charge Not covered Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. No charge Not covered Inpatient Hospice No charge Not covered Durable Medical Equipment No charge Not covered Prosthetic Devices No charge Not covered 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. • 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 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. 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# Page 6 of 8 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 i mpairments. 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# Page 7 of 8 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 tulo ng, mangyaring tumawag kaagad sa 1-888-254-2721. (TTY/TDD: 711) Thai หมายเหตุส าคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ ้าหน ้าที่มาอ่านให ้ท่านฟังได ้ ท่านยังอาจให ้เจ้าหน ้าที่ช่วยเข ียนจดหมายในภาษาของท่านอีกด ้วย หากต ้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย โปรดโทรต ิดต่อที่หมายเลข 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) 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# Page 8 of 8 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 discrim inate, 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 as sistance 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. Page 1 of 9 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) County of Fresno: PPO 250 Your Network: Prudent Buyer PPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $250 person / $500 family $250 person / $500 family Out-of-Pocket Limit $3,000 person / $5,000 family $10,000 person / $15,000 family When more than a single person is enrolled, the per person deductible does not apply and the family deductible must be met by any one person or collection of persons, but each is capped at his or her per person out -of-pocket maximum for covered services applied to the family deductible. 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 50% coinsurance after medical deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 50% coinsurance after medical 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 a PCP $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Mental Health and Substance Abuse care by Providers other than a PCP $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Page 2 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Specialist $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met 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 $20 copay per visit medical deductible does not apply Specialist Care $20 copay per visit medical deductible does not apply Visits in an Office Primary Care (PCP) $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Specialist Care $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Retail Health Clinic $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Manipulation Therapy Coverage is limited to 24 visits per benefit period. 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Acupuncture Coverage is limited to 12 visits per benefit period. 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Other Services in an Office Allergy Testing 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Page 3 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Chemo/Radiation Therapy 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Dialysis/Hemodialysis 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Surgery 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Diagnostic Services Lab Office 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Freestanding Lab 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met X-Ray Office 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Freestanding Radiology Center 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Page 4 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Freestanding Radiology Center 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Emergency and Urgent Care Urgent Care $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Emergency Room Facility Services $100 deductible waived if admitted directly from ER. 0% coinsurance after medical deductible is met Covered as In-Network Emergency Room Doctor and Other Services 0% coinsurance after medical deductible is met Covered as In-Network Ambulance 0% coinsurance after medical deductible is met Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit $20 copay per visit medical deductible does not apply 50% coinsurance after medical deductible is met Facility Visit Facility Fees 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Doctor Services 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Page 5 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Outpatient Surgery Facility Fees Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Freestanding Surgical Center 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Doctor and Other Services Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Doctor and other services 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Rehabilitation services Coverage for physical therapy and occupational therapy is limited to 24 visits combined per benefit period. Chiropractic visits count towards your physical and occupational therapy limits. Office 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Page 6 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Outpatient Hospital 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Inpatient Hospice 0% coinsurance after medical deductible is met 0% coinsurance after medical deductible is met Durable Medical Equipment 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met Prosthetic Devices 0% coinsurance after medical deductible is met 50% coinsurance after medical deductible is met 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 service for Non-Network Providers. Includes Diagnostic Services, X-ray, Surgery, Rehabilitation, Habilitation, and Cardiac Therapy. This also includes Surgery at Freestanding Facilities. Inpatient Hospital/Residential Treatment Centers $500 per service for Non-Network Providers (waived for Emergency Admissions). •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 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. 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# Page 7 of 9 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# Page 8 of 9 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 หมายเหตุส าคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ ้าหน ้าที่มาอ่านให ้ท่านฟังได ้ ท่านยังอาจให ้เจ้าหน ้าที่ช่วยเข ียนจดหมายในภาษาของท่านอีกด้วย หากต ้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย โปรดโทรต ิดต่อที่หมายเลข 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) 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# Page 9 of 9 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 l anguage 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. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees 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: (855) 333-5730 or visit us at www.anthem.com/ca CA/LG/San Joaquin Valley Insurance Authority (JPA)- County of Fresno: Modified Anthem PPO Health Savings Account (HSA-H)/48C5/01-01-2022 Page 1 of &quot Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA)- County of Fresno: Anthem PPO (HSA) 1500 Your Network: Prudent Buyer PPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $1,500 person / $2,800 member/ $3,000 family $1,500 person / $2,800 member/ $3,000 family Out-of-Pocket Limit $3,000 person / $3,000 member/ $5,000 family $10,000 person / $10,000 member/ $15,000 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 and out-of-pocket maximum amounts are separate 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 a PCP 20% coinsurance after deductible is met 40% coinsurance after deductible is met Mental Health and Substance Abuse care by Providers other than a PCP 20% coinsurance after deductible is met 40% coinsurance after deductible is met Page 2 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Specialist 20% coinsurance after deductible is met 40% coinsurance after deductible is met 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 20% coinsurance after deductible is met Specialist Care 20% coinsurance after deductible is met Visits in an Office Primary Care (PCP) 20% coinsurance after deductible is met 40% coinsurance after deductible is met Specialist Care 20% coinsurance after deductible is met 40% coinsurance after deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) 20% coinsurance after deductible is met 40% coinsurance after deductible is met Retail Health Clinic 20% coinsurance after deductible is met 40% coinsurance after deductible is met Manipulation Therapy Coverage is limited to 24 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met Acupuncture Coverage is limited to 12 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met Other Services in an Office Allergy Testing 20% coinsurance after deductible is met 40% coinsurance after deductible is met Chemo/Radiation Therapy 20% coinsurance after deductible is met 40% coinsurance after deductible is met Dialysis/Hemodialysis 20% coinsurance after deductible is met 40% coinsurance after deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 30% coinsurance after deductible is met 40% coinsurance after deductible is met Surgery 20% coinsurance after deductible is met 40% coinsurance after deductible is met Page 3 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Diagnostic Services Lab Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met Freestanding Lab 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met X-Ray Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met Freestanding Radiology Center 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met Freestanding Radiology Center 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Emergency and Urgent Care Urgent Care 20% coinsurance after deductible is met 40% coinsurance after deductible is met Emergency Room Facility Services 20% coinsurance after deductible is met Covered as In-Network Emergency Room Doctor and Other Services 20% coinsurance after deductible is met Covered as In-Network Ambulance 20% coinsurance after deductible is met Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit 20% coinsurance after deductible is met 40% coinsurance after deductible is met Page 4 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Facility Visit Facility Fees 20% coinsurance after deductible is met 40% coinsurance after deductible is met Doctor Services 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Freestanding Surgical Center 20% coinsurance after deductible is met 40% coinsurance after deductible is met Doctor and Other Services Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees 20% coinsurance after deductible is met 40% coinsurance after deductible is met Doctor and other services 20% coinsurance after deductible is met 40% coinsurance after deductible is met Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met Rehabilitation services Coverage for rehabilitative and habilitative physical therapy and occupational therapy combined is limited to 24 visits per benefit period. Chiropractic visits count towards your physical and occupational therapy limits Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office 20% coinsurance after deductible is met 40% coinsurance after deductible is met Page 5 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Outpatient Hospital 20% coinsurance after deductible is met 40% coinsurance after deductible is met Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. 20% coinsurance after deductible is met 40% coinsurance after deductible is met Inpatient Hospice 20% coinsurance after deductible is met 40% coinsurance after deductible is met Durable Medical Equipment 20% coinsurance after deductible is met 40% coinsurance after deductible is met Prosthetic Devices 20% coinsurance after deductible is met 40% coinsurance after deductible is met Outpatient Prescription Drug Benefits Supply Limits2 ➢ Retail Pharmacy (participating and non-participating) 30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) ➢ Home Delivery 90-day supply ➢ Specialty Pharmacy 30-day supply 1 Insured person remains responsible for the costs in excess of the prescription drug maximum amount allowed. 2 Supply limits for certain drugs may be different. Please refer to the Certificate of Insurance for complete information. Covered Services Traditional Health Coverage Insured Person Copay In-Network Out-of-Network (Insured is also responsible for charges in excess of the prescription drug maximum allowed amount) ➢ Preventive immunizations administered by a retail pharmacy - No copay (deductible waived) ➢ Female oral contraceptives generic and single source brand, No copay (deductible waived) ➢ Flu, Zostavax & Pneumococcal vaccines No copay ➢ Retail pharmacy prescription drug maximum allowed amount 20% ➢ Home Delivery prescription drug maximum allowed amount 20% ➢ Specialty pharmacy drugs (obtained through specialty pharmacy program) 20% 40%1 Not applicable Not applicable Page 6 of 9 The Outpatient Prescription Drug Benefit covers the following: ➢All eligible immunizations administered by a participating retail pharmacy. ➢Outpatient prescription drugs and medications which the law restricts to sale by prescription. ➢Formulas prescribed by a physician for the treatment of phenylketonuria. ➢Insulin ➢Syringes when dispensed for use with insulin and other self-injectable drugs or medications ➢All FDA-approved contraceptives for women, including oral contraceptives; contraceptive diaphragms and over-the-counter contraceptives prescribed by a doctor. ➢Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person. ➢Drugs that have Food and Drug Administration (FDA) labeling for self-administration ➢All compound prescription drugs that contain at least one covered prescription ingredient ➢Diabetic supplies (i.e., test strips and lancets) ➢Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non -psychological) causes. ➢Inhaler spacers and peak flow meters for the treatment of pediatric asthma. ➢Smoking cessation products requiring a physician’s prescription. ➢Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary. ➢Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist 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 service for Non-Network Providers. Includes Diagnostic Services, X-ray, Surgery, Rehabilitation, Habilitation, and Cardiac Therapy. This also includes Surgery at Freestanding Facilities. •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 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. 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# Page 7 of 9 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# Page 8 of 9 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 หมายเหตุส าคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ ้าหน ้าที่มาอ่านให ้ท่านฟังได ้ ท่านยังอาจให ้เจ้าหน ้าที่ช่วยเข ียนจดหมายในภาษาของท่านอีกด ้วย หากต ้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย 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) 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# Page 9 of 9 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, a ge, 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. Page 1 of 9 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA)- County of Fresno: Anthem PPO (HSA) 3000 Your Network: Prudent Buyer PPO Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Overall Deductible $3,000 person / $6,000 family $3,000 person / $6,000 family Out-of-Pocket Limit $3,000 person / $6,000 family $5,000 person / $10,000 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 and out-of-pocket maximum amounts are separate and do not accumulate toward each other. Preventive Care / Screening / Immunization No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 50% 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 a PCP 0% coinsurance after deductible is met 50% coinsurance after deductible is met Mental Health and Substance Abuse care by Providers other than a PCP 0% coinsurance after deductible is met 50% coinsurance after deductible is met Specialist 0% coinsurance after deductible is met 50% coinsurance after deductible is met Virtual Visits from Online Provider LiveHealth Online via www.livehealthonline.com; our mobile app, website or Anthem-enabled device Page 2 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Primary Care (PCP) and Mental Health and Substance Use Disorder 0% coinsurance after deductible is met Specialist Care 0% coinsurance after deductible is met Visits in an Office Primary Care (PCP) 0% coinsurance after deductible is met 50% coinsurance after deductible is met Specialist Care 0% coinsurance after deductible is met 50% coinsurance after deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) 0% coinsurance after deductible is met 50% coinsurance after deductible is met Retail Health Clinic 0% coinsurance after deductible is met 50% coinsurance after deductible is met Manipulation Therapy Coverage is limited to 24 visits per benefit period. 0% coinsurance after deductible is met 50% coinsurance after deductible is met Acupuncture Coverage is limited to 12 visits per benefit period. 0% coinsurance after deductible is met 50% coinsurance after deductible is met Other Services in an Office Allergy Testing 0% coinsurance after deductible is met 50% coinsurance after deductible is met Chemo/Radiation Therapy 0% coinsurance after deductible is met 50% coinsurance after deductible is met Dialysis/Hemodialysis 0% coinsurance after deductible is met 50% coinsurance after deductible is met Prescription Drugs Dispensed in the office Maximum of $250 member cost share per drug. 30% coinsurance after deductible is met 50% coinsurance after deductible is met Surgery 0% coinsurance after deductible is met 50% coinsurance after deductible is met Diagnostic Services Lab Office 0% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Lab 0% coinsurance after deductible is met 50% coinsurance after deductible is met Page 3 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Outpatient Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met X-Ray Office 0% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Radiology Center 0% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office 0% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Radiology Center 0% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Emergency and Urgent Care Urgent Care 0% coinsurance after deductible is met 50% coinsurance after deductible is met Emergency Room Facility Services 0% coinsurance after deductible is met Covered as In-Network Emergency Room Doctor and Other Services 0% coinsurance after deductible is met Covered as In-Network Ambulance 0% coinsurance after deductible is met Covered as In-Network Outpatient Mental Health and Substance Use Disorder Doctor Office Visit 0% coinsurance after deductible is met 50% coinsurance after deductible is met Facility Visit Facility Fees 0% coinsurance after deductible is met 50% coinsurance after deductible is met Doctor Services 0% coinsurance after deductible is met 50% coinsurance after deductible is met Page 4 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Outpatient Surgery Facility Fees Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Freestanding Surgical Center 0% coinsurance after deductible is met 50% coinsurance after deductible is met Doctor and Other Services Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder) Facility Fees 0% coinsurance after deductible is met 50% coinsurance after deductible is met Doctor and other services 0% coinsurance after deductible is met 50% coinsurance after deductible is met Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. 0% coinsurance after deductible is met 50% coinsurance after deductible is met Rehabilitation services Coverage for rehabilitative and habilitative physical therapy and occupational therapy combined is limited to 24 visits per benefit period. Chiropractic visits count towards your physical and occupational therapy limits Office 0% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Cardiac rehabilitation Coverage is limited to 36 visits per benefit period. Office 0% coinsurance after deductible is met 50% coinsurance after deductible is met Outpatient Hospital 0% coinsurance after deductible is met 50% coinsurance after deductible is met Page 5 of 9 Covered Medical Benefits Cost if you use an In- Network Provider Cost if you use a Non-Network Provider Skilled Nursing Care (facility) Coverage is limited to 100 days per benefit period. 0% coinsurance after deductible is met 50% coinsurance after deductible is met Inpatient Hospice 0% coinsurance after deductible is met 50% coinsurance after deductible is met Durable Medical Equipment 0% coinsurance after deductible is met 50% coinsurance after deductible is met Prosthetic Devices 0% coinsurance after deductible is met 50% coinsurance after deductible is met Covered Services Traditional Health Coverage Insured Person Copay In-Network Out-of-Network (Insured is also responsible for charges in excess of the prescription drug maximum allowed amount) Outpatient Prescription Drug Benefits ➢ Preventive immunizations administered by a retail pharmacy No copay (deductible waived) ➢ ➢ Female oral contraceptives generic and single source brand, Flu, Zostavax & Pneumococcal vaccines No copay (deductible waived) No copay ➢ Retail pharmacy prescription drug maximum allowed amount No copay 50%1 ➢ Home Delivery prescription drug maximum allowed amount No copay Not applicable ➢ Specialty pharmacy drugs (obtained through specialty pharmacy program) No copay Not applicable Supply Limits2 ➢ Retail Pharmacy (participating and non-participating) 30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) ➢ Home Delivery 90-day supply 1 Insured person remains responsible for the costs in excess of the prescription drug maximum amount allowed. 2 Supply limits for certain drugs may be different. Please refer to the Certificate of Insurance for complete information. Page 6 of 9 The Outpatient Prescription Drug Benefit covers the following: ➢ All eligible immunizations vaccines administered by a participating retail pharmacy. ➢ Outpatient prescription drugs and medications which the law restricts to sale by prescription. ➢ Formulas prescribed by a physician for the treatment of phenylketonuria. ➢ Insulin ➢ Syringes when dispensed for use with insulin and other self-injectable drugs or medications ➢ All FDA-approved contraceptives for women, including oral contraceptives; contraceptive diaphragms and over-the-counter contraceptives prescribed by a doctor. ➢ Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or insured person. ➢ Drugs that have Food and Drug Administration (FDA) labeling for self-administration ➢ All compound prescription drugs that contain at least one covered prescription ingredient ➢ Diabetic supplies (i.e., test strips and lancets) ➢ Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. ➢ Inhaler spacers and peak flow meters for the treatment of pediatric asthma. ➢ Smoking cessation products requiring a physician’s prescription. ➢ Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription drug formulary. ➢ Flu, Zostavax & Pneumococcal vaccines obtained at a local network pharmacy must be administered by a pharmacist 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 service for Non-Network Providers. Includes Diagnostic Services, X-ray, Surgery, Rehabilitation, Habilitation, and Cardiac Therapy. This also includes Surgery at Freestanding Facilities. • 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 wh en a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. This summary of benefits is a brief outline of coverage, designed to help you with t he 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. 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# Page 7 of 9 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 i mpairments. 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# Page 8 of 9 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 ਤੁਸ􁶣 ਇਹ ਪੱਤਰ ਪੜਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹ􁶣, ਤਾਂ ਅਸ􁶣 ਇਸ ਨੂੂੰ ਪੜਹ੍ ਿ ਵੱਚ ਤੁਹਾਡੀ ਮਦਦ ਲਈ ਿ ਕਸੇ ਨੂੂੰ ਬੁਲਾ ਸਕਦਾ ਹਾਂ ਤੁਸ􁶣 ਸ਼ਾਇਦ ਪੱਤਰ ਨੂੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿ ਵੱਚ ਿ ਿਲਖਆ ਹੋਇਆ ਵਬੀ ਪਰ੍ ਾਪ ਾ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 หมายเหตุส าคัญ: ท่านสามารถอ่านจดหมายฉบับนี้หรือไม่ หากท่านไม่สามารถอ่านจดหมายฉบับนี้ เราสามารถจัดหาเจ ้าหน ้าที่มาอ่านให ้ท่านฟังได ้ ท่านยังอาจให ้เจ้าหน ้าที่ช่วยเข ียนจดหมายในภาษาของท่านอีกด ้วย หากต ้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย โปรดโทรต ิดต่อที่หมายเลข 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) 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# Page 9 of 9 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, a ge, 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. EmpiRx Health Member Services 877-262-7435; TDD: 1-888-907-0020 24 hours a day, 7 days a week Frequently Asked Questions How do I find a participating network pharmacy? You can use your EmpiRx Health ID card at over 68,000 pharmacies nationwide including all pharmacy chains. You can find a network pharmacy by logging onto www.empirxhealth.com or calling 877-262-7435. What is a prior authorization and why is it necessary? Certain medications require prior authorization (PA) because of their potential side effects, potentially harmful interactions with other prescription medications, or to confirm they are being prescribed in accordance with Food & Drug Administration (FDA) approved indications. This process is designed to help ensure your health and safety. If a PA is needed, EmpiRx Health will work directly with your physician to obtain the necessary information prior to fulfillment. How do I find out if a particular prescription is covered by my benefits? Call 877-262-7435 to speak to a representative who can assist you with drug coverage questions or log onto www.empirxhealth.com for details. How can I find out if generic or lower cost alternatives may be available to me? Log into the member portal at www.empirxhealth.com and select “Drug Pricing.” Search your medication and if there is a generic available, you will see the cost for both the brand as well as the generic. You can also call 877-262-7435 to speak to a representative who can assist you, or consult your physician or pharmacist to determine if generic equivalents are available for your prescription. Why does my copay change from month to month? The cost of medications changes regularly and prices are not all the same at each pharmacy. If your copay is based on a percentage rather than a fixed dollar amount then depending on the pharmacy you use and the cost of the medication at the time your prescription is filled, you may see a variation in your copay amount. This brochure is only a general description of your prescription benefit program and it is not a contract. All benefits described herein are subject to the terms, conditions and limitations of the group master contract and applicable law. All personal health information is kept strictly confidential, as required by the privacy rules of the Health Insurance Portability and Accountability Act. Logos are service marks of EmpiRx Health. CDPK.90.1800.000 Standard Brochure 1.2017 SJVIA County of Fresno Prescription Benefit Plan Your Prescription Benefit Program Annual Maximum Out of Pocket Amount Your plan includes a $2,000 individual / $4,000 family annual maximum out of pocket amount. Retail Pharmacy Copayment You are responsible to pay the retail pharmacist the copayment per prescription which is listed below: 30-Day Supply 90-Day Supply $10.00 for a Generic Medication $20.00 for a Generic Medication $20.00 for a Preferred Brand Medication $40.00 for a Preferred Brand Medication $35.00 for a Non-Preferred Brand Medication $70.00 for a Non-Preferred Brand Medication This is a Dispense As Written Plan (DAW), meaning your pharmacist must dispense the generic equivalent drug when one is available unless your physician specifically requests the brand be dispensed. If you request the brand name medication from your pharmacist, you are responsible for the difference in cost between the brand and the generic plus the copayment. Retail quantities will be dispensed according to your physician’s instructions written on the prescription up to a maximum of a 90-day supply. Please Note: If the cost of your medication is less than your calculated copayment, you will only pay the cost of the medication. Mail Order Pharmacy Copayment Maintenance medications can be submitted to Benecard Central Fill, the EmpiRx Health mail order facility. Your plan allows for up to a 90-day supply with three (3) refills, according to your physician’s instructions. Your copay amount will be: $15.00 for a Generic Medication $30.00 for a Preferred Brand Medication $60.00 for a Non-Preferred Brand Medication Specialty Medication Copayment Specialty medications are high-cost biotechnology drugs requiring special distribution, handling, and administration. These medications are typically designed to treat chronic diseases. $10.00 for a Generic Specialty Medication $20.00 for a Preferred Brand Specialty Medication $35.00 for a Non-Preferred Brand Specialty Medication Specialty medications can be filled one (1) time at a retail pharmacy. All future prescriptions must be obtained at Benecard Central Fill’s Specialty Pharmacy. Please note that specialty medications are limited to a 30-day supply. Online Member Tools Maximize your benefit and find out how you can save on your out-of-pocket costs with our valuable member resource tools online at www.empirxhealth.com including: •Plan coverage details and copay information •Network pharmacy finder •Mail service access to request refills and check order status •Updated preferred medication list •Drug comparison pricing tool to identify lower cost alternatives •Drug information •Recent personal drug utilization history including the amount you have paid and what the plan has paid on your behalf. This is helpful for year-end tax purposes Registration is easy! Along with your EmpiRx Health ID card, you will need basic member information, a phone number and an email address. Refer to our website periodically for the most recent pharmacy network finder and preferred medication list. Retail Pharmacy Network Your EmpiRx Health prescription benefit program provides you with access to an extensive national pharmacy network, including all chain pharmacies and most independents. This plan allows for a 90-day supply of maintenance medications. Your ID card provides all the information your pharmacist will need to process your prescription through EmpiRx Health. To locate a participating network pharmacy, log onto www.empirxhealth.com or call EmpiRx Health Member Services toll-free at 877-262-7435 (TDD: 1-888-907-0020). Mail Order Pharmacy The EmpiRx Health mail service pharmacy, Benecard Central Fill, is an option for you to obtain maintenance medications. Typically, prescriptions filled through mail service include medications used to treat chronic conditions and are written for up to a 90-day supply, plus refills. Prescriptions that you need to use right away should always be taken to your local pharmacy. You do have the option to obtain 90-day supplies through the retail network. For your first order, complete the enclosed Mail Service Order Form and mail it along with your original prescription using the pre-addressed envelope provided to Benecard Central Fill. You can also have your physician submit your prescription electronically to Benecard Central Fill or fax your prescription to 1-888-907-0040. Be sure that your physician includes the cardholder name, ID number, shipping address, and patient’s date of birth. Only prescriptions faxed from a doctor’s office will be accepted via fax. To order refills you have three options: • Internet: Visit www.empirxhealth.com. If you have not yet registered, click on Register. If you are a registered user, log in and select Mail Order. • Phone: Call Member Services toll-free, 877-262-7435, 24 hours a day, 7 days a week and use the prompts to order your refills. Have your identification number and credit card information ready. • Mail: Send the Refill Request Order Form provided with your last shipment back to Benecard Central Fill mail service in the pre-addressed envelope EmpiRx Health does NOT automatically refill your prescriptions. To avoid delays, always include the appropriate copayment (if applicable) when your order is placed. Visa, MasterCard, Discover, or American Express and debit cards are accepted. You may also pay by check or money order made payable to Benecard Central Fill. Please do not send cash. Please allow up to two (2) weeks for delivery. Emergency prescriptions can be expedited at an additional charge. Preferred Medication List The Preferred Medication List is a guide for selecting clinically and therapeutically appropriate medications. It should not take the place of a physician’s or pharmacist’s judgment with regard to a patient’s pharmaceutical care. Refer to www.empirxhealth.com for the most recent version of the Preferred Medication List. Exclusions Your prescription program covers most Medically Necessary, Federal Legend, State Restricted and Compounded Medications which, by law, may not be dispensed without a prescription. Be sure to present your EmpiRx Health ID card at a participating network pharmacy to receive a discount off the retail price of medications that may not be covered. Specialty Pharmacy Specialty pharmaceuticals are typically produced through biotechnology, administered by injection, and/or require special handling and patient monitoring. Through the Specialty Pharmacy, you receive personalized attention to help you manage your medical condition including one-on-one counseling with our team of pharmacists and trained medical professionals. Our clinical team partners with you and your prescribing doctor to ensure you understand: • How to manage your condition • What medications you have been prescribed • How to take your medication • What lower cost options may be available • How to coordinate delivery of your medication • How to safely handle and store your medication Shipments will arrive in secure, temperature-controlled packaging (if necessary) and will include everything you will need to take your medication. Due to the sensitive nature of specialty medications, some packages may require a signature. Where Can I Ship My Medications? We offer the convenience you need. Your medication can be shipped directly to: • Your home • Your work • Your doctor’s office • Or a convenient location of your choice Save with Generic Medications Generic equivalent drugs must meet the same Food & Drug Administration (FDA) standards for purity, strength, and safety as brand name drugs. They also must have the same active ingredients and identical absorption rate within the body as the brand name version. If you wish to take advantage of this savings opportunity, speak with your physician about the use of generics. You may also consult with your pharmacist regarding generic drug options that may be available to you. ID Cards If your ID card is lost, you may print a temporary card online at www.empirxhealth.com. If there is an emergency and you need a prescription filled, call EmpiRx Health Member Services toll-free at 877-262-7435 (TDD: 1-888-907-0020) and we will provide your pharmacist with the required information to facilitate processing the claim. Direct Member Reimbursement If you must pay out-of-pocket for your medication which is covered by your plan, submit a Direct Member Reimbursement Form, which is available online at www.empirxhealth.com. You will need to provide an itemized receipt showing: the amount charged, prescription number, medication dispensed, manufacturer, dosage form, strength, quantity, and date dispensed. Your pharmacist can assist you if you do not have a detailed receipt. Direct reimbursement is based upon your plan benefits and the amount reimbursed may be significantly lower than the retail price you paid; therefore, always try to use a participating network pharmacy and present your ID card to reduce any unnecessary out-of-pocket expenses. Benefit Summary 8974.61.1.S000641782 - TRADITIONAL HMO (continues) 580 SJVIA - CO OF FRESNO (SAN JOAQUIN VALLEY INSURANCE AUTHORITY) Principal Benefits for Kaiser Permanente Traditional HMO Plan (1/1/22—12/31/22) Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. Amounts Per Accumulation Period Self-Only Coverage (a Family of one Member) Family Coverage Each Member in a Family of two or more Members Family Coverage Entire Family of two or more Members Plan Out-of-Pocket Maximum $1,000 $1,000 $2,000 Plan Deductible None None None Drug Deductible None None None Professional Services (Plan Provider office visits)You Pay Most Primary Care Visits and most Non-Physician Specialist Visits .......................... $15 per visit Most Physician Specialist Visits................................................................................. $15 per visit Routine physical maintenance exams, including well-woman exams ........................ No charge Well-child preventive exams (through age 23 months) .............................................. No charge Family planning counseling and consultations........................................................... No charge Scheduled prenatal care exams ................................................................................ No charge Routine eye exams with a Plan Optometrist .............................................................. No charge Urgent care consultations, evaluations, and treatment .............................................. $15 per visit Most physical, occupational, and speech therapy ..................................................... $15 per visit Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures ...................................... $15 per procedure Allergy antigens (including administration) ................................................................ $3 per visit Most immunizations (including the vaccine) .............................................................. No charge Most X-rays and laboratory tests ............................................................................... No charge Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs .............. No charge Emergency Health Coverage You Pay Emergency Department visits .................................................................................... $100 per visit Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the Emergency Department Cost Share (see “Hospitalization Services” for inpatient Cost Share) Ambulance Services You Pay Ambulance Services .................................................................................................. No charge Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy ..................................................... $10 for up to a 30-day supply Most generic (Tier 1) refills through our mail-order service .................................... $20 for up to a 100-day supply Most brand-name items (Tier 2) at a Plan Pharmacy ............................................. $20 for up to a 30-day supply Most brand-name (Tier 2) refills through our mail-order service ............................. $40 for up to a 100-day supply Most specialty items (Tier 4) at a Plan Pharmacy .................................................. $20 for up to a 30-day supply Durable Medical Equipment (DME) You Pay DME items as described in the EOC ......................................................................... No charge Mental Health Services You Pay Inpatient psychiatric hospitalization ........................................................................... No charge Individual outpatient mental health evaluation and treatment .................................... $15 per visit Group outpatient mental health treatment ................................................................. $7 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification ............................................................................................... No charge Individual outpatient substance use disorder evaluation and treatment .................... $15 per visit Group outpatient substance use disorder treatment .................................................. $5 per visit Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ................................... No charge Benefit Summary (continued) 8974.61.1.S000641782 - TRADITIONAL HMO 8974.61.1.S000641782 Other You Pay Eyeglasses or contact lenses every 24 months ......................................................... Amount in excess of $175 Allowance Hearing aids every 36 months ................................................................................... Amount in excess of $1,000 Allowance per aid Skilled nursing facility care (up to 100 days per benefit period) ................................. No charge Prosthetic and orthotic devices as described in the EOC .......................................... No charge Services to diagnose or treat infertility and artificial insemination (such as outpatient procedures or laboratory tests) as described in the EOC ........................................ the Cost Share you would pay if the Services were to treat any other condition Assisted reproductive technology (“ART”) Services .................................................. Not covered Hospice care.............................................................................................................. No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). SEE HEALTHY AND LIVE HAPPY WITH HELP FROM COUNTY OF FRESNO AND VSP. As a VSP® member, you get personalized care from a VSP network doctor at low out-of-pocket costs. VALUE AND SAVINGS YOU LOVE. Save on eyewear and eye care when you see a VSP network doctor. Plus, take advantage of Exclusive Member Extras for additional savings. PROVIDER CHOICES YOU WANT. With an average of five VSP network doctors within six miles of you, it’s easy to find a nearby in-network doctor. Plus, maximize your coverage with bonus offers and additional savings that are exclusive to Premier Program locations. Like shopping online? Go to eyeconic.com and use your vision benefits to shop over 50 brands of contacts, eyeglasses, and sunglasses. QUALITY VISION CARE YOU NEED. You’ll get great care from a VSP network doctor, including a WellVision Exam®—a comprehensive exam designed to detect eye and health conditions. PROVIDER NETWORK: VSP Choice EFFECTIVE DATE: 01/01/2022 COPAYDESCRIPTIONBENEFIT YOUR COVERAGE WITH A VSP PROVIDER $10WELLVISION EXAM Focuses on your eyes and overall wellness Every 12 months $10PRESCRIPTION GLASSES Included in Prescription GlassesFRAME $170 featured frame brands allowance $150 frame allowance 20% savings on the amount over your allowance $80 Costco® frame allowance Every 24 months Included in Prescription GlassesLENSES Single vision, lined bifocal, and lined trifocal lenses Impact-resistant lenses for dependent children Every 12 months $0 LENS ENHANCEMENTS Standard progressive lenses $95 - $105Premium progressive lenses $150 - $175Custom progressive lenses Average savings of 30% on other lens enhancements Every 12 months Up to $60 CONTACTS (INSTEAD OF GLASSES) $150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Every 12 months $0 PRIMARY EYECARESM Retinal screening for members with diabetes $20 per examAdditional exams and services for members with diabetes, glaucoma, or age-related macular degeneration. Treatment and diagnoses of eye conditions, including pink eye, vision loss, and cataracts available for all members. Limitations and coordination with your medical coverage may apply. Ask your VSP doctor for details. As needed Glasses and Sunglasses EXTRA SAVINGS Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Routine Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities YOUR COVERAGE WITH OUT-OF-NETWORK PROVIDERS Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details. VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP does business. Contact us: 800.877.7195 or vsp.com Classification: Restricted ©2021 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, Eyeconic, and WellVision Exam are registered trademarks, and VSP Diabetic Eyecare Plus Program is a service mark of Vision Service Plan. All other brands or marks are the property of their respective owners. 45943 VCCM A LOOK AT YOUR VSP VISION COVERAGE BOARD OF DIRECTORS STEVE BRANDAU NATHAN MAGSIG BUDDY MENDES LARRY MICARI BRIAN PACHECO AMY SHUKLIAN PETE VANDER POEL Exhibit B County of Fresno Plan Year 2022 Rates