Questions: Call (855) 383-7248 or visit us at www.anthem.com/ca CA/S/F/Anthem Gold PPO 500/20%/4500/1ZHT/NA/01-16

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov or call (855) 383-7248 to request a copy.

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Anthem Blue Cross of CaliforniaAnthem Gold PPO 500/20%/4500Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2016 – 12/31/2016

Coverage for: Individual + Family | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan

document at https://eoc.anthem.com/eocdps/ca/1ZHTSMG01012016 or by calling (855) 383-7248.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$500 person / $1,500 family forIn-Network Providers. Doesnot apply to Prescription Drugs,Preventive Care, Primary Carevisit, and Specialist visit. $1,000person / $2,000 family for Out-of-Network Providers. Doesnot apply to Prescription Drugs.

You must pay all costs up to the deductible amount before this plan begins to pay for

covered services you use. Check your policy or plan document to see when the deductible

starts over (usually, but not always, January 1st). See the chart starting on page 3 for how

much you pay for covered services after you meet the deductible.

Are there other

deductibles for specificservices?

Yes; $250 person / $500 familyfor In-Network and Non-Network Providers combinedTier 2, Tier 3 and Tier 4Prescription Drugs. There areno other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount

before this plan begins to pay for these services.

Is there anout–of–pocket limit onmy expenses?

Yes; $4,500 person / $9,000family for In-NetworkProviders. $9,000 person /$18,000 family for Out-of-Network Providers.

The out-of-pocket limit is the most you could pay during a coverage period (usually one

year) for your share of the cost of covered services. This limit helps you plan for health care

expenses.

What is not included in

the out–of–pocketlimit?

Premiums, Balance-Billedcharges, and Health Care thisplan doesn't cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Is there an overallannual limit on whatthe plan pays?

No.The chart starting on page 3 describes any limits on what the plan will pay for specific

covered services, such as office visits.

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Important Questions Answers Why this Matters:

Does this plan use anetwork of providers?

Yes, Prudent Buyer PPO.For a list of In-Networkproviders, seewww.anthem.com/ca or call(855) 383-7248. Dental andVision benefits may access adifferent network of providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all

of the costs of covered services. Be aware, your in-network doctor or hospital may use an

out-of-network provider for some services. Plans use the term in-network, preferred, or

participating for providers in their network. See the chart starting on page 3 for how this

plan pays different kinds of providers.

Do I need a referral tosee a specialist?

No; you do not need a referral

to see a specialist. You can see the specialist you choose without permission from this plan.

Are there services thisplan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 8. See your policy or plandocument for additional information about excluded services.

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· Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

· Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, ifthe plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change ifyou haven’t met your deductible.

· The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay andthe allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

· This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts

CommonMedical Event Services You May Need

Your Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

If you visit ahealth careprovider’s officeor clinic

Primary care visit to treat an injuryor illness

$30 copay per visitmedical deductible does

not apply

50% coinsurance aftermedical deductible is met

--------none--------

Specialist visit$60 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

--------none--------

Other practitioner office visit$30 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

--------none--------

Preventivecare/screening/immunization

No charge50% coinsurance after

medical deductible is met--------none--------

If you have a test

Diagnostic test (x-ray, blood work)

Lab – Office20% coinsurance aftermedical deductible is

metX-Ray – Office

20% coinsurance aftermedical deductible is

met

Lab – Office50% coinsurance after

medical deductible is metX-Ray – Office

50% coinsurance aftermedical deductible is met

Lab – Office--------none--------X-Ray – Office--------none--------

Imaging (CT/PET scans, MRIs)20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

Coverage for Non-Network Providersis limited to $800 maximum benefitper procedure.

If you need drugsto treat yourillness or

Tier1 - Typically Generic

$15 copay perprescription after

pharmacy deductible ismet (retail only) and

50% coinsurance afterpharmacy deductible ismet (retail only homedelivery not covered)

Covers up to a 30 day supply (retail

pharmacy). Covers up to a 90 day

supply (home delivery program). No

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CommonMedical Event Services You May Need

Your Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

condition

More informationabout prescriptiondrug coverage isavailable athttp://www.anthem.com/pharmacyinformation/

Anthem SelectDrug List

$38 copay perprescription after

pharmacy deductible ismet (home delivery

only)

coverage for non-formulary drugs.

Tier2 - Typically Preferred / Brand

$40 copay perprescription after

pharmacy deductible ismet (retail only) and

$120 copay perprescription after

pharmacy deductible ismet (home delivery

only)

50% coinsurance afterpharmacy deductible ismet (retail only homedelivery not covered)

Covers up to a 30 day supply (retailpharmacy). Covers up to a 90 daysupply (home delivery program). Nocoverage for non-formulary drugs.

Tier3 - Typically Non-Preferred /Specialty Drugs

$80 copay perprescription after

pharmacy deductible ismet (retail only) and

$240 copay perprescription after

pharmacy deductible ismet (home delivery

only)

50% coinsurance afterpharmacy deductible ismet (retail only homedelivery not covered)

Covers up to a 30 day supply (retailpharmacy). Covers up to a 90 daysupply (home delivery program). Nocoverage for non-formulary drugs.

Tier4 - Typically Specialty Drugs

25% coinsurance up to$250 after pharmacy

deductible is met (retailand home delivery)

50% coinsurance afterpharmacy deductible ismet (retail only homedelivery not covered)

Covers up to a 30 day supply (retailpharmacy). Covers up to a 30 daysupply (home delivery program). Nocoverage for non-formulary drugs.

If you haveoutpatient surgery

Facility fee (e.g., ambulatory surgerycenter)

20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

Coverage for Non-Network Providersis limited to $380 maximum benefitper admission.

Physician/surgeon fees20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

--------none--------

If you needimmediatemedical attention

Emergency room services

Emergency RoomPhysician Fee

20% coinsurance aftermedical deductible is

Emergency RoomPhysician Fee

Covered as In-NetworkEmergency Room

Emergency Room Physician Fee--------none--------Emergency Room Facility FeeCopay waived if admitted.

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CommonMedical Event Services You May Need

Your Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

metEmergency Room

Facility Fee$200 copay per visit andthen 20% coinsurance

medical deductible doesnot apply

Facility FeeCovered as In-Network

Emergency medical transportation20% coinsurance aftermedical deductible is

metCovered as In-Network --------none--------

Urgent care$100 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

--------none--------

If you have ahospital stay Facility fee (e.g., hospital room)

20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

Coverage for Non-Network Providersis limited to $650 maximum benefitper day.

Physician/surgeon fee20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

--------none--------

If you have mentalhealth, behavioralhealth, orsubstance abuseneeds

Mental/Behavioral health outpatientservices

Mental/BehavioralHealth Office Visit$30 copay per visit

medical deductible doesnot apply

Mental/BehavioralHealth Facility Visit -

Facility Charges20% coinsurance aftermedical deductible is

met

Mental/BehavioralHealth Office Visit

50% coinsurance aftermedical deductible is met

Mental/BehavioralHealth Facility Visit -

Facility Charges50% coinsurance after

medical deductible is met

Mental/BehavioralHealth Office Visit--------none--------Mental/BehavioralHealth Facility Visit - Facility Charges--------none--------

Mental/Behavioral health inpatientservices

Inpatient Facility Fee20% coinsurance aftermedical deductible is

metInpatient Physician

Fees20% coinsurance after

Inpatient Facility Fee50% coinsurance after

medical deductible is metInpatient Physician Fees50% coinsurance after

medical deductible is met

Inpatient Facility FeeCoverage for Non-Network Providersis limited to $650 maximum benefitper day.Inpatient Physician Fees--------none--------

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CommonMedical Event Services You May Need

Your Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

medical deductible ismet

Substance use disorder outpatientservices

Substance Use DisorderOffice Visit

$30 copay per visitmedical deductible does

not applySubstance Use DisorderOther Outpatient Items

and Services20% coinsurance aftermedical deductible is

met

Substance Use DisorderOffice Visit

50% coinsurance aftermedical deductible is metSubstance Use DisorderOther Outpatient Items

and Services50% coinsurance after

medical deductible is met

Substance Use Disorder Office Visit--------none--------Substance Use Disorder OtherOutpatient Items and Services--------none--------

Substance use disorder inpatientservices

Inpatient Facility Fee20% coinsurance aftermedical deductible is

metInpatient Physician

Fees20% coinsurance aftermedical deductible is

met

Inpatient Facility Fee50% coinsurance after

medical deductible is metInpatient Physician Fees50% coinsurance after

medical deductible is met

Inpatient Facility FeeCoverage for Non-Network Providersis limited to $650 maximum benefitper day.Inpatient Physician Fees--------none--------

If you arepregnant Prenatal and postnatal care

20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

--------none--------

Delivery and all inpatient services

Inpatient Facility Fee20% coinsurance aftermedical deductible is

metInpatient Physician

Fees20% coinsurance aftermedical deductible is

met

Inpatient Facility Fee50% coinsurance after

medical deductible is metInpatient Physician Fees50% coinsurance after

medical deductible is met

Inpatient Facility FeeCoverage for Non-Network Providersis limited to $650 maximum benefitper day. Applies to inpatient facility.Other cost shares may applydepending on services provided.Inpatient Physician Fees--------none--------

If you need helprecovering or haveother special

Home health care$30 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 100 visits per

7 of 12

CommonMedical Event Services You May Need

Your Cost if YouUse an In-NetworkProvider

Your Cost if YouUse an Non-NetworkProvider

Limitations & Exceptions

health needs benefit period. Coverage for Non-Network Providers is limited to $75maximum benefit per visit.

Rehabilitation services$30 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

--------none--------

Habilitation services$30 copay per visit

medical deductible doesnot apply

50% coinsurance aftermedical deductible is met

--------none--------

Skilled nursing care20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 100 days perbenefit period. Coverage for Non-Network Providers is limited to $150maximum benefit per day.

Durable medical equipment20% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

--------none--------

Hospice service0% coinsurance aftermedical deductible is

met

50% coinsurance aftermedical deductible is met

--------none--------

If your childneeds dental oreye care

Eye exam No charge No charge

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 1 exam perbenefit period.

Glasses No charge No charge

Coverage for In-Network Providersand Non-Network Providerscombined is limited to 1 unit perbenefit period.

Dental check-up No charge No charge

Coverage for In-Network Providers islimited to 2 visits per benefit period.Coverage for Non-Network Providersis limited to 2 visits per benefit period.

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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

· Cosmetic surgery

· Dental care (Adult)

· Hearing aids

· Infertility treatment

· Long-term care

· Non-Formulary drugs

· Routine foot care

· Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these

services.)

· Acupuncture

· Bariatric surgery

· Chiropractic care Coverage is limited to20 visits per benefit period.

· Most coverage provided outside theUnited States. Seewww.bcbs.com/bluecardworldwide

· Private-duty nursing Coverage is limitedto 100 visits per benefit period.

· Routine eye care (Adult) Coverage islimited to 1 exam per benefit period.

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Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you paywhile covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at (855) 383-7248. You may also contact your state insurance department, theU.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health andHuman Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact:

ATTN: Grievances and AppealsP.O. Box 4310Woodland Hills, CA 91365-4310

Department of Labor, EmployeeBenefits Security Administration(866) 444-EBSA (3272)www.dol.gov/ebsa/healthreform

Department of Managed Health CareCalifornia Help Center980 9th StreetSuite 500Sacramento, CA 95814-2725(888) HMO-2219

California Consumer AssistanceProgramOperated by the CaliforniaDepartment of Managed Health Care980 9th St, Suite #500Sacramento, CA 95814(888) 466-2219http://www.HealthHelp.ca.gov

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Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy doesprovide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). Thishealth coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:如果您是非會員並需要中文協助，請聯絡您的銷售代表或小組管理員。如果您已參保，則請使用您 ID 卡上的號碼聯絡客戶服務人員。

Doo bee a’tah ni’liigoo eí dooda’í, shikáa adoołwoł íínízinigo t’áá diné k’éjíígo, t’áá shoodí ba na’ałníhí ya sidáhí bich’į naabídííłkiid. Eí doo biigha daago niba’nija’go ho’aałagíí bich’į hodiilní. Hai’dąą iini’taago eíya, t’áá shoodí diné ya atáh halne’ígíí ní béésh bee hane’í wólta’ bi’ki si’niilígíí bi’kéhgo bich’į hodiilní.

Si no es miembro todavía y necesita ayuda en idioma español, le suplicamos que se ponga en contacto con su agente de ventas o con el administrador de sugrupo. Si ya está inscrito, le rogamos que llame al número de servicio de atención al cliente que aparece en su tarjeta de identificación.

Kung hindi ka pa miyembro at kailangan ng tulong sa wikang Tagalog, mangyaring makipag-ugnayan sa iyong sales representative o administrator ng iyongpangkat. Kung naka-enroll ka na, mangyaring makipag-ugnayan sa serbisyo para sa customer gamit ang numero sa iyong ID card.

아직가입하지않았거나한국어로된도움말이필요한경우영업관리자나그룹관리자에게문의하시기바랍니다.이미가입한경우

ID카드에있는번호를사용하여고객서비스에문의하시기바랍니다.

Nếu quý vị chưa phải là một hội viên và cần được giúp đỡ bằng Tiếng Việt, xin liên lạc với đại diện thương mãi của quý vị hoặc quản trị viên nhóm.Nếu quý

vị đã ghi danh, xin liên lạc với dịch vụ khách hàng qua việc dùng số điện thoại ghi trên thẻ ID của quý vị.

––––––––––––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

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About These CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.

This isnot a costestimator.

Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost of thatcare will also be different.

See the next page forimportant information aboutthese examples.

Having a baby(normal delivery)

n Amount owed to providers: $7,540n Plan pays $5,660n Patient pays $1,880

Sample care costs:Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:Deductibles $500

Copays $80

Coinsurance $1,300

Limits or exclusions $0

Total $1,880

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

n Amount owed to providers: $5,400n Plan pays $2,900n Patient pays $2,500

Sample care costs:Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:Deductibles $700

Copays $1,600

Coinsurance $0

Limits or exclusions $200

Total $2,500

Questions: Call (855) 383-7248 or visit us at www.anthem.com/ca CA/S/F/Anthem Gold PPO 500/20%/4500/1ZHT/NA/01-16

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.cciio.cms.gov or call (855) 383-7248 to request a copy.

12 of 12

Questions and answers about the Coverage Examples:What are some of the assumptionsbehind the Coverage Examples?

· Costs don’t include premiums.

· Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, and aren’tspecific to a particular geographic area orhealth plan.

· The patient’s condition was not anexcluded or preexisting condition.

· All services and treatments started andended in the same coverage period.

· There are no other medical expenses forany member covered under this plan.

· Out-of-pocket expenses are based only ontreating the condition in the example.

· The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.

What does a Coverage Exampleshow?For each treatment situation, the Coverage Examplehelps you see how deductibles, copayments, and coinsurance can add up. Italso helps you see what expenses might beleft up to you to pay because the service ortreatment isn’t covered or payment is limited.

Does the Coverage Example predictmy own care needs?

ûNo. Treatments shown are just examples.

The care you would receive for this conditioncould be different based on your doctor’sadvice, your age, how serious your conditionis, and many other factors.

Does the Coverage Example predictmy future expenses?

ûNo. Coverage Examples are not cost

estimators. You can’t use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Can I use Coverage Examples tocompare plans?

üYes. When you look at the Summary of

Benefits and Coverage for other plans,you’ll find the same Coverage Examples.When you compare plans, check the“Patient Pays” box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider when comparingplans?

üYes. An important cost is the premium

you pay. Generally, the lower yourpremium, the more you’ll pay in out-of-pocket costs, such as copayments,deductibles, and coinsurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.