2012 COVA Care & COVA HDHP Benefits At A Glance July 1, 2012 to June 30, 2013 2012 Benefits At-A-Glance — COVA Care & COVA HDHP In-Network Benefits COVA Care COVA HDHP You Pay You Pay Deductible – per plan year • One person $225 $1,750 • Two or more persons $450 $3,500 • One person $1,500 $5,000 • Two or more persons $3,000 $10,000 • Primary Care Physician $25 20% after deductible • Specialist $40 20% after deductible • Inpatient $300 per stay 20% after deductible • Outpatient $125 per visit 20% after deductible Ambulance travel 20% after deductible (no plan year limit) 20% after deductible (no plan year limit) Emergency room visits $125 per visit (waived if admitted) 20% after deductible Outpatient diagnostic, x-rays, lab tests, and shots 20% after deductible 20% after deductible Infusion Services (includes IV or injected chemotherapy) 20% after deductible 20% after deductible • Occupational, physical and speech therapy $25 PCP / $35 Specialist 20% after deductible • Chiropractic (up to 30 visit plan year limit) Out-of-pocket expense limit – per plan year Doctor’s visits Hospital services Outpatient therapy visits $35 20% after deductible Applied behavior analysis (ABA) for autism spectrum disorder – ages 2 through 6 $35,000 annual limit $25 per service 20% after deductible Behavioral Health visits $25 20% after deductible Employee Assistance Program (EAP) Up to 4 visits per incident $0 $0 • Primary care physician $25 copayment 20% after deductible • Specialty care provider $40 copayment Maternity • Professional provider services (prenatal & postnatal care) There is no copayment if your doctor submits one bill for delivery, prenatal and postnatal services. 20% after deductible • Primary care physician $0, no deductible 20% after deductible • Specialty care provider $0, no deductible 20% after deductible • Hospital services for delivery (delivery room, anesthesia, routine nursing care for newborn) $300 copayment per stay* 20% after deductible • Outpatient diagnostic tests 20% coinsurance after deductible 20% after deductible • Delivery Medical equipment, appliances, formulas and supplies 20% coinsurance after deductible 20% after deductible Prescription drugs – mandatory generic • Retail Pharmacy • Home Delivery Pharmacy (Mail Service) Up to 34-day supply: $15/$25/$40/$50 Up to 34-day supply: 20% after deductible Up to 90-day supply $30/$50/$80/$100 Up to 90-day supply 20% after deductible * COVA Care plan will waive the $300 hospital maternity copayment if the member enrolls in the Future Moms pre-natal program in the first trimester of pregnancy, has a dental cleaning, and completes the program. Call Future Moms at 800-828-5891 to enroll. In-Network Benefits (continued) Wellness & Preventive Services COVA Care COVA HDHP You Pay You Pay $0 $0 • Birth to 18 years • Office visits at specified intervals, immunizations, lab and x-rays • 18 years and older • Annual check-up visit (primary care or specialist), immunizations, lab and x-rays • Routine gynecological exam, Pap test, mammography screening, prostate exam (digital rectal exam), prostate specific antigen (PSA) test, and colorectal cancer screening. Basic Dental • Maximum Benefit - per member (except Orthodonic) $2,000 $2,000 • Deductible $50/$100/$150 $50/$100/$150 • Diagnostic and preventive $0, no deductible $0, no deductible • Primary (basic) care 20% after deductible 20% after deductible COVA Care COVA HDHP You Pay You Pay 50% after deductible 50% after deductible Optional Benefits (offered for an additional premium) Expanded Dental • Complex Restorative (inlays, onlays, crowns, dentures, bridgework) • Orthodontic — Lifetime orthodontic maximum benefit (per member) 50%, no deductible 50%, no deductible $2,000 $2,000 Routine Vision & Hearing Not available Vision (once every 12 months from Blue View Vision or EyeMed network providers) • Routine eye exam $40 • Eyeglass frames 20% off balance after plan pays $100 • Lenses — Eyeglass lenses (standard plastic; single, bifocal or trifocal) or $20 — Contact lenses — • Elective* conventional 15% off balance after plan pays $100 • Elective* disposable $100 allowance (no additional discount) • Non-elective* Balance after plan pays $250 Hearing (once every 48 months) • Routine hearing exam $40 • Hearing aids and other hearing aid related services Balance after plan pays $1,200 • Benefit maximum $1,200 Out-of-Network Plan payment reduced by 25%. Provider may balance bill for amount above allowable charge Not available *Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are covered when eyeglasses are not an option for vision correction. Who To Contact For Assistance COVA Care Anthem Blue Cross and Blue Shield (Medical, Optional Vision & Hearing). . . . . . . . . . . . . . . . . . . . . . . . . 800-552-2682 Delta Dental (Routine Dental). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888-335-8296 Medco Health Solutions (Pharmacy) . . . . . . . . . . . . . . . . . . . . . . 800-355-8279 ValueOptions (Behavioral Health & EAP). . . . . . . . . . . . . . . . . . . . 866-725-0602 COVA HDHP Anthem Blue Cross and Blue Shield. . . . . . . . . . . . . . . . . . . . . . 800-552-2682 Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliated HMO HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association T20835 (4/2012)