1 of 13

Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
#%i" i" onl a "ummar& If you want more detail about your coverage and costs, you can get the complete
terms in the policy or plan document at www.anthem.com or by calling 1-800-634-8638.
'm$or!an! (ue"!ion" An"wer" )% !%i" Ma!!er":
What is the overall
deductible?
For in-network providers
*5+0,0 individual /
*10+1-0 family
Doesnt apply to in-network
preventive care
You must pay all the costs up to the deductible amount
before this plan begins to pay for covered services you use.
heck your policy or plan document to see when the
deductible starts over !usually, but not always, "anuary
#st$. %ee the chart starting on page & for how much you pay
for covered services after you meet the deductible.
Are there other
deductibles for
specifc services?
Yes
You dont have to meet deductibles for speci'c services,
but see the chart starting on page & for other costs for
services this plan covers.
Is there an outof
oc!et limit on m"
e#enses?
Yes. In-(etwork )roviders
*5+0,0 Individual * *10+1-0
Family
+his plan has a separate ,ut
of
)ocket -a.imum of *1+2.0
Individual/*2+5/0 per family
for in and out of network
prescription drugs
+he out-of-oc!et limit is the most you could pay during a
coverage period !usually one year$ for your share of the cost
of covered services. +his limit helps you plan for health care
e.penses
What is not included
in the outofoc!et
limit?
/alance-/illed charges,
0ealth are this plan doesnt
cover, and )remiums
1ven though you pay these e.penses, they dont count
toward the out-of-oc!et limit.
Is there an overall
annual limit on what
the lan a"s?
(o.
+he chart starting on page & describes any limits on what
the plan will pay for specifc covered services, such as o2ice
visits.
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
2 of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
(oes this lan use a
networ! of
roviders?
Yes. For a list of referred
roviders, see
www.anthem.com or
call #-566-576-&#88.
If you use an in-network doctor or other health care
rovider, this plan will pay some or all of the costs of
covered services. /e aware, your in-network doctor or
hospital may use an out-of-network rovider for some
services. )lans use the term in-network, referred, or
participating for roviders in their networ!. %ee the chart
starting on page & for how this plan pays di2erent kinds of
roviders.
(o I need a referral
to see a secialist?
Yes.
+his plan will pay some or all of the costs to see a secialist
for covered services but only if you have the plans
permission before you see the secialist from this plan.
)re there services
this lan doesn*t
cover?
Yes.
%ome of the services this plan doesnt cover are listed on
page 9. %ee your policy or plan document for additional
information about e#cluded services.
+oa"ments are '.ed dollar amounts !for e.ample, :#9$ you pay for covered health care, usually when you
receive the service.
+oinsurance is your share of the costs of a covered service, calculated as a percent of the allowed
amount for the service. For e.ample, if the plans allowed amount for an overnight hospital stay is
:#,666, your coinsurance payment of 86; would be :866. +his may change if you havent met your
deductible.
+he amount the plan pays for covered services is based on the allowed amount. If an out-of-network
rovider charges more than the allowed amount, you may have to pay the di2erence. For e.ample, if an
out-of-network hospital charges :#,966 for an overnight stay and the allowed amount is :#,666, you may
have to pay the :966 di2erence. !+his is called balance billin,.$
+his plan may encourage you to use in-networ! roviders by charging you lower deductibles,
coa"ments and coinsurance amounts.
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
3 of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
Common
Medi0al 1ven!
Servi0e" 2ou Ma 3eed
2our Co"! 'f
2ou 4"e an
'n5ne!wor6
Provider
7imi!a!ion" 8 190e$!ion"
If "ou visit a
health care
rovider*s
o-ice or clinic
)rimary care visit to treat an in<ury or
illness
:&9 copay *visit ============none============
%pecialist visit :>6 copay *visit ============none============
,ther practitioner o2ice visit
hiropractor
:>6 copay*visit
?cupuncturist
(ot covered
============none============
)reventive care*screening*immuni@ation (o cost share ============none============
If "ou have a
test
Diagnostic test !.-ray, blood work$
(o cost share for
labs in o2ice or
independent labA
other services 6;
coinsurance
Deductible waived when lab
services performed in o2ice or
independent lab. osts may
vary by site of service.
Imaging !+*)1+ scans, -BIs$ 6; coinsurance ============none============
If "ou need
dru,s to treat
"our illness or
condition
3eneric drugs !Betail*&6 dayC -ail*D6 day$ :#9 Betail*:&6 -ail
-aintenance -eds are re4uired to be
'lled mail order after & 'lls at retail
!penalty applies$. If pre-auth re4uired
E not obtained, drug may not be
covered. ertain )reventive meds no
copay. If a generic e4uivalent is
available E brand is
prescribed*member will pay brand
name cost di2erence. )lan uses
preferred drug list to identify
coverage.
)referred brand drugs !Betail*&6 dayC -ail*D6 day$ :&9 Betail*:57.9 -ail
(on-preferred brand !Betail*&6dayC -ail*D6day$ :76 Betail*:#79 -ail
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
/ of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
Common
Medi0al 1ven!
Servi0e" 2ou Ma 3eed
2our Co"! 'f
2ou 4"e an
'n5ne!wor6
Provider
7imi!a!ion" 8 190e$!ion"
-ore
information
about
rescrition
%pecialty drugs
?ll %pecialty meds
process through
?ccredo at the mail
order costs.
+he mail order cost will be based
on the medication tier !generic,
preferred, non-preferred$.
%pecialty meds can not be 'lled at
retail pharmacies.
If "ou have
outatient
sur,er"
Facility fee !e.g., ambulatory surgery
center$
:#89*copay visit
+his copay applies
to free standing
ambulatory
surgical center
onlyA other
providers sub<ect
to deductible.
============none============
)hysician*surgeon fees 6; coinsurance
Deductible waived if services
are provided at a free standing
ambulatory surgical center.
If "ou need
immediate
medical
attention
1mergency room services
:896 copay *visitA
professional and
other services
sub<ect to
deductible.
:896 copay is waived if
admitted for inpatient stay.
-embers may be balance billed
for out of network services.
1mergency medical transportation 6; coinsurance -embers may be balance billed
for out of network services.
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
5 of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
Common
Medi0al 1ven!
Servi0e" 2ou Ma 3eed
2our Co"! 'f
2ou 4"e an
'n5ne!wor6
Provider
7imi!a!ion" 8 190e$!ion"
Frgent care
:>6 copay *visitA
professional and
other services
sub<ect to
deductible
============none============
If "ou have a
hosital sta"
Facility fee !e.g., hospital room$ 6; coinsurance
Inpatient physical medicine
rehabilitation is limited to >6
days per member per calendar
year.
)hysician*surgeon fee 6; coinsurance ============none============
If "ou have
mental health.
behavioral
health. or
substance
abuse needs
-ental*/ehavioral health outpatient
services
-ental*/ehavioral
0ealth ,2ice
Gisit
:&9 copay*visit
-ental*/ehavioral
0ealth Facility
Gisit
6; coinsurance
============none============
-ental*/ehavioral health inpatient
services
6; coinsurance ============none============
%ubstance use disorder outpatient services %ubstance ?buse
,2ice Gisit
:&9 copay*visit
%ubstance ?buse
Facility Gisit
6; coinsurance
============none============
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
- of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
Common
Medi0al 1ven!
Servi0e" 2ou Ma 3eed
2our Co"! 'f
2ou 4"e an
'n5ne!wor6
Provider
7imi!a!ion" 8 190e$!ion"
%ubstance use disorder inpatient services 6; coinsurance ============none============
If "ou are
re,nant
)renatal and postnatal care 6; coinsurance
,2ice visits not sub<ect to
deductible
Delivery and all inpatient services 6; coinsurance ============none============
If "ou need
hel recoverin,
or have other
secial health
needs
0ome health care 6; coinsurance ============none============
Behabilitation services
:>6 copay*visit for
outpatient visitA
inpatient services
sub<ect to
deductible.
,utpatient limited to 86 visits
each therapy physical therapy,
speech therapy and
occupational therapy.
0abilitation services
:>6 copay*visit for
outpatient visitA
inpatient services
sub<ect to
deductible.
?ll rehabilitation and
habilitation visits count toward
your rehabilitation visit limit.
%killed nursing care 6; coinsurance
Himited to #66 days per
calendar year
Durable medical e4uipment 6; coinsurance ============none============
0ospice service 6; coinsurance ============none============
If "our child
needs dental or
e"e care
1ye e.am (ot overed ============none============
3lasses (ot overed ============none============
Dental check-up (ot overed ============none============
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
. of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
190luded Servi0e" 8 O!%er Covered Servi0e":
Servi0e" 2our Plan :oe" 3O# Cover /0his isn*t a comlete list. +hec! "our olic" or lan document for other
e#cluded services.1
I ?cupuncture
I osmetic surgery
I Dental care !?dult$
I Hong-term care
I )rivate-duty nursing
I Boutine foot care
I Jeight loss programs
O!%er Covered Servi0e" /0his isn*t a comlete list. +hec! "our olic" or lan document for other covered
services and "our costs for these services.1
I /ariatric surgery !Himitations may
apply$
I hiropractic care
I 0earing aids !Himitations may apply$
I Infertility treatment !Himitations may
apply$
I -ost coverage provided outside
the Fnited %tates.
%ee www.//%.com*bluecardworld
wide
I Boutine eye care !?dult$
2our ;ig%!" !o Con!inue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and %tate laws may provide
protections that allow you to keep health coverage. ?ny such rights may be limited in duration and will re4uire you
to pay a remium, which may be signi'cantly higher than the premium you pay while covered under the plan.
,ther limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at #-566-895-9&#5. You may also contact
your state insurance department, the F.%. Department of Habor, 1mployee /ene'ts %ecurity ?dministration at #-5>>-
KKK-&878 or www.dol.gov*ebsa, or the F.%. Department of 0ealth and 0uman %ervices at #-577-8>7-8&8& .>#9>9 or
www.cciio.cms.gov.
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
, of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
2our <rievan0e and A$$eal" ;ig%!":
If you have a complaint or are dissatis'ed with a denial of coverage for claims under your plan, you may be able to
aeal or 'le a ,rievance. For 4uestions about your rights, this notice, or assistance, you can contactC
?nthem /lue ross E /lue %hield
).,. /o. 9#5
(orth 0aven, onnecticut 6>K7&-69#5
For grievances and*or appeals regarding you prescription drug coverage, call the number listed on the back of
prescription member ID card or visit www.e.press-scripts.com.
For 1BI%? information contactC
Department of Habors 1mployee /ene'ts %ecurity ?dministration
#-5>>-KKK-1/%? !&878$
www.dol.gov*ebsa*healthreform
?dditionally, a consumer assistance program can help you 'le your appeal. ontactC
(ew 0ampshire Department of Insurance
8# %outh Fruit %treet, %uite #K
oncord, (0 6&&6#
!566$ 598-&K#>
www.nh.gov*insurance
consumerservicesLins.nh.gov
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
= of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Summar of Benefi!" and Coverage: What this Plan Covers & What it Costs Coverage for: Individual / Family| Plan #$e: HMO
:oe" !%i" Coverage Provide Minimum 1""en!ial Coverage>
+he ?2ordable are ?ct re4uires most people to have health care coverage that 4uali'es as Mminimum essential
coverage.N This plan or policy does
provide minimum essential coverage.
:oe" !%i" Coverage Mee! !%e Minimum ?alue S!andard>
+he ?2ordable are ?ct establishes a minimum value standard of bene'ts of a health plan. +he minimum value
standard is >6; !actuarial value$. This health coverage does meet the minimum value standard for the
benefts it provides.
7anguage A00e"" Servi0e":
======================To see examples of how this plan might cover costs for a sample medical situation, see the next
page.===========
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
Having a @a@
!normal delivery$
Managing !$e 2 dia@e!e"
!routine maintenance of
a well-controlled condition$
10 of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Coverage 19am$le"
Coverage for: Individual / Family| Plan #$e: HMO
A@ou! !%e"e Coverage
19am$le":
+hese e.amples show how this plan
might cover medical care in given
situations. Fse these e.amples to
see, in general, how much 'nancial
protection a sample patient might
get if they are covered under
di2erent plans.
Amoun! owed !o $rovider": $7,5!
Plan $a" $5,"7!
Pa!ien! $a" $#,$7!
Sam$le 0are 0o"!":
0ospital charges !mother$
:8,76
6
Boutine obstetric care
:8,#6
6
0ospital charges !baby$ :D66
?nesthesia :D66
Haboratory tests :966
)rescriptions :866
Badiology :866
Gaccines, other preventive :K6
0otal
2&.34
0
Pa!ien! $a":
Deductibles
:8,68
6
opays :6
oinsurance :6
Himits or e.clusions :#96
0otal
2'.1&
0
Amoun! owed !o $rovider": $5,!!
Plan $a" $#,5%!
Pa!ien! $a" $#,&$!
Sam$le 0are 0o"!":
)rescriptions
:8,D6
6
-edical 14uipment and
%upplies
:#,&6
6
,2ice Gisits and )rocedures :766
1ducation :&66
Haboratory tests :#66
Gaccines, other preventive :#66
0otal
23.40
0
Pa!ien! $a":
Deductibles
:8,#6
6
opays :>&6
oinsurance :6
Himits or e.clusions :56
0otal
2'.81
0
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.

#%i" i"
no! a 0o"!
e"!ima!or&
Dont use these
e.amples to estimate
your actual costs under
this plan. +he actual
care you receive will be
di2erent from these
e.amples, and the cost
of that care will also be
di2erent.
%ee the ne.t page for
important information
about these e.amples.
11 of 13
Awane: Sanel 2000 Core HMO Blue Coverage Period: 01/01/2015 12/31/2015
Coverage 19am$le"
Coverage for: Individual / Family| Plan #$e: HMO
$uestions% all 1-800-8&0-31'' or visit us at www.anthem.com
If you arent clear about any of the underlined terms used in this form, see the 3lossary. You can view the 3lossary
at www.anhem.com or call 1-800-8&0-31'' to re4uest a copy.
(ue"!ion" and an"wer" a@ou! !%e Coverage 19am$le":
)%a! are "ome of !%e
a""um$!ion" @e%ind !%e
Coverage 19am$le">
osts dont include remiums.
%ample care costs are based on
national averages supplied by
the F.%. Department of 0ealth
and 0uman %ervices, and
arent speci'c to a particular
geographic area or health plan.
+he patients condition was not
an e.cluded or pree.isting
condition.
?ll services and treatments
started and ended in the same
coverage period.
+here are no other medical
e.penses for any member
covered under this plan.
,ut-of-pocket e.penses are
based only on treating the
condition in the e.ample.
+he patient received all care
from in-network roviders. If
the patient had received care
from out-of-network roviders,
costs would have been higher.
)%a! doe" a Coverage 19am$le
"%ow>
For each treatment situation, the
overage 1.ample helps you see
how deductibles, coa"ments,
and coinsurance can add up. It
also helps you see what e.penses
might be left up to you to pay
because the service or treatment
isnt covered or payment is limited.
:oe" !%e Coverage 19am$le
$redi0! m own 0are need">
4o. +reatments shown are <ust
e.amples. +he care you would
receive for this condition could
be di2erent based on your
doctors advice, your age, how
serious your condition is, and
many other factors.
:oe" !%e Coverage 19am$le
$redi0! m fu!ure e9$en"e">
4o. overage 1.amples are not
cost estimators. You cant use
the e.amples to estimate costs
for an actual condition. +hey are
for comparative purposes only.
Your own costs will be di2erent
depending on the care you
receive, the prices your
roviders charge, and the
reimbursement your health plan
allows.
Can ' u"e Coverage 19am$le"
!o 0om$are $lan">
5es. Jhen you look at the
%ummary of /ene'ts and
overage for other plans, youll
'nd the same overage
1.amples. Jhen you compare
plans, check the M)atient )aysN
bo. in each e.ample. +he
smaller that number, the more
coverage the plan provides.
Are !%ere o!%er 0o"!" ' "%ould
0on"ider w%en 0om$aring
$lan">
5es. ?n important cost is the
remium you pay. 3enerally,
the lower your remium, the
more youll pay in out-of-pocket
costs, such as coa"ments,
deductibles, and coinsurance.
You should also consider
contributions to accounts such
as health savings accounts
!0%?s$, Oe.ible spending
arrangements !F%?s$ or health
reimbursement accounts !0B?s$
that help you pay out-of-pocket
e.penses.