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"Bold" print
identifies plan changes effective 1/1/2003
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Plan
Name
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Burns
Harbor PHP
In-Network
(Salaried)
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Burns
Harbor PHP Out-of-Network
(Salaried)
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Web Site
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www.anthem-inc.com
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www.anthem-inc.com
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Member
Service Number
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1-866-528-2658
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1-866-528-2658
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Individual
Lifetime Maximum Benefits
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$1
Million combined in/out-of-network
|
$1
Million combined in/out-of-network
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Annual
Deductible
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Individual
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None
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None
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Family
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None
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None
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Coinsurance
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None
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25%
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Annual
Out-of-Pocket Maximum
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|
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Individual
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None
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$2,000
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Family
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None
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$4,000
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Inpatient
Hospital
|
100%
|
75%
UCR
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Physician
Services: PCP Office Visit
|
$10
copay
|
75%
UCR less $10 copay
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Emergency
Care: In-area Hospital
|
100% -
less $25 copay (Waived if admitted)
|
75%
UCR less $25 copay
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Outpatient
X-Ray and Lab
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100%
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75%
UCR
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Durable
Medical Equipment
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100%
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100%
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Retail
Prescription Coverage
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|
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Generic
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20%
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20%
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Brand Name
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30%
if generic unavailable; 50% if generic available and medically
necessary
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30%
if generic unavailable; 50% if generic available and medically
necessary
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Mail-Order
Prescription Coverage
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Generic
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10% generic; 20% brand if generic unavailable; 40% if generic
available and medically necessary
|
10%
generic; 20% brand if generic unavailable; 40% if generic available
and medically necessary |
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Brand Name
|
See Above
|
See
Above
|
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Diabetic
Benefits
|
|
|
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Insulin
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
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Chem. Strips/Lancets
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
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Home Health Care
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100%
up to 100 visits per calendar year
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Not Covered
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Mental
Health
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|
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Inpatient
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100%
up to 60 days per calendar year (OP days count toward maximum)
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Not Covered
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Outpatient
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100%
up to 80 days per calendar year (IP days count towards maximum
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Not Covered
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Substance Abuse
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|
|
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Inpatient
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100%
up to 60 days per lifetime (combined with OP days)
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Not Covered
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Outpatient
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100%
up to 60 days per lifetime (combined with IP days)
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Not Covered
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Vision
Care
|
|
|
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Routine Eye Exam |
Not Covered
|
Not Covered
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Eyeglasses and Contact Lenses
|
$10
copay for screening exam
|
Not Covered
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Hearing
Care |
|
|
|
Exam |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
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Not Covered
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Hearing Aids |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
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Not Covered
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Dental
Care |
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|
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Basic Services |
Not Covered
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Not Covered
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Major Services |
Not Covered
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Not Covered
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Preventive Services |
Not Covered
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Not Covered
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Wellness
Benefits |
$10
copay
|
No
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