Anthem Blue Cross PPO High Deductible HSA Plan - Judy Madrigal ...

Anthem Blue Cross PPO High Deductible HSA Plan* Benefit Summary Effective June 1, 2011
Judy Madrigal & Associates
The services described below are covered only if all the following conditions are satisfied:
· The services are medically necessary; AND
· Certain services may require pre-authorization. Please refer to your Evidence of Coverage (EOC) booklet from Anthem Blue Cross.
Preferred
Providers
Non- Preferred
Providers
Anthem Blue Cross
Preventative Benefits - Not Subject to Deductible
Annual routine physical exam office visit (one per calendar year) $0 Not Covered
Deductible
All the remaining services are subject to the annual deductible. Those who cover 2 or
more people under the plan all share one combined deductible.
Employee:
Employee with Deps:
$2,500
$5,000
Note: To help offset the deductible amount, Judy Madrigal & Associates makes a monthly Health Savings Account (HSA) deposit of $210/month for
single coverage and $420/month for those who cover 1 or more of their dependents.
Physician Services - Inpatient and Outpatient Services
Office visit/consultations (not including routine exams - see above), specialists, laboratory & diagnostics 80% 50%
Inpatient visits and consultations, surgeons and assistants, anesthesiologists, pathologists, radiologists 80% 50%
Hospital Services - Inpatient and Outpatient
Semi-private room rate and board, medically necessary services and supplies, including subacute care 80% 50% ¹
Outpatient Surgery · Renal dialysis 80% 50% ¹
Pregnancy & Maternity Care
Prenatal and postnatal care and all necessary inpatient hospital services 80% 50% ¹
Ambulance 80% 50%
Prescriptions - Deductible Must be Satisfied Before Co-pays Apply
Per 30 day supply or 100 unit doses
Formulary:
Non-Formulary:
$15 Generic
$30 Brand
$50 Brand
Home Medical Equipment 50% 50%
Psychiatric - Outpatient severe and inpatient severe and non-severe 80% 50% ¹
Psychiatric - Outpatient non-severe 50% Not Covered
Chiropractic Services - Chiropractic manipulative treatment 80% Up to $25
Maximum visits per calendar year:
24
Maximum Out-of-Pocket Co-insurance Limit
Single:
Employee with Deps:
$1,500
$1,000
*The benefits listed here are simply a summary of the plan. For a complete listing of all plan provisions, please refer to the Evidence of Coverage
(EOC ).
1. The maximum allowed charge for non-emergency hospital services at non-preferred hospitals is $650 per day. Members are responsible for all
charges in excess of $650.
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Eligible HSA Expenses and OTC Products
• Acupuncture
• Alcoholism treatment
• Allergy shots and testing
• Ambulance (ground or air)
• Artificial limbs
• Blind services and equipment
• Car controls for handicapped*
• Chiropractor services
• Coinsurance and deductibles
• Contact lenses
• Crutches, wheelchairs, walkers
• Deaf services -- hearing aid/batteries,
hearing aid animal & care, lip reading
expenses, modified telephone, etc.
• Dental treatment
• Dentures
• Diagnostic tests
• Doctor’s fees
• Drug addiction treatment & facilities
• Drugs (prescription)
Eligible HSA Healthcare Expenses
Please note that this list is not intended to be comprehensive tax advice.
For more detailed information, please consult IRS Publication 502 or see your tax advisor.
• Eye examinations and eyeglasses
• Home health and/or hospice care
• Hospital services
• Insulin
• Laboratory fees
• LASIK eye surgery
• Medical alert (bracelet, necklace)
• Medical monitoring and testing
devices*
• Nursing services
• Obstetrical expenses
• Occlusal guards
• Operations and surgeries (legal)
• Optometrists
• Orthodontia
• Orthopedic services
• Osteopaths
• Oxygen/oxygen equipment
• Physical exams (except for employment-related
physicals)
*if prescribed for a particular ailment or medical condition; provider letter required
Important Change Regarding Over-the Counter (OTC) Medications
Starting January 1, 2011, OTC medications will require a doctor’s prescription to be eligible for HSA reimbursement.
As a result, OTC medications cannot be purchased using a debit card after 12/31/10 unless dispensed by a
pharmacy the same as a standard prescription. If a manual claim is submitted for purchase of an OTC medication after
12/31/10, a prescription receipt must be included with the claim in order to receive reimbursement.
Non-medicated OTC products (gauze pads, diabetes test strips, saline solution, etc.) are not affected by this change in the
law. You can continue to receive HSA reimbursement for such items after 12/31/10 in the same manner you do now.
Eligible HSA OTC Medications and Products
• Physical therapy
• Psychiatric care, psychologists, psychotherapists
• Radial keratotomy
• Schools (special, relief, or handicapped)
• Sexual dysfunction treatment
• Smoking cessation
• Surgical fees
• Television or telephone for the hearing
impaired
• Therapy treatments*
• Transportation (essentially and primarily
for medical care; limits apply)
• Vaccinations
• Vitamins (prescription only)*
• Weight loss programs*
• X-rays
ELIGIBLE NOW, BUT WILL REQUIRE
PRESCRIPTION TO REMAIN ELIGIBLE
AFTER 12/31/10:
• Acne medications & treatments
• Allergy & sinus, cold, flu & cough
remedies (antihistimines, decongestants,
cough syrups, cough drops,
nasal sprays, medicated rubs, etc.)
• Antacids & acid controllers (tablets,
liquids, capsules)
• Antibiotic & antiseptic sprays, creams
& ointments
• Anti-diarrheals
• Anti-fungals
• Anti-gas & stomach remedies
• Anti-itch & insect bite remedies
• Anti-parasitics
• Digestive aids
• Baby care (diaper rash ointments,
teething gel, rehydration fluids, etc.)
• Contraceptives (condoms, gels,
foams, suppositories, etc.)
• Eczema & psoriasis remedies
• Eye drops, ear drops, nasal sprays
• First aid kits
• Hemorrhoidal preparations
• Hydrogen peroxide, rubbing alcohol
• Laxatives
• Medicated bandaids & dressings
• Motion sickness remedies
• Nicotine medications (smoking cessation
aids)
• Pain relievers (aspirin, ibuprofen,
acetaminophen, naproxen, etc.)
• Sleep aids & sedatives
• Wart removal remedies, corn patches
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ELIGIBLE NOW AND WILL REMAIN
ELIGIBLE AFTER 12/31/10 WITH NO
PRESCRIPTION REQUIRED:
• Braces & supports
• Contact lens solution
• Diabetic testing supplies & equipment
• Durable medical equipment (power
chairs, walkers, wheelchairs, CPAP
equipment & supplies, etc.)
• Home diagnostic (pregnancy tests,
ovulation kits, thermometers, blood
pressure monitors, etc.)
• Non-medicated bandaids, rolled
bandages & dressings
• Reading glasses
All OTC items listed are examples.

NON-ELIGIBLE HSA Expenses and OTC Products
NON-ELIGIBLE HSA Healthcare Expenses
• Advance payment for services to be rendered
• Automobile insurance premium allocable to medical
coverage
• Boarding school fees
• Body piercing
• Bottled water
• Chauffeur services
• Controlled substances
• Cosmetic surgery and procedures
• Cosmetic dental procedures
• Dancing lessons
• Diapers for Infants
• Diaper service
• Ear piercing
• Electrolysis
• Fees written off by provider
• Food supplements
• Funeral, cremation, or burial expenses
• Hair transplant
• Herbs & herbal supplements
• Household & domestic help
• Health programs, health clubs, and gyms
• Illegal operations and treatments
• Illegally procured drugs
• Insurance premiums (not reimburseable under FSA…
only PRA)
• Long-term care services
• Maternity clothes
• Medical savings sccounts
• Premiums for life insurance, income protection, disability,
loss of limbs, sight or similar benefits
• Personal items
• Preferred provider discounts
• Social activities
• Special foods and beverages
• Swimming lessons
• Tattoos/tattoo removal
• Teeth whitening
• Transportation expenses to & from work
• Travel for general health improvement
• Uniforms
• Vitamins & supplements without prescription
NON-ELIGIBLE HSA Over-the-Counter Products
The following are examples of OTC medications & products which are NOT eligible for HSA reimbursement.
Additional items will join this list effective January 1, 2011, due to changes in the law brought about by the Patient
Protection and Affordable Care Act (PPACA) of 2010.
• Aromatherapy
• Baby bottles & cups
• Baby oil
• Baby wipes
• Breast enhancement system
• Cosmetics (including face cream & moisturizer)
• Cotton swabs
• Dental floss
• Deodorants & anti-perspirants
• Dietary supplements
• Feminine care items
• Fiber supplements
• Food
• Fragrances
• Hair regrowth preparations
• Herbs & herbal supplements
• Hygiene products & similar items
• Low-carb & low-fat foods
• Low calorie foods
• Lip balm
• Medicated shampoos & soaps
• Petroleum jelly
• Shampoo & conditioner
• Spa salts
• Suntan lotion
• Toiletries (including toothpaste)
• Vitamins & supplements without prescription
• Weight loss drugs for general well-being
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