Individual and Family
Health Care Plans for Colorado
BluePreferred PPO: The Reliable Protection You
services after you meet the plan
deductible. For out-of-network
covered services, we pay 60 percent
of the allowed charge after you meet
the out-of-network deductible.
• Doctor office visits. For most plans,
non-routine office visits with in-
network doctors are covered at 100
percent after a copayment. (One
exception is the $3,000 deductible
plan — office visits are subject to the
deductible and coinsurance.) Lab
services, X-rays and out-of-network
office visits are subject to the annual
deductible and coinsurance.
• Preventive care. Many services are
covered, including well-child doctor
office visits, most immunizations
for children, and health screenings
like mammograms, Pap tests, and
prostate and colorectal cancer
In today’s world of early Benefits at a Glance screenings.
retirement offers, BluePreferred PPO plans provide the
benefits you care about most and • Inpatient and outpatient surgery.
self-employment and then some. Here’s a snapshot of the Depending on the plan you choose,
single parenting, the need coverage they offer: we pay a percentage of the allowed
charge for in-network and out-of-
for reliable health care • Hospital care. You get coverage network covered services after you
coverage for individuals is for approved days in a semi-private meet the plan deductible.
room, or in a private room if it’s
more critical than ever before. medically necessary. This includes • Prescriptions. You’ll have coverage
When you don’t have employer- covered prescription drugs, lab for many prescriptions, including oral
sponsored health insurance, choosing services, X-rays, anesthesia and contraceptives and contraceptive
the right health care plan becomes oxygen received during those days. devices. You can fill prescriptions at
even more important — because you Depending on the plan you choose, any pharmacy in our network, which
need dependable protection from high we pay a percentage of the allowed includes nearly every independent
health care expenses. At Anthem Blue charges for in-network covered and chain-store pharmacy in the state.
Cross and Blue Shield, we understand.
That’s why we offer BluePreferred PPO
Anthem.com — Your One-stop Resource
Our BluePreferred PPO plans provide
affordable coverage you can count on. Visit our website to:
They offer comprehensive benefits, • Learn more about our BluePreferred PPO for Individuals plans.
convenience and access to one of the
state’s largest provider networks — all • Get an instant quote and apply for coverage.
at competitive rates. Most importantly, • Find an in-network doctor or hospital.
BluePreferred PPO plans are backed by
the strength, stability and security of • Find health information at MyHealth@Anthem powered by WebMD®.
Anthem Blue Cross and Blue Shield. • Check the status of a claim.
You’ll find all this and more at anthem.com.
1 BluePreferred PPO
Want — from the Name You Trust
Copayment amounts depend on • Many extras. We provide coverage for However, unlike many other Individual
whether your prescription is filled many types of health care services health plans, BluePreferred PPO offers
with a generic ($15 copayment), you might not expect, including significant coverage when you receive
brand-name ($40 copayment) or non- physical rehabilitation, occupational care from out-of-network providers.
formulary ($60 copayment) drug. If you and speech therapy, dental care for And, an annual out-of-pocket maximum
need a maintenance medication, our accidental injuries, and home health protects you from unmanageable health
convenient mail-order prescription and hospice care. We even cover care costs related to out-of-network
service is also available. second surgical opinions. services.
• Emergency care and ambulance Please refer to the Health Plan A note about preauthorization: Some
service. If you have an emergency Description Form and certificate for services, such as non-emergency
illness or injury, BluePreferred PPO has complete details about plan benefits, hospital admissions, surgical
you covered — including coverage for limitations and exclusions. procedures, durable medical equipment
ground and air ambulance travel up to and home health care, require prior
our maximum allowable amount. One of the State’s Largest approval, or preauthorization, from
• Vision care. You’ll have coverage for Provider Networks Anthem Blue Cross and Blue Shield.
eye exams, lenses, frames and/or Our network has more than 9,700 Preauthorization helps ensure that
contacts. Our convenient Blue View health care providers and 70 hospitals treatment plans are medically necessary
Vision national network has over throughout Colorado. When you use and consistent with generally accepted
35,000 vision care providers, including these in-network providers, you’ll be medical standards.
independent ophthalmologists and covered at a higher level, which means If you use out-of-network providers,
optometrists, as well as LensCrafters®, lower out-of-pocket costs for you. You you’re responsible for ensuring that your
Target® Optical, and most Sears also won’t have to complete and submit doctor gets preauthorization.
Optical and Pearle Vision® locations. claim forms. For a current listing of
You also have coverage when you see providers in our network, go to anthem.
out-of-network providers, although com and click the Find the Doctor link.
your out-of-pocket costs will be higher. If you use an out-of-network provider,
• Accident benefits. We’ll pay the first you’ll still have coverage, but you’ll
$500 of your covered health care pay a higher deductible and a greater More than 80 percent
expenses if you’re involved in an accident. percentage of your health care costs. of U.S. hospitals and more
than 90 percent of doctors
accept Blue Cross and
Save time and money on health products and services
Blue Shield ID cards.
At Anthem Blue Cross and Blue Shield, we don’t just talk about improving Protection to Carry with You,
your health and well-being. We provide incentives — and savings — to help Wherever You Go
you live better. Go to anthem.com, log in as a health plan member, and click When you’re an Anthem Blue Cross and
SpecialOffers@Anthem for information and discounts on health-related products Blue Shield member, your health plan
and services like these: ID card is your passport to health care
• Weight-loss programs coverage wherever you go — across the
country and around the world — within
• Fitness club memberships plan and benefit limitations. Our
• Vision correction surgery BlueCard® program gives you access to
doctors and hospitals almost everywhere
• Cosmetic dentistry in the United States and in over 200
• Smoking cessation programs countries around the world. That’s
a real plus when you travel or if you
• Maternity and baby needs
have covered family members who are
• Health and wellness books temporarily living out of state.
2 BluePreferred PPO
Blues Quality Is Surprisingly Or, apply online at anthem.com. Security from a Name You Can
Affordable Simply click the Members tab, choose Count On
At Anthem Blue Cross and Blue Shield, Colorado from the drop-down menu BluePreferred PPO for Individuals plans
we believe comprehensive coverage, and click Enter. Then click Apply Now for are brought to you by Anthem Blue Cross
convenience and choice don’t have Individual and Family Health Insurance! and Blue Shield, an industry leader
to add up to a high price tag. We If you’re approved for coverage, we’ll that provides health care coverage
encourage you to shop around and send your health plan ID card(s) and to more than 12.7 million Americans.
compare our benefits and services detailed benefit information. After we Our mission is to improve the lives of
with other major health plans. receive and approve your completed the people we serve and the health of
We think you’ll be pleased at how application, you can choose any our communities. We appreciate the
affordable our premiums are, making effective date for your policy within 60 opportunity to serve you.
it possible for you to enjoy the security days of your signature.
of Blue. Nearly one in three
BluePreferred PPO for Individuals
Save Time and Postage with plans are also just right if you need Americans is protected by
Automatic Payment coverage for a short time. Simply
notify us in writing 31 days before you
the Cross and Shield.
We offer the convenience of automatic
want to terminate your policy.
premium payments through your
personal checking account or credit
card (Visa, MasterCard or Discover).
Our automatic pay service saves you
time and postage and ensures your
monthly premium payments arrive by
their due date.
Automatic payment is entirely
voluntary. To apply, just complete
and mail the authorization form in
the postage-paid envelope. Be sure
to include a voided check if you’re
requesting automatic payment
through your checking account.
How to Apply
To apply for BluePreferred PPO for
Individuals coverage, complete the
member application and mail it with
a check for the first month’s premium.
Individual Sales ...................................................866-293-2892
or call your authorized Anthem agent for help
Network Providers .............................................800-992-6907
BlueCard Provider Information Line.............800-810-BLUE
BluePreferred PPO 3
Choosing the Plan That’s Right for You
When it comes to health care plans, one Deductibles unmanageable health care costs by
size doesn’t fit all. With BluePreferred A deductible is an annual dollar amount you putting a ceiling on the total coinsurance
PPO for Individuals, you can choose from must pay before we begin to cover most you’ll pay per family member each year.
a variety of plans. You determine the health care services. There are separate If your applicable expenses reach this
deductible and out-of-pocket maximum deductibles for in-network and out-of- maximum, we’ll cover 100 percent of
that fit your life and budget. The table network care. We apply expenses to your allowed charges for the remainder of
below summarizes the differences deductible when we process your claims. the benefit period, up to the lifetime
between our available plans. maximum the plan will pay. Please
Coinsurance note there are separate out-of-pocket
What You Pay Once you meet your deductible, we start maximums for in-network and out-of-
Understanding your financial paying a percentage of eligible health network care.
responsibilities will help prevent care expenses. For most care, we pay The out-of-pocket maximum doesn’t
unwelcome surprises. So, take a few 80 percent of the allowed charge for apply to copayments or deductibles.
minutes to review these basics about in-network covered services. We pay 60 You’ll continue to pay your copayments
your share of health care costs. If you percent of the allowed charge for out-of- for office visits and prescription drugs
have questions, call our Individual sales network covered services. You pay the even if you reach your out-of-pocket
department at 866-293-2892, or call your remaining coinsurance until applicable maximum.
authorized Anthem agent. expenses reach your plan’s annual out-of-
Copayments pocket maximum. Explanation of Benefits
A note about out-of-network provider After each claim is processed, you’ll
A copayment is a flat dollar amount you
fees: To help control costs, Anthem Blue receive an explanation of benefits (EOB)
pay for a service. You don’t have to meet
Cross and Blue Shield has negotiated form from Anthem Blue Cross and Blue
your deductible to take advantage of
discounts with in-network providers. Shield. An EOB describes how benefits
copayments. For most benefits, just pay
They’ve agreed to accept our contracted have been paid, helps you understand
your copayment at the time of service,
allowed charge as payment in full for the cost of care and illustrates the true
and the plan pays 100 percent of the
services covered by the plan. Out-of- value of your health plan.
remaining expenses. BluePreferred
PPO plans include copayments for network providers may charge you more; Review each EOB carefully. It includes
prescription drugs and medical office if they do, you’ll have to pay any amounts information about non-covered services,
visits (except the $3,000 deductible over our allowable charge. amounts applied toward deductibles and
plan). If an office visit includes lab or X- the status of out-of-pocket maximums.
Out-of-pocket Maximums If you ever have questions or concerns
ray services, those expenses are subject
An annual out-of-pocket maximum about how benefits have been paid,
to the deductible and coinsurance.
protects you and your family from please call customer service.
Member’s Office Rx Drug Annual In-network Coinsurance Member Pays In-network
Visit Copayment Copayments1 Deductible Per Person In-network/Out-of-network2 Out-of-pocket Maximum Per Person3
BluePreferred PPO for
Individuals Plan Design
BP 500-25-80/60 $25 $15/$40/$60 $500 20%/40% $1,000
BP 1,000-25-80/60 $25 $15/$40/$60 $1,000 20%/40% $1,000
BP 2,000-25-80/60 $25 $15/$40/$60 $2,000 20%/40% $1,000
BP 500-25-80/60 $25 $15/$40/$60 $500 20%/40% $2,000
BP 1,000-25-80/60 $25 $15/$40/$60 $1,000 20%/40% $2,000
BP 2,000-25-80/60 $25 $15/$40/$60 $2,000 20%/40% $2,000
BP 3,000-80/60 20% coinsurance $15/$40/$60 $3,000 20%/40% $2,000
Dollar amounts for prescription drug copayments refer to generic/brand-name/non-formulary drugs.
Coinsurance applies to most, but not all, covered services that aren’t subject to copayments.
Copayments and deductibles don’t apply toward annual out-of-pocket maximums.
See the BluePreferred PPO for Individuals Health Plan Description Form and certificate for more information about out-of-network deductibles and out-of-pocket maximums.
4 BluePreferred PPO
Important Information You • Services by a family member • Provided for the diagnosis or direct care and treatment
• Dental and orthodontic services of the medical condition.
Should Know • Hearing aids and ear examinations • Within standards of good medical practice in the
• Complications from non-covered services organized medical community.
Rate Determination • Not primarily for the convenience of the member, the
• Rates are based on age, gender, benefit plan, family size, • Private duty nursing
member’s physician or another provider.
geographic location and tobacco use. • Alcohol and substance abuse care
• The most appropriate supply or level of service that can
• The rates for BluePreferred PPO for Individuals plans are • Coverage for injectables, except insulin and syringes safely be provided. For hospital stays, this means acute
subject to change with 30-day advance written notice. used for administration of insulin care as an inpatient is necessary due to the kind of
Guaranteed Renewability of All Individual • When an application for BluePreferred PPO for Individuals services received or the severity of the condition, and
coverage is approved, Anthem will not pay expenses for that safe and adequate care cannot be received as an
Health Policies services related to a pre-existing condition for up to
Anthem Blue Cross and Blue Shield will not cancel or refuse outpatient or in a less acute medical setting.
12 consecutive months after the original membership
to renew any Individual policy, except under the following effective date. See the application for a full explanation. Network Access Plan
conditions: Anthem Blue Cross and Blue Shield strives to provide an
• Based on medical screening, some conditions may be
• Non-payment of premium excluded from coverage for the lifetime of the policy extensive provider network that adequately addresses
• Fraud/misrepresentation by the insured under a rider to the certificate. members’ health care needs. The network access plan
• Anthem Blue Cross and Blue Shield elects to discontinue describes Anthem’s provider network standards for network
• Expenses for acupuncture, chiropractic services, artificial adequacy in service, access and availability, as well as
offering all Individual policies. conception, biofeedback, convalescent or custodial care, assessment procedures for determining if the network
• The state insurance commissioner finds that continuation sex change operations, temporomandibular joint therapy, continues to meet member needs. The network access plan
of the coverage would not be in the best interests of the and other specific procedures listed in the certificate is available on request for in-person review at
policyholders. • Subrogation (third-party liability): Except for automobile 700 Broadway, Individual Sales Department, Denver,
• The state insurance commissioner finds that the product accidents, benefits will not be provided for any condition Colorado.
form is obsolete and is being replaced with comparable or injury resulting from a wrongful act or omission of
coverage. another party for which that party is or may be legally Colorado Health Plan Description Form
responsible. Colorado law requires carriers to make available a Colorado
Limitations and Exclusions Health Plan Description Form, which is intended to facilitate
This plan does not cover some services. The plan includes • Preauthorization is required for many procedures,
including covered cosmetic surgery, surgery for obesity, comparison of health plans. The form must be provided
limitations and exclusions to protect against duplicate or automatically within three business days to a potential
unnecessary services that could unfairly offset the cost of inpatient hospice care and organ transplants.
policyholder who has expressed interest in a particular
health care coverage for the entire plan. Medical Emergency plan. The carrier also must provide the form, on oral or
Please note the following examples of some of the “Medical emergency” means the sudden and, at the time, written request, within three business days to any person
plan’s limitations and exclusions: unexpected onset of a health condition that requires who is interested in coverage under, or who is covered by, a
• Cosmetic surgery, unless it is required to correct a immediate medical attention, where failure to provide health care benefits plan of the carrier.
congenital anomaly, is related to reconstruction of the medical attention would result in serious impairment to If you would like a copy of the state-mandated Colorado
breast(s) following mastectomy, or is reconstructive bodily functions or serious dysfunction of a bodily organ Health Plan Description Form, which provides information
surgery resulting from an accidental injury that occurred or part, or would place the person’s health in serious on health plan benefits, provider contract arrangements and
after the effective date of coverage jeopardy. The plan covers emergency services necessary to other information, please call 866-412-9149.
• Pregnancy expenses, unless they result from screen and stabilize a member without preauthorization if Please refer to the Health Plan Description Form
complications of pregnancy a prudent lay person, having average knowledge of health and certificate for complete details about plan
services and medicine and acting reasonably, would have limitations and exclusions. If there is a conflict
• Blood transfusions (the first three pints of blood per believed that an emergency medical condition or life- or
hospital admission are the member’s responsibility) between the limitations and exclusions listed in this
limb-threatening emergency existed. brochure and the Health Plan Description Form and
• Benefits provided under any local, state or federal laws,
including workers’ compensation and Medicare Medically Necessary certificate, the Health Plan Description Form and
Claims for services that are not medically necessary may certificate will prevail.
• Routine physicals, immunizations and preventive services
for adults be denied either before or after payment of such services. For more information about Anthem Blue Cross and Blue
Benefits are payable only for medically necessary covered Shield’s products and services, please contact your
services and supplies that are: authorized Anthem insurance agent, or visit our website at
• Appropriate and necessary for the symptoms, diagnosis anthem.com.
or treatment of the medical condition.
Our mission is to improve the lives of the people we serve and the health of our communities.
Thank you for considering Anthem Blue Cross and Blue Shield.
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. An independent licensee of the Blue Cross and Blue Shield Association.
MCOBR1728A (6/08) ® 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.