University of Colorado Boulder - Student Health Insurance Plan (SHIP) Anthem Student Advantage
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2020-2021 University of Colorado Boulder Student Health Insurance Plan (SHIP) www.anthem.com/studentadvantage Anthem Student Advantage Keeping you at your personal best A00332COMENABS 08/20
Important notice
This is a brief description of your
student health plan underwritten
by Anthem Blue Cross and Blue Shield
(Anthem). If you would like more
details about your coverage and
costs, you can find the complete terms
in the policy or plan document online
at www.anthem.com.
2
Table
of contents
Welcome................................................................................................. 4
Coverage periods and rates............................................................. 6
Important contacts............................................................................. 8
Your CU Boulder Medical services................................................. 9
Easy access to care..........................................................................11
Summary of benefits........................................................................13
Global benefits...................................................................................20
Exclusions............................................................................................22
Access help in your language........................................................28
3
Welcome
to Anthem
Student
Advantage
4
As your new school year begins, it’s important to understand your health care benefits and
how they work.
Your Anthem Student Advantage plan can help keep you at your personal best. This book will
guide you through your plan benefits, with information about who is eligible, what is covered,
how to access the right type of care when you need it, and more.
What you need to know about
Anthem Student Advantage
Who is eligible? the University of Boulder Colorado Gold
SHIP and can do so by contacting the
› Degree-seeking undergraduate students
Student Insurance Office at 303-492-5107
enrolled in six or more credit hours
or studentinsurance@colorado.edu for
and graduate students enrolled in one
additional details.
graduate credit hour or more.
› Students approved for the Leave of
› Non-degree seeking Continuing
Absence Program are eligible to enroll
Education students, Study Abroad
in the University of Boulder Colorado
(including Semester at Sea) students,
Gold SHIP for one semester that they
Evening MBA students and students
are not registered for classes and
taking exclusively Be Boulder Anywhere
can do so by contacting the Student
courses, enrolled in six or more credit
Insurance Office at 303-492-5107 or
hours and paying the base student and
studentinsurance@colorado.edu for
health fees, may be eligible to enroll in
additional details.
Please refer to Anthem policy for additional eligibility provisions.
5
Coverage periods
and rates
Coverage will
become effective at
12:01 a.m., and will end
at 11:59 p.m. on the
dates shown below.
Costs and dates of coverage
Coverage Coverage Enroll or request
Semester Premium
Start Date End Date a waiver by:
Fall August 1, 2020 December 31, 2020 $1,948 September 11, 2020
Spring/Summer January 1, 2021 July 31, 2021 $1,948 February 12, 2021
Summer Only May 1, 2021 July 31, 2021 $994 May 31, 2021
6
7
Keep in touch
with your benefits
information
Student Student
Health Center Counseling Center
Wardenburg Health Center Center for Community, Suite N352
1900 Wardenburg Drive 2249 Willard Loop Dr.
119 UCB 104 UCB
Boulder, CO 80309 Boulder, CO 80309
303-492-5101 (24/7 nurse line) 303-492-2277 (24/7 support)
www.colorado.edu/healthcenter/ www.colorado.edu/counseling/
Please check website for hours. Please check website for hours.
Saturday and Sunday: Closed
Eligibility and
Benefits Enrollment
and Claims Wardenburg Health Center
Contact AmeriBen at 119 18th St, Room 332
(855) 258-2656 or visit Boulder, CO 80305
MyAmeriben.com. 303-492-5107
studentinsurance@colorado.edu
8
Your CU Boulder
Medical services
CU Boulder Medical Services is the primary medical provider for Covered Students enrolled in the Student
Health Insurance Plan. These services and benefits are not insured benefits under the Student Health
Insurance Plan but are provided by CU Boulder Medical Services to all Covered Students enrolled in the
Student Health Insurance Plan.
Most services rendered at CU Boulder Medical Services are not subject to the coinsurance,
co-pay or deductible amounts applicable to the Student Health Insurance Plan.
Medical care Counseling and psychiatry
Primary and preventive care including: › 20 counseling and psychiatry visits per policy
year including:
› Physical exams
— Individual counseling
› Treatment for illnesses and injuries
— Couples counseling
› Travel health services
— Medication management
(excluding specialty travel immunizations)
— Crisis care
› Routine vaccinations
› Allergy shots › Unlimited group therapy
(antigen not provided by health center) › 50% coverage of psychological testing
(ordered by a Medical Services Provider
at CU Boulder Medical Services; subject
Nutrition services to availability)
› Nutrition counseling for a variety of concerns
Physical therapy and integrative care
Laboratory and X-ray › 25 physical therapy visits per policy year
› C
overage for lab services ordered and › 10 chiropractic visits per policy year
managed by a Medical Services provider › Orthopedic surgeon consultations
› Coverage for X-ray services
Note: CU Sports Medicine at the Champion Center
is not part of CU Boulder Medical Services
9
Sexual and reproductive health These services are offered at CU
› Gynecology services
Boulder Medical Services, but not
› One annual exam covered by CU Boulder Gold SHIP:
› Birth control consultations › Acupuncture
› Sexually transmitted infection testing › Bike fits
and treatment › Copies of X-rays and medical records
› Human papillomavirus (HPV) vaccinations › Custom knee braces
› Transgender patient care and hormone therapy › Vaccinations for Japanese encephalitis, rabies,
yellow fever and typhoid
› Loaned equipment
Annual eye exam
› Massage therapy
CU Boulder Gold SHIP members are entitled to one › Missed appointment fees
routine eye exam per policy year at no additional › Patient-requested lab tests
cost through College Optical in Boulder. This (not medically necessary)
includes visual fields testing, glaucoma screening,
› Replacement of medical supplies
refraction, and a dilated exam if needed.
Eyeglass frames, lenses, contacts and contact
fittings are available with a discount and are the
patient’s responsibility.
Annual dental exam
CU Boulder Gold SHIP members are entitled to one
dental exam, cleaning and x-ray per policy year at
no additional cost through PEREFECT TEETH™.
Discounts for services beyond the covered exam are
available through the PEREFECT TEETH™ discount
plan and are the patient’s responsibility.
10Easy access
to care
Access the care you need, in the way
that works best for you.
ID Cards and Online Services app Provider finder
For a copy of your insurance ID card, claims You can find the right doctor or facility
status, and information about your Health Benefit close to where you are by visiting:
Resources, please visit MyAmeriBen.com or › www.anthem.com
download the MyAmeriBen app on your iOS or › www.colorado.edu/health/insurance
Android device.
› MyAmeriBen.com
› Calling AmeriBen at (855) 258-2656.
LiveHealth Online Important tips:
From your mobile device or computer with › W
hen you need health care, please access
a webcam, you can use LiveHealth Online to visit care at the University of Colorado Boulder
with a board-certified doctor, psychiatrist or Health Services first or to obtain a referral to
licensed therapist through live video.2 To use, go to an In-Network Provider. This can help you
www.livehealthonline.com. You can also download save on out-of-pocket costs.
the free LiveHealth Online app to sign up.
› N
etworks may change, so make sure you
contact the provider before getting care to
24/7 NurseLine confirm they are in the network.
Call 1-844-545-1429 to speak to a registered
nurse who can help you with health issues like
fever, allergy relief, cold and flu symptoms and
where to go for care. Nurses can also help you
enroll in health management programs if you
have specific health conditions, remind you about
scheduling important screenings and
exams, and more.
2 Appointments subject to availability of a therapist. Psychologists or therapists using LiveHealth Online cannot prescribe medications. Online counseling is not appropriate for all kinds of problems. If you are in crisis or have suicidal thoughts, it’s important that you seek help
immediately. Please call 1-800-784-2433 (National Suicide Prevention Lifeline) or 911 and ask for help. If your issue is an emergency, call 911 or go to your nearest emergency room. LiveHealth Online does not offer emergency services.
LiveHealth Online is the trade name of Health Management Corporation, a separate company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.
1112
Your summary Anthem Blue Cross
Blue Shield
of benefits
Student health insurance plan:
University of Colorado Boulder
Your network:
Anthem PPO
This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the
formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage
(EOC) will prevail. Plan benefits are pending approval with the state and subject to change.
Student Health Center Benefits: No Charge for Covered Medical Expenses, Deductible Waived, 100% of Usual and Reasonable Charge for
Covered RX Expenses
Medical
Cost if you use an Cost if you use an
Covered Medical Benefits
In-Network Provider Out-of-Network Provider
Overall Deductible
See notes section to understand how your deductible works.
Your plan may also have a separate Prescription Drug Deductible. $500 student $1,000 student
See Prescription Drug Coverage section.
Out-of-Pocket Limit
When you meet your out-of-pocket limit, you will no longer have
to pay cost- shares during the remainder of your benefit period.
$5,000 student $10,000 student
See notes section for additional information regarding your out
of pocket maximum.
Preventive care/screening/immunization
In-network preventive care is not subject to deductible, if your
plan has a deductible. Deductible does not apply to the following 50% coinsurance after
No charge
Out-Of-Network services: Immunizations, well woman visits, alcohol deductible is met
and/or drugs counseling office visits, routine cancer screenings.
Doctor Home and Office Services
$40 copay per visit
$40 copay per visit
Primary Care Visit to treat an injury or illness 50% coinsurance
deductible does not apply
deductible does not apply
$40 copay per visit
$40 copay per visit
Specialist Care Office Visit 50% coinsurance
deductible does not apply
deductible does not apply
$40 copay per visit
Prenatal and Post-natal Care $40 copay per visit
50% coinsurance after
In-Network preventive prenatal services are covered at 100%. deductible does not apply
deductible is met
13Cost if you use an Cost if you use an
Covered Medical Benefits
In-Network Provider Out-of-Network Provider
Other Practitioner Visits:
40 copay per visit,
$40 copay per visit
Retail Health Clinic 50% coinsurance
deductible does not apply
deductible does not apply
On-line Visit
Includes Mental/Behavioral Health and Substance Abuse $20 copay per visit $20 copay per visit
Live Health Online is the preferred telehealth solution. deductible does not apply deductible does not apply
(www.livehealthonline.com).
20% coinsurance after 50% coinsurance after
Chiropractic
deductible is met deductible is met
Other Services in an Office:
$40 copay per visit,
$40 copay per visit
Allergy Testing 50% coinsurance
deductible does not apply
deductible does not apply
$40 copay per visit,
$40 copay per visit
Chemo/Radiation Therapy 50% coinsurance
deductible does not apply
deductible does not apply
$40 copay per visit,
$40 copay per visit
Hemodialysis 50% coinsurance
deductible does not apply
deductible does not apply
Prescription Drugs
20% coinsurance after 50% coinsurance after
For the drugs itself dispensed in the office through
deductible is met deductible is met
infusion/injection.
Diagnostic Services Lab:
Office $40 copay per visit,
20% coinsurance after
Office Cost Share applies only when Freestanding/Reference 50% coinsurance
deductible is met
Labs are not used. deductible does not apply
20% coinsurance after 50% coinsurance after
Freestanding Lab/Reference Lab
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
X-Ray:
$40 copay per visit,
$40 copay per visit,
Office 50% coinsurance
deductible does not apply
deductible does not apply
20% coinsurance after 50% coinsurance after
Freestanding Radiology Center
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
Advanced Diagnostic Imaging
(for example, MRI/PET/CAT scans):
$40 copay per visit,
$40 copay per visit,
Office 50% coinsurance
deductible does not apply
deductible does not apply
20% coinsurance after 50% coinsurance after
Freestanding Radiology Center
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
14Cost if you use an Cost if you use an
Covered Medical Benefits
In-Network Provider Out-of-Network Provider
Emergency and Urgent Care
$75 copay per visit, $75 copay per visit,
Urgent Care (Office Setting) 20% coinsurance 50% coinsurance
deductible does not apply deductible does not apply
Emergency Room Facility Services $150 copay per visit,
Emergency Room copay is waived if directly admitted 20% coinsurance after Covered as In-Network
to the hospital. deductible is met
20% coinsurance after
Emergency Room Doctor and Other Services Covered as In-Network
deductible is met
Ambulance (Air and Ground)
20% coinsurance after
Non-emergency, Non-Network ambulance services are limited Covered as In-Network
deductible is met
to an Anthem maximum payment of $50,000 per trip.
Outpatient Mental/Behavioral Health and Substance Abuse
$20 copay per visit, $20 copay per visit,
Doctor Office Visit 0 coinsurance 50% coinsurance
deductible does not apply deductible does not apply
Facility visit:
20% coinsurance after 50% coinsurance after
Facility Fees
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Doctor Services
deductible is met deductible is met
Outpatient Surgery Facility Fees:
20% coinsurance after 50% coinsurance after
Hospital
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Freestanding Surgical Center
deductible is met deductible is met
Doctor and Other Services:
20% coinsurance after 50% coinsurance after
Hospital
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Freestanding Surgical Center
deductible is met deductible is met
Hospital Stay (all inpatient stays including Maternity,
Mental / Behavioral Health, and Substance Abuse)
Facility fees (for example, room & board)
$200 copay per visit, $200 copay per visit,
Rehabilitation services in an inpatient hospital or acute care
20% coinsurance after 50% coinsurance after
facility are limited to 60 days combined per benefit period. Limit
deductible is met deductible is met
is combined In- Network and Non-Network.
20% coinsurance 50% coinsurance
Doctor and other services
after deductible is met after deductible is met
15Cost if you use an Cost if you use an
Covered Medical Benefits
In-Network Provider Out-of-Network Provider
Recovery & Rehabilitation
Home Health Care
Coverage is limited to 28 hours per week. Limit is combined
20% coinsurance 50% coinsurance
In-Network and Non-Network. Visit limit does not apply to
after deductible is met after deductible is met
Home Infusion Therapy or Home Dialysis. Limits are combined
for home health care and private duty nursing.
Rehabilitation services (for example, physical/speech/
occupational therapy):
20% coinsurance after 50% coinsurance after
Office
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
Habilitation services (for example, physical/speech/
occupational therapy):
20% coinsurance after 50% coinsurance after
Office
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
Cardiac rehabilitation
20% coinsurance after 50% coinsurance after
Office
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Outpatient Hospital
deductible is met deductible is met
$200 copay per visit, 200 copay per visit,
Skilled Nursing Care (in a facility) 20% coinsurance after 50% coinsurance after
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Hospice
deductible is met deductible is met
20% coinsurance after 50% coinsurance after
Durable Medical Equipment
deductible is met deductible is met
Prosthetic Devices
Coverage for hearing aids services is limited to 1 item per ear every 20% coinsurance after 50% coinsurance after
5 years. Covered for children 18 years of age or under. Limit is deductible is met deductible is met
combined In-Network and Non-Network across all settings.
16Pharmacy
Cost if you use an Cost if you use an
Covered Prescription Drug Benefits
In-Network Provider Out-of-Network Provider
Pharmacy Deductible Not applicable Not applicable
Combined with medical Combined with medical
Pharmacy Out of Pocket
out of pocket maximum out of pocket maximum
Prescription Drug Coverage
Traditional Drug List
This product has a 90-day Retail Pharmacy Network available.
A 90 day supply is available at most retail pharmacies.
Tier 1 - Typically Lower Cost Generic
Covers up to a 30 day supply (retail pharmacy). Covers up to $25 copay per prescription,
Covered as In-Network
90 day supply (retail maintenance pharmacy). No coverage for deductible does not apply
non-formulary drugs.
Tier 2 – Typically Preferred Brand
Covers up to a 30 day supply (retail pharmacy). Covers up to $45 copay per prescription,
Covered as In-Network
90 day supply (retail maintenance pharmacy). No coverage for deductible does not apply
non-formulary drugs.
Tier 3 - Typically Non-Preferred Brand/Specialty
Covers up to a 30 day supply (retail pharmacy). Covers up to $75 copay per prescription,
Covered as In-Network
90 day supply (retail maintenance pharmacy). No coverage for deductible does not apply
non-formulary drugs.
17Dental
Cost if you use an Cost if you use an
Covered Dental Benefits
In-Network Provider Out-of-Network Provider
This is a brief outline of your dental coverage. Not all cost shares for covered services are shown below. For a full list, including benefits,
exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this
summary and either Evidence of Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail.
Only children’s dental services count towards your out of pocket limit.
Children’s Dental Essential Health Benefits (Up to age 19)
Diagnostic and preventive
No charge 50% coinsurance
Includes cleanings, exams, x-rays, sealants, fluoride
Basic services
30% coinsurance 50% coinsurance
Includes filing and simple extractions
Major services/Prosthodontic 50% coinsurance 50% coinsurance
50% coinsurance after
Endodontic, Periodontics, Oral Surgery 50% coinsurance
deductible is met
Medically Necessary Orthodontia 50% coinsurance 50% coinsurance
Deductible Not applicable Not applicable
Adult Dental (Age 19 and over) Not covered Not covered
18Vision
Cost if you use an Cost if you use an
Covered Vision Benefits
In-Network Provider Out-of-Network Provider
This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. Benefits include coverage for
student’s choice of eyeglass lenses or contact lenses, but not both. For a full list, including benefits, exclusions and limitations, see
the combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this summary and either Evidence of
Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail.
Children’s Vision Essential Health Benefits (up to age 19)
Child Vision Deductible $0 $0
Vision exam
Reimbursed
Coverage for In-Network Providers and Non-Network Providers No charge
Up to $30
is limited to 1 exam per benefit period.
Frames
Reimbursed
Coverage for In-Network Providers and Non-Network Providers No charge
Up to $45
is limited to 1 unit per benefit period.
Lenses
Coverage for In-Network Providers and Non-Network Providers is
limited to 1 unit per benefit period.
Single vision lenses $0 copay $0 copay (up to $25)
Bifocal lenses $0 copay $0 copay (up to $45)
Trifocal lenses $0 copay $0 copay (up to $55)
Lenticular lenses $0 copay $0 copay (up to $70)
Progressive lenses (standard, premium, select, ultra) $0 copay $0 copay (up to $40)
Transitions Lenses $0 copay Not covered
Standard polycarbonate $0 copay Not covered
Factory Scratch Coating $0 copay Not covered
Elective contact lenses
Reimbursed
Coverage for In-Network Providers and Non-Network Providers No charge
Up to $60
is limited to 1 unit per benefit period.
Non-Elective Contact Lenses
Reimbursed
Coverage for In-Network Providers and Non-Network Providers No charge
Up to $210
is limited to 1 unit per benefit period.
Adult Vision (age 19 and older)
Adult Vision Coverage
Limited to certain vision screenings required by Federal law
See “Preventive Care” benefit See “Preventive Care” benefit
and covered under the “Preventive Care” benefit.
19Benefits that go
with you
You are covered for emergency health situations when travelling abroad. With our 24/7 help center
and international network of doctor advisors, you have the right support and services when you need
them through GeoBlue®.
In a medical emergency:
1 Go immediately to the nearest doctor or hospital.
2 Call us at 1-833-511-4763. The GeoBlue Global Health & Safety Team will contact the doctor treating
you and closely monitor your situation to decide whether a medical evacuation is needed. When you
call, have this information ready:
› Your name › The ID number on the front of your member ID card
› Details of the emergency › The name of your health coverage program:
› The name and contact information of the Anthem Student Advantage
doctor and/or the hospital treating you › Your specific location, using GPS if it
is available
Your GeoBlue benefits
Emergency medical evacuation Unlimited
Repatriation of remains Unlimited
Emergency family travel arrangements Maximum benefit up to $5,000 per coverage year
Covered 100% up to $100,000 per person. Subject to a
Political emergency and natural disaster evacuation
combined $5,000,000 limit per any one covered event
(Available only when traveling outside the U.S.)
for all people covered under the plan.
Accidental death and dismemberment Maximum benefit up to $10,000 per coverage year
Use of benefits must be coordinated and approved by GeoBlue.
GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association. GeoBlue is the administrator of coverage provided under insurance policies issued in the District of Columbia by
4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association.
20Keeping you at your best
Offering you healthy support
and easy-to-use benefits to help
you stay focused on your
education and your future.
21Exclusions
The below exclusions apply. For a full list of exclusions please refer to the certificate of coverage.
1. Acupuncture Therapy Uterine fibroids
a) Maintenance treatment Xerostomia
b) Acupuncture when provided for the following conditions: Whiplash
Acute low back pain 2. Acts of War, Disasters, or Nuclear Accidents
Addiction In the event of a major disaster, epidemic, war, or other event beyond our
AIDS control, we will make a good faith effort to give you Covered Services. We
Amblyopia will not be responsible for any delay or failure to give services due to lack of
Allergic rhinitis available Facilities or staff. Benefits will not be given for any illness or injury
Asthma that is a result of war, service in the armed forces, a nuclear explosion,
Bell’s Palsy nuclear accident, release of nuclear energy, a riot, or civil disobedience.
Burning mouth syndrome
Cancer-related dyspnea 3. Administrative Charges
Carpal tunnel syndrome a) Charges to complete claim forms,
Chemotherapy-induced leukopenia b) Charges to get medical records or reports,
Chemotherapy-induced neuopathic pain c) Membership, administrative, or access fees charged by Doctors or other
Chronic pain syndrome (e.g., RSD, facial pain) Providers. Examples include, but are not limited to, fees for educational
Chronic obstructive pulmonary disease brochures or calling you to give you test results.
Diabetic peripheral neuropathy 4. Alternative / Complementary Medicine
Dry eyes Services and supplies given by a provider for alternative health care. This
Erectile dysfunction includes but is not limited to aromatherapy, naturopathic medicine, herbal
Facial spasm remedies, homeopathy, energy medicine, Christian faith-healing medicine,
Fetal breech presentation Ayurvedic medicine, yoga, hypnotherapy, and traditional Chinese medicine.
Fibromyalgia 5. Armed Forces
Fibrotic contractures Services and supplies received from a provider as a result of an injury
Glaucoma sustained, or illness contracted, while in the service of the armed forces of
Hypertension any country. When you enter the armed forces of any country, we will
Induction of labor refund any unearned pro-rata premium to the policyholder.
Infertility (e.g., to assist oocyte retrieval and embryo transfer
during IVF treatment cycle) 6. Applied Behavioral Treatment
Insomnia (including, but not limited to, Applied Behavior Analysis and intensive
Irritable bowel syndrome behavior interventions) for all indications except as described under Autism
Menstrual cramps/dysmenorrhea Services in the “Benefits/Coverage (What is Covered)” section.
Mumps 7. Before Effective Date or After Termination Date
Myofascial pain Charges for care you get before your Effective Date or after your coverage
Myopia ends, except as written in this Plan.
Neck pain/cervical spondylosis
8. Breasts
Obesity
Services and supplies given by a provider for breast reduction or
Painful neuropathies
gynecomastia.
Parkinson’s disease
Peripheral arterial disease (e.g., intermittent claudication) 9. Certain Providers
Phantom leg pain Services you get from Providers that are not licensed by law to provide
Polycystic ovary syndrome Covered Services as defined in this Booklet, or which are not recognized by
Post-herpetic neuralgia us as an eligible Provider under this Plan.
Psoriasis 10. Charges Over the Maximum Allowed Amount
Psychiatric disorders (e.g., depression) Charges over the Maximum Allowed Amount for Covered Services, except as
Raynaud’s disease pain written in this Plan.
Respiratory disorders
Rheumatoid arthritis 11. Charges Not Supported by Medical Records
Rhinitis Charges for services not described in your medical records.
Sensorineural deafness 12. Clinically-Equivalent Alternatives
Shoulder pain (e.g., bursitis) Certain Prescription Drugs may not be covered if you could use a clinically
Stroke rehabilitation (e.g., dysphagia) equivalent Drug, unless required by law. “Clinically equivalent” means Drugs
Tennis Elbow/epicondylitis that for most Members, will give you similar results for a disease or
Tension headache condition. If you have questions about whether a certain Drug is covered
Tinnitus and which Drugs fall into this group, please call the number on the back of
Tobacco Cessation your Identification Card, or visit our website at www.anthem.com.
Urinary incontinence
2213. Complications of/or Services Related to Non-Covered Services 20. Dental Care for Adults
Services, supplies or treatment related to or, for problems directly related a) Dental services for adults including services related to:
to a service that is not covered by this Plan. Directly related means that the The care, filling, removal or replacement of teeth and treatment
care took place as a direct result of the non-Covered Service and would not of injuries to or diseases of the teeth
have taken place without the non-Covered Service. Dental services related to the gums
14. Compound Drugs Apicoectomy (dental root resection)
Compound Drugs unless all of the ingredients are FDA-approved as Orthodontics
designated in the FDA’s Orange Book: Approved Drug Products with Root canal treatment
Therapeutic Equivalence Evaluations, require a prescription to dispense, and Soft tissue impactions
the compound medication is not essentially the same as an FDA-approved Alveolectomy
product from a drug manufacturer. Exceptions to non-FDA approved Augmentation and vestibuloplasty treatment of periodontal disease
compound ingredients may include multi-source, non-proprietary vehicles False teeth
and/or pharmaceutical adjuvants. Prosthetic restoration of dental implants
Dental implants
15. Cosmetic Services and Plastic Surgery
Any treatment, surgery (cosmetic or plastic), service or supply to alter, This exception does not include removal of bony impacted teeth, bone
improve or enhance the shape or appearance of the body. Whether or not fractures, removal of tumors, and odontogenic cysts.
for psychological or emotional reasons. Injuries that occur during medical 21. Dental Services
treatments are not considered accidental injuries even if unplanned or a) Dental care for Members age 19 or older, unless listed as covered in the
unexpected. This exclusion does not apply to: medical benefits of this Booklet.
a) Surgery after an accidental injury when performed as soon as b) Dental services or health care services not specifically covered in this
medically feasible. Booklet (including any hospital charges, prescription drug charges and
b) Coverage that may be provided under the Eligible health services dental services or supplies that do not have an American Dental
under your plan – Gender reassignment (sex change) treatment section. Association Procedure Code, unless covered by the medical benefits of
16. Court-ordered Services and Supplies this Plan).
Includes those court-ordered services and supplies, or those required as a c) Services of anesthesiologists, unless required by law.
condition of parole, probation, release or as a result of any legal proceeding d) Analgesia, analgesia agents, oral sedation, and anxiolysis nitrous oxide.
other than substance related disorders treatment and mental health e) Anesthesia services (such as intravenous conscious sedation, IV
treatment described as covered in the “Benefits/Coverage (What is sedation and general anesthesia) are not covered when given separate
Covered)” section and required by state law. from a covered oral surgery service. EXCEPTION: General anesthesia for
dental services for members under age 19 years of age when rendered
17. Crime in a hospital, outpatient surgical facility or other facility licensed
Treatment of an injury or illness that results from a crime you committed, or pursuant to Section 25-3-101 of the Colorado Revised Statutes if the
tried to commit. This Exclusion does not apply if your involvement in the child, in the opinion of the treating Dentist, satisfies one or more of the
crime was solely the result of a medical or mental condition, or where you following criteria: (a) the child has a physical, mental, or medically
were the victim of a crime, including domestic violence. compromising condition; (b) the child has dental needs for which local
18. Custodial Care anesthesia is ineffective because of acute infection, anatomic
Examples are: variations, or allergy; (c) the child is an extremely uncooperative,
a) Routine patient care such as changing dressings, periodic turning and unmanageable, anxious, or uncommunicative child or adolescent with
positioning in bed dental needs deemed sufficiently important that dental care cannot
b) Administering oral medications be deferred; or (d) the child has sustained extensive orofacial and
c) Care of a stable tracheostomy (including intermittent suctioning) dental trauma.
d) Care of a stable colostomy/ileostomy f) Dental services, appliances or restorations that are necessary to alter,
e) Care of a bladder catheter (including emptying/changing containers restore or maintain occlusion. Includes increasing vertical dimension,
and clamping tubing) replacing or stabilizing tooth structure lost by attrition, realignment of
f) Watching or protecting you teeth, periodontal splinting and gnathologic recordings.
g) Respite care, adult (or child) day care, or convalescent care except in g) Dental services or supplies provided solely for the purpose of improving
connection with hospice care the appearance of the tooth when tooth structure and function are
h) Institutional care. This includes room and board for rest cures, adult satisfactory and no pathologic conditions (such as cavities) exist,
day care and convalescent care h) Retreatment or additional treatment necessary to correct or relieve the
i) Help with walking, grooming, bathing, dressing, getting in or out of bed, results of treatment previously covered under the Plan.
toileting, eating or preparing foods i) Separate services billed when they are an inherent component of
j) Any other services that a person without medical or paramedical another covered service.
training could be trained to perform j) Services to treat Temporomandibular Joint Disorder (TMJ) except as
k) Any service that can be performed by a person without any medical or covered under your medical coverage.
paramedical training k) Oral hygiene instructions.
l) Case presentations, office visits and consultations.
19. Delivery Charges
m) Implant services, except as listed in this Booklet.
Charges for delivery of Prescription Drugs.
n) Removal of pulpal debridement, pulp cap, post, pin(s), resorbable or
23non-resorbable filling materials, nor the procedures used to prepare and disorder, conjunctivitis/pink eye, back pain that is not sudden and severe in
place material(s) in the canals (tooth roots). onset, or dental caries/cavity in an emergency room. For non-emergency
o) Root canal obstruction, internal root repair of perforation defects, care please use the closest network Urgent Care Center or your Primary
incomplete endodontic treatment and bleaching of discolored teeth. Care Physician.
p) Incomplete root canals. 30. Experimental or Investigational Services
q) Adjunctive diagnostic tests. Experimental or investigational drugs, devices, treatments or procedures
22. Drugs Contrary to Approved Medical and Professional Standards unless otherwise covered under clinical trial therapies (experimental or
Drugs given to you or prescribed in a way that is against approved medical investigational) or covered under clinical trials (routine patient costs). See
and professional standards of practice. the “Benefits/Coverage (What is Covered)” section.
23. Drugs Over Quantity or Age Limits 31. The fact that a service or supply is the only available treatment
Drugs which are over any quantity or age limits set by the Plan or us. will not make it Covered Service if we conclude it is Experimental /
24. Drugs Over the Quantity Prescribed or Refills After One Year Investigational.
Drugs in amounts over the quantity prescribed, or for any refill given more 32. Eyeglasses and Contact Lenses
than one year after the date of the original Prescription Order. Eyeglasses and contact lenses to correct your eyesight unless listed as
25. Drugs Prescribed by Providers Lacking Qualifications/Registrations/ covered in this Booklet. This Exclusion does not apply to lenses needed
Certifications after a covered eye surgery.
Prescription Drugs prescribed by a Provider that does not have the 33. Eye Exercises
necessary qualifications, registrations, and/or certifications, as determined Orthoptics and vision therapy.
by us. 34. Eye Surgery
26. Drugs That Do Not Need a Prescription Eye surgery to fix errors of refraction, such as near-sightedness. This
Drugs that do not need a prescription by federal law (including Drugs that includes, but is not limited to, LASIK, radial keratotomy or keratomileusis,
need a prescription by state law, but not by federal law), except for and excimer laser refractive keratectomy.
injectable insulin. 35. Family Members
27. Durable Medical Equipment (DME) Services prescribed, ordered, referred by or given by a member of your
Examples of these items are: immediate family, including your spouse, child, brother, sister, parent,
a) Whirlpools in-law, or self.
b) Portable whirlpool pumps 36. Foot Care
c) Sauna baths Services and supplies for:
d) Massage devices a) The treatment of calluses, bunions, toenails, flat feet, hammertoes,
e) Over bed tables fallen arches
f) Elevators b) The treatment of weak feet, chronic foot pain or conditions caused by
g) Communication aids routine activities, such as walking, running, working or wearing shoes
h) Vision aids c) Supplies (including orthopedic shoes), foot orthotics, arch supports,
i) Telephone alert systems shoe inserts, ankle braces, guards, protectors, creams, ointments and
j) Personal hygiene and convenience items such as air conditioners, other equipment, devices and supplies
humidifiers, hot tubs, or physical exercise equipment even if they are d) Routine pedicure services, such as cutting of nails, corns and calluses
prescribed by a physician. when there is no illness or injury of the feet unless specifically required
28. Educational Services for treatment or to prevent complications of diabetes.
Except as described as covered services for autism spectrum disorders, 37. Foot Surgery
therapies for congenital defects and birth abnormalities and early Surgical treatment of flat feet; subluxation of the foot; weak, strained,
intervention services in the Benefits/coverage (what is covered) section, unstable feet; tarsalgia; metatarsalgia; hyperkeratoses.
examples of these services are:
a) Any service or supply for education, training or retraining services 38. Free Care
or testing. This includes: Services you would not have to pay for if you didn’t have this Plan. This
Special education includes, but is not limited to government programs, services during a jail or
Remedial education prison sentence, services you get from Workers Compensation, and services
Wilderness treatment program from free clinics.
Job training 39. If Workers’ Compensation benefits are not available to you, this
Job hardening programs Exclusion does not apply.
b) Services provided by a governmental school district. This Exclusion will apply if you get the benefits in whole or in part.
29. Emergency Room Services for non-Emergency Care 40. Health Club Memberships and Fitness Services
Services provided in an emergency room for conditions that do not meet the Health club memberships, workout equipment, charges from a physical
definition of Emergency. This includes, but is not limited to, suture removal, fitness or personal trainer, or any other charges for activities, equipment, or
routine pregnancy test, sore throat, ear ache/infection, rashes, sprains/ facilities used for physical fitness, even if ordered by a Doctor. This
strains, constipation, diarrhea, upper respiratory illness, abrasions, sleep Exclusion also applies to health spas.
2441. Hearing Aids and Exams in your situation. Reimbursement will be based on the Maximum
The following services or supplies: Allowable Amount for a standard item that is a Covered Service, serves
a) A replacement of: the same purpose, and is Medically Necessary. Any expense that
A hearing aid that is lost, stolen or broken exceeds the Maximum Allowable Amount for the standard item which is
A hearing aid installed within the prior 12 month period a Covered Service is your responsibility.
b) Replacement parts or repairs for a hearing aid 45. Medical Supplies: Outpatient Disposable
c) Batteries or cords a) Any outpatient disposable supply or device. Examples of these are:
d) A hearing aid that does not meet the specifications prescribed for Sheaths
correction of hearing loss Bags
e) Any ear or hearing exam performed by a physician who is not certified as Elastic garments
an otolaryngologist or otologist Support hose
f) Hearing exams given during a stay in a hospital or other facility, except Bandages
those provided to newborns as part of the overall hospital stay Bedpans
g) Any tests, appliances and devices to: Syringes
Improve your hearing. This includes hearing aid batteries, amplifiers, Blood or urine testing supplies
and auxiliary equipment Other home test kits
Enhance other forms of communication to make up for hearing loss Splints
or devices that simulate speech. Neck braces
42. Infertility Treatment Compresses
a) Injectable infertility medication, including but not limited to menotropins, Other devices not intended for reuse by another patient
hCG, and GnRH agonists. 46. Medicare
b) All charges associated with: Services and supplies available under Medicare, if you are entitled to
Surrogacy for you or the surrogate. A surrogate is a female carrying premium-free Medicare Part A or enrolled in Medicare Part B, or if you are not
her own genetically related child where the child is conceived with the entitled to premium-free Medicare Part A or enrolled in Medicare Part B
intention of turning the child over to be raised by others, including the because you refused it, dropped it, or did not make a proper request for it.
biological father.
Cryopreservation (freezing) of eggs, embryos or sperm. 47. Missed or Cancelled Appointments
Storage of eggs, embryos, or sperm. Charges for missed or cancelled appointments.
Thawing of cryopreserved (frozen) eggs, embryos or sperm. 48. Non-approved Drugs
The care of the donor in a donor egg cycle which includes, but is not Drugs not approved by the FDA.
limited to, any payments to the donor, donor screening fees, fees for
49. Non-Medically Necessary Services
lab tests, and any charges associated with care of the donor required
Services and supplies which are not medically necessary for the diagnosis,
for donor egg retrievals or transfers.
care, or treatment of an illness or injury or the restoration of physiological
The use of a gestational carrier for the female acting as the
functions. This includes behavioral health services that are not primarily
gestational carrier. A gestational carrier is a female carrying an
aimed at the treatment of illness, injury, restoration of physiological
embryo to which the person is not genetically related.
functions or that do not have a physiological or organic basis. This applies
Obtaining sperm from a person not covered under this plan for
even if they are prescribed, recommended, or approved by your physician,
ART services.
dental provider, or vision care provider. This exception does not apply to
c) Home ovulation prediction kits or home pregnancy tests.
Preventive care and wellness benefits.
d) The purchase of donor embryos, donor oocytes, or donor sperm.
e) Reversal of a voluntary sterilizations, including follow-up care. 50. Nutritional Support
f) Ovulation induction with menotropins, Intrauterine insemination and Except as covered in the “Benefits/Coverage (What is Covered)” section –
any related services, products or procedures. Nutritional support benefit, the following are not covered services:
g) In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete a) Any food item, including:
intrafallopian transfer (GIFT), Cryopreserved embryo transfers and any Infant formulas
related services, products or precedures (such as Intracytoplasmic Nutritional supplements
sperm injection (ICSI) or ovum microsurgery). Vitamins
h) ART services are not provided for out-of-network care. Other nutritional items even if it is the sole source of nutrition.
43. Lost or Stolen Drugs 51. Off label use
Refills of lost or stolen Drugs. Off label use, unless we must cover it by law or if we approve it.
44. Medical Equipment, Devices, and Supplies 52. Personal Care, Comfort or Convenience Items
a) Replacement or repair of purchased or rental equipment because of Any service or supply primarily for your convenience and personal comfort or
misuse, or loss. that of a third party.
b) Surgical supports, corsets, or articles of clothing unless needed to 53. Private Duty Nursing
recover from surgery or injury. Private Duty Nursing Services, except as specifically stated in this Booklet.
c) Non-Medically Necessary enhancements to standard equipment
and devices. 54. Prosthetics Devices
d) Supplies, equipment and appliances that include comfort, luxury, or a) Services covered under any other benefit
convenience items or features that exceed what is Medically Necessary b) Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices
25to support the feet, unless required for the treatment of or to prevent 63. Vein Treatment
complications of diabetes, or if the orthopedic shoe is an integral part Treatment of varicose veins or telangiectatic dermal veins (spider veins)
of a covered leg brace. by any method (including sclerotherapy or other surgeries) for cosmetic
c) Trusses, corsets, and other support items. purposes.
d) Repair and replacement due to loss, misuse, abuse or theft 64. Vision Services
e) Communication aids a) Eyeglass frames, non-prescription lenses and non-prescription
55. Residential accommodations contact lenses that are for cosmetic purposes.
Residential accommodations to treat medical or behavioral health b) Vision services not specifically listed as covered in this Booklet.
conditions, except when provided in a Hospital, Hospice, Skilled Nursing c) For services or supplies combined with any other offer, coupon or
Facility, or Residential Treatment Center. This Exclusion includes in-store advertisement, or for certain brands of frames where the
procedures, equipment, services, supplies or charges for the following: manufacture does not allow discounts.
a) Domiciliary care provided in a residential institution, treatment center, d) Safety glasses and accompanying frames.
halfway house, or school because a Member’s own home arrangements e) For two pairs of glasses in lieu of bifocals.
are not available or are unsuitable, and consisting chiefly of room and f) Plano lenses (lenses that have no refractive power).
board, even if therapy is included. g) Lost or broken lenses or frames, unless the Member has reached their
b) Care provided or billed by a hotel, health resort, convalescent home, normal interval for service when seeking replacements.
rest home, nursing home or other extended care facility home for the h) Blended lenses.
aged, infirmary, school infirmary, institution providing education in i) Oversize lenses.
special environments, supervised living or halfway house, or any similar j) Sunglasses.
facility or institution. k) For Members through age 18, no benefits are available for frames and
c) Services or care provided or billed by a school, Custodial Care center contact lenses purchased outside of our formulary.
for the developmentally disabled, or outward bound programs, even if l) Cosmetic lenses or options, such as special lens coatings or
psychotherapy is included. non-prescription lenses, unless specifically stated as covered in
d) Wilderness camps. this Booklet
56. Riot m) Services and materials not meeting accepted standards of optometric
Services and supplies that you receive from providers as a result of an practice or services that are not performed by a licensed Provider.
injury from your “participation in a riot”. This means when you take part in Adult Vision Care
a riot in any way such as inciting, or conspiring to incite, the riot. It does a) Office visits to an ophthalmologist, optometrist or optician related to
not include actions that you take in self-defense as long as they are not the fitting of prescription contact lenses.
against people who are trying to restore law and order. b) Eyeglass frames, non-prescription lenses and non-prescription
contact lenses that are for cosmetic purposes.
57. Routine Physicals
Physical exams and immunizations required for travel, enrollment in any Adult Vision Care Services and Supplies
insurance program, as a condition of employment, for licensing, sports Your plan does not cover adult vision care services and supplies, except as
programs, or for other purposes, which are not require by law under the described in the Benefits/coverage (what is covered) section.
“Preventive Care” benefit. a) Special supplies such as non-prescription sunglasses
b) Special vision procedures, such as orthoptics or vision therapy.
58. Sexual Dysfunction and Enhancement c) Eye exams during your stay in a hospital or other facility for
Any treatment, prescription drug, service, or supply to treat sexual health care.
dysfunction, enhance sexual performance or increase sexual desire, d) Eye exams for contact lenses or their fitting.
including: e) Eyeglasses or duplicate or spare eyeglasses or lenses or frames.
a) Surgery, prescription drugs, implants, devices or preparations to f) Replacement of lenses or frames that are lost or stolen or broken.
correct or enhance erectile function, enhance sensitivity, or alter the g) Acuity tests.
shape or appearance of a sex organ. h) Eye surgery for the correction of vision, including radial keratotomy,
b) Sex therapy, sex counseling, marriage counseling, or other counseling LASIK and similar procedures.
or advisory services. i) Services to treat errors of refraction.
Not eligible for coverage are prescription drugs in 60 day supplies.
65. Waived Cost-Shares Out-of-Network
59. Stand-By Charges For any service for which you are responsible under the terms of this Plan
Stand-by charges of a Doctor or other Provider. to pay a Copayment, Coinsurance or Deductible, and the Copayment,
60. Surrogate Mother Services Coinsurance or Deductible is waived by an Out-of-Network Provider.
Services or supplies for a person not covered under this Plan for a surrogate 66. Weight Loss Programs
pregnancy (including, but not limited to, the bearing of a child by another Programs, whether or not under medical supervision, unless listed as
woman for an infertile couple). covered in this Booklet.
61. Temporomandibular Joint Dysfunction Treatment (TMJ) and This Exclusion includes, but is not limited to, commercial weight loss
Craniomandibular Joint Dysfunction Treatment (CMJ) programs (Weight Watchers, Jenny Craig, LA Weight Loss) and
a) Dental implants fasting programs.
62. Travel Costs 67. Weight Loss Surgery
Mileage, lodging, meals, and other Member-related travel costs except as Services and supplies related to bariatric surgery, or surgical treatment of
described in this Plan. obesity, unless listed as covered in the Booklet.
2668. Pharmacy: In addition to the above Exclusions, certain items are not related to the introduction of genetic material into a person intended
covered under the Prescription Drug Retail or Home Delivery (Mail Order) to replace or correct faulty or missing genetic material.]
Pharmacy benefit: o) Infertility Drugs - Drugs used in assisted reproductive technology
a) Administration Charges - Charges for the administration of any Drug procedures to achieve conception (e.g., IVF, ZIFT, GIFT), except as
except for covered immunizations as approved by us or the PBM. listed in this booklet.
b) Charges Not Supported by Medical Records - Charges for pharmacy p) Items Covered as Durable Medical Equipment (DME) - Therapeutic
services not related to conditions, diagnoses, and/or recommended DME, devices and supplies except peak flow meters, spacers, and
medications described in your medical records. blood glucose monitors. Items not covered under the Prescription
c) Clinically-Equivalent Alternatives - Certain Prescription Drugs may not Drug Benefit at a Retail or Home Delivery (Mail Order) Pharmacy
be covered if you could use a clinically equivalent Drug, unless benefit may be covered under the “Durable Medical Equipment and
required by law. “Clinically equivalent” means Drugs that for most Medical Devices” benefit. Please see that section for details.
Members, will give you similar results for a disease or condition. If you q) Items Covered Under the “Allergy Services” Benefit - Allergy
have questions about whether a certain Drug is covered and which desensitization products or allergy serum. While not covered under
Drugs fall into this group, please call the number on the back of your the Prescription Drug Benefit at a Retail or Home Delivery (Mail Order)
Identification Card, or visit our website at www.anthem.com. Pharmacy benefit, these items may be covered under the “Allergy
d) Compound Drugs - Compound Drugs unless all of the ingredients are Services” benefit. Please see that section for details.
FDA-approved as designated in the FDA’s Orange Book: Approved Drug r) Lost or Stolen Drugs - Refills of lost or stolen Drugs.
Products with Therapeutic Equivalence Evaluations, require a s) Mail Order Providers other than the PBM’s Home Delivery Mail Order
prescription to dispense, and the compound medication is not Provider - Prescription Drugs dispensed by any Mail Order Provider
essentially the same as an FDA-approved product from a drug other than the PBM’s Home Delivery Mail Order Provider, unless we
manufacturer. Exceptions to non-FDA approved compound ingredients must cover them by law.
may include multi-source, non-proprietary vehicles and/or t) Non-approved Drugs - Drugs not approved by the FDA.
pharmaceutical adjuvants. u) Non-Medically Necessary Services - Services we conclude are not
e) Contrary to Approved Medical and Professional Standards - Drugs Medically Necessary. This includes services that do not meet our
given to you or prescribed in a way that is against approved medical medical policy, clinical coverage, or benefit policy guidelines.
and professional standards of practice. v) Nutritional or Dietary Supplements - Nutritional and/or dietary
f) Delivery Charges - Charges for delivery of Prescription Drugs. supplements, except as described in this Booklet or that we must
g) Drugs Given at the Provider’s Office / Facility - Drugs you take at the cover by law. This Exclusion includes, but is not limited to, nutritional
time and place where you are given them or where the Prescription formulas and dietary supplements that you can buy over the counter
Order is issued. This includes samples given by a Doctor. This and those you can get without a written Prescription or from a
Exclusion does not apply to Drugs used with a diagnostic service, licensed pharmacist.
Drugs given during chemotherapy in the office as described in the w) Off label use - Off label use, unless we must cover the use by law or if
“Prescription Drugs Administered by a Medical Provider” section, or we, or the PBM, approve it.
Drugs covered under the “Medical and Surgical Supplies” benefit x) Onychomycosis Drugs - Drugs for Onychomycosis (toenail fungus)
– they are Covered Services. except when we allow it to treat Members who are immuno-
h) Drugs Not on the Anthem Prescription Drug List (a formulary) - You can compromised or diabetic.
get a copy of the list by calling us or visiting our website at www. y) Over-the-Counter Items - Drugs, devices and products, or Prescription
anthem.com. If you or your Doctor believes you need a certain Legend Drugs with over the counter equivalents and any Drugs, devices or
Prescription Drug not on the list, please refer to “Prescription Drug products that are therapeutically comparable to an over the counter Drug,
List” in the section “Prescription Drug Benefit at a Retail or Home device, or product may not be covered, even if written as a Prescription.
Delivery (Mail Order) Pharmacy” for details on requesting an This includes Prescription Legend Drugs when any version or strength
exception. becomes available over the counter.
i) Drugs Over Quantity or Age Limits - Drugs which are over any quantity 69. This Exclusion does not apply to over-the-counter products that
or age limits set by the Plan or us. we must cover as a “Preventive Care” benefit under federal law
j) Drugs Over the Quantity Prescribed or Refills After One Year - Drugs in with a Prescription.
amounts over the quantity prescribed, or for any refill given more a) Sexual Dysfunction Drugs - Drugs to treat sexual or erectile problems.
than one year after the date of the original Prescription Order. b) Syringes - Hypodermic syringes except when given for use with insulin
k) Drugs Prescribed by Providers Lacking Qualifications/Registrations/ and other covered self-injectable Drugs and medicine.
Certifications - Prescription Drugs prescribed by a Provider that does c) Weight Loss Drugs - Any Drug mainly used for weight loss.
not have the necessary qualifications, registrations and/or
certifications, as determined by Anthem.
l) Drugs That Do Not Need a Prescription - Drugs that do not need a
prescription by federal law (including Drugs that need a prescription
by state law, but not by federal law), except for injectable insulin.
m) Family Members - Services prescribed, ordered, referred by or given
by a member of your immediate family, including your spouse, child,
brother, sister, parent, in-law, or self.
n) {Option to remove: [Gene Therapy - Gene therapy as well as any Drugs,
procedures, health care services related to it that introduce or is
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