* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/aso. Page 4 of 7 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Hospice services 20% coinsurance, deductible does not apply 40% coinsurance, deductible does not apply Life expectancy up to 12 months. If your child needs dental or eye care Children’s eye exam Not covered Not covered --------none-------- Children’s glasses Not covered Not covered Children’s dental check-up Not covered Not covered --------none-------- Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Hearing aids • Routine eye care (Adult) • Children’s dental check-up • Eye exams for a child • Infertility treatment • Routine foot care unless medically necessary • Cosmetic surgery • Glasses for a child • Long-term care • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric surgery 1 surgery/lifetime • Private-duty nursing Facility Setting only • Chiropractic care 12 visits/benefit period • Most coverage provided outside the United States. See www.bcbsglobalcore.com Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395, www.in.gov/idoi/3008.htm, Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568 Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov