little or no cost Form

17 Benefits Details Copay Doctor care Includes: preventive care, physical exams, prenatal care, well-child checkups, immunizations, specialty care None Chiropractic services Package A: up to five visits per year and 50 therapeutic physical medicine treatments
per year Package C: up to five visits per year and 14 therapeutic physical medicine treatments in a rolling 12-month period None Hospital care Includes: emergency room, inpatient services, outpatient services and surgeries, lab tests and X-rays, post-stabilization services, ambulance rides for emergencies Package C: $10 for
ambulance transport Medical supplies Includes: diabetes supplies, durable medical equipment, hearing aids, orthopedic shoes and leg braces, orthotics, and
prosthetic devices None Therapy services Physical, speech, occupational and respiratory therapy Package C: maximum of 50 visits for each therapy type, per 12-month period None Pharmacy Package C: $3 generic drugs, $10 brand-name drugs You don’t have copays if you’re:  Under 18 years old.  Getting pregnancy or family planning services.  Getting services in the ER, hospital or
nursing home. Behavioral health Services for mental health and
substance abuse None Services offered by Anthem From preventive care to vision and pharmacy services, we’re here to help you get and
stay healthy. Learn more about your benefits and copays below.

18 Benefits Details Copay Smoking cessation Includes:  One 12-week course of treatment per calendar year  Prescription and over-the-counter treatment, such as nicotine patches
or gum  Counseling services (a limit of eight hours of counseling services) None Skilled nursing facility Package A: up to 60 days per rolling
12-month period Package C: not offered None Vision services Package A  One exam every 12 months  Glasses every two years  Contact lenses, if medically necessary Package C  One exam every 12 months  Glasses every two years, contacts if medically necessary None Podiatry services Package A: up to six routine foot care visits
per year Package C: routine foot care is not offered None Nonemergency transportation Package A: unlimited trips to any approved medical, behavioral health, dental and
vision appointment Package C: up to 20 one-way trips each year and up to 50 miles each way Anthem also allows trips:  For those enrolled in the Women, Infants, and Children (WIC) program.  To the Division of Family Resources (DFR).  To health education programs. None What is post-stabilization? This is the free care you get in the ER or hospital after your condition is stable, but before you leave the ER or hospital. See the Extra Benefits section in the Quick Guide in front of the handbook to learn more about all the extras Anthem offers!