ClearProtection Plus How It Works

2 Two Separate Deductibles Each plan has two deductibles: Inpatient/outpatient surgical/ER services deductible Outpatient professional services deductible IP/OP Surgical/ER Deductible $1000$3300 Outpatient Professional Deductible $4500$6800

3 Two Separate Deductibles 40% coinsurance applies for inpatient, outpatient surgical, and emergency room services after the Inpatient/Outpatient Surgical/ER Deductible is met Member pays 100% of the negotiated rate before the deductible is met IP/OP Surgical/ER Deductible $1000$3300 Outpatient Professional Deductible $4500$6800

4 Two Separate Deductibles 0% coinsurance applies to outpatient professional services after the Outpatient Professional services Deductible is met Member pays 100% of the negotiated rate before the deductible is met IP/OP Surgical/ER Deductible $1000$3300 Outpatient Professional Deductible $4500$6800

5 Two Separate Deductibles The Outpatient Professional Services Deductible amount is equal to the Total OOP Maximum amount IP/OP Surgical/ER Deductible $1000$3300 Outpatient Professional Deductible $4500$6800 Total OOP Maximum (deductible plus Calendar OOP Maximum) $4500$6800 All in-network covered services covered at 100% (0% coinsurance) after the Total OOP Maximum is met.

6 ClearProtection Plus Scenario 1 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met $1000 deductible satisfied; member pays 40% of balance (40% of $4000 = $1,600) No amounts appliedNo – $2600 applied ($ $1600) $1000 Deductible ClearProtection Plus Plan: Member gets $5000 Inpatient Procedure

7 ClearProtection Plus Scenario 1 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met $1000 deductible satisfied; member pays 40% of balance (40% of $4000 = $1,600) No amounts appliedNo – $2600 applied ($ $1600) $1000 deductible satisfied; member pays 40% of $1000 ($400) No amounts appliedNo – total amount applied is now $3000 $1000 Deductible ClearProtection Plus Plan: Member gets $5000 Inpatient Procedure; member then gets $1000 outpatient surgical procedure

8 ClearProtection Plus Scenario 1 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met $1000 deductible satisfied; member pays 40% of balance (40% of $4000 = $1,600) No amounts appliedNo – $2600 applied ($ $1600) $1000 deductible satisfied; member pays 40% of $1000 ($400) No amounts appliedNo – total amount applied is now $3000 No amounts applied$1500 applied; $500 balance is paid at 100% after Total OOP Max is met Yes – total amount applied is $4500 $1000 Deductible ClearProtection Plus Plan: Member gets $5000 Inpatient Procedure; member then gets $1000 outpatient surgical procedure; member needs $2000 in professional services

9 ClearProtection Plus Scenario 2 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met No amounts applied$4500 applied; $500 balance is paid at 100% after Total OOP Max is met Yes – total amount applied is $4500 $1000 Deductible ClearProtection Plus Plan: Member gets $5000 in professional services

10 ClearProtection Plus Scenario 2 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met No amounts applied$4500 applied; $500 balance is paid at 100% after Total OOP Max is met Yes – total amount applied is $4500 Inpatient charges paid at 100% after Total OOP Max is met No amounts applied $1000 Deductible ClearProtection Plus Plan: Member gets $5000 in professional services; member needs $5000 inpatient procedure

11 ClearProtection Plus Scenario 3 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met $2000 appliedNo amounts appliedNo – $2000 applied $3300 Deductible ClearProtection Plus Plan: Member gets $2000 outpatient surgical procedure

12 ClearProtection Plus Scenario 3 IP/OP Surgical/ER Deductible OP Professional Deductible Total OOP Maximum Amount Met $2000 appliedNo amounts appliedNo – $2000 applied No amounts applied$4800 appliedYes -- $6800 total amount applied $3300 Deductible ClearProtection Plus Plan: Member gets $2000 outpatient surgical procedure; member spends $4,800 in outpatient/diagnostic services Neither IP/Surgical or OP Professional Services Deductible met, however all subsequent services will be covered at 100% because the Total OOP Max is met

13 In a nutshell… Anthem shares cost of inpatient/surgical/ER procedures after inpatient/Surgical/ER deductible $1000/$3300 – Individual $2000/$6800 – Family Anthem shares cost of outpatient/professional services after outpatient/professional deductible $4500/$6800 – Individual $9000/$13600 – Family Anthem will pay 100% of all in-network covered services, including outpatient professional services, after the total OOP Maximum is met $4500/$6800 – Individual $9000/$13600 – Family

14 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.