Plan Comparison

Important Note: This form is not a contract; it is only a summary. The contents of this form are subject to the provisions of the Benefits Booklet, which contains all terms, covenants and conditions of coverage.

  CU Health Plan - Exclusive CU Health Plan - Access Network CU Health Plan - Kaiser CU Health Plan - High Deductible
ELIGIBLE PARTICIPANTS Faculty, officers and university staff

Classified staff

Retirees younger than 65

Surviving spouses younger than 65
(CURRENT ENROLLEES ONLY) Faculty, officers and university staff

Classified staff

Retirees younger than 65

Surviving spouses younger than 65
Faculty, officers and university staff

Classified staff

Retirees younger than 65

Surviving spouses younger than 65
TYPE OF COVERAGE
Type of plan Client-specific plan Health Maintenance Organization (HMO) Exclusive Provider Organization (EPO) Preferred Provider Plan (PPO)
Is out-of-network care covered? Only for emergency and urgent care Only for emergency and urgent care Only for emergency care Yes, but the patient pays more for out-of-network care
Where the plan is available? Available throughout Colorado This plan is available only to members who are currently enrolled and do not reside in certain Metro Denver zip codes.

Please visit Anthem's CU Health Plan website  for a complete list of excluded zip codes.
Denver/Boulder

This plan is available& only in the following areas:

Portions of Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park and Weld counties as determined by zip code



Southern Colorado
This plan is available only in the following areas:

Portions of Crowley, Custer, Douglas, El Paso, Fremont, Huerfano, Las Animas, Lincoln, Otero, Park, Pueblo and Teller Counties as determined by zip code
Available throughout the United States
SUMMARY OF BENEFITS IN NETWORK OUT OF NETWORK
2014-15 plan year (July 1, 2014-June 30, 2015)
Plan-year deductible
a) Single $250 No deductibles No deductibles $1,500 $3,000
b) Non-Single $750

Family members meet only their individual deductible and then their claims will be paid at 100 percent, except those services that are subject to a copayment.

If the family deductible has been met before the individual deductible, their claims will be paid at 100 percent, except those services that are subject to a copayment.
No deductibles No deductibles $3,000

If you select non-single membership, no single deductible applies and the non-single deductible must be met before the Plan provides benefits. The non-single deductible amount is met as follows: when one member has satisfied the non-single deductible, that member and all other members are eligible for benefits. When no member meets the non-single deductible, but the members collectively meet the entire non-single deductible, then all members will be eligible for benefits.

Some covered services have a maximum benefit of days, visits or dollar amounts. When the deductible is applied to a covered service that has a maximum number of days or visits, those maximum benefits will be reduced by the amount applied toward the deductible, whether or not the covered service is paid.
$6,000

If you select non-single membership, no single deductible applies, and the non-single deductible must be met before the Plan provides benefits.

The non-single deductible amount is met as follows:

When one member has satisfied the non-single deductible, that member and all other members are eligible for benefits.

When no member meets the nonsingle deductible, but the members collectively meet the entire non-single deductible, then all members will be eligible for benefits.

Some covered services have a maximum benefit of days, visits or dollar amounts. When the deductible is applied to a covered service with a maximum number of days or visits, those maximum benefits will be reduced by the amount applied toward the deductible, whether or not the covered service is paid.

OUT-OF-POCKET PLAN-YEAR MAXIMUM

a) Single In-network: $6,350
RX not included
In-network: $6,350
​RX not included
$4,000
includes copayments, except for RX
$3,000 per single

includes deductible and coinsurance
$6,000 per single

includes deductible and coinsurance
b) Non-Single $12,700 family aggregate
RX not included
$12,700 family aggregate
​RX not included
$10,000 family 
does include copayments, except for RX
$6,000 single or non-single

Includes deductible and coinsurance
$12,000 single or non-single

Includes deductible and coinsurance
         If you select non-single membership, no single out-of-pocket maximum applies, and the non-single out-of pocket maximum must be met.

When the out-of-pocket maximum is met, the plan pays 100 percent.

The out-of-pocket maximum is met as follows:

When one member has satisfied the out-of-pocket maximum, that member and all other members are eligible for benefits.

When no member meets the out-of-pocket maximum, but the members collectively meet the entire out-of-pocket maximum, then all members will be eligible for benefits.

Some covered services have a maximum numbers of days, visits or dollar amounts. These maximums apply even if the applicable out-of-pocket maximum is satisfied.
If you select non-single membership, no single out-of-pocket maximum applies, and the non-single out-of-pocket maximum must be met.

When the out-of-pocket maximum is met, the plan pays 100 percent.

The out-of-pocket maximum is met as follows:

When one member has satisfied the out-of-pocket maximum, that member and all other members are eligible for benefits.

When no member meets the out-of-pocket maximum, but the members collectively meet the entire out-of-pocket maximum, then all members will be eligible for benefits.

Some covered services have a maximum numbers of days, visits or dollar amounts. These maximums apply even if the applicable out-of-pocket maximum is satisfied.

The difference between billed charges and the maximum allowed amount for non-participating providers does not count toward the out-of-pocket maximum.

Even once the out-of-pocket maximum is satisfied, the member will still be responsible for paying the difference between the maximum allowed amount and the non-participating providers' billed charges.
c) Is deductible included in the out-of-pocket maximum? Yes Yes Not applicable

Each family member has an individual out-of-pocket maximum amount within the family out-of-pocket maximum.

The individual cannot contribute more than the amount of a single out-of-pocket maximum to the family out-of-pocket maximum.
Yes Yes
LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE No lifetime maximum No lifetime maximum No lifetime maximum No lifetime maximum No lifetime maximum
COVERED PROVIDERS Client specific network

Your selection of a primary care provider determines your specific provider network.

See the provider directory on Anthem's CU Health Plan website for a complete list of current providers.
HMO Colorado managed care network

See the provider directory at Anthem's CU Health Plan website .
Denver/Boulder

Colorado Permanente Medical Group, P.C.

See the provider directory for a complete list of current providers.

Southern Colorado

Kaiser Permanente southern Colorado plan providers

See the provider directory for a complete list of current providers.
Anthem Blue Cross Blue Shield PPO provider network

Visit Anthem's CU Health Plan website for a complete list of current providers.
All providers licensed or certified to provide covered benefits
MEDICAL OFFICE VISITS          
a) Primary Care Providers $30 co-payment per visit $30 co-payment per visit $30 co-payment each primary care office visit Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
b) Specialist Providers $40 co-payment per visit

Services provided as part of an office visit may be subject to the deductible, such as diagnostic services; for a complete list of services, please refer to  Anthem's CU Health Plan website.
$40 co-payment per visit $40 co-payment each specialist care office visit Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
PREVENTIVE CARE
a) Children's services to age 13 Covered person pays no coinsurance (100% covered), not subject to deductible. No copayment (100% covered) No copayment (100% covered) Up to age 13, Covered person pays no coinsurance (100% covered), not subject to deductible. Up to age 13, covered person pays 35% coinsurance not subject to deductible.
b) Adults' services Covered person pays no coinsurance (100% covered), not subject to deductible.

For Coverage of non-preventive colonoscopies and sigmoidoscopies, benefits are described under"Outpatient Ambulatory / Surgery."

For a detail list of covered preventive services please visit Anthem's CU Health Plan website .
No copayment (100% covered)

For Coverage of non-preventive colonoscopies and sigmoidoscopies, benefits are described under "Outpatient Ambulatory/Surgery."

For a detail list of covered preventive services please visit  Anthem's CU Health Plan website .
No copayment (100% covered) Age 13 and above, Covered person pays no coinsurance (100% covered), not subject to deductible.

For Coverage of non-preventive colonoscopies and sigmoidoscopies, benefits are described under "Outpatient / Ambulatory Surgery."
Age 13 and above, Covered person pays 35% after deductible.

Age 13 and above, mammogram, colonoscopies, sigmoidoscopies and prostate screenings, covered person pays 35% not subject to deductible.

For Coverage of non-preventive colonoscopies and sigmoidoscopies, benefits are described under "Outpatient / Ambulatory Surgery."
      For a detailed list of covered preventive services, please visit Anthem's CU Health Plan website .
MATERNITY    
a) Physicians care $15 copayment for the first prenatal care visit. This copayment includes physicians prenatal care services and deliveries. $15 copayment for the first prenatal care visit. This copayment includes physicians prenatal care services and deliveries. Visit to confirm pregnancy

$30 primary

$40 specialty

Eligible sick newborn professional and facility charges are covered under the sick newborn.
Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
b) Inpatient hospital care Covered person pays no coinsurance (100% covered) after deductible.

Eligible sick newborn inpatient charges may be subject to a separate deductible.
$250 copayment per day up to a maximum of $1,000 in copayments per admission for facility services.

Eligible sick newborn inpatient charges may be subject to a separate copayment.
$250 co-payment each day up to a maximum of $1000 per admission -
Applies toward OPM

Eligible Well Newborn Professional and Facility charges are covered under the mother. Eligible Sick Newborn Professional and Facility charges are covered under the Sick Newborn.
Covered person pays 15% coinsurance after deductible.

Eligible sick newborn inpatient charges may be subject to a separate deductible.
Covered person pays 35% coinsurance after deductible.

Eligible sick newborn inpatient charges may be subject to a separate deductible.
PRESCRIPTION DRUGS

Level of coverage and restrictions on prescriptions
    Does not apply toward OPM

Denver/Boulder- For drugs on our approved list, please contact your Clinical Pharmacy Call Center at 1-866-244-4119 or toll-free at 1-800-632-9700 or TTY 1-800-521-4874

Southern Colorado - For drugs on our approved list, please contact Southern Colorado Member Services toll-free at 1-888-681-7878 or TTY 1-800-521-4874
   
a) Inpatient care Included with the inpatient hospital benefit Included with the inpatient hospital benefit Included with the inpatient hospital co-payment Covered person pays 15 percent coinsurance after deductible. Covered person pays 35 percent coinsurance after deductible.
b) Outpatient care Copayments for Prescriptions filled at UCH Retail Pharmacy
Locations:


• Tier 1 generic prescription $13 copayment for up to a 30 day
supply;

• Tier 2 preferred brand-name prescription $30 copayment for up
to a 30 day supply;

• Tier 3 non-preferred brand-name prescription $50 copayment
for up to a 30 day supply;

• Tier 4 Specialty Oral and Injectable prescription $75 copayment for up to a 30 day supply.

Copayments for Prescriptions filled at Anthem Participating Retail Pharmacy Locations:

• Tier 1 generic prescription $15 copayment, for up to a 30 day
supply;

• Tier 2 brand-name prescription $35 copayment, for up to a 30
day supply;

• Tier 3 non-preferred brand-name prescription $50 copayment
for up to a 30 day supply;

• Tier 4 Specialty Oral and Injectable prescription $75 copayment for up to a 30 day supply.

Specialty Rx:  Per fill, a maximum of up to 30 days of Specialty
medication may be purchased at a retail pharmacy. After 3 fills, UCH
pharmacies must be used for Specialty medication to be covered. 

For a complete listing of University of Colorado Hospital (UCH) Retail Pharmacy Locations, please visit  Anthem's CU Health Plan website .
Copayments for Prescriptions filled at either UCH or Anthem
Participating Retail Pharmacy Locations


• Tier 1 generic prescription $15 copayment, for up to 30 day
supply;

• Tier 2 brand-name prescription $35 copayment, for up to 30
day supply;

• Tier 3 non-preferred brand-name prescription $50 copayment,
for up to 30 day supply;

• Tier 4 Specialty Oral and Injectable prescription $75
copayment, for up to 30 day supply.

For a complete listing of University of Colorado Hospital (UCH) Retail Pharmacy Locations, please visit  Anthem's CU Health Plan website .
  • $15 generic / $35 brand per prescription up to a 30-day supply.

    20% for specialty Rx, including Self Administered injectables, up to a maximum of $75 per Rx, up to 30 days supply
Covered person pays 20% coinsurance after deductible for up to a 30 day supply at Anthem Retail Pharmacies or up to a 90-day supply at UCH Retail Pharmacies. Covered person pays 20% coinsurance after deductible up to a 30-day supply.
c) Prescription Mail Service • Tier 1 generic prescription $26 copayment, for up to a 90 day
supply;

• Tier 2 brand-name prescription $60 copayment, for up to a 90
day supply;

• Tier 3 non-preferred brand-name prescription $100 copayment,
for up to a 90 day supply.

• Tier 4 Specialty Oral and Injectable prescription $75 copayment for up to a 30 day supply.

Maintenance Medication:  Per fill, a maximum of up to 30 days of maintenance medication may be purchased at a retail pharmacy. 

After 3 fills, UCH Retail Pharmacies or UCH Mail Order Prescription Service must be used for maintenance medication to be covered.

Diabetic Medication:  Members diagnosed with diabetes are eligible to have diabetic medication filled with no applicable copayment (100% covered). Please contact customer service or visit Anthem's CU Health Plan website  for additional information.

Mail Order Pharmacy Location
University of Colorado Hospital
Mail Order Prescription Service
12605 E. 16th Ave.
Mail Stop A014
Aurora, CO 80045
Phone (720) 848-1432
Fax (720) 848-1433
• Tier 1 generic prescription $30 copayment, for up to 90 day
supply;

• Tier 2 brand-name prescription $70 copayment, for up to 90
day supply;

• Tier 3 non-preferred brand-name prescription $100
copayment, for up to 90 day supply.

• Tier 4 Specialty Oral and Injectable prescription $75
copayment, for up to 30 day supply.

Maintenance Medication:  Per fill, up to 30 days of maintenance medication may be purchased at a retail pharmacy. If using mail order for up to a 90 day supply, UCH Mail Order Prescription Service must be used for maintenance medication to be covered.

Diabetic Medication:  Members diagnosed with diabetes are eligible to have diabetic medication filled with no applicable copayment (100% covered). Please contact customer service or visit  Anthem's CU Health Plan website  for additional information.

Mail Order Pharmacy Location
University of Colorado Hospital
Mail Order Prescription Service
12605 E. 16th Avenue
Mail Stop A014
Aurora, CO 80045
Phone (720) 848-1432
Fax (720) 848-1433
Generic - $15 up to 30 days supply and $30 from 31 up to 90 days' supply

Brand - $35 up to 30 days supply and $70 from 31 up to 90 days supply

Specialty - 20% for specialty Rx, including Self-Administered injectables, up to a maximum of $75 per Rx, up to 30 days supply
Covered person pays 20% coinsurance after deductible for up to a 90 day supply.

Maintenance Medication:  If using mail order, UCH Mail Order Prescription Service must be used for maintenance medication to be covered.

Diabetic Medication: Members diagnosed with diabetes are eligible to have diabetic medication filled with no applicable cost share (100% covered). Please contact customer service or visit Anthem's CU Health Plan website for additional information.

Mail Order Pharmacy Location
UCH Mail Order Prescription Service
12605 E. 16th Ave.
Mail Stop A014
Aurora, CO 80045
Phone (720) 848-1432
Fax (720) 848-1433
Not covered
INPATIENT HOSPITAL Covered person pays no coinsurance (100% covered) after deductible. $250 copayment per day up to a maximum of $1,000 in copayments per admission for facility services.
$250 co-payment each day up to a maximum of $1000 per admission
Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
OUTPATIENT/AMBULATORY SURGERY Covered person pays no coinsurance (100% covered) after deductible. $250 copayment per surgery

$250 co-payment each visit for outpatient surgery performed in any setting other than inpatient.
Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
DIAGNOSTICS
a) Laboratory & X-ray Covered person pays no coinsurance (100% covered) after deductible. No copayment (100% covered) Diagnostic Lab and X-ray - No Charge (100% covered) Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
b) MRI, nuclear medicine, and other high-tech services Covered person pays no coinsurance (100% covered) after deductible. $100 copayment per procedure for MRI/MRA/CT/PET scans $100 per procedure Covered person pays 15% coinsurance after deductible. Covered person pays 35% after deductible
EMERGENCY CARE $150 copayment per emergency room visit. Copayment is waived if admitted. 

Care is covered in-network or out-of-network.

Contact your PCP within 48 hours.
$150 copayment per emergency room visit. Copayment is waived if admitted. Care is covered in-network or out-of-network.

Contact your PCP within 48 hours.


$150 co-payment each visit at a Kaiser Permanente designated Plan or non-Plan emergency room, waived if admitted as an inpatient
Covered person pays 15% coinsurance after deductible. Out-of-network care is paid as in-network.
RETAIL HEALTH CLINIC $30 copayment per visit

Retail Health Clinics (limited to Little Clinics) are only available if a Central PCP is selected.
$30 copayment per visit   Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
AMBULANCE Covered person pays no coinsurance (100% covered) after deductible.
Care is covered in-network or out-of-network.
No copayment (100% covered) Care is covered in-network or out-of-network. No Charge (100% covered) Covered person pays 15% coinsurance after deductible. Out-of-network care is paid as in-network.
URGENT, NON-ROUTINE, AFTER HOURS CARE $30 copayment per urgent care visit. Urgent care may be received from your PCP or from an urgent care center. Care is covered in-network or out-of-network.

$150 copayment for urgent care received in an emergency room.
$30 copayment per urgent care visit. Urgent care may be received from your PCP or from an urgent care center. Care is covered in-network or out-of-network.

$150 copayment for urgent care received in an emergency room.
$30 co-payment

$150 copayment for urgent care received in an emergency room
Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
MENTAL HEALTH CARE, ALCOHOL DEPENDENCY & SUBSTANCE DEPENDENCY SERVICES
a) Inpatient care Covered person pays no coinsurance (100% covered) after deductible. $250 copayment per day up to a maximum of $1,000 in copayments per admission for facility services. $250 copayment per day - up to a maximum of $1000 per admission Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
b) Outpatient care For outpatient facility services, covered person pays no coinsurance (100% covered) after deductible. For outpatient office visits and professional services $30 copayment per visit.

Services provided as part of an office visit or professional service may be subject to the deductible, such as diagnostic services; for a complete list of services, please visit; Anthem's CU Health Plan website .
For outpatient facility services, covered person pays no copayment (100% covered). For outpatient office visits and professional services

$30 copayment per visit.
$30 co-payment each individual visit. Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
PHYSICAL, OCCUPATIONAL, & SPEECH THERAPY
a) Inpatient Covered person pays no coinsurance (100% covered) after deductible. $250 copayment per day up to a maximum of $1,000 in copayments per admission. $250 co-payment each day up to a maximum of $1000 per admission Included with inpatient hospital benefit Included with inpatient hospital benefit
b) Outpatient $30 copayment per visit. Limited to a maximum of up to 40 visits each for physical, occupational and speech therapy. $30 copayment per visit. Limited to a maximum of up to 40 visits each for physical, occupational and speech therapy. $30 co-payment each visit for up to 20 visits per plan year for each type of therapy (i.e. physical, occupational and speech therapy) Covered person pays 15% coinsurance after deductible.

Up to 40 visits each for physical, occupational and speech therapy per Plan Year in and out of network combined.
Covered person pays 35% coinsurance after deductible.

Up to 40 visits each for physical, occupational and speech therapy per Plan Year in and out of network combined.
DURABLE MEDICAL EQUIPMENT & OXYGEN Covered person pays 20% not subject to deductible for Prosthetic Appliances. Covered person pays no coinsurance (100% covered) after deductible for all other durable medical equipment. Covered person pays 20% coinsurance for Prosthetic appliances. No copayment (100% covered) for all other durable medical equipment. $0 (covered 100%) Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible
ORGAN TRANSPLANTS
a) Inpatient Covered person pays no coinsurance (100% covered) after deductible. $250 copayment per day up to a maximum of $1,000 in copayments per admission for facility services. See "Inpatient Hospital" information above Covered person pays 15% coinsurance after deductible. Not covered
b) Outpatient $30 copayment per visit for PCP

$40 copayment per visit for specialist

Transportation and lodging services are limited to a maximum benefit of $10,000 per transplant. Unrelated donor searches are not subject to a maximum benefit.
$30 copayment per visit for PCP

$40 copayment per visit for specialist

Transportation and lodging services are limited to a maximum benefit of $10,000 per transplant. Unrelated donor searches are not subject to a maximum benefit.
$40 copay per visit for specialist

Travel, lodging and daily expense limits, as well as reimbursements are coordinated and determined by the regional Transplant Coordinator.
Covered person pays 15% coinsurance after deductible

Transportation and lodging services are limited to a maximum benefit of $10,000 per transplant. Unrelated donor searches are not subject to a maximum benefit.
Not covered
BARIATRIC SURGERY Benefit determined by place of service.

Bariatric surgery is for treatment of clinically severe obesity, as defined by the body mass index (BMI).
Benefit determined by place of service.

Bariatric surgery is for treatment of clinically severe obesity, as defined by the body mass index (BMI).
Office Visit:  $40 Specialty Care

Outpatient Surgery:  30%

Inpatient Hospital per day:  30%
Benefit determined by place of service.

Bariatric surgery is for treatment of clinically severe obesity, as defined by the body mass index (BMI).
Not covered
HOME HEALTH CARE Covered person pays no coinsurance (100% covered) after deductible. No co-payment (100% covered) $0 (100% covered) for prescribed medically necessary part-time home health services. Unlimited plan visits per Plan year. Not covered outside the Service Area. Covered person pays 15% coinsurance after deductible.

Up to 100 visits per Plan Year in and out of network combined.
Covered person pays 35% coinsurance after deductible

Up to 100 visits per Plan Year in and out of network combined.
HOSPICE CARE Covered person pays no coinsurance (100% covered) after deductible. No co-payment (100% covered) $0 (100% covered) Unlimited days per Plan year. Covered person pays 15% coinsurance after deductible. Covered person pays 35% coinsurance after deductible.
SKILLED NURSING FACILITY CARE Covered person pays no coinsurance (100% covered) after deductible. Up to 100 days per plan year. No copayment (covered at 100%). Up to 100 days per plan year. $0 up to 100 days per Plan year Covered person pays 15% coinsurance after deductible.

Up to 100 days per Plan Year in and out of network combined.
Covered person pays 35% coinsurance after deductible

Up to 100 days per Plan Year in and out of network combined.
DENTAL CARE Not covered Not covered Not covered Not Covered Not Covered
VISION CARE The following benefits are not administered through your medical plan and are instead administered through Blue View Vision:

2-year enrollment period required.
$30 copayment - Exam Only (See Separate Blue View Vision Benefit Summary).
The following benefits are not administered through your medical plan and are instead administered through Blue View Vision:

2-year enrollment period required.
$30 copayment - Exam Only (See Separate Blue View Vision Benefit Summary).
$30 Optometrist

$40 Ophthalmologist

Routine vision exam (refractive)

Hardware not covered
Not Covered Not Covered
CHIROPRACTIC CARE $30 copayment per visit. Up to 20 visits per plan year. $30 copayment per visit. Up to 20 visits per plan year. $30 copayment 20 visits per plan year Covered person pays 15% coinsurance after deductible.

Up to 20 visits per Plan Year in and out of network combined.
Covered person pays 35% coinsurance after deductible

Up to 20 visits per Plan Year in and out of network combined.
HEARING AIDS
a) Child Hearing Aids (up to age 18) Benefit level determined by place of service. Hearing aids are limited to one set of hearing aids every 60 months. Benefit level determined by place of service. Hearing aids are limited to one set of hearing aids every 60 months. Persons under age of 18 years

One hearing aid every 60 months unless alterations to existing hearing aid cannot adequately meet the needs of the child
Covered person pays 15% coinsurance after deductible.

Hearing aids are limited to one set of hearing aids every 60 months.
Covered person pays 35% coinsurance after deductible.

Hearing aids are limited to one set of hearing aids every 60 months.
b) Adult Hearing Aids (18 and older) Covered person pays no coinsurance after deductible. Benefit is 1 pair every 5 years. Covered person pays no coinsurance. Benefit is 1 pair every 5 years. Not covered Covered person pays 15% coinsurance after deductible.

Benefit is limited 1 pair every 5 years.
Covered person pays 35% coinsurance after deductible.

Benefit is 1 pair every 5 years.
TREATMENT OF AUTISM SPECTRUM DISORDERS Benefit level determined by type of service provided. Benefit level determined by type of service provided. Same as other similar Services Benefit level determined by type of service provided. Benefit level determined by type of service provided.
ALLERGY SERVICES $10 copayment per visit for allergy injections, this copayment includes the cost of allergy serum. Allergy testing is subject to the medical office visit copayment. $10 copayment per visit for allergy injections, this copayment includes the cost of allergy serum. Allergy testing is subject to the medical office visit copayment. $40 copayment per office visit for allergy injections, this copayment includes the cost of allergy serum.  
CARDIAC REHABILITATION $40 copayment per visit for cardiac rehabilitation.

Up to 36 visits per plan year.
$40 copayment per visit for cardiac rehabilitation.

Up to 36 visits per plan year.
$30 Primary Care

$40 Specialty Care
Covered person pays 15% coinsurance after deductible.

Up to 36 visits per Plan Year in and out of network combined.
Covered person pays 35% coinsurance after deductible.

Up to 36 visits per Plan Year in and out of network combined.

LIMITATIONS AND EXCLUSIONS

PRE-EXISTING CONDITIONS AND PLAN EXCLUSIONS Plan does not exclude coverage for pre-existing conditions. Exclusions vary by Benefits Booklet. List of exclusions is available at Anthem's CU Health Plan website . Review them to see if a service or treatment you may need is excluded from the Benefits Booklet. Plan does not exclude coverage for pre-existing conditions.

Exclusions vary by Benefits Booklet. List of exclusions is available at  Anthem's CU Health Plan website.

Review them to see if a service or treatment you may need is excluded from the Benefits Booklet.
Plan does not exclude coverage for pre-existing conditions.

Exclusions vary by Benefits Booklet. List of exclusions is available at Kaiser's CU Health Plan website.

Review them to see if a service or treatment you may need is excluded from the Benefits Booklet.
Plan does not exclude coverage for pre-existing conditions.

Exclusions vary by Benefits Booklet. List of exclusions is available at Anthem's CU Health Plan website . Review them to see if a service or treatment you may need is excluded from the Benefits Booklet.

USING THE PLAN

Does the enrollee have to obtain a referral and/or prior authorization for specialty care in most or all cases? Yes No No No No
Is prior authorization required for surgical procedures and hospital care (except in an emergency)? Yes; the physician who scheduled the procedure or hospital care is responsible for obtaining the pre-authorization. Yes; the physician who scheduled the procedure or hospital care is responsible for obtaining the pre-authorization. Yes Yes; the physician who schedules the procedure or hospital care is responsible for obtaining pre-authorization. Yes; the member is responsible for obtaining pre-authorization unless the provider participates with Anthem Blue Cross and Blue Shield.
If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? No No No No Yes, unless the provider participates with Anthem Blue Cross and Blue Shield
What is the main customer service number? 1-800-735-6072 1-800-735-6072 1-877-883-6698 1-800-735-6072
Whom do I write/call if I have a complaint or want to file an appeal or grievance?          
a) Complaint HMO Colorado

Customer Service Department

P.O. Box 17549

Denver, CO 80217-0549

800-735-6072
HMO Colorado

Customer Service Department

P.O. Box 17549

Denver, CO 80217-0549

800-735-6072
  Anthem Blue Cross Blue Shield

Customer Service Department

P.O. Box 17549

Denver, CO 80217-0549

800-735-6072
b) Appeal HMO Colorado

Appeals Department

700 Broadway CO0104-0430

Denver, CO 80273

800-735-6072
HMO Colorado

Anthem Blue Cross Blue Shield

Appeals Department

700 Broadway CO 0104-0430

Denver, CO 80273

800-735-6072
Kaiser Permanente Insurance Company - Appeals

3701 Boardman-Canfield Road

Canfield, OH 44406
Anthem Blue Cross Blue Shield

Appeals Department

700 Broadway CO 0104-0430

Denver, CO 80273

800-735-6072
c) Grievance HMO Colorado

Quality Management Department

700 Broadway CO0104-0430

Denver, CO 80273

800-735-6072
HMO Colorado

Quality Management Department

700 Broadway CO 0104-0430

Denver, CO 80273

800-735-6072
  Anthem Blue Cross Blue Shield

Quality Management Department

700 Broadway CO 0104-0430

Denver, CO 80273

800-735-6072
40. Does the plan have a binding arbitration clause? No No No No