NCQA Summary of Benefits Documentation

PW_E181038
These Summary of Benefits documents explain the extent to which covered services are available to covered persons on your policy. Your copayments, coinsurance, and/or limits for covered services are shown below and are per covered person. These summaries are not a complete explanation of these benefits. To understand them, you must also read your Premium Explanation, your policy, and any endorsements. 
Important: These Summary of Benefits documents are only a guide, not an official insurance policy. If there is any difference between these documents and the information in your policy, please understand that your policy overrides these documents. 

Grandfathered Plans

Plan Name 
Group Numbers (see your ID Card) 
Plan Type 
84005-001 to 84005-012 
PPO 
84008-001 to 84008-012 
PPO 
84009-001 to 84009-012 
PPO 
84010-001 to 84010-012 
PPO 
84011-001 to 84011-012 
PPO 
84012-001 to 84012-012 
PPO 
84013-001 to 84013-012 
PPO 
84017-001 to 84017-012 
PPO 
     
     

Non-Grandfathered Plans

Plan Name 
Group Numbers (see your ID Card) 
Plan Type 
84905-001 to 84905-012 
PPO 
84908-001 to 84908-012 
PPO 
84909-001 to 84909-012 
PPO 
84910-001 to 84910-012 
PPO 
84911-001 to 84911-012 
PPO 
84912-001 to 84912-012 
PPO 
84913-001 to 84913-012 
PPO 
84917-001 to 84917-012 and 84917-101 to 84917-112 
PPO 
84917-001 to 84917-012 and 84917-101 to 84917-112 
PPO 
     

Grandfathered and/or Non-Grandfathered Plans

Plan Name 
Group Numbers 
Plan Type 
N/A 
PPO 
N/A 
HMO 
N/A 
HMO 
N/A 
HMO 
N/A 
PPO 
N/A 
PPO 
N/A 
PPO 
N/A 
PPO 
N/A 
PPO 
     

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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use