Roanoke



Autism Spectrum Disorder and Early Intervention

(Autism Spectrum Disorder is for Employers with 51 or more Employees)

|Covered Services |You Pay |

|Autism Spectrum Disorder (ASD) – For children from age 2 through 6 | |

|Diagnosis of autism spectrum disorder; | |

|Treatment of autism spectrum disorder; | |

|Behavioral Health Treatment* |Member cost shares will be dependent on |

|Pharmacy Care |the services rendered. Please refer to |

|Psychiatric Care |the Summary of Benefits. |

|Psychological Care | |

|Therapeutic Care** | |

|* Mental Health Services | |

|**Unlimited physical, occupational and speech therapy. | |

|Applied Behavioral Analysis | |

|Limited to a $35,000 per member annual maximum. |20% after applicable deductible if any |

|Early Intervention – For children from birth through age 3 | |

|Limited to $5,000 per member annual maximum* |Member cost shares will be dependent on |

|*Unlimited physical, occupational and speech therapy |the services rendered. Please refer to |

| |the Summary of Benefits. |

|Out-of-Network Services |

|Using Doctors, Hospitals and Other Health Care Professionals not Contracted to Provide Benefits |

|If your plan includes out-of-network benefits and you receive covered services from a health care provider outside of our network, the |

|out-of-network deductible and coinsurance applies as outlined in the Summary of Benefits. |

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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. Anthem Blue Cross and Blue Shield and its affiliated HMO HealthKeepers, Inc. are independent licensees of the Blue Cross 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.

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