Summary of Benefits and Coverage: What This Plan Covers & What You Pay for Covered Services 01/01/ /31/2019.

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1 Summary of Benefits and : What This Plan Covers & What You Pay for Covered Services 01/01/ /31/2019 Period: Important Questions What is overall deductible? Are re services covered before you meet your deductible? Are re or deductibles for specific services? What is out-ofpocket limit for this plan? Answers $0 PCP / Plan-Approved; $300 member / $600 family Self- Referred. Yes. Emergency room and emergency transportation. No. For medical benefits, $2,000 member / $4,000 family; and for prescription drug benefits, $1,000 member / $2,000 family. Why This Matters: Generally, you must pay all of costs from providers up to deductible amount before this plan begins to pay. If you have or family members on plan, each family member must meet ir own individual deductible until total amount of deductible expenses paid by all family members meets overall family deductible. This plan covers some items and services even if you haven t yet met deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at ntive-care-benefits/. You don t have to meet deductibles for specific services. The out-of-pocket limit is most you could pay in a year for covered services. If you have or family members in this plan, y have to meet ir own out-of-pocket Blue Cross Blue Shield of Massachusetts is an Independent Licensee of Blue Cross and Blue Shield Association1 of 11

2 What is not included in out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Premiums, balance-billing charges, and health care this plan doesn't cover. Yes. See bluecrossma.com/findadoctor or call Member Service number on your ID card for a list of network providers. Yes, PCP / Plan-Approved level of benefits only. limits until overall family out-of-pocket limit has been met. Even though you pay se expenses, y don't count toward out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in plan s network. You will pay most if you use an out-of-network provider, and you might receive a bill from a provider for difference between provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. This plan will pay some or all of costs to see a specialist for covered services but only if you have a referral before you see specialist. 2 of 11

3 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization What You Will Pay PCP/Plan- Approved least) Limitations, Exceptions, & Or Important Information most) $15 / visit 20% coinsurance $20 / visit; $20 / chiropractor visit No charge 20% coinsurance; 20% coinsurance / chiropractor visit 20% coinsurance Diagnostic test (x-ray, blood work) No charge 20% coinsurance Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Generic drugs Preferred brand drugs $10 / retail or supply $15 / retail or ($10 / generic $10 / retail or supply $15 / retail or ($10 / generic ; limited to 20 chiropractor visits per calendar year ; GYN exam limited to one exam per calendar year. You may have to pay for services that aren't preventive. Ask your provider if services needed are preventive. Then check what your plan will pay for. may be required Up to 30-day retail (90-day ) supply; cost share may be waived for certain covered drugs and supplies and may be higher if generic available; pre- 3 of 11

4 Common Medical Event available at bluecrossma.com/me dications If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral Services You May Need Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) What You Will Pay PCP/Plan- Approved least) drugs) $35 / retail or supply Applicable cost share (generic, preferred, nonpreferred) No charge Limitations, Exceptions, & Or Important Information most) drugs $35 / retail or supply Applicable cost share (generic, preferred, nonpreferred) 20% coinsurance Physician/surgeon fees No charge 20% coinsurance Emergency room care $100 / visit $100 / visit authorization certain drugs When obtained from a designated specialty pharmacy; pre-authorization certain drugs Copayment waived if admitted or for observation stay Emergency medical transportation No charge No charge None Urgent care $20 / visit 20% coinsurance Facility fee (e.g., hospital room) No charge 20% coinsurance required Physician/surgeon fees No charge 20% coinsurance required Outpatient services No charge 20% coinsurance ; pre- 4 of 11

5 Common Medical Event health, or substance abuse services If you are pregnant If you need help recovering or have or special health needs Services You May Need What You Will Pay PCP/Plan- Approved least) Limitations, Exceptions, & Or Important Information most) Inpatient services No charge 20% coinsurance authorization Office visits No charge 20% coinsurance ; maternity care Childbirth/delivery professional No charge 20% coinsurance may include tests and services services described elsewhere in Childbirth/delivery facility services No charge 20% coinsurance SBC (i.e. ultrasound) Home health care No charge 20% coinsurance Rehabilitation services Habilitation services $20 / visit for physical and occupational rapy; $15 / visit for speech rapy $20 / visit for physical and occupational rapy; $15 / visit for speech rapy required ; limited to 60 visits per calendar year for PCP / Plan-Approved (or than for 20% coinsurance autism, home health care, and speech rapy); preauthorization 20% coinsurance ; rehabilitation rapy coverage limits apply; cost share and coverage limits waived for early intervention services for eligible children; pre-authorization 5 of 11

6 Common Medical Event If your child needs dental or eye care Services You May Need What You Will Pay PCP/Plan- Approved least) Limitations, Exceptions, & Or Important Information most) Skilled nursing care No charge 20% coinsurance Durable medical equipment 30% coinsurance 50% coinsurance Hospice services No charge 20% coinsurance Children s eye exam Children s glasses Children s dental check-up through Davis Vision through Davis Vision through separate BCBSMA dental plan through Davis Vision through Davis Vision through separate BCBSMA dental plan ; limited to 100 days per calendar year; preauthorization required ; PCP / Plan- Approved cost share waived for one breast pump per birth See SPD Attachment #9 See SPD Attachment #9 See SPD Attachments #7 & #8 Excluded Services & Or Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any or excluded services.) Acupuncture Children s eye exam (coverage through Davis Vision) Children's glasses (coverage through Davis Vision) Cosmetic surgery Dental care (coverage through separate BCBSMA dental plan) Long-term care Non-emergency care when traveling outside U.S. Private-duty nursing Routine eye care adult (coverage through Davis Vision) 6 of 11

7 Routine foot care (only for patients with systemic circulatory disease) Or Covered Services (Limitations may apply to se services. This isn t a complete list. Please see your plan document.) Bariatric surgery Chiropractic care (20 visits per calendar year) Infertility treatment Hearing aids (See Benefit Descriptions and Riders) Weight loss and Fitness programs Wellness programs 7 of 11

8 Your Rights to Continue : There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S. Department of Labor, Employee Benefits Security Administration at EBSA (3272) or and U.S. Department of Health and Human Services at x61565 or Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact Massachusetts Division of Insurance at or Or coverage options may be available to you too, including buying individual insurance coverage through Health Insurance Marketplace. For more information about Marketplace, visit or call For more information about possibly buying individual coverage through a state exchange, you can contact your state s marketplace, if applicable. If you are a Massachusetts resident, contact Massachusetts Health Connector by visiting For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually member s employer or organization that provides group health coverage to member.) Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Member Service number listed on your ID card or contact your plan sponsor. (A plan sponsor is usually member s employer or organization that provides group health coverage to member.) Does this plan provide Minimum Essential? [Yes] If you don t have Minimum Essential for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? [Yes] If your plan doesn t meet Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through Marketplace. Disclaimer: This document contains only a partial description of benefits, limitations, exclusions and or provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all details of this coverage, including benefits, exclusions and policy limitations. In event re are discrepancies between this document and policy, terms and conditions of policy will govern. To see examples of how this plan might cover costs for a sample medical situation, see next section. 8 of 11

9 About se Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on actual care you receive, prices your providers charge, and many or factors. Focus on cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under plan. Use this information to compare portion of costs you might pay under different health plans. Please note se coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network prenatal care and a hospital delivery) Managing Joe's Type 2 Diabetes (a year of routine innetwork care of a wellcontrolled condition) Jacquie s Simple Fracture (in-network emergency room visit and follow-up care) The plan s overall deductible Delivery fee copay Facility fee copay Diagnostic tests copay $0 overall The plan s deductible $0 Specialist visit copay $0 care visit Primary copay $0 Diagnostic tests copay $0 overall The plan s deductible $20 Specialist visit copay $15 Emergency room copay $0 services Ambulance copay $0 $20 $100 $0 This EXAMPLE event This EXAMPLE event This EXAMPLE event includes services like: 9 of 11

10 includes services like: Specialist office visits (prenatal care) Childbirth/Deliv ery Professional Services Childbirth/Deliv ery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anessia) includes services like: Primary care physician office visits (including disease education) Diagnostic test (x-ray) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Emergency room care (including medical supplies) Durable medical equipment (crutches) Rehabilitation services (physical rapy) Total Example Cost $12,713 Total Example Cost $7,389 Total Example Cost $1,925 In this example, Peg would pay: In this example, Joe would pay: In this example, Jacquie would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $0 Deductibles $0 Deductibles $0 Copayments $16 Copayments $1,068 Copayments $200 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn't What isn't What isn't covered covered covered Limits or $60 Limits or $55 Limits or $0 10 of 11

11 exclusions exclusions exclusions The total Peg would pay is $76 The total Joe would pay is $1,123 The total Jacquie would pay is $200 The plan would be responsible for or costs of se EXAMPLE covered services. Registered Marks of Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc CE (8/18) PDF LC 11 of of 11