Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 AutoNation: Bronze Plan EPO Coverage for: Individual/Family Plan Type: EPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit www.knowyourbenefits.org or call (888)979-7677. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (888)979-7677 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out of pocket limit? Will you pay less if you use a network provider? Do I need a referral to see a specialist? $2,000 individual/$4,000 family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Deductible does not apply to preventive care services. This plan covers some items and services even if you haven t yet met the deductible amount. For example, this plan covers certain preventive services without costsharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. No. You don t have to meet deductibles for specific medical services. There is a separate drug deductible. $6,000 individual/$12,000 family total The out-of-pocket limit is the most you could pay in a year for covered services. If you maximum out-of-pocket. have other family members in this plan, they have to meet their own out-of-pocket Premiums, balance-billed charges, and health care this plan doesn't cover do not apply to your total maximum out-ofpocket. Yes. This plan only covers services at in-network providers. No. limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don't count toward the out-of-pocket limit. This plan uses a provider network. Be aware your network provider might use an outof-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 7 20180101_SBC
All coinsurance costs shown in this chart are after your overall deductible has been met. Common Medical Event If you visit a health care provider s Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Primary care visit to treat an injury or illness coinsurance Not covered Specialist visit coinsurance Not covered Not covered office or clinic Preventive care/screening/immunization No charge for preventive care services If you have a test If you need drugs to treat your illness or condition Limitations, Exceptions, and Other Important Information You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.please refer to your preventive schedule for additional information. Diagnostic test (x-ray, blood work) coinsurance Not covered Covered if performed at a free-standing facility only. Check with your plan before getting services Imaging (CT/PET scans, MRIs) coinsurance Not covered Precertification is required. Covered if performed at a free-standing facility only. Generic drugs 20% coinsurance Not covered Formulary Brand drugs coinsurance Not covered Non-Formulary Brand drugs 60% coinsurance Not covered Specialty Drugs Lower of coinsurance or $400 per script. Not covered $125 individual deductible; $250 family. Coinsurance applies after deductible is met. Both the drug deductible and drug coinsurance apply to the medical out-ofpocket. Up to 30-day retail pharmacy. Up to a 90-day supply mainteneance prescription drugs through mail order. You get 3 month s supply of drugs for the cost of a 2-month supply. Mandatory after 2 retail fills. 90-days at Walgreens for maintenance drugs. You get 3 month s supply of drugs for the cost of a 2-month supply (slightly better discounts at mail). No Retail pharmacy fills allowed for most specialty drugs. All fills must go through Accredo mail order pharmacy. If you have Facility fee (e.g., ambulatory surgery center) coinsurance Not covered Precertification required. outpatient surgery Physician/surgeon fees coinsurance Not covered Precertification required. 2 of 7
Common Medical Event Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information coinsurance Emergency Room Care coinsurance coinsurance Non emergencies not covered Emergency medical transportation coinsurance coinsurance To closest medical facility. Urgent care coinsurance Not covered If you have a Facility fee (e.g., hospital room) coinsurance Not covered Precertification required. hospital stay Physician/surgeon fee coinsurance Not covered Precertification required. If you have mental Outpatient services coinsurance Not covered Intensive OP Pre-certification Required health, behavioral Inpatient services coinsurance Not covered Precertification required for inpatient and for health, or partial hospitalization. substance abuse needs If you are pregnant Office visits coinsurance Not covered Pre-certification required for inpatient Childbirth/delivery professional services coinsurance Not covered services. Childbirth/delivery facility services coinsurance Not covered If you need help recovering or have other special health needs If your child needs dental or eye care Home health care coinsurance Not covered Precertification required. Rehabilitation services coinsurance Not covered Precertification required. Habilitation services Not covered Not covered none Skilled nursing care coinsurance Not covered Precertification required. Durable medical equipment coinsurance Not covered Precertification required for all rentals and any purchase over $500. Hospice service coinsurance Not covered Precertification may be required. Children s Eye exam Not covered Not covered none Children s Glasses Not covered Not covered none Children s Dental check-up Not covered Not covered none 3 of 7
Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Bariatric surgery Habilitation services Routine eye care (Adult) Cosmetic surgery Hearing aids Routine foot care Dental care (Adult) Long-term care Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Acupuncture Chiropractic care Coverage provided outside the United States. See http://www.bcbsa.com Infertility treatment Private-duty nursing Non-emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. The Pennsylvania Department of Consumer Services at 1-877-881-6388. Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit http://www.healthcare.gov or call 1-800-318-2596. 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 the 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: Your plan administrator/employer. The Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Does this plan provide Minimum Essential Coverage? YES If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? YES If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 4 of 7
About these Coverage 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 the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care)!the plan s overall deductible!specialist coinsurance!hospital (facility) coinsurance!other coinsurance $2,000!The plan s overall deductible!specialist coinsurance!hospital (facility) coinsurance!other coinsurance $2,000!The plan s overall deductible!specialist coinsurance!hospital (facility) coinsurance!other coinsurance $2,000 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $2,000 Deductibles $2,000 Deductibles $1,900 Copayments NA Copayments NA Copayments NA Coinsurance $4,320 Coinsurance $2,160 Coinsurance NA What isn t covered What isn t covered What isn t covered The total Peg would pay is $6,320 The total Joe would pay is $4,160 The total Mia would pay is $1,900 The plan would be responsible for the other costs of these EXAMPLE covered services. Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield and Highmark Choice Company which are independent licensees of the Blue Cross and Blue Shield Association. Health care plans are subject to terms of the benefit agreement. To find more information about Highmark s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call 1-855-873-4106. 5 of 7