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1 Cost Sharing - Member's Responsibility Deductible (DED) (Per Person/Family Aggregate) $5,000 / $10,000 $1,000 / $3,000 $2,000 / $6,000 Out-of-Network $10,000 / $30,000 $3,000 / $6,000 $6,000 / $18,000 Coinsurance (BCBSF pays / Member pays) 70% / 30% 80% / 20% 80% / 20% Out-of-Network 50% / 50% 50% / 50% 50% / 50% Out of Pocket Maximum (Per Person/Family Aggregate) $6,350 / $12,700 $3,500 / $7,000 $5,500 / $11,000 Out-of-Network $20,000 / $40,000 $7,000 / $14,000 $11,000 / $22,000 Medical Pharmacy OOP Maximum (Per Person Per Calendar Month) (Preferred) $200 $200 $200 (Non-Preferred) Combined with Preferred OOP Combined with Preferred OOP Combined with Preferred OOP Medical / Surgical Care by a Physician Out-of-Network NA NA NA E-Office Visit Services Family Physician $10 Copayment $10 Copayment $10 Copayment Office Services Specialist $10 Copayment $10 Copayment $10 Copayment services in Office, Urgent Care Family Physician $30 Copayment $25 Copayment $35 Copayment Specialist $55 Copayment $45 Copayment $65 Copayment Page 1 of 8 Printed on 1/28/2015
2 Allergy Injections (Office) Family Physician $10 Copayment $10 Copayment $10 Copayment Specialist $10 Copayment $10 Copayment $10 Copayment Health Care Professional Administered Medications in the Office (Medical Pharmacy) (Preferred) 20% 20% 20% (Non-Preferred) 20% 20% 20% Cost share applies for first maternity visit. Remaining cost share for routine pregnancy applicable at delivery. Additional services outside of routine pregnancy (e.g.,amniocentesis) may require additional cost share. services in Office, Urgent Care Cost share applies for first maternity visit. Remaining cost share for routine pregnancy applicable at delivery. Additional services outside of routine pregnancy (e.g.,amniocentesis) may require additional Cost share applies for first maternity visit. Remaining cost share for routine pregnancy applicable at delivery. Additional services outside of routine pregnancy (e.g.,amniocentesis) may require additional Maternity Office Services cost share. cost share. Family Physician $30 Copayment $25 Copayment $35 Copayment Convenient Care Center Physician Services at Hospital Specialist $55 Copayment $45 Copayment $65 Copayment services in Office, Urgent Care $30 Copayment $25 Copayment $35 Copayment DED + 30% $100 Copayment DED + 20% Out-of-Network INN DED + 30% $100 Copayment INN DED + 20% Page 2 of 8 Printed on 1/28/2015
3 Radiology, Pathology and Anesthesiology Provider Services at Hospital DED + 30% $100 Copayment DED + 20% Out-of-Network INN DED + 30% $100 Copayment INN DED + 20% Radiology, Pathology and Anesthesiology Provider Services at ASC DED + 30% $45 Copayment $65 Copayment Out-of-Network INN DED + 30% $45 Copayment $65 Copayment Physician Services at Locations other than Office, Hospital and ER Family Physician DED + 30% $25 Copayment $35 Copayment Specialist DED + 30% $45 Copayment $65 Copayment Preventive Services-Adult Wellness Services Office Services Family Physician $0 Copayment $0 Copayment $0 Copayment Specialist $0 Copayment $0 Copayment $0 Copayment Independent Clinical Laboratory $0 Copayment $0 Copayment $0 Copayment Medical / Surgical Care at a Facility Ambulatory Surgical Center (ASC) DED + 30% $150 Copayment $250 Copayment Inpatient Hospital Facility (per admit) Option 1:DED + 30% Option 2:DED + 30% Option 1:$100 PAD + DED + 20% Option 2:$100 PAD + DED + 20% Out-of-Network DED + 50% $3,500 Copayment $500 PAD + DED + 50% Outpatient Hospital Facility (per visit) (Surgical) Page 3 of 8 Printed on 1/28/2015
4 Option 1:DED + 30% Option 2:DED + 30% Outpatient Hospital Facility (per visit)(non- Surgical) Included with Surgical Services Included with Surgical Services Included with Surgical Services Emergency and Urgent Care Emergency Room Facility Physician Services at ER Urgent Care Centers Ambulance Diagnostic Testing (e.g., Lab, x-ray) Out-of-Network Included with Surgical Services Included with Surgical Services Included with Surgical Services Emergency Room Facility services are subject to the Copay Limit, then DED and Coinsurance. If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. If admitted as an inpatient from ER, the hospital will submit an inpatient hospital claim instead of an ER facility claim. ER Copay will not apply on the claim; only inpatient facility cost share will apply. $300 Copayment $200 Copayment $300 Copayment Out-of-Network $300 Copayment $200 Copayment $300 Copayment DED + 30% $100 Copayment DED + 20% Out-of-Network INN DED + 30% $100 Copayment INN DED + 20% $60 Copayment $50 Copayment $70 Copayment DED + 30% DED + 20% DED + 20% Out-of-Network INN DED + 30% INN DED + 20% INN DED + 20% Physician Office Family Physician $30 Copayment $25 Copayment $35 Copayment Specialist $55 Copayment $45 Copayment $65 Copayment Independent Clinical Laboratory $0 Copayment $0 Copayment $0 Copayment Page 4 of 8 Printed on 1/28/2015
5 Independent Diagnostic Testing Center DED + 30% $50 Copayment $50 Copayment Outpatient Hospital Facility Option 1:DED + 30% Option 2:DED + 30% Advanced Imaging (AIS) (MRI, MRA, PET, CT & Nuclear Medicine) Physician Office Family Physician DED + 30% $200 Copayment $300 Copayment Specialist DED + 30% $200 Copayment $300 Copayment Independent Diagnostic Testing Center DED + 30% $200 Copayment $300 Copayment Outpatient Hospital Facility Option 1:DED + 30% Option 2:DED + 30% Outpatient Therapy services in Office, Urgent Care Physician Office Family Physician $30 Copayment $25 Copayment $35 Copayment Specialist $55 Copayment $45 Copayment $65 Copayment Outpatient Rehabilitation Facility $55 Copayment $45 Copayment $65 Copayment Page 5 of 8 Printed on 1/28/2015
6 Outpatient Hospital Facility Mental Health / Sub. Abuse Option 1:$65 Copayment Option 2:$75 Copayment Option 1:$45 Copayment Option 2:$60 Copayment Option 1:$65 Copayment Option 2:$80 Copayment Physician Office Family Physician $0 Copayment $0 Copayment $0 Copayment Inpatient Hospital Facility Outpatient Hospital Facility Specialist $0 Copayment $0 Copayment $0 Copayment Out-of-Network 50% $500 Copayment 50% Emergency Room Facility(per visit) $0 Copayment $0 Copayment $0 Copayment Physician Services at Hospital Physician Services at ER Out-of-Network $0 Copayment $0 Copayment $0 Copayment $0 Copayment $0 Copayment $0 Copayment Out-of-Network $0 Copayment $0 Copayment $0 Copayment $0 Copayment $0 Copayment $0 Copayment Out-of-Network $0 Copayment $0 Copayment $0 Copayment Physician Services at Locations other than Office, Hospital and ER Family Physician $0 Copayment $0 Copayment $0 Copayment Other Special Services and Locations Specialist $0 Copayment $0 Copayment $0 Copayment Specialist $0 Copayment $0 Copayment $0 Copayment Page 6 of 8 Printed on 1/28/2015
7 One personal breast pump provided through One personal breast pump provided through Durable Medical Equipment CareCentrix per delivery. CareCentrix per delivery. Motorized Wheelchairs DED + 30% DED + 20% DED + 20% One personal breast pump provided through CareCentrix per delivery. All Other DED + 30% DED + 20% DED + 20% Orthotics & Prosthetics Family Physician DED + 30% DED + 20% DED + 20% Skilled Nursing Facility Home Health Care Benefit Maximums Emergency Room Visits Specialist DED + 30% DED + 20% DED + 20% DED + 30% DED + 20% DED + 20% DED + 30% DED + 20% DED + 20% Emergency Room Facility services are subject to the Copay Limit, then DED and Coinsurance. 2 at Copay then DED + Coin (PBP) N/A N/A High Risk Colonoscopy Combined (INN & OON) 1 / 2 years 1 / 2 years 1 / 2 years Home Health Care Combined (INN & OON) 20 Visits PBP 20 Visits PBP 20 Visits PBP Inpatient Rehabilitation Therapy Combined (INN & OON) 30 Days PBP 30 Days PBP 30 Days PBP Office Visits services in Office, Urgent Care 6 at Copay then DED + Coin (PBP) N/A N/A Outpatient Therapy & Spinal Manipulations Outpatient therapy for autism will continue to be covered after the benefit maximum is met. Outpatient therapy for autism will continue to be covered after the benefit maximum is met. Outpatient therapy for autism will continue to be covered after the benefit maximum is met. Page 7 of 8 Printed on 1/28/2015
8 Combined (INN & OON) 25 Visits PBP 35 Visits PBP 35 Visits PBP Outpatient Therapy Modalities Combined (INN & OON) 4 / 1 day 4 / 1 day 4 / 1 day Preventive Colonoscopy Combined (INN & OON) 1 / 10 years 1 / 10 years 1 / 10 years Skilled Nursing Facility Combined (INN & OON) 60 Days PBP 60 Days PBP 60 Days PBP Spinal Manipulations Combined (INN & OON) 26 PBP 26 PBP 26 PBP Prescription Drugs - Retail - Mail Order Generic/Brand/Non-Preferred $10 Generic Only 10/50/80 10/60/100 Generic/Brand/Non-Preferred $25 Generic Only 25/125/200 25/150/250 Page 8 of 8 Printed on 1/28/2015
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