Anthem Blue Cross and Blue Shield Your Plan: Lumenos Health Savings Account (HSA-Compatible) Plan $ /20 Your Network: PPO

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1 Anthem Blue Cross and Blue Shield Your Plan: Lumenos Health Savings Account (HSA-Compatible) Plan $ /20 Your Network: PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail. Covered Medical Benefits Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $3,500 single / $7,000 family $7,000 single / $14,000 family Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum. $5,500 single / $11,000 family $11,000 single / $22,000 family Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible. There may be other levels of cost share that are contingent on how services are provided. Doctor Home and Office Services No charge Primary care visit to treat an injury or illness Specialist care visit Prenatal and Post-natal Care Your doctor's charge for delivery are part of prenatal and postnatal care Other practitioner visits: Retail health clinic Not covered On-line Visit Not covered Spinal Manipulation Coverage for is limited to 20 visit limit per year. Not covered Page 1 of 7

2 Covered Medical Benefits Acupuncture Coverage is limited to 20 visits per year combined for Acupuncture and Massage Therapy Not covered Other services in an office: Allergy testing Costs may vary by site of service. Chemo/radiation therapy Hemodialysis Prescription drugs For the drugs itself dispensed in the office thru infusion/injection Diagnostic Services Lab: X-ray: Office Freestanding Lab Outpatient Hospital Office Freestanding Radiology Center Outpatient Hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding Radiology Center Outpatient Hospital Emergency and Urgent Care Emergency room facility services Covered as In- Network Emergency room doctor and other services There may be other levels of cost share that are contingent on how services are Covered as In- Network Page 2 of 7

3 Covered Medical Benefits provided. Ambulance (air and ground) Covered as In- Network Urgent Care (office setting) Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit Facility visit: Facility fees Outpatient Surgery Facility fees: Hospital Freestanding Surgical Center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fees (for example, room & board) Coverage for and combined is limited to 30 day limit per calendar Year for Inpatient Rehabilitation. Doctor and other services Recovery & Rehabilitation Home health care Coverage for is limited to 100 visit limit per year. Rehabilitation services (for example, physical/speech/occupational therapy): Office Coverage is limited to 20 visit limit per year for Physical Therapy. Coverage is limited to 20 visit limit per year for Occupational Therapy. Coverage is limited to 20 visit limit per year for Speech Therapy. Apply to Not covered Page 3 of 7

4 Covered Medical Benefits and combined. Costs may vary by site of service. Outpatient hospital Habilitation services Habilitation visits count towards your rehabilitation limit. Cardiac rehabilitation Office Coverage for and combined is limited to 36 visit limit per year. Outpatient hospital Coverage for and combined is limited to 36 visit limit per year. Skilled nursing care (in a facility) Coverage for and combined is limited to 100 day limit per year. Hospice Durable Medical Equipment Not covered Prosthetic Devices Not covered Page 4 of 7

5 Covered Prescription Drug Benefits Pharmacy Deductible medical deductible medical deductible Pharmacy Out of Pocket Prescription Drug Coverage medical out of pocket medical out of pocket Preventive Drugs Preventive Rx Plus: Deductible is waived for certain drugs for diabetes, asthma, heart health, high blood pressure, high cholesterol, stroke, and osteoporosis. Tier1 - Typically Generic Not covered Not covered Tier2 - Typically Preferred / Brand Not covered Not covered Other Drug Coverage Tier1 - Typically Generic Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program) Specialty drug network must be used for In-network coverage. You pay additional copays or coinsurance on all tiers for retail fills that exceed 30 days. Tier2 - Typically Preferred / Brand Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program) Specialty drug network must be used for In-network coverage. Tier3 - Typically Non-Preferred / Specialty Drugs Covers up to a 30 day supply (retail pharmacy) Covers up to a 90 day supply (home delivery program) Specialty drug network must be used for In-network coverage. (retail and home delivery) (retail and home delivery) (retail and home delivery) Page 5 of 7

6 Covered Prescription Drug Benefits Tier4 - Typically Specialty Drugs Covers up to a 30 day supply (retail pharmacy) Specialty drug network must be used for In-network coverage. Page 6 of 7

7 Notes: The representations of benefits in this document are subject to Division of Insurance approval and are subject to change. The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. 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. Questions:(855) or visit us at CO/L/F/LUMENOS HSA/CDHP $ /20-CDHP/NA/VLS41/NA/01-17 Page 7 of 7

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