Empire Blue Cross Blue Shield Your Plan: Empire Bronze EPO 5500/20%/6550 w/hsa Your Network: PPO/EPO

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1 Empire Blue Cross Blue Shield Your Plan: Empire Bronze EPO 5500/20%/6550 w/hsa Your Network: PPO/EPO 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. Cost if you use an In-Network $5,500 person / $11,000 family Cost if you use a Non-Network $0 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. $6,550 person / $13,100 family $0 Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible. Doctor Home and Office Services Hospital clinics are not covered. Primary care visit to treat an injury or illness Specialist care visit Page 1 of 12

2 Prenatal Care Covered at 100% per pregnancy Post-natal Care Covered at 100% per pregnancy Other practitioner visits: Retail health clinic On-line Visit Chiropractor services Acupuncture Other services in an office: Allergy testing Chemo/radiation therapy Page 2 of 12

3 Hemodialysis Coverage for Non-Network s is limited to 10 visits per benefit period. Prescription drugs For the drugs itself dispensed in the office thru infusion/injection Diagnostic Services Lab: Office X-ray: Freestanding Lab Outpatient Hospital Office Freestanding Radiology Center deductible deductible Page 3 of 12

4 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 Emergency room member cost share (except deductible if applicable) is waived if admitted. Emergency room doctor and other services Ambulance (air and ground) deductible deductible visit visit deductible trip visit deductible trip Page 4 of 12

5 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 deductible deductible deductible 2 deductible Page 5 of 12

6 Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fees (for example, room & board) For covered Inpatient Medical Rehabilitation, this plan covers 60 days per Plan Year. A separate 60 days per Plan Year is covered for Inpatient Habilitation. Copay is waived for readmission within 90 days of a previous discharge. Doctor and other services Recovery & Rehabilitation Home health care Coverage for In-Network s is limited to 40 visits per benefit period. Rehabilitation services (for example, physical/speech/occupational therapy): Office Coverage for physical therapy, occupational therapy and speech therapy combined In-Network s is limited to 60 visits per benefit period. Outpatient hospital Coverage for physical therapy, occupational therapy and speech therapy combined In-Network s is limited to 60 visits per benefit period. Habilitation services Habilitation therapy for outpatient Physical, Speech, Occupational therapies have a separate 60 day limit from outpatient rehabilitation therapies. $500 copay per deductible deductible Page 6 of 12

7 Cardiac rehabilitation Office Outpatient hospital Skilled nursing care (in a facility) Coverage for In-Network s is limited to 200 days per benefit period. Copay is waived for readmission within 90 days of a previous discharge. Hospice Durable Medical Equipment Covered external hearing aids are limited to a single purchase (including/repair replacement) once every 3 years. Prosthetic Devices Coverage for In-Network is limited to 1 unit per limb, per lifetime. $500 copay per deductible 2 deductible 2 deductible 2 deductible Page 7 of 12

8 Covered Prescription Drug Benefits Pharmacy Deductible Pharmacy Out of Pocket Prescription Drug Coverage BCBS National Drug List (3 Tier) Tier 1 - Typically Generic Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. Tier 2 - Typically Preferred Brand & Non-Preferred Generics Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Tier 3 - Typically Non-Preferred Brand Covers up to a 30 day supply (retail pharmacy). Covers up to a 30 day supply for Specialty Drugs (home delivery program). Cost if you use an In-Network Combined with Combined with medical out of pocket $15 copay per prescription after deductible (retail only) and $38 copay per prescription after deductible (home delivery only) $50 copay per prescription after deductible (retail only) and $150 copay per prescription after deductible (home delivery only) $90 copay per prescription after deductible (retail only) and $270 copay per prescription after deductible (home delivery only) Cost if you use a Non-Network Tier 4 - Typically Specialty (brand and generic) Not Applicable Not Applicable Page 8 of 12

9 Covered Vision Benefits This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/certificate, the Evidence of Coverage/Disclosure form/certificate will prevail. Only children's vision services count towards your out of pocket limit. Cost if you use an In-Network Cost if you use a Non-Network Children's Vision Essential Health Benefits Child Vision Deductible Not Applicable Not Applicable Vision exam Coverage for In-Network s is limited to 1 exam per benefit period. Frames Coverage for In-Network s is limited to 1 unit per benefit period. Lenses Coverage for In-Network s is limited to 1 unit per benefit period. Elective contact lenses Coverage for In-Network s is limited to 1 unit per benefit period. Non-Elective Contact Lenses Coverage for In-Network s is limited to 1 unit per benefit period. Adult Vision Adult Vision Deductible Not Applicable Not Applicable Vision exam Coverage for In-Network s is limited to 1 exam per benefit period. $20 copay per visit Frames Coverage is limited to 1 unit every 2 years. Coverage is limited to $130 maximum benefit per occurrence. Apply to In-Network s. Lenses Coverage for Eye Glasses or Contact Lens In-Network s is limited to 1 unit every 2 years. $20 copay per unit Elective contact lenses Coverage is limited to $80 maximum benefit per occurrence. Coverage for Eye Glasses or Contact Lens is limited to 1 unit every 2 years. Page 9 of 12

10 Covered Vision Benefits Cost if you use an In-Network Cost if you use a Non-Network Non-Elective Contact Lenses Page 10 of 12

11 Covered Dental Benefits This is a brief outline of your dental coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/certificate, the Evidence of Coverage/Disclosure form/certificate will prevail. Only children's dental services count towards your out of pocket limit. Children's Dental Essential Health Benefits Diagnostic and preventive Coverage for In-Network s is limited to 2 visits per12months. Basic services Major services Medical Necessary Orthodontia services Cost if you use an In-Network after deductible after deductible 5 after deductible is met 5 after deductible is met Cost if you use a Non-Network Cosmetic Orthodontia services Deductible Adult Dental Combined with Diagnostic and preventive Basic services Major services Deductible Not Applicable Not Applicable Annual maximum Not Applicable Not Applicable Page 11 of 12

12 Notes: 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. For additional information on this plan, please visit sbc.anthem.com to obtain a "Summary of Benefit Coverage". Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. Your copays, coinsurance and deductible count toward your out of pocket amount. Vision services are not subject to the annual deductible. You may obtain Urgent Care from a Non-Participating Urgent Care Center or Physician outside our Service Area. We do not cover Urgent Care from Non-Participating Urgent Care Centers or Physicians in Our Service Area without a preauthorization Speech and Physical Therapy are only covered following a hospital stay or surgery Empire's Service Area: Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Fulton, Green, Kings, Montgomery, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester. Services provided by Empire HealthChoice HMO, Inc and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The prescription drug plan listed on this summary meets the Centers for Medicare and Medicaid Services (CMS) standard for Creditable Coverage under the Medicare Modernization Act of This plan provides a Gym Reimbursement benefit up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse. Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Questions:(855) or visit us at NY/S/F/Empire Bronze EPO 5500/20%/6550 w/hsa/1zw2/na/01-17 Page 12 of 12

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