You can see the specialist you choose without permission from this plan.

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1 This is only a summary. If you wt more detail about your coverage d costs, you c get the complete terms in the policy or pl document at by calling Importt Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there out of pocket limit on my expenses? Network Providers: Employee Only: $400 Person; Employee + 1: $800; Family: $1,200; Per Calendar Year Non-Network Providers: No. Yes. Network Providers: Employee Only: $2,500 Person; Employee + 1: $5,000; Family: $7,500; Per Calendar Year Non-Network Providers: You must pay all the costs up to the deductible amount before this pl begins to pay for covered services you use. Check your policy or pl document to see when the deductible starts over (usually, but not always, Juary 1st). See the Common Medical Event chart for how much you pay for covered services after you meet the deductible. You must pay all of the costs for these services up to the specific deductible amount before this pl begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you pl for health care expenses. What is not included in the out of pocket limit? Is there overall nual limit on what the pl pays? Does this pl use a network of providers? Do I need a referral to see a specialist? Premiums, Balce Billed Charges, d Health Care this pl doesn't cover. No. Yes. For a full listing of network providers, see or call No. You don t need a referral to see a specialist. Even though you pay these expenses, they don t count toward the out-ofpocket limit. The Common Medical Event chart describes y limits on what the pl will pay for specific covered services, such as office visits. If you use in-network doctor or other health care provider, this pl will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use out-of-network provider for some services. Pls use the term in-network, preferred, or participating for providers in their network. See the Common Medical Event chart for how this pl pays different kinds of providers. You c see the specialist you choose without permission from this pl. 1 of 10

2 Are there services this pl doesn t cover? Yes. Some of the services this pl doesn t cover are listed in Excluded Services & Other Covered Services. See your policy or pl document for additional information about excluded services. Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurce is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the pl s allowed amount for overnight hospital stay is $1,000, your coinsurce payment of 20% would be $200. This may chge if you haven t met your deductible. The amount the pl pays for covered services is based on the allowed amount. If out-of-network provider charges more th the allowed amount, you may have to pay the difference. For example, if out-of-network hospital charges $1,500 for overnight stay d the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balce billing.) This pl may encourage you to use Preferred providers by waiving or charging you lower deductibles, copayments d coinsurce amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need In-network Provider Out-of-network Provider Primary care visit to treat injury or illness $25 copayment per visit None Specialist visit $50 copayment per visit None Other practitioner office visit $25 copayment per visit None Limitations & Exceptions Preventive care/screening No Cost Age d/or time restrictions apply Diagnostic test (x-ray, blood work) Office, Free Stding Independent Diagnostic Testing Facility, or Contracted Reference Lab: 0% coinsurce Outpatient Hospital: 0% coinsurce after deductible None 2 of 10

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available by calling (800) If you have outpatient surgery If you need immediate medical attention Services You May Need Imaging (CT/PET scs, MRIs) Generic Drugs ($30 Maximum per 30 day prescription, up to the $1,500 Out-of-Pocket Maximum per Person per Pl Year) Preferred Drugs ($55 Maximum per 30 day prescription, up to the $1,500 Out-of-Pocket Maximum per Person per Pl Year) Non-Preferred Drugs d Specialty Drugs ($80 Maximum per 30 day prescription, up to the $1,500 Out-of-Pocket Maximum per Person per Pl Year) Facility fee (e.g., ambulatory surgery center) Physici/surgeon fees Emergency room services Emergency medical trsportation In-network Provider Out-of-network Provider Limitations & Exceptions $50 copayment per visit $0 after Maximum Out-of- Pocket is met $20 after Maximum Out-of- Pocket is met $40 after Maximum Out-of- Pocket is met 50% coinsurce In State 80% coinsurce-out of State 50% coinsurce In State 80% coinsurce-out of State $100 copayment per visit 0% coinsurce after deductible Facility - $150 copayment Non-Facility Charges 0% coinsurce after deductible Ground-$50 copayment per trip: Air-$250 copayment per trip Facility - $150 copayment Non-Facility Charges 0% coinsurce after deductible Appetite suppresst drugs; Dietary supplements; Topical forms of Minoxidil; Nutritional or parenteral therapy; Vitamins d minerals; Drugs available over the counter; medical foods; bulk chemicals; y federal legend drug with over the counter equivalent available Utilization magement criteria may apply to specific drugs or drug categories to be determined by PBM. None Facility copayment waived if admitted For emergency medical trsportation only. 3 of 10

4 Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substce abuse needs If you are pregnt Services You May Need In-network Provider Out-of-network Provider Urgent care $50 copayment per visit None $100 copayment per day; Facility fee (e.g., hospital maximum of $300 per room) admission Physici/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substce use disorder outpatient services Substce use disorder inpatient services Prenatal d postnatal care Delivery d all inpatient services 0% coinsurce after deductible $25 copayment per visit $100 copayment per day; Maximum of $300 per admission $25 copayment per visit $100 copayment per day; Maximum of $300 per admission $90 copayment per pregncy $100 copayment per day; Maximum of $300 per admission Limitations & Exceptions None Must obtain authorization for Intensive Outpatient Programs, Partial Hospitalization Programs, d services performed at Residential Treatment Centers. Must obtain authorization for Intensive Outpatient Programs, Partial Hospitalization Programs, d services performed at Residential Treatment Centers. None Authorization may be required if the mother's length of stay exceeds 48 or 96 hours following a vaginal or caesare delivery, respectively. 4 of 10

5 Common Medical Event Services You May Need In-network Provider Out-of-network Provider Home health care 0% coinsurce Rehabilitation services $25 copayment per visit regardless of provider type or location Limitations & Exceptions Services limited to 60 visits per pl year. Physical & Occupational Therapy Must obtain Authorization for additional visits over the limit of 50 visits combined per year. Services performed by Licensed Massage Therapists are not covered. If you need help recovering or have other special health needs Habilitation services $25 copayment per visit regardless of provider type or location Physical & Occupational Therapy Must obtain Authorization for additional visits over the limit of 50 visits combined per year. Services performed by Licensed Massage Therapists are not covered. Skilled nursing care Durable medical equipment Hospice service $100 copayment per day; Maximum of $300 per admission 20% coinsurce of first $5,000 Allowable per year (after deductible); 0% coinsurce of Allowable in Services limited to 90 days per benefit period. Must obtain authorization for durable medical equipment, orthotic devices, d prosthetics greater th $300. excess of $5,000 per year. 0% coinsurce Services limited to 180 days per benefit period. 5 of 10

6 Common Medical Event If your child needs dental or eye care Services You May Need In-network Provider Out-of-network Provider Eye exam Not Covered Glasses Frames limited to a maximum benefit of $50 Dental check-up Not Covered Limitations & Exceptions Purchased within 6 months following cataract surgery. Services are subject to pl year deductible d are available to all members. 6 of 10

7 Excluded Services & Other Covered Services: Services Your Pl Does NOT Cover (This isn t a complete list. Check your policy or pl document for other excluded services.) Acupuncture Bariatric Surgery Cosmetic Surgery Hearing Aids (Adult) Infertility Treatment Long-Term Care Non-emergency care when traveling outside the United States Private-Duty Nursing Residential Treatment Centers Routine Eye Care Routine Foot Care (except for Diabetes) Weight Loss Programs Other Covered Services (This isn t a complete list. Check your policy or pl document for other covered services d your costs for these services.) Chiropractic Care (Some restrictions apply) Dental Care (Coverage is only available for Oral Surgery for Impacted Teeth) 7 of 10

8 Your Rights to Continue Coverage: If you lose coverage under the pl, then, depending upon the circumstces, Federal d State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration d will require you to pay a premium, which may be significtly higher th the premium you pay while covered under the pl. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the pl at You may also contact your state insurce department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health d Hum Services at x61565 or Your Grievce d Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your pl, you may be able to appeal or file a grievce. For questions about your rights, this notice, or assistce, you c contact: Blue Cross d BlueShield of Louisia at or OR the U.S. Department of Labor, Employee Benefits Security Administration at or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This pl or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Stdard? The Affordable Care Act establishes a minimum value stdard of benefits of a health pl. The minimum value stdard is 60% (actuarial value). This health coverage does meet the minimum value stdard for the benefits it provides. To see examples of how this pl might cover costs for a sample medical situation, see the next page. 8 of 10

9 About these Coverage Examples: These examples show how this pl might cover medical care in given situations. Use these examples to see, in general, how much fincial protection a sample patient might get if they are covered under different pls. This is not a cost estimator. Don t use these examples to estimate your actual costs under this pl. The actual care you receive will be different from these examples, d the cost of that care will also be different. See the next page for importt information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Pl pays $6,677 Patient pays $863 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Inpatient Medications $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $400 Co-pays $313 Coinsurce $0 Limits or exclusions $150 Total $863 Maging type 2 diabetes (routine maintence of a well-controlled condition) Amount owed to providers: $5,400 Pl pays $3,278 Patient pays $2,122 Sample care costs: Prescriptions $2,900 Medical Equipment d Supplies $1,300 Office Visits $250 Procedures $450 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $400 Co-pays $1,450 Coinsurce $193 Limits or exclusions $79 Total $2,122 9 of 10

10 Questions d swers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health d Hum Services, d aren t specific to a particular geographic area or health pl. The patient s condition was not excluded or preexisting condition. All services d treatments started d ended in the same coverage period. There are no other medical expenses for y member covered under this pl. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, d coinsurce c add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, d my other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You c t use the examples to estimate costs for actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, d the reimbursement your health pl allows. C I use Coverage Examples to compare pls? Yes. When you look at the Summary of Benefits d Coverage for other pls, you ll find the same Coverage Examples. When you compare pls, check the Patient Pays box in each example. The smaller that number, the more coverage the pl provides. Are there other costs I should consider when comparing pls? Yes. An importt cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, d coinsurce. 10 of 10

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