Your Plan: BCBSHP Essential DirectAccess gjia Your Network: Blue Open Access POS 10NR S-OAP2 4K/20 6.3K p1

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1 Your Plan: BCBSHP Essential DirectAccess gjia Your Network: Blue Open Access POS 10NR S-OAP2 4K/20 6.3K p1 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 contract of coverage. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. Covered Medical Benefits Overall Deductible Deductibles and out-of-pocket maximums are added separately for in-network and outof-network services. One family member may reach his or her Individual and be eligible for coverage on health care expenses before other family members. Each family member s amount also goes toward the Family and out-ofpocket maximum. Not everyone has to meet his or her and out-of-pocket maximum for the family to meet theirs. When the Family is met, all family members can access coverage for health care expenses. See notes below to understand how your works. This plan has a separate Prescription Drug Deductible. See Retail Prescription Drug Coverage section. 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. Your copays, coinsurance and s count toward your out-of-pocket limit. If Pediatric Vision and/or Dental services are covered under this plan, these services count towards your out of pocket limit. For prescription drug, all cost shares count towards your annual out-of-pocket limit. Doctor Home and Services Preventive care In-network preventive care is not subject to, if your plan has a. Member: $4,000 For Family: $8,000 Member: $6,350 For Family: $12,700 (not subject to ) Member: $8,000 For Family: $16,000 Member: $12,700 For Family: $25,400 30% coinsurance after ( waived through age 5) Primary care visit to treat an injury or illness Specialist care visit $75 copay Prenatal and post-natal visit Other practitioner visits: Retail health clinic Chiropractor services Limited to 20 visits across outpatient and other professional visits. (Combined for Chiropractic and Osteopathic services.) Other services in an office: Allergy testing Chemo/radiation therapy Hemodialysis Prescription drugs Page 1 of 6

2 Covered Medical Benefits Diagnostic Services Lab: Freestanding lab X-ray: Freestanding radiology center Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Freestanding radiology center Emergency and Urgent Care Emergency room facility services No coverage for non-emergency use of emergency room. Copay waved if admitted. $250 copay + 20% coinsurance after Same as in-network Emergency room doctor and other services No coverage for non-emergency use of emergency room Same as in-network Ambulance (air and ground) Covered when medically necessary Same as in-network Urgent care (office setting) $75 copay Outpatient Mental/Behavioral Health and Substance Abuse (*services must be authorized by calling ) Doctor office visit Page 2 of 6

3 Facility visit: Facility fees Doctor and other services Covered Medical Benefits Outpatient Surgery Facility fee: Hospital Freestanding surgical center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fee (for example, room & board) Doctor and other services Recovery & Rehabilitation Home health care Limited to 120 visits; limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health. Rehabilitation services (for example, physical/speech/occupational therapy): Limited to 20 combined visits for Phys & Occupat Therapy. 20 separate visits for Speech Therapy. Massage Therapy covered only when rendered by a physical therapist for treatmt of a disease/injury. Visit limits combined across outpt & other prof visits. Cardiac rehabilitation $75 copay Page 3 of 6

4 Skilled nursing care (in a facility) Skilled Nursing Facility and Rehab conducted in a Skilled Nursing Facility setting is limited to 30 combined days. Durable medical equipment & prosthetics Covered Prescription Drug Benefits Retail Prescription Drug Coverage This plan includes Home Delivery (Mail Order). Home Delivery copays are 2.5 times retail copays for 90 day supply. Notes: If a member receives a brand name drug that falls on Tier 2 or Tier 3 that has a generic equivalent available, the member pays the Tier 1 copay, plus the difference in cost between the brand drug and generic drug. This applies even when physician indicates DAW (dispense as written) or obtains an authorization. Members must file a claim form for reimbursement when using an out-of-network pharmacy. Specialty drugs can only be obtained from a Specialty Pharmacy. Out of Pocket plan amount listed on page 1 is combined for medical and pharmacy services. Deductible Your prescription drug applies to Tiers 2,3, and 4 only,and is combined innetwork and out-of-network if your plan includes out-of-network coverage. Drug Deductible (Member) : $500 Drug Deductible (Family) : $1,000 Drug tier 1 *30 day at retail; 90 day at mail order $15 copay (retail) $38 copay (mail order) 25% coinsurance Drug tier 2 *30 day at retail; 90 day at mail order $35 copay (retail) $88 copay (mail order) 25% coinsurance Drug tier 3 *30 day at retail; 90 day at mail order $70 copay (retail) $175 copay (mail order) 25% coinsurance Drug tier 4 *30 day at retail and mail order for Specialty Drugs 25% coinsurance 25% coinsurance Drug tier 4 per-prescription maximum cost share (in-network only) $250 Page 4 of 6

5 Covered Vision Benefits This is a brief outline of your in-network coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, and out-of-network coverage (If applicable), 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. In-network Pediatric Vision benefit cost shares accumulate to the Medical plan out-of-pocket limit and are not subject to the Medical plan, if your plan includes a. Children's Vision Essential Health Benefits Vision exam (once every calendar year) Frames (once every calendar year) Lenses (once every calendar year) Elective contact lenses (once every calendar year) Page 5 of 6

6 Notes: All medical services subject to a coinsurance are also subject to the annual medical. If your plan includes a hospital stay copay and you are readmitted within 72 hours of a prior admission for the same diagnosis, your hospital stay copay for your readmission is waived. If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived. If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. When using out-of-network providers, members are responsible for any difference between the Maximum Allowed Amount and the amount the provider actually charges, as well as any copayments, s and/or applicable coinsurance. Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. If you elect a medical plan that does not include qualified Pediatric/Children s Dental coverage you will be enrolled in a separate Children s Dental plan, unless notification is received that you have enrolled in coverage elsewhere. If your plan includes out of network benefit and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. Physical Therapy: Athletic Trainers are covered by mandate for out-of-network only since athletic trainers are not contracted nor credentialed, therefore are not in-network. For additional information on this plan, please visit sbc.bcbsga.com to obtain a Summary of Benefit Coverage. Blue Cross and Blue Shield of Georgia and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Page 6 of 6

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