Important Questions Answers Why this Matters:

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1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 St. Francis Plan: SSM Health Coverage for: Individual, +1, Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit MyHR on the SSM Health intranet site or For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call (660) to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? 3 options available: $300/person or $600/family $500/person or $1,000/family $1,000/person or $2,000/family Does not apply to preventive services or services that require a co-payment. Yes. No. Limits vary for each of the 3 options For participating providers: $2,000/person or $4,000/family $3,500/person or $7,000/family $5,000/person or $10,000/family Non-participating providers: $3,000/person or $6,000/family $5,000/person or $10,000/family $7,500/person or $15,000/family Prescription drugs all plans: $1,600/person or $3,200/family Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Preventive care and services requiring a co-payment are covered before you meet your deductible. You do not have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. 1 of 8

2 What is not included in the out-of-pocket limit? Will you pay less if you use a network provider Do you need a referral to see a specialist Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn t cover. Yes. For a list of preferred providers, visit MyHR on the SSM Health intranet site or medical-benefits-plans/st-francis. No. Even though you pay these expenses, they don t count toward the out of pocket limit This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization $20 co-payment ($300 Plan) $25 co-payment ($500 & $1,000 Plans) $25 co-payment ($300 Plan) $30 co-payment ($500 & $1,000 Plans) No Charge No Charge Not covered Excludes any service that incurs a separate billing charge (i.e. billings from a lab, radiologist, etc.) Excludes any service that incurs a separate billing charge. Examples: billings from a lab, radiologist, etc. You may have to pay for services that are not preventive. Check what your plan will pay. One visit/screening per year. If you have a test Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) 2 of 8

3 Common If you need drugs to treat your illness or condition More information about prescription drug coverage is available at (Tier 1) Generic drugs and some low cost brands (Tier 2) Formulary and some high cost generics (Tier 3) Non formulary brands and high cost generics $12 co-payment/ $30 co-payment/ $35 co-payment/ $87.50 co-payment/ $70 co-payment/ $175 co-payment/ $12 co-payment/ $30 co-payment/ $35 co-payment/ $87.50 co-payment/ $70 co-payment/ $175 co-payment/ Not Covered Same as above Same as above All plans include an out-of-pocket maximum of $1,600/person or $3,200/family for prescription drugs. Covers up to a 30-day supply (retail prescription); day supply (mail order and retail prescription) Some drugs may require preauthorization. If the necessary preauthorization is not obtained, the drug may not be covered. You must use a participating Navitus pharmacy or the drug will not be covered. The prescription drug out-of-pocket maximum is separate from the medical plan out-of-pocket maximum. If you have outpatient surgery If you need immediate medical attention Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Physician/surgeon fees After deductible $200 co-payment, then 10% coinsurance 10% coinsurance $200 co-payment, Then 10% coinsurance 10% coinsurance $300 co-payment, then $200 co-payment, then 10% coinsurance 10% coinsurance Preauthorization required or a penalty will apply. Co-payment is waived if admitted. $200 co-payment, then 70% of charges if NOT a medical emergency. Emergency medical transportation 3 of 8

4 Common If you need immediate medical attention Urgent care $40 co-payment Not covered, unless medical emergency Not covered, unless medical emergency Physical exams for employment, school and recreation are not covered. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fees $500 co-payment per day for 3 days, then Preauthorization required or a penalty will apply. Outpatient services $20 co-payment ($300 Plan Only) $25 co-payment ($500/$1000 Plans) $25 co-payment ($300 Plan Only) $30 co-payment ($500/$1000 Plans) Includes an individual session, a group or family therapy session or a brief office visit to adjust medication. If you need mental health, behavioral health, or substance abuse services Inpatient services Same as hospital stay facility and physician fees. Same as hospital stay facility and physician fees. Same as hospital stay facility and physician fees. Preauthorization required or a penalty will apply. Residential care services for mental health or substance abuse treatment are excluded. Partial Hospitalization Intensive Outpatient, or Partial Day program Preauthorization required or a penalty will apply. These services are typically provided in a hospital. 4 of 8

5 Common Office visits If you are pregnant Childbirth/delivery professional services Childbirth/delivery facility services 20% at coinsurance $500 co-payment per day for 3 days, then Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Home health care Limited to 100 visits per year. Preauthorization is required or a penalty will apply. If you need help recovering or have other special health needs Rehabilitation services Habilitation services Chiropractic Services Same as above Same as above Same as above Assumes services are provided on an outpatient basis. Preauthorization is required or a penalty will apply. Same as above Same as above Same as above Assumes services are provided on an outpatient basis. Preauthorization is required or a penalty will apply. Same as above Same as above Same as above Skilled nursing care Same as above Same as above Same as above Limited to 20 visits per year. Limited to 70 visits per year. Preauthorization is required or a penalty will apply. Durable medical equipment Same as above Same as above Same as above Preauthorization required for rental or purchases over $500. Hospice services Preauthorization is required or a penalty will apply. 5 of 8

6 Common If your child needs dental or eye care Children s eye exam Not covered Not covered Not Covered None Children s glasses Not covered Not covered Not Covered None Children s dental check-up Not covered Not covered Not Covered None Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Artificial insemination or in vitro fertilization Cosmetic surgery Non-emergency care when travelling outside the U.S. Nutritional or Dietary Supplements Routine dental care Routine eye care Routine foot care Services, pharmaceuticals or supplies that are not medically necessary or meet plan provisions Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Dietary counseling services Dental care as treatment for accidental injury to the jaw and/or natural teeth Hearing aids or cochlear implant when patient s condition meets specific criteria Weight Loss Programs when patients condition meets certain medical criteria Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. For more information on your rights to continue coverage, contact the COBRA Plan Administrator at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact SSM Health Medical Management at or the Department of Labor s Employee Benefit Security Administration at EBSA (3272) or Additionally, for Missouri and 6 of 8

7 Illinois residents, a consumer assistance program can help you file your appeal details available at and Does this plan provide Minimum Essential Coverage? Yes. If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: CoreSource provides free language assistance services to help you communicate with us in your preferred language for health care. Ask your health care professional or call: ( ) Español CoreSource proporciona servicios de asistencia de idiomas para ayudarle a comunicarse con nosotros en su idioma preferido para obtener atención médica. Pregúntele a su profesional de atención médica o llame al: ( ) 简体中文 CoreSource 提供免费语言协助服务, 帮助您以母语与我们沟通健康护理 请咨询您的健康护理专员, 或拨打 :( ) To see examples of how this plan might cover costs for a sample medical situation, see the next section. 7 of 8

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