Healthcare Benefit Information. for. The Episcopal Diocese of Los Angeles

Transcription

1 Healthcare Benefit Information for The Episcopal Diocese of Los Angeles 2016

2 Network Access Directions Medical Plan Design Comparison Table of Contents Medical Plan Summary of Benefits and Coverage: Anthem BCBS 90/70 PPO Plan Anthem BCBS 80/60 PPO Plan Anthem BCBS EPO 75/50 PPO Plan Anthem BCBS EPO 90 Plan Anthem BCBS EPO 80 Plan Anthem BCBS High Deductible Health Plan Anthem BCBS High Deductible 15 Plan Anthem BCBS High Deductible 40 Plan Anthem BCBS PPO 70 SLV Plan Kaiser High Option EPO Plan Kaiser Mid Option EPO Plan Kaiser Option EPO 80 Plan Prescription Plan Design Comparison Vision Plan Design Comparison EyeMed Vision Summary of Benefits and Coverage Dental Plan Design Comparison Cigna Dental Plan Summary of Benefits and Coverage Cigna Dental & Orthodontia Plan Cigna Basic Dental Plan Cigna Preventive Dental Plan

3 For active and retired members: Accessing provider networks and benefits information online Cigna Dental (800) Go to 2. Click on Find A Doctor at the top of the screen. Then select the orange box that reads, If your insurance plan is offered through work or school 3. Click on Dentist 4. Enter the geographic location you wish to search 5. Select Cigna Dental PPO or EPO and click Choose 6. Under Popular Searches, choose the type of dentist you are looking for Cigna Behavioral Health (mental health and EAP) (866) Go to 2. Click on Find a Therapist or Psychiatrist 3. Log in (on left) to review your EAP benefits. Episcopal is the Employer ID 4. Select Find a Therapist/Psychiatrist 5. Click Search Anthem Blue Cross and Blue Shield (844) Go to 2. Under Useful Tools at right, Click on Find a Doctor 3. Under Search by selecting a plan/network, enter the search criteria 3. Under Medical/Employer Sponsored, select National PPO (BlueCard PPO) 4. Click Search and Continue 5. Choose the type of provider you are looking for and click Search

4 Kaiser Permanente Colorado (877) Georgia (866) Mid-Atlantic States (877) Northwest (866) Northern California (800) Southern California (800) Go to 2. Click on Clinical Staff Directory. Select your region and click Continue 3. Select the criteria for your search Mid-Atlantic members: Select Search for a doctor, hospital or other provider. Then, select Kaiser Permanente Select HMO, enter a search type, and input your criteria. Click Find Providers EyeMed Vision Care (866) Go to 2. Click on Find a Provider 3. Enter your zip code, under select your network, choose Access, then click "Get Results". Express Scripts (pharmacy benefit) (800) Go to and follow the steps to register. Then log in to price medications, view the Express Scripts formulary (list of preferred drugs), locate a participating pharmacy, etc. 2. Express Scripts has special representatives to assist you with any Open Enrollment questions. Call (800) and select option #1 Health Advocate (866) Go to 2. Click on the Members icon 3. Enter Episcopal in the log-in box and click Submit to view your benefits Medical Trust Client Services Call Center (800) For active and retired members

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9 Anthem Blue Cross and Blue Shield 90/70 Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Tiers Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my medical expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $250 Individual/$500 Family network $500 Individual/$1,000 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. Yes, $50 deductible for prescription drug coverage when using a retail pharmacy. Yes, $1,750 Individual/$3,500 Family network (includes deductible) $4,500 Individual/$9,000 Family out-of-network (includes deductible) Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. See page 5 for the out-of-pocket limit for the pharmacy benefit. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

10 Copayments are fixed dollar amounts (for example, $25) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments, and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $25 copay/visit 30% coinsurance None Specialist visit $25 copay/visit 30% coinsurance None Other practitioner office visit $25 copay/ visit for 30% coinsurance Limited to 20 visits per year for chiropractor, 50% for chiropractor, chiropractor services, 12 visits per year coinsurance for 50% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 30% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 20% coinsurance 20% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance 20% coinsurance None Facility fee (e.g., ambulatory surgery center) 10% coinsurance 30% coinsurance None Physician/surgeon fees 10% coinsurance 30% coinsurance None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 9

11 Common Medical Event If you need immediate medical attention If you have a hospital stay Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Emergency room services $100 copay/visit $100 copay/visit The $100 copay will be waived if you are admitted to the hospital as an inpatient within 24 hours. Emergency medical transportation 10% coinsurance 10% coinsurance None Urgent care 10% coinsurance 30% coinsurance None $100 per day copay Facility fee (e.g., hospital room) to a maximum of 30% coinsurance $600, then 10% Prior authorization is required. coinsurance Physician/surgeon fee 10% coinsurance 30% coinsurance None. Benefits are provided Mental/Behavioral health outpatient services $20 copay/visit 30% coinsurance through Cigna, NOT Anthem. If you have mental health, behavioral health, or substance abuse needs. Your mental health/ substance abuse benefits are provided through Cigna Behavioral Health. For more information, visit cignabehavorial.com or call Substance use disorder outpatient services $20 copay/visit 30% coinsurance Mental/Behavioral health inpatient services Substance use disorder inpatient services $100 per day copay to a maximum of $600 $100 per day copay to a maximum of $600 30% coinsurance 30% coinsurance Colleague group 30% coinsurance 30% coinsurance None. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. The plan will reimburse 70% up to a maximum reimbursable fee (MRF) of $40. The member is responsible for all costs above that amount. Benefits are provided through Cigna, NOT Anthem. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 9

12 Common Medical Event Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Prenatal and postnatal care $25 copay 30% coinsurance The copay applies only to the visit to confirm pregnancy $100 per day copay Prior authorization is required. Wellnewborn Delivery and all inpatient services care is also covered, but is to a maximum of 30% coinsurance $600, then 10% not subject to the inpatient hospital coinsurance deductible. Home health care 10% coinsurance 30% coinsurance Limited to 210 visits per plan year. Precertification is required. Rehabilitation services $25 copay/visit 30% coinsurance Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, Habilitation services $25 copay/visit 30% coinsurance combined facility and office, per each of the three therapies. Skilled nursing care (facility) 10% coinsurance 30% coinsurance Limited to 60 days per Plan year. Durable medical equipment 10% coinsurance 10% coinsurance None. Hospice service 10% coinsurance 30% coinsurance Limited to 210 days per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 9

13 Your cost if you have Common Medical Event Services You May Need Standard Prescription Plan Premium Prescription Plan Limitations & Exceptions Retail Mail Order Retail Mail Order If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Generic Drugs Up to $10 Up to $25 Up to $5 Up to $12 Preferred brand drugs Up to $35 Up to $90 Up to $25 Up to $70 Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home delivery. There is a $50 deductible when using a retail pharmacy. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 9

14 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 9

15 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 9

16 The Episcopal Church Medical Trust: Anthem 90/70 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,830 Patient pays $710 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $250 Copays $220 Coinsurance $90 Limits or exclusions $150 Total $710 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,290 Patient pays $1,110 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $250 Copays $650 Coinsurance $130 Limits or exclusions $80 Total $1,110 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 9

17 The Episcopal Church Medical Trust: Anthem 90/70 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 9 of 9

18 Anthem Blue Cross and Blue Shield 80/60 Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:all Tiers Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my medical expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $500 Individual/$1,000 Family network $1,000 Individual/$2,000 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. Yes, $50 deductible for prescription drug coverage when using a retail pharmacy Yes, $2,500 Individual/$5,000 Family network (includes deductible) $6,500 Individual/$13,000 Family out-of-network (includes deductible) Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. See page 5 for the out-of-pocket limit for your pharmacy benefit. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

19 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $25 copay/visit 40% coinsurance None Specialist visit $25 copay/visit 40% coinsurance None Other practitioner office visit $25 copay/ visit for 40% coinsurance Limited to 20 visits per year for chiropractor, 50% for chiropractor, chiropractor services, 12 visits per year coinsurance for 50% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 40% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 20% coinsurance 20% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance 20% coinsurance None Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance None Physician/surgeon fees 20% coinsurance 40% coinsurance None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

20 Common Medical Event If you need immediate medical attention If you have a hospital stay Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services $100 copay/visit $100/visit Limitations & Exceptions The $100 copay will be waived if you are admitted to the hospital as an inpatient within 24 hours. Emergency medical transportation 20% coinsurance 20% coinsurance Your coinsurance will be 40% for facility/non-emergency services. Urgent care 20% coinsurance 40% coinsurance None $100 per day copay Facility fee (e.g., hospital room) to a maximum of 40% coinsurance $600, then 20% Prior authorization is required. coinsurance Physician/surgeon fee 20% coinsurance 40% coinsurance None. Benefits are provided Mental/Behavioral health outpatient services $20 copay/visit 30% coinsurance through Cigna, NOT Anthem. If you have mental health, behavioral health, or substance abuse needs. Your mental health/ substance abuse benefits are provided through Cigna Behavioral Health. For more information, visit cignabehavorial.com or call Substance use disorder outpatient services $20 copay/visit 30% coinsurance Mental/Behavioral health inpatient services Substance use disorder inpatient services $100 per day copay to a maximum of $600 $100 per day copay to a maximum of $600 30% coinsurance 30% coinsurance Colleague group 30% coinsurance 30% coinsurance None. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. The plan will reimburse 70% up to a maximum reimbursable fee (MRF) of $40. The member is responsible for all costs above that amount. Benefits are provided through Cigna, NOT Anthem. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

21 Prenatal and postnatal care $25 copay 40% coinsurance The copay applies only to the visit to confirm pregnancy If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services $100 per day copay, to a maximum of $600, then 20% coinsurance 40% coinsurance Home health care 20% coinsurance 40% coinsurance Rehabilitation services $25 copay/visit 40% coinsurance Habilitation services $25 copay/visit 40% coinsurance Prior authorization is required. Wellnewborn care is also covered, but is not subject to the inpatient hospital deductible. Limited to 210 visits per plan year. Precertification is required. Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, combined facility and office, per each of the three therapies. Skilled nursing care (facility) 20% coinsurance 40% coinsurance Limited to 60 days per Plan year. Durable medical equipment 20% coinsurance 20% coinsurance None Hospice service 20% coinsurance 40% coinsurance Limited to 210 days per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

22 Your cost if you have Common Medical Event Services You May Need Standard Prescription Plan Premium Prescription Plan Limitations & Exceptions Retail Mail Order Retail Mail Order If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Generic Drugs Preferred brand drugs Up to $10 Up to $35 Up to $25 Up to $90 Up to $5 Up to $25 Up to $12 Up to $70 You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 delivery. There is a $50 deductible when using a retail pharmacy. Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine eye care (adult) Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

23 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

24 The Episcopal Church Medical Trust: Anthem 80/60 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,630 Patient pays $910 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $500 Copays $220 Coinsurance $40 Limits or exclusions $150 Total $910 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,950 Patient pays $1,450 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $500 Copays $630 Coinsurance $240 Limits or exclusions $80 Total $1,450 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

25 The Episcopal Church Medical Trust: Anthem 80/60 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

26 Anthem Blue Cross and Blue Shield 75/50 PPO Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:all Tiers Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my medical expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $900 Individual/$1,800 Family network $1,800 Individual/$3,600 Family out-of-network Network deductible does not apply to preventive care or emergency care Yes, $50 deductible for prescription drug coverage when using a retail pharmacy Yes, $4,100 Individual/$8,200 Family network (includes deductible) $8,200 Individual/$16,400 Family out-of-network (includes deductible) Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. Prescription drug benefits are through Express Scripts 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 plan for health care expenses. See page 5 for the out-of-pocket limits for your pharmacy benefit. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

27 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $35 copay/visit 50% coinsurance None. Specialist visit $45 copay/visit 50% coinsurance None. Other practitioner office visit $45 copay/visit for 50% coinsurance Limited to 20 visits per year for chiropractor, 50% for chiropractor, chiropractor services, 12 visits per year coinsurance for 50% coinsurance for acupuncture. acupuncture for acupuncture Preventive care/screening/immunization No charge 50% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 25% coinsurance 25% coinsurance None Imaging (CT/PET scans, MRIs) 25% coinsurance 25% coinsurance None Facility fee (e.g., ambulatory surgery center) 25% coinsurance 50% coinsurance None Physician/surgeon fees 25% coinsurance 50% coinsurance None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

28 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs. Your mental health/ substance abuse benefits are provided through Cigna Behavioral Health. For more information, visit cignabehavorial.com or call Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services $100 copay/visit $100/visit Limitations & Exceptions The $100 copay will be waived if you are admitted to the hospital as an inpatient within 24 hours. Emergency medical transportation 25% coinsurance 25% coinsurance None Urgent care 25% coinsurance 50% coinsurance None $100 per day copay Facility fee (e.g., hospital room) to a maximum of $600, then 25% 50% coinsurance Prior authorization is required. coinsurance Physician/surgeon fee 25% coinsurance 50% coinsurance Mental/Behavioral health outpatient services $20 copay/visit 30% coinsurance None. Benefits are provided through Cigna, NOT Anthem. Substance use disorder outpatient services $20 copay/visit 30% coinsurance None. Benefits are provided through Cigna, NOT Anthem. Mental/Behavioral health inpatient services Prior authorization is required. $100 per day copay Benefits are through Cigna, NOT to a maximum of 30% coinsurance Anthem. $600 Substance use disorder inpatient services $100 per day copay to a maximum of $600 30% coinsurance Colleague group 30% coinsurance 30% coinsurance Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. The plan will reimburse 70% up to a maximum reimbursable fee (MRF) of $40. The member is responsible for all costs above that amount. Benefits are provided through Cigna, NOT Anthem. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

29 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your cost if you use a Network Provider Prenatal and postnatal care $35 copay PCP / $45 copay specialist Delivery and all inpatient services $100 per day copay, to a maximum of $600, then 25% coinsurance Out-of-network Provider 50% coinsurance 50% coinsurance Home health care 25% coinsurance 50% coinsurance Rehabilitation services Habilitation services $35 copay/pcp $45 copay/ Specialist per visit $35 copay/pcp $45 copay/ Specialist per visit 50% coinsurance 50% coinsurance Limitations & Exceptions The copay applies only to the visit to confirm pregnancy The Plan s coinsurance for hospital expenses will be reduced to 50% if you do not follow the procedures required by the Medical Management Program. This penalty does not apply to the outof-pocket maximum. Well-newborn care is also covered, but is not subject to the inpatient hospital deductible. Limited to 210 visits per plan year. Precertification is required. Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, combined facility and office, per each of the three therapies. Skilled nursing care (facility) 25% coinsurance 50% coinsurance Limited to 60 days per Plan year. Durable medical equipment 25% coinsurance 25% coinsurance Hospice service 25% coinsurance 50% coinsurance Limited to 210 days per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

30 Your cost if you have Common Medical Event Services You May Need Standard Prescription Plan Premium Prescription Plan Limitations & Exceptions Retail Mail Order Retail Mail Order If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Generic Drugs Preferred brand drugs Up to $10 Up to $35 Up to $25 Up to $90 Up to $5 Up to $25 Up to $12 Up to $70 You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 delivery. There is a $50 deductible when using a retail pharmacy. Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

31 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

32 The Episcopal Church Medical Trust: Anthem 75/50 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,270 Patient pays $1,270 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $900 Copays $220 Coinsurance $0 Limits or exclusions $150 Total $1,270 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,510 Patient pays $1,890 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $900 Copays $640 Coinsurance $270 Limits or exclusions $80 Total $1,890 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

33 The Episcopal Church Medical Trust: Anthem 75/50 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: PPO Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

34 Anthem Blue Cross and Blue Shield EPO 90 Plan (Network Only) Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/ /31/2016 Coverage for: All Tiers Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my medical expenses? Answers $200 Individual/$500 Family Deductible does not apply to preventive care received in network and emergency care. Yes, $50 deductible for prescription drug coverage when using a retail pharmacy $1,700 Individual/$3,500 Family (includes deductible) Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. See page 4 for the out-of-pocket limit for your pharmacy benefit. What is not included in the out of pocket limit? Does this plan use a network of providers? Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call Even though you pay these expenses, they don t count toward the out-of-pocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesn t cover? No Yes You can see the specialist that you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

35 Copayments are fixed dollar amounts (for example, $25) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery If you need immediate medical attention Services You May Need Your Cost Limitations & Exceptions Primary care visit to treat an injury or illness $25 copay/visit None Specialist visit $25 copay/visit None $25 copay/visit for Other practitioner office visit chiropractor, 50% coinsurance for acu- plan year for chiropractor services. Limited to 12 visits per plan year for acupuncture, 20 visits per puncture Preventive care/screening/immunization No charge Diagnostic test (x-ray, blood work) 20% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance None Facility fee (e.g., ambulatory surgery center) 10% coinsurance None Physician/surgeon fees Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Emergency room services $100 copay/visit The $100 copay will be waived if you are admitted to the hospital as an inpatient within 24 hours. Emergency medical transportation 10% coinsurance None Urgent care 10% coinsurance None Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

36 Common Medical Event Services You May Need Your Cost Limitations & Exceptions If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs. All Mental Health / Substance Abuse benefits are through Cigna Behavioral Health. For more information, call or visit cignabehavioral.com Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Substance use disorder outpatient services Mental/Behavioral health inpatient services Substance use disorder inpatient services Colleague group 10% coinsurance Prior authorization is required. $20 copay/visit network. 30% coinsurance outof-network. $20 copay/visit network; 30% coinsurance outof-network 10% coinsurance network. 30% co-insurance outof-network. 10% coinsurance network; 30% coinsurance outof-network. 30% coinsurance inand out-of-network None. Benefits are provided through Cigna, NOT Anthem. None. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. The plan will reimburse 70% up to a maximum reimbursable fee (MRF) of $40. The member is responsible for all costs above that amount. Benefits are provided through Cigna, NOT Anthem. If you are pregnant Prenatal and postnatal care $25 copay The copay applies only to the visit to confirm pregnancy Delivery and all inpatient services 10% coinsurance Well-newborn care is also covered. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

37 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost Limitations & Exceptions Home health care 10% coinsurance Limited to 210 visits per plan year. Rehabilitation services $25 copay/visit Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per plan year, combined facility and office, Habilitation services $25 copay/visit per each of the three therapies. Skilled nursing care (facility) 10% coinsurance Limited to 60 days per plan year. Durable medical equipment 10% coinsurance None Hospice service (facility) 10% coinsurance Limited to 210 days per lifetime Eye exam Not covered Glasses Not covered Vision benefits are available through EyeMed Vision Care. Dental check-up Not covered Your cost if you have Common Medical Event Services You May Need Standard Prescription Plan Premium Prescription Plan Limitations & Exceptions Retail Mail Order Retail Mail Order If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Generic Drugs Preferred brand drugs Up to $10 Up to $35 Up to $25 Up to $90 Up to $5 Up to $25 Up to $12 Up to $70 You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home delivery. Remember, your phar- Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 macy benefit is through Express Scripts. Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

38 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

39 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

40 The Episcopal Church Medical Trust: Anthem EPO 90 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,640 Patient pays $900 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $200 Copays Coinsurance $550 Limits or exclusions $150 Total $900 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,340 Patient pays $1,060 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $200 Copays $650 Coinsurance $130 Limits or exclusions $80 Total $1,060 Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

41 Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

42 Anthem Blue Cross and Blue Shield EPO 80 Plan (Network Only) Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/ /31/2016 Coverage for: All Tiers Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my medical expenses? Answers $350 Individual/$700 Family Deductible does not apply to preventive care received in network and emergency care. Yes, $50 deductible for prescription drug coverage when using a retail pharmacy $2,350 Individual/$4,700 Family (includes deductible) Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. The retail pharmacy deductible does not apply to your out-of-pocket limit. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. See page 4 for the out-of-pocket limit for your pharmacy benefit. What is not included in the out of pocket limit? Does this plan use a network of providers? Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call Even though you pay these expenses, they don t count toward the out-of-pocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Are there services this plan doesn t cover? No Yes You can see the specialist that you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8

43 Copayments are fixed dollar amounts (for example, $25) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery If you need immediate medical attention Services You May Need Your Cost Limitations & Exceptions Primary care visit to treat an injury or illness $25 copay/visit None. Deductible does not apply. Specialist visit $25 copay/visit None. Deductible does not apply. Other practitioner office visit $25 copay/visit for Limited to 12 visits per plan year for acupuncture, 20 visits per chiropractor, 50% coinsurance for acu- plan year for chiropractor services. Deductible does not apply to chiropractor services. puncture Preventive care/screening/immunization No charge Diagnostic test (x-ray, blood work) 20% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance None Facility fee (e.g., ambulatory surgery center) 20% coinsurance None Physician/surgeon fees Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Emergency room services $100 copay/visit The $100 copay will be waived if you are admitted to the hospital as an inpatient within 24 hours. Emergency medical transportation 20% coinsurance For emergency transportation only (network and out-of-network) Urgent care 20% coinsurance None Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

44 Common Medical Event Services You May Need Your Cost Limitations & Exceptions If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs. All Mental Health / Substance Abuse benefits are through Cigna Behavioral Health. For more information, call or visit cignabehavioral.com Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Substance use disorder outpatient services Mental/Behavioral health inpatient services Substance use disorder inpatient services Colleague group 20% coinsurance Prior authorization is required. $20 copay/visit network. 30% coinsurance out-of-network. $20 copay/visit network; 30% coinsurance out-of-network 20% coinsurance network. 30% coinsurance outof-network. 20% coinsurance network; 30% coinsurance outof-network. 30% coinsurance inand out-of-network None. Benefits are provided through Cigna, NOT Anthem. None. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. Prior authorization is required. Benefits are provided through Cigna, NOT Anthem. The plan will reimburse 70% up to a maximum reimbursable fee (MRF) of $40. The member is responsible for all costs above that amount. Benefits are provided through Cigna, NOT Anthem. If you are pregnant Prenatal and postnatal care $25 copay The copay applies only to the visit to confirm pregnancy Delivery and all inpatient services 20% coinsurance Well-newborn care is also covered. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

45 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost Limitations & Exceptions Home health care 20% coinsurance Limited to 210 visits per plan year. Rehabilitation services $25 copay/visit Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per plan year, combined facility and office, Habilitation services $25 copay/visit per each of the three therapies. Deductible does not apply. Skilled nursing care (facility) 20% coinsurance Limited to 60 days per plan year. Precertification required. Durable medical equipment 20% coinsurance None. Deductible does not apply. Hospice service (facility) 20% coinsurance Limited to 210 days per lifetime. Eye exam Not covered Glasses Not covered Vision benefits are available through EyeMed Vision Care. Dental check-up Not covered Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Services You May Need Standard Prescription Plan Your cost if you have Premium Prescription Plan Retail Mail Order Retail Mail Order Generic Drugs Up to $10 Up to $25 Up to $5 Up to $12 Preferred brand drugs Up to $35 Up to $90 Up to $25 Up to $70 Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. Limitations & Exceptions You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home delivery. There is a $50 deductible when using a retail pharmacy. Remember, your pharmacy benefit is through Express Scripts. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

46 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

47 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

48 The Episcopal Church Medical Trust: Anthem EPO 80 Plan Coverage Period: 01/01/ /31/2016 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,080 Patient pays $1,460 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $350 Copays Coinsurance $960 Limits or exclusions $150 Total $1,460 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,080 Patient pays $1,320 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $350 Copays $650 Coinsurance $240 Limits or exclusions $80 Total $1,320 Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

49 Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

50 Anthem Blue Cross and Blue Shield High Deductible Health Plan Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:all Tiers Plan Type: HDHP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $2,700 Individual/$5,450 Family network $3,000 Individual/$6,000 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. No Yes, $4,200 Individual/$8,450 Family Network $7,000 Individual/$13,000 Family out-of-network Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

51 Copayments are fixed dollar amounts (for example, $30) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness 20% coinsurance 45% coinsurance None Specialist visit 20% coinsurance 45% coinsurance None Other practitioner office visit 20% coinsurance 45% coinsurance Limited to 20 visits per year for for chiropractor for chiropractor, chiropractor services, 12 visits per year services and 20% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 45% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 20% coinsurance 20% coinsurance None Imaging (CT/PET scans, MRIs) 20% coinsurance 45% coinsurance None If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 20% coinsurance 45% coinsurance None None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

52 Common Medical Event If you need immediate medical attention Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services 20% coinsurance 20% coinsurance Emergency medical transportation 20% coinsurance 45% coinsurance None Urgent care 20% coinsurance 45% coinsurance None Limitations & Exceptions Hospital admission must be certified within 24 hours. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee 20% coinsurance 45% coinsurance Prior authorization is required.. Mental/Behavioral health outpatient services 20% coinsurance 45% coinsurance None Substance use disorder outpatient services 20% coinsurance 45% coinsurance None If you have mental health, behavioral health, or substance abuse needs. Mental/Behavioral health inpatient services 20% coinsurance 45% coinsurance Admissions must be precertified. Substance use disorder inpatient services 20% coinsurance 45% coinsurance Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

53 Common Medical Event Services You May Need Your cost if you use a Network Provider Out-of-network Provider Prenatal and postnatal care 20% coinsurance 45% coinsurance Limitations & Exceptions If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services 20% coinsurance 45% coinsurance Prior authorization is required. Home health care 20% coinsurance 45% coinsurance Limited to 210 visits per plan year. Precertification is required. Rehabilitation services 20% coinsurance 45% coinsurance Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, Habilitation services 20% coinsurance 45% coinsurance combined facility and office, per each of the three therapies. Skilled nursing care (facility) 20% coinsurance 45% coinsurance Limited to 60 days per Plan year. Durable medical equipment 20% coinsurance 20% coinsurance None Hospice service 20% coinsurance 45% coinsurance Limited to one episode per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

54 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Services You May Need Generic Drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Retail Your Cost 15% (after deductible) 25% (after deductible) 50% (after deductible) Mail Order Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. Limitations & Exceptions You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using the mail order pharmacy. Your prescription deductible is combined with your medical deductible. Prescription drug benefits are through Express Scripts. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

55 Your Deductible This plan has an embedded deductible. This means that once each member of your family has met the individual deductible, this plan will cover his or her medical expenses minus the appropriate cost share. The individual deductible is also credited toward the family deductible. Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

56 The Episcopal Church Medical Trust: Anthem High Deductible Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $4,190 Patient pays $3,350 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $2,700 Copays $0 Coinsurance $500 Limits or exclusions $150 Total $3,350 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $2,180 Patient pays $3,220 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $2,700 Copays $ Coinsurance $440 Limits or exclusions $80 Total $3,220 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

57 The Episcopal Church Medical Trust: Anthem High Deductible Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

58 High Deductible Plan - 15 Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:all Tiers Plan Type: HDHP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $1,400 Individual/$2,800 Family network $2,800 Individual/$5,600 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. No Yes, $2,400 Individual/$4,800 Family Network $4,800 Individual/$9,600 Family out-of-network Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

59 Copayments are fixed dollar amounts (for example, $30) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness 15% coinsurance 40% coinsurance None Specialist visit 15% coinsurance 40% coinsurance None Other practitioner office visit 15% coinsurance 40% coinsurance Limited to 20 visits per year for for chiropractor for chiropractor, chiropractor services, 12 visits per year services and 15% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 40% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 15% coinsurance 15% coinsurance None Imaging (CT/PET scans, MRIs) 15% coinsurance 15% coinsurance None If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 15% coinsurance 40% coinsurance None None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

60 Common Medical Event If you need immediate medical attention Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services 15% coinsurance 15% coinsurance Emergency medical transportation 15% coinsurance 40% coinsurance None Urgent care 15% coinsurance 40% coinsurance None Limitations & Exceptions Hospital admission must be certified within 24 hours. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee 15% coinsurance 40% coinsurance Prior authorization is required.. Mental/Behavioral health outpatient services 15% coinsurance 40% coinsurance None Substance use disorder outpatient services 15% coinsurance 40% coinsurance None If you have mental health, behavioral health, or substance abuse needs. Mental/Behavioral health inpatient services 15% coinsurance 40% coinsurance Admissions must be precertified. Substance use disorder inpatient services 15% coinsurance 40% coinsurance Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

61 Common Medical Event Services You May Need Your cost if you use a Network Provider Out-of-network Provider Prenatal and postnatal care 15% coinsurance 40% coinsurance Limitations & Exceptions If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services 15% coinsurance 40% coinsurance Prior authorization is required. Home health care 15% coinsurance 40% coinsurance Limited to 210 visits per plan year. Precertification is required. Rehabilitation services 15% coinsurance 40% coinsurance Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, Habilitation services 15% coinsurance 40% coinsurance combined facility and office, per each of the three therapies. Skilled nursing care (facility) 15% coinsurance 40% coinsurance Limited to 60 days per Plan year. Durable medical equipment 15% coinsurance 15% coinsurance None Hospice service 15% coinsurance 40% coinsurance Limited to one episode per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

62 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Services You May Need Generic Drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Retail Your Cost 15% (after deductible) 25% (after deductible) 50% (after deductible) Mail Order Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. Limitations & Exceptions You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using the mail order pharmacy. Your prescription deductible is combined with your medical deductible. Prescription drug benefits are through Express Scripts. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

63 Your Deductible: This plan has a non-embedded deductible. If you have single coverage, then the Plan will begin to provide benefits once you have met the individual deductible. If you have spousal or family coverage, then the family deductible must be met before the Plan begins to pay for benefits for any covered family member. Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

64 The Episcopal Church Medical Trust: Anthem High Deductible - 15 Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,110 Patient pays $2,430 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,400 Copays $0 Coinsurance $880 Limits or exclusions $150 Total $2,430 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,340 Patient pays $2,060 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,400 Copays $0 Coinsurance $580 Limits or exclusions $80 Total $2,060 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

65 The Episcopal Church Medical Trust: Anthem High Deductible - 15 Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

66 High Deductible Plan - 40 Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:all Tiers Plan Type: HDHP This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $3,500 Individual/$7,000 Family network $7,000 Individual/$14,000 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. No Yes, $6,000 Individual/$12,000 Family Network $10,000 Individual/$20,000 Family out-of-network Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

67 Copayments are fixed dollar amounts (for example, $30) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness 40% coinsurance 60% coinsurance None Specialist visit 40% coinsurance 60% coinsurance None Other practitioner office visit 40% coinsurance 60% coinsurance Limited to 20 visits per year for for chiropractor for chiropractor, chiropractor services, 12 visits per year services and 40% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 60% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 40% coinsurance 40% coinsurance None Imaging (CT/PET scans, MRIs) 40% coinsurance 60% coinsurance None If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 40% coinsurance 60% coinsurance None None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

68 Common Medical Event If you need immediate medical attention Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services 40% coinsurance 40% coinsurance Emergency medical transportation 40% coinsurance 40% coinsurance None Urgent care 40% coinsurance 60% coinsurance None Limitations & Exceptions Hospital admission must be certified within 24 hours. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee 40% coinsurance 60% coinsurance Prior authorization is required.. Mental/Behavioral health outpatient services 40% coinsurance 60% coinsurance None Substance use disorder outpatient services 40% coinsurance 60% coinsurance None If you have mental health, behavioral health, or substance abuse needs. Mental/Behavioral health inpatient services 40% coinsurance 60% coinsurance Admissions must be precertified. Substance use disorder inpatient services 40% coinsurance 60% coinsurance Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

69 Common Medical Event Services You May Need Your cost if you use a Network Provider Out-of-network Provider Prenatal and postnatal care 40% coinsurance 60% coinsurance Limitations & Exceptions If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services 40% coinsurance 60% coinsurance Prior authorization is required. Home health care 40% coinsurance 60% coinsurance Limited to 210 visits per plan year. Precertification is required. Rehabilitation services 40% coinsurance 60% coinsurance Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, Habilitation services 40% coinsurance 60% coinsurance combined facility and office, per each of the three therapies. Skilled nursing care (facility) 40% coinsurance 60% coinsurance Limited to 60 days per Plan year. Durable medical equipment 40% coinsurance 40% coinsurance None Hospice service 40% coinsurance 60% coinsurance Limited to one episode per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

70 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Services You May Need Generic Drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Retail Your Cost 15% (after deductible) 25% (after deductible) 50% (after deductible) Mail Order Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. Limitations & Exceptions You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using the mail order pharmacy. Your prescription deductible is combined with your medical deductible. Prescription drug benefits are through Express Scripts. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

71 Your Deductible: This Plan has an embedded deductible. This means that once each member of your family has met the individual deductible, this Plan will begin to provide benefits for that individual. The individual deductible is also credited toward the family deductible. Once the family deductible has been met, all covered members of your family will receive benefits, whether or not they have met the individual deductible. Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

72 The Episcopal Church Medical Trust: Anthem High Deductible - 40 Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $2,380 Patient pays $5,160 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $3,500 Copays $0 Coinsurance $1,510 Limits or exclusions $150 Total $5,160 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $1,110 Patient pays $4,290 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $3,500 Copays $0 Coinsurance $710 Limits or exclusions $80 Total $4,290 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

73 The Episcopal Church Medical Trust: Anthem High Deductible - 40 Coverage Period: 01/01/ /31/2016 Coverage Examples Coverage for: Individual Plan Type: HDHP Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

74 PPO 70 SLV Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/ /31/2016 Coverage for:all Tiers Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $3,000 Individual/$6,000 Family network $6,000 Individual/$12,000 Family out-of-network Deductible does not apply to preventive care received in network and emergency care. Yes, $50 deductible for prescription drug coverage when using a retail pharmacy. Yes, $4,000 Individual/$8,000 Family Network $8,000 Individual/$16,000 Family out-of-network Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 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 plan begins to pay for these services. Prescription drug benefits are through Express Scripts. 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 plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

75 Copayments are fixed dollar amounts (for example, $30) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Primary care visit to treat an injury or illness $35 copay 50% coinsurance None Specialist visit $45 copay 50% coinsurance None Other practitioner office visit $45 coinsurance for 50% coinsurance Limited to 20 visits per year for chiropractor for chiropractor, chiropractor services, 12 visits per year services and 50% coinsurance for acupuncture acupuncture for acupuncture Preventive care/screening/immunization No charge 50% Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. Diagnostic test (x-ray, blood work) 30% coinsurance 30% coinsurance None Imaging (CT/PET scans, MRIs) 30% coinsurance 30% coinsurance None If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees 30% coinsurance 50% coinsurance None None Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 8

76 Common Medical Event If you need immediate medical attention Services You May Need Your cost if you use a Network Provider Out-of-network Provider Emergency room services $150 copay $150 copay Emergency medical transportation 30% coinsurance 30% coinsurance None Urgent care 30% coinsurance 50% coinsurance None Limitations & Exceptions Hospital admission must be certified within 24 hours. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee $100 per day copay to a maximum of $600, then 30% coinsurance 50% coinsurance Prior authorization is required.. Mental/Behavioral health outpatient services $20 copay 30% coinsurance None. Provided through Cigna Behavioral Health. Substance use disorder outpatient services $20 copay 30% coinsurance None. Provided through Cigna Behavioral Health. If you have mental health, behavioral health, or substance abuse needs. Mental Health/Substance Abuse Benefits are provided through Cigna Behavioral Health. Mental/Behavioral health inpatient services Substance use disorder inpatient services $100 per day to a maximum of $600 $100 per day to a maximum of $600 30% coinsurance 30% coinsurance Admissions must be precertified. Provided through Cigna Behavioral Health. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 8

77 Common Medical Event Services You May Need Your cost if you use a Network Provider Out-of-network Provider Limitations & Exceptions Prenatal and postnatal care 30% coinsurance 50% coinsurance If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services 30% coinsurance 50% coinsurance Prior authorization is required. Home health care 30% coinsurance 50% coinsurance Limited to 210 visits per plan year. Precertification is required. Rehabilitation services 30% coinsurance 50% coinsurance Benefits include hearing/speech, physical, and occupational therapy. Limited to 60 visits per Plan year, Habilitation services 30% coinsurance 50% coinsurance combined facility and office, per each of the three therapies. Skilled nursing care (facility) 30% coinsurance 50% coinsurance Limited to 60 days per Plan year. Durable medical equipment 30% coinsurance 30% coinsurance None Hospice service 30% coinsurance 50% coinsurance Limited to one episode per lifetime. Precertification is required. Eye exam Not Covered Not Covered Vision benefits are available through Glasses Not Covered Not Covered EyeMed Vision Care. Dental check-up Not Covered Not Covered Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 8

78 Your cost if you have Common Medical Event Services You May Need Standard Prescription Plan Premium Prescription Plan Limitations & Exceptions Retail Mail Order Retail Mail Order If you need drugs to treat your illness or condition More information about prescription drug coverage is available at express-scripts.com Generic Drugs Preferred brand drugs Up to $10 Up to $35 Up to $25 Up to $90 Up to $5 Up to $25 Up to $12 Up to $70 You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using home Non-preferred brand drugs Up to $60 Up to $150 Up to $45 Up to $110 delivery. There is a $50 deductible when using a retail pharmacy. Specialty drugs Your cost is based on whether the specialty drug is a preferred brand or non-preferred brand drug. The annual out-of-pocket limit for pharmacy benefits, which is separate from your medical out-of-pocket limit, is $2,500 individual/$5,000 family in-network. Prescription drugs received out-of-network or over-the-counter are not included in the out-of-pocket limit. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Routine eye care (adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Non-emergency care when traveling outside the United States* Private duty nursing * Applies only to services covered by Anthem Blue Cross and Blue Shield. Coverage for non-emergency care and services outside of the United States is not available through Cigna Behavioral Health or Express Scripts. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 8

79 Your Deductible: This Plan has an embedded deductible. This means that once each member of your family has met the individual deductible, this Plan will begin to provide benefits. The individual deductible is also credited toward the family deductible. Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirements 1. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Anthem Blue Cross and Blue Shield at 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 1 Under Section 4980B(d) of the Code and Treasury Regulation Section B-2, Q. and A. No. 4. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 8

80 The Episcopal Church Medical Trust: Anthem PPO 70 SLV Coverage Examples Coverage Period: 01/01/ /31/2016 Coverage for: Individual Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $3,390 Patient pays $4,150 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $3,000 Copays $0 Coinsurance $1,000 Limits or exclusions $150 Total $4,150 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Anthem Blue Cross and Blue Shield at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $1,640 Patient pays $3,760 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $3,000 Copays $0 Coinsurance $680 Limits or exclusions $80 Total $3,760 Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 8

81 The Episcopal Church Medical Trust: Anthem PPO 70 SLV Coverage Examples Coverage Period: 01/01/ /31/2016 Coverage for: Individual Plan Type: PPO Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

82 Administered by: High Option EPO (Network Only) Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Tiers Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Answers Why this Matters: $0 See the chart starting on page 2 for your costs for services this plan covers. No You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. $1,500 Individual/$3,000 Family 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 plan for health care expenses. Contributions, (premiums), balancebilled charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call Even though you pay these expenses, they don t count toward the out-of-pocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a specialist? Yes The plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Are there services this plan doesn t cover? Yes Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 7

83 Copayments are fixed dollar amounts (for example, $20) you pay for covered health care, usually when you receive the service. Coinsurance 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 plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you have outpatient surgery Services You May Need Your Cost Limitations & Exceptions Primary care visit to treat an injury or illness $20 copay/visit None Specialist visit $20 copay/visit None Other practitioner office visit $20 copay/visit for Limited to 12 visits per plan year for acupuncture, 20 visits per chiropractor and acupuncture plan year for chiropractor services. Preventive care/screening/immunization No charge Diagnostic test (x-ray, blood work) No charge None Imaging (CT/PET scans, MRIs) No charge None Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees $20 copay/visit None Preventive care is based on guidelines from the U.S. Preventive Services Task Force, American Cancer Society, The Advisory Committee on Immunization Practices (ACIP), and the American Academy of Pediatrics. Coverage for child immunizations is based on the published guidelines of the American Academy of Pediatrics. If you need immediate medical attention Emergency room services $75 copay/visit Copay waived if admitted as an inpatient within 24 hours. Emergency medical transportation $50 copay/occurrence None Urgent care $20 copay/visit None Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 2 of 7

84 Common Medical Event Services You May Need Your Cost Limitations & Exceptions If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs. Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Substance use disorder outpatient services Mental/Behavioral health inpatient services No charge $20 copay/day individual, $10 copay/day group $20 copay/day individual, $10 copay/day group No charge None None None None Substance use disorder inpatient services No charge None If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Prenatal and postnatal care $20 copay The copay applies only to the visit to confirm pregnancy. Separate cost share may apply to prenatal lab and radiology tests. Delivery and all inpatient services No charge Benefits include contracted birthing centers. Home health care No charge Includes nurse visits (2 hours), aide visits (4 hours), therapy visits, and supplies. Limited to 210 visits per plan year. Rehabilitation services $20 copay/visit Benefits include speech, physical, and occupational therapy. Limited to 60 visits per plan year, combined facility and office, per Habilitation services $20 copay/visit each of the three therapies. Skilled nursing care No charge Limited to 60 days per plan year. Durable medical equipment No charge None Hospice service No charge None Eye exam $20 copay Additional vision benefits are available through EyeMed Vision Glasses Not covered Care. Dental check-up Not covered Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 3 of 7

85 Common Medical Event Services You May Need Retail Your Cost Mail Order Limitations & Exceptions If you need drugs to treat your illness or condition Generic Drugs Preferred brand drugs $10 copay $25 copay $10 copay for up to 30- day supply, $20 copay for up to a 90-day supply $25 copay for up to a 30- day supply, $50 copay for up to a 90-day supply You may get up to a 30-day supply when using a retail pharmacy, and up to a 90-day supply when using the mail order pharmacy. Specialty drugs $25 copay $25 copay for up to a 30- day supply, $50 copay for up to a 90-day supply Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Dental Care (Adult) Hearing Aids Long-term care Non-emergency care when traveling outside the United States Routine Eye Care (Adult) Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Infertility treatment Private duty nursing Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 4 of 7

86 Your Rights to Continue Coverage: The Plan s Extension of Benefits program is similar, but not identical, to the healthcare continuation coverage provided under Federal law (known as COBRA ) for non-church plans. Because the Plan is a church plan as described under Section 3(33) of ERISA, the Plan is exempt from COBRA requirementsi. Nonetheless, subscribers and/or their enrolled dependents will have the opportunity to continue benefits for a limited time in certain instances when coverage through the health plan would otherwise cease. Individuals who elect to continue coverage must pay for the coverage. Call for more information. For more information on your rights to continue coverage, contact the plan 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 Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Kaiser Permanente at You may also contact the U.S. Department of Labor s 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 plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' Your health benefits will be self-insured by your employer, union, or Plan sponsor. Kaiser Permanente Insurance Company will provide certain administrative services for the Plan and will not be an insurer of the Plan or financially liable for health care benefits under the Plan. To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 5 of 7

87 The Episcopal Church Medical Trust: High Option EPO Administered by Kaiser Permanente Coverage Examples Coverage Period: 01/01/ /31/2016 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,370 Patient pays $170 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $20 Coinsurance $0 Limits or exclusions $150 Total $170 These numbers assume the patient has given notice of her pregnancy to the Plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information please contact Kaiser Permanente at Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,720 Patient pays $680 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $600 Coinsurance $0 Limits or exclusions $80 Total $680 Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 6 of 7

88 Questions and answers 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 and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. 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, and coinsurance can 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, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an 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, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 7 of 7

89 Administered by: Mid Option EPO (Network Only) Coverage Period: 01/01/ /31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Tiers Plan Type: EPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? Answers Why this Matters: $0 See the chart starting on page 2 for your costs for services this plan covers. No You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. $2,000 Individual/$4,000 Family 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 plan for health care expenses. What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Contributions (premiums), balance-billed charges, health care this plan doesn t cover, and penalties. Yes. For a list of network providers, see or call Yes Yes Even though you pay these expenses, they don t count toward the out-of-pocket limit. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. The plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 7