Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Premera BCBS of AK: Global 20 Plan Grandfathered $500 Deductible Coverage for: Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.premera.com or by calling 1-800-508-4722 or TTY 1-800-842-5357. For general definitions of common terms, such as allowed amount, balance billing,, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/sbcuniformglossary.pdf or call 1-800-508-4722 or TTY 1-800-842-5357 to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out of pocket limit? Will you pay less if you use a network provider? Do I need a referral to see a specialist? $500. Individual / $1,000 Family. Yes. Does not apply to copayments, prescription drugs and services listed below as No charge. No. In-network: $3,500 Individual / $7,000 Family. Out-of-network: Not applicable. Copayments, Premiums, balance-billed charges, and health care this plan doesn't cover. Yes. See www.premera.com or call 1-800-508-4722 for a list of in-network providers. No. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or may apply. You don't have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Even though you pay these expenses, they don t count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 1 of 6
All copayment and costs shown in this chart are after your overall deductible has been met, if a deductible applies. Common Medical Event Services You May Need Primary care visit to treat an injury or illness Network Provider (You will pay the least) What You Will Pay 20% (deductible does not apply first 6 visits) Out-of-Network Provider (You will pay the most) 20% (deductible does not apply first 6 visits) Limitations, Exceptions, & Other Important Information Office and home visits combined count toward the 6 visit limit. If you visit a health care provider s office or clinic Specialist visit Preventive care / screening / immunization 20% (deductible does not apply first 6 visits) 20% (deductible does not apply first 6 visits) Office and home visits combined count toward the 6 visit limit. You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Deductible does not apply for preventive exams. No charge for routine immunizations or preventive screening. If you have a test If you need drugs to treat your illness or condition More information about prescription Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Preferred generic drugs Preferred brand drugs Non-preferred brand drugs No charge for preventive screening. Covers up to a 90 day supply (retail and in-network mail-order). 2 of 6
Common Medical Event drug coverage is available at https://client.formular ynavigator.com/sear ch.aspx?sitecode=6 065073448 If you have outpatient surgery Services You May Need Network Provider (You will pay the least) What You Will Pay Specialty drugs 20% Not covered Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Out-of-Network Provider (You will pay the most) $50 copayment + 20% $50 copayment + 20% Limitations, Exceptions, & Other Important Information Covers up to a 30-day supply. Only covered at specific contracted specialty pharmacies. Copayment is waived if admitted to hospital. If you need immediate medical attention Emergency medical transportation Urgent care 20% (deductible does not apply first 6 visits) 20% (deductible does not apply first 6 visits) Office and home visits combined count toward the 6 visit limit. If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fees If you need mental health, behavioral health, or substance abuse services Outpatient services Mental/Behavioral health outpatient services: Not covered Substance use disorder outpatient services: 20% Mental/Behavioral health outpatient services: Not covered Substance use disorder outpatient services: 20% Inpatient services Mental/Behavioral health Mental/Behavioral health 3 of 6
Common Medical Event Services You May Need Network Provider (You will pay the least) inpatient services: Not covered What You Will Pay Out-of-Network Provider (You will pay the most) inpatient services: Not covered Limitations, Exceptions, & Other Important Information Substance use disorder inpatient services: 20% Substance use disorder inpatient services: 20% Office visits Coverage after the first 12 consecutive months on the plan. If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Childbirth/delivery professional services Childbirth/delivery facility services Coverage after the first 12 consecutive months on the plan. Home health care Limited to 130 visits per calendar year. Rehabilitation services Limited to 15 outpatient professional visits per calendar year, limited to 10 inpatient days per calendar year. Habilitation services Not covered Not covered None Skilled nursing care Limited to 20 days per calendar year. Durable medical equipment Hospice services Children's eye exam Not covered Not covered None Children's glasses Not covered Not covered None Children's dental check-up Not covered Not covered None Limited to 240 respite hours, limited to 10 inpatient days - 6 month overall lifetime benefit limit. 4 of 6
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Assisted fertilization treatment Bariatric surgery Cosmetic surgery Dental care (Adult) Habilitation Hearing aids Long-term care Mental health care Private-duty nursing Routine eye care (Adult) Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Abortion Acupuncture Chiropractic care or other spinal manipulations Foot care Non-Emergency care when traveling outside the U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-907-269-7900 or 1-800-467-8725 for the state insurance department, or the insurer at 1-800-508-4722. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.healthcare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-907-269-7900 or 1-800-467-8725 for the state insurance department, or the insurer at 1-800-508-4722. Does this plan provide Minimum Essential Coverage? Yes. If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-508-4722 or TTY 1-800-842-5357. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-508-4722 or TTY 1-800-842-5357. Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 1-800-508-4722 or TTY 1-800-842-5357. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-508-4722 or TTY 1-800-842-5357. To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 6
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and ) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible $500 Specialist 20% Hospital (facility) 20% Other 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost Sharing Deductibles $500 Copayments $0 Coinsurance $2,400 What isn't covered Limits or exclusions $60 The total Peg would pay is $2,960 Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan's overall deductible $500 Specialist 20% Hospital (facility) 20% Other 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $500 Copayments $0 Coinsurance $1,400 What isn't covered Limits or exclusions $20 The total Joe would pay is $1,920 Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $500 Specialist 20% Hospital (facility) 20% Other 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $500 Copayments $50 Coinsurance $300 What isn't covered Limits or exclusions $0 The total Mia would pay is $850 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6 Premera Blue Cross Blue Shield of Alaska is an Independent Licensee of the Blue Cross Blue Shield Association 025992 (10-2017)