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 wwwhorizonbluecom/bedandbeyond or by calling 1-800-355 -BLUE (2583) Important Questions What is the overall? Answers $1,30000 employee only/ $2,60000 employee +1 /$3,90 000 employee +2/ $5,20000 employee +3 or more for in- Why this Matters: You must pay all the costs up to the amount before this plan begins to pay for covered services you use Check your policy or plan document to see when the starts over (usually, but not always, January 1st) See the Common Medical Events chart for how much you pay for covered services after you meet the network services No one individual required to satisfy more than $1,30000 $1,50000 employee only/ $3,00000 employee +1 /$4,500 00 employee +2/$6,000 employee +3 or more for out-of-network services No one individual required to satisfy more than $1,50000 Aggregate family Are there other Yes, $5000 prescription for out- You don t have to meet s for specific services, but see Common Medical s for specific of-network retail Events chart for other costs for services this plan covers services? Is there an out-ofthe out-of-pocket limit is the most you could pay during a coverage period (usually Yes, $4,00000 employee only/ pocket limit on my $8,00000 employee +1 /$12,0 00000 one year) for your share of the cost of covered services This limit helps you plan for expenses? employee +2 / For in-network providers health care expenses Prescription drug copays accumulate towards the out-of-pocket maximum Yes, $8,00000 employee only/ $16,00000 employee +1 /$24,00000 employee +2 / For outof-network Aggregate family Pharmacy/Health Consolidated What is not included in Premiums, balance-billed charges, penalties Even though you pay these expenses, they don t count toward the out-of-pocket limit the out-of-pocket for failure to obtain pre-authorization for limit? services and health care this plan doesn t cover 1 of 11
Is there an overall annual limit on what the plan pays? 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? No The Common Medical Events chart describes any limits on what the plan will pay for specific covered services, such as office visits Yes For a list of in-network providers, see If you use an in-network doctor or other health care provider, this plan will pay some wwwhorizonbluecom/bedbathandbeyond or all of the costs of covered services Be aware, your in-network doctor or hospital or call 1-800 -355 BLUE (2583) 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 Common Medical Events chart for how this plan pays different kinds of providers No You don't need a referral to see a You can see the specialist you choose without permission from this plan specialist Yes Some of the services this plan doesn t cover are listed on the Services Your Plan Does Not Cover chart See your policy or plan document for additional information about excluded services 2 of 11
Common Medical Event Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service Co-insurance 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 co-insurance payment of 20% would be $200 This may change if you haven t met your 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 participating providers by charging you lower s, co-payments and co-insurance amounts Services You May Need If you visit a health Primary care visit to treat care provider s an injury or illness office or clinic Specialist visit Other practitioner office visit Participating Provider Non-Participating Provider Limitations & Exceptions Combined in and out-of-network benefits This is the lowest age that this benefit is available In-network & Out-of-network routine physical exam minimum age limit coverage is limited to 20 years old (or older) Well child care (including preventive exams is to age 19) One per calendar year If a diagnostic procedure (eg, colonoscopy) is performed by an in-network surgeon, then all related services associated with that procedure (eg, anesthesia, laboratory) will be paid at the innetwork level of benefits Preventive care/screening No Charge /immunization Combined In-network & Out-of-network chiropractic care and therapeutic manipulations are limited to 90 visits per calendar year 3 of 11
Common Medical Event Services You May Need Participating Provider Retail:20% coinsurance with a $10 minimum /$20 maximum copay Mail Order: 20% coinsurance with a $25 minimum/$50 maximum copay Scripts Preferred brand drugs Retail:20% coinsurance wwwexpress scriptscom with a $30 minimum / $50 or 1-855-315-3497 maximum copay Mail Order: 20% coinsurance with a $75 5088 minimum/$125 maximum copay Non-preferred brand drugs Retail:20% coinsurance with a $75 minimum/ $100 maximum copay Mail Order: 20% coinsurance with a $18750 minimum/$250 maximum copay Specialty drugs 20% Coinsurance after in above applicable tiers If you have Facility fee (eg, outpatient surgery ambulatory surgery center) If you have a test Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) If you need drugs to Generic drugs treat your illness or condition More information about prescription drug coverage is available at Express Non-Participating Provider Limitations & Exceptions Retail: 50% coinsurance after $5000 Covered up to a 30 day supply at retail, and a 90 day supply at mail order The Pharmacy has a consolidated maximum out-of-pocket of, $4,00000 employee only/ $8,00000 employee +1 / $12,000000 employee + 2 In Network Retail: 50% coinsurance after $5000 Retail: 50% coinsurance after $5000 See page 1 for out-of-network out-of-pocket maximum Covered up to a 30 day supply at retail, and a 90 day supply at mail order The Pharmacy has a consolidated maximum out-of-pocket of, $4,00000 employee only/ $8,00000 employee +1 / $12,00000 employee + 2 In Network See page 1 for out-of-network out-of-pocket maximum Covered up to a 30 day supply at retail, and a 90 day supply at mail order The Pharmacy has a consolidated maximum out-of-pocket- of, $4,00000 employee only/$ 8,00000 employee +1 / $12,00000 employee +2 See page 1 for out-of-network out-of-pocket maximum $12,00000 none 4 of 11
Common Medical Event Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions 30% coinsurance after Out-of-network payment at the in-network level of benefits applies only to true medical emergencies and accidental injuries Urgent care Facility fee (eg, hospital room) $75000 cutback applies for non-compliance day limit coverage is limited to 365 days In-network & Out-of-network inpatient separation period coverage is limited to 90 days Physician/surgeon fee If you have mental Mental/Behavioral health Outpatient Facility: health, behavioral outpatient services health, or substance abuse needs Mental/Behavioral health inpatient services $75000 cutback applies for non-compliance day limit coverage is limited to 365 days In-network Physician/surgeon fees If you need Emergency room services immediate medical attention Emergency medical transportation If you have a hospital stay 5 of 11
Common Medical Event Services You May Need Participating Provider Non-Participating Provider Substance use disorder outpatient services Outpatient Facility: Substance use disorder inpatient services If you are pregnant Prenatal and postnatal care Delivery and all inpatient services If you need help Home health care recovering or have other special health needs Rehabilitation services Limitations & Exceptions & Out-of-network inpatient separation period coverage is limited to 90 days $75000 cutback applies for non-compliance day limit coverage is limited to 365 days In-network & Out-of-network inpatient separation period coverage is limited to 90 days $75000 cutback applies for non-compliance day limit coverage is limited to 365 days In-network & Out-of-network inpatient separation period coverage is limited to 90 days $75000 cutback applies for non-compliance Combined in and out-of-network benefits subject to a 100 day visit maximum per calendar year with direct admission $75000 cutback applies for non-compliance day limit coverage is limited to 90 days In-network & Out-of-network inpatient separation period coverage is limited to 90 days 6 of 11
Common Medical Event Services You May Need Participating Provider Non-Participating Provider Limitations & Exceptions Habilitative services $75000 cutback applies for non-compliance day limit coverage is limited to 90 days In-network & Out-of-network inpatient separation period coverage is limited to 90 days Skilled nursing care Durable medical equipment Hospice service $75000 cutback applies for non-compliance Combined In-network and Out-of-network inpatient skilled nursing facility day limit coverage is limited to 90 days Requires pre-approval; 50% penalty if not pre-approved $75000 cutback applies for non-compliance Respite Day Limit is 10 days Glasses Dental check-up If your child needs Eye exam dental or eye care 7 of 11
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 Infertility treatment Routine foot care Dental care Long-term care Weight loss programs Hearing aids Routine eye care + vision wear Non-emergency care when traveling outside the US See wwwhorizonbluecom/bedbathandbeyond (glasses/frames/lenses) 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 Most coverage provided outside the United States See wwwhorizonbluecom/bedbathandbeyond Private-duty nursing 8 of 11
Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan Other limitations on your rights to continue coverage may also apply For more information on your rights to continue coverage, contact the plan at 1-800-355-BLUE (2583) You may also contact your state insurance department, the US Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or wwwdolgov/ebsa, or the US Department of Health and Human Services at 1-877-267-2323 x61565 or wwwcciiocmsgov 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: 1-800-355-BLUE (2583) You may also contact the Department of Labor s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or wwwdolgov/ebsa/healthreform 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 1-800-355-BLUE (2583) Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-355-BLUE (2583) Chinese (中文): 如果需要中文的帮助 请拨打这个号码 1-800-355-BLUE (2583) Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-355-BLUE (2583) 9 of 11
About these Coverage Examples: These examples show how this plan might cover medical care in three 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 also will be different See the next page for important information about these examples Managing type 2 diabetes Having a baby (routine maintenance of a well-controlled condition) (Normal delivery) Amount owed to providers: $7,540 Plan pays $ 4,300 Patient pays $3,240 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 Copays Coinsurance Limits or exclusions Total $1300 $0 $1790 $150 $3,240 Amount owed to providers: $5,400 Plan pays $ 3,070 Patient pays $2,330 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures Education Laboratory tests Vaccines, other preventive Total $2,900 $1,300 $700 $300 $100 $100 $5,400 Patient pays: Deductibles Copays Coinsurance Limits or exclusions Total $1300 $0 $950 $80 $2,330 10 of 11
Questions and answers about 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 US Department of Health and Human Services, and aren't specific to a particular geographic area or health plan 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 s, copayments and co-insurance 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 for 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 co-payments, s and co-insurance You should consider also 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 11 of 11