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Important Questions Answers Why This Matters What is the overall Deductible? $3,000 person/$6,000 family Generally, you must pay all of the costs from Providers up to the Deductible amount before this Plan begins to pay. If you have other family members on the Plan, each family member must meet their own individual Deductible until the total amount of Deductible expenses paid by all family members meets the overall family Deductible. Are there services covered before you meet your Deductible? Yes. Pharmacy, services that require Copays, immunizations or In-Network hospice care and Preventive Care are covered before you meet your Deductible. This Plan covers some items and services even if you haven't yet met the Deductible amount. But a Copayment or Cost Sharing may apply. For example, this Plan covers certain Preventive Services without Cost Sharing and before you meet your Deductible. See a list of covered Preventive Services at benefits/. Are there other Deductibles for specific services ? No. There are no other specific Deductibles. You don't have to meet Deductibles for specific services. What is the Out-of-pocket Limit for this Plan? For In-Network Provider $3,500 person / $7,000 family For Out-of-Network Provider $5,000 person /$10,000 family The Out-of-pocket Limit is the most you could pay in a year for covered services. If you have other family members in this Plan, they have to meet their own Out-of-pocket Limits until the overall family Out-of-pocket Limit has been met. What is not included in the Out-of- pocket Limit ? Contributions, Balance-Billing charges and health care this Plan doesn't cover. Even though you pay these expenses, they don't count toward the Out-of-pocket Limit. Will you pay less if you use a Network Provider? Yes. See www.bcidaho.com or call 1- [PHONE REDACTED] for a list of Network Providers. 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 Providers 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. Do you need a Referral to see a Specialist? No. You can see the Specialist you choose without a Referral. ASC PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/1/2025 - 9/30/2026 Coverage for: Enrollee + Eligible Dependents I 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 the plan (called the contribution) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit contract.page. For general definitions of common terms, such as allowed amount, balance billing, cost sharing, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-[PHONE REDACTED] to request a copy. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 1 of 9 ---PAGE BREAK--- What You Will Pay Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you visit a health care Provider's office or clinic Primary care visit to treat an injury or illness $20 Copay/visit, Deductible does not apply 40% Cost Sharing after Deductible Copay does not apply to additional services. Cost Sharing may not apply for pediatric physician office visit. Additional telehealth services may be provided by your Provider. Specialist visit $20 Copay/visit, Deductible does not apply 40% Cost Sharing after Deductible Copay does not apply to additional services. Cost Sharing may not apply for pediatric physician office visit. Preventive care/Screening/immunization No charge for listed preventive, Screening and immunization services. Deductible does not apply. No charge for listed immunizations, 40% Cost Sharing after Deductible for preventive and Screening. 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. No charge for supplemental breast Screening. If you have a test Diagnostic test (x-ray, blood work) 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Imaging (CT/PET scans, MRIs) 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.SmithRx.com. Generic drugs Retail: Copay up to $10 per 30- day supply Visit SmithRx.com for Network information. Visit SmithRx.com for Network information. Preferred brand drugs Retail: Copay up to $25 per 30- day supply Visit SmithRx.com for Network information. Visit SmithRx.com for Network information. Non-preferred brand drugs Retail: Copay up to $40 per 30- day supply Visit SmithRx.com for Network information. Visit SmithRx.com for Network information. Specialty Drugs Copay up to $40 per 30-day supply N/A Visit SmithRx.com for Network information. If you have outpatient surgery Facility fee ambulatory surgery center) 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. Physician/surgeon fees 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. All copayments and Cost sharing costs shown in this chart are after your deductible has been met, if a deductible applies. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 2 of 9 ---PAGE BREAK--- What You Will Pay Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency Room Care $100 Copay/visit, 20% Cost Sharing after Deductible $100 Copay/visit, 20% Cost Sharing after Deductible In-Network Cost Sharing applies to both In-Network and Out-of-Network services. Copay waived if admitted. Emergency Medical Transportation 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible In-Network Cost Sharing applies for air ambulance services. Urgent Care $20 Copay/visit, Deductible does not apply 40% Cost Sharing after Deductible Copay does not apply to additional services. Cost Sharing may not apply for pediatric physician office visit. If you have a hospital stay Facility fee hospital room) 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. Physician/surgeon fee 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. If you have mental health, behavioral health, or substance abuse services Outpatient services $20 Copay/visit, 20% Cost Sharing after Deductible for facility and other services 40% Cost Sharing after Deductible Cost Sharing may not apply for pediatric outpatient Additional telehealth services may be provided by your Provider. Inpatient services 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. If you are pregnant Office Visits 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible For pregnancy services, Cost Sharing does not apply to certain Preventive Services. Depending on the type of services, a Copay, Cost Sharing or Deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Childbirth/delivery facility services 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 3 of 9 ---PAGE BREAK--- What You Will Pay Common Medical Event Services You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need help recovering or have other special health needs Home Health Care 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. ReHabilitation Services $20 Copay/visit for outpatient physical, occupational and speech therapies; $10 Copay/visit for outpatient cardiac rehabilitation. 40% Cost Sharing after Deductible Coverage is limited to 40 visit annual max for physical; 40 visit annual max for speech and occupational. Habilitation Services $20 Copay/visit for outpatient physical, occupational and speech therapies. 40% Cost Sharing after Deductible Coverage is limited to 40 visit annual max for physical; 40 visit annual max for speech and occupational. Skilled Nursing Care 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Coverage is limited to 30 day annual max. Durable Medical Equipment 20% Cost Sharing after Deductible 40% Cost Sharing after Deductible Preauthorization required. Hospice Services No charge. Deductible does not apply. 40% Cost Sharing after Deductible If your child needs dental or eye care Children's eye exam Not covered Not covered Children's glasses Not covered Not covered Children's dental check-up Not covered Not covered Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 4 of 9 ---PAGE BREAK--- Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Chiropractic care • Hearing aids • Non-emergency care when traveling outside the U.S. Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services) Excluded Services & Other Covered Services: • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (Adult) • Dental check-up (Child) • Eye exam (Child) • Glasses (Child) • Hearing aids (Child) • Infertility treatment • Long-term care • Private-duty nursing • Routine eye care (Adult) • Routine foot care • Weight loss programs Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 5 of 9 ---PAGE BREAK--- Your Rights to Continue Coverage: Group health coverage - There are agencies that can help if you want to continue coverage after it ends. The contact information for those agencies is: Department of Labor's Employee Benefits Security Administration at 1-866-4444-EBSA(3272) or www.dol.gov/ebsa/healthreform or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-[PHONE REDACTED] x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance through Your Health Idaho. For more information about Your Health Idaho, visit www.YourHealthIdaho.org or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of 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: For any inital questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at 1-[PHONE REDACTED] Or 1-[PHONE REDACTED], www.bcidaho.com or at P.O. Box 7408, Boise, ID 83707. If your plan is subject to ERISA, you may contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA or www.dol.gov/ebsa/healthreform. If your plan Is fully insured or self-funded and subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of Insurance at 1-[PHONE REDACTED] or www.DOI.Idaho.gov Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the 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. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 6 of 9 ---PAGE BREAK--- 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 Cost sharing) 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. About These Coverage Examples: Peg is Having a baby (9 months of in-network pre-natal care and a hospital delivery) Deductibles $3,000 Copayments $0 Cost sharing $500 In this example, Peg would pay: The plan's overall deductible Specialist copay: Hospital (facility) cost sharing: Other cost sharing: Total Example Cost $12,690 Cost Sharing What isn't Covered The total Peg would pay is $3,570 Limits or Exclusions $70 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) Managing Joe's type 2 Diabetes (a year of routine in-network care of a well-controlled condition) Deductibles $120 Copayments $160 Cost sharing $0 In this example, Joe would pay: The plan's overall deductible: Specialist copay: Hospital (facility) cost sharing: Other cost sharing: Total Example Cost $5,830 Cost Sharing What isn't Covered The total Joe would pay is $4,580 Limits or Exclusions $4,300 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) Mia's Simple Fracture (in-network emergency room visit and follow up care) Deductibles $2,690 Copayments $100 Cost sharing $0 In this example, Mia would pay: The plan's overall deductible: Specialist copay: Hospital (facility) cost sharing: Other cost sharing: Total Example Cost $2,800 Cost Sharing What isn't Covered The total Mia would pay is $2,800 Limits or Exclusions $10 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) The plan would be responsible for the other costs of these EXAMPLE covered services. $3,000 $20 20% 20% $3,000 $20 20% 20% $3,000 $20 20% 20% Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 7 of 9 ---PAGE BREAK--- Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 8 of 9 ---PAGE BREAK--- Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A City of Blackfoot Fire District I 10035553 I III-A Trust ASC PPO 80-B I 3000 I 10/01/25 I PPO I 2025 I AHCR I SBC ID: 235715 Page 9 of 9