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III-A Trust ASC PPO 70-C Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/1/2022 - 9/30/2023 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 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. Important Questions Answers Why This Matters: What is the overall Deductible? 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. $3,000 person/$6,000 family Are there services 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 Yes. Pharmacy, services that require Copays, immunizations or In-Network hospice care and Preventive Care are covered before you meet your Deductible. Are there other Deductibles for specific services ? You don't have to meet Deductibles for specific services. No. There are no other specific Deductibles. What is the Out-of-pocket Limit for this Plan? 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. For In-Network Provider $3,500 person /$9,000 family For Out-of-Network Provider $9,000 person /$12,000 family What is not included in the Out-of-pocket Limit ? Even though you pay these expenses, they don't count toward the Out-of-pocket Limit. Contributions, Balance-Billing charges and health care this Plan doesn't cover. Will you pay less if you use a Network Provider? 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. Yes. See www.bcidaho.com or call 1-[PHONE REDACTED] for a list of Network Providers. Do you need a Referral to see a Specialist? You can see the Specialist you choose without a Referral. No. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 1 of 9 ---PAGE BREAK--- All copayments and cost sharing costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Out-of-Network Provider (You will pay the most) Network Provider (You will pay the least) 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 $40 Copay/visit, Deductible does not apply 50% 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 $40 Copay/visit, Deductible does not apply 50% 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, 50% 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. If you have a test none Diagnostic Test (x-ray, blood work) 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Imaging (CT/PET scans, MRIs) 30% Cost Sharing after Deductible 50% 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.proactrx.com. Generic drugs Retail: Copay up to $10 per 30-day supply Visit ProActRx.com for Network information. Mail order: 90-day supply for two Copays. Visit www.ProactRx.com for more information Preferred brand drugs Retail: Copay up to $25 per 30-day supply Visit ProActRx.com for Network information. Mail order: 90-day supply for two Copays. Visit www.ProactRx.com for more information Non-preferred brand drugs Retail: Copay up to $40 per 30-day supply Visit ProActRx.com for Network information. Mail order: 90-day supply for two Copays. Visit www.ProactRx.com for more information Specialty Drugs Copay up to $40 per 30-day supply N/A Visit www.ProactRx.com for more information If you have outpatient surgery Facility fee ambulatory surgery center) 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. Physician/surgeon fees 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 2 of 9 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Out-of-Network Provider (You will pay the most) Network Provider (You will pay the least) Limitations, Exceptions, & Other Important Information If you need immediate medical attention Emergency Room Care $100 Copay/visit, 30% Cost Sharing after Deductible $100 Copay/visit, 30% 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 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible In-Network Cost Sharing applies for air ambulance services. Urgent Care $40 Copay/visit, Deductible does not apply 50% 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) 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. Physician/surgeon fee 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. If you have mental health, behavioral health, or substance abuse services Outpatient services $40 Copay/visit, 30% Cost Sharing after Deductible for facility and other services 50% Cost Sharing after Deductible Cost Sharing may not apply for pediatric outpatient Additional telehealth services may be provided by your Provider. Inpatient services 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. If you are pregnant Office Visits 30% Cost Sharing after Deductible 50% 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). none Childbirth/delivery professional services 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible none Childbirth/delivery facility services 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 3 of 9 ---PAGE BREAK--- Common Medical Event Services You May Need What You Will Pay Out-of-Network Provider (You will pay the most) Network Provider (You will pay the least) Limitations, Exceptions, & Other Important Information If you need help recovering or have other special health needs Home Health Care 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. ReHabilitation Services 30% Cost Sharing after Deductible; $40 Copay/visit physical therapy 50% Cost Sharing after Deductible Coverage is limited to 30 visit annual max for outpatient physical; 20 visit annual max for outpatient speech and occupational; 36 visit annual max for outpatient cardiac rehabilitation. Habilitation Services 30% Cost Sharing after Deductible; $40 Copay/visit physical therapy 50% Cost Sharing after Deductible Coverage is limited to 30 visit annual max for outpatient physical; 20 visit annual max for outpatient speech and occupational. Skilled Nursing Care 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Coverage is limited to 30 day annual max. Durable Medical Equipment 30% Cost Sharing after Deductible 50% Cost Sharing after Deductible Preauthorization required. none Hospice Services No charge. Deductible does not apply. 50% Cost Sharing after Deductible If your child needs dental or eye care none 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 Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 4 of 9 ---PAGE BREAK--- 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 other excluded services.) Weight loss programs • Cosmetic surgery • Dental care (Adult) • Dental check-up (Child) • Eye exam (Child) • Glasses (Child) • Infertility treatment • • Long-term care Private-duty nursing • • Routine eye care (Adult) Routine foot care • Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Acupuncture • Bariatric surgery • Chiropractic care • Hearing aids • Non-emergency care when traveling outside the U.S. • Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 5 of 9 ---PAGE BREAK--- Does this plan provide Minimum Essential Coverage? Yes. Your Rights to Continue Coverage: 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. 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 Iadho, visit www.YourHealthIdaho.org or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: To see examples of how this plan might cover costs for a sample medical situation, see the next section. 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. 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 Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 6 of 9 ---PAGE BREAK--- Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) n The plan's overall deductible n Specialist copay n Hospital (facility) cost sharing n Other cost sharing Total Example Cost $12,690 In this example, Peg would pay: Copayments Limits or exclusions $70 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. $3,000 $0 $500 $3,000 $40 30% 30% 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) The total Peg would pay is Cost Sharing What isn't Covered Total Example Cost $5,830 In this example, Joe would pay: Deductibles Copayments $3,000 $40 30% 30% 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) Cost Sharing What isn't Covered The total Joe would pay is Limits or exclusions Mia's Simple Fracture (in-network emergency room visit and follow up care) Total Example Cost $2,800 In this example, Mia would pay: Copayments Limits or exclusions $3,000 $40 30% 30% 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 total Mia would pay is Cost Sharing What isn't Covered $0 $0 $4,740 $3,570 $2,380 $120 $320 $1,990 $380 $4,300 $10 About these Coverage Examples: n The plan's overall deductible n Specialist copay n Hospital (facility) cost sharing n Other cost sharing n The plan's overall deductible n Specialist copay n Hospital (facility) cost sharing n Other cost sharing Cost sharing Cost sharing The plan would be responsible for the other costs of these EXAMPLE covered services. Deductibles Deductibles Cost sharing Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 7 of 9 ---PAGE BREAK--- DISCRIMINATION IS AGAINST THE LAW Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc., (collectively referred to as Blue Cross of Idaho) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Blue Cross of Idaho Customer Service Department. Call 1-[PHONE REDACTED] (TTY: 711), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho’s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone: 1-[PHONE REDACTED] Fax: [PHONE REDACTED] Email: grievances&[EMAIL REDACTED] TTY: 711 You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-[PHONE REDACTED], [PHONE REDACTED] (TTY). Complaint forms are available at Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 8 of 9 ---PAGE BREAK--- ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian, Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are available to you. Call 1-[PHONE REDACTED] (TTY: 711). III-A Trust 70-C I Standard I III-A Trust ASC PPO 70-C I 3000 I 10/01/22 I PPO I 2022 I AHCR I SBC ID: 90637 Page 9 of 9