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Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/1/2017 - 9/30/2018 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 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, 1-[PHONE REDACTED]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary as 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. $2,000 person/$4,000 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 coinsurance 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 /$7,000 family For Out-of-network provider $5,000 person /$10,000 family For prescription drugs $3,000 person / $6,000 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. Premiums, 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 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. 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. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 1 of 8 ---PAGE BREAK--- All copayments and coinsurance 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 $30 copay/visit 40% coinsurance Does not apply to additional services. Specialist visit $30 copay/visit 40% coinsurance Does not apply to additional services. Preventive care/screening/immunization No charge for listed preventive, screening and immunization services. deductible does not apply. No charge for listed immunizations, 40% coinsurance 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) 20% coinsurance 40% coinsurance Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Preauthorization required. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcidaho.com Generic drugs $15 copay/prescription (retail and mail order) $15 copay/prescription (retail and mail order) Covers up to a 90 day supply with multiple copays. Preferred brand drugs $30 copay/prescription (retail and mail order) $30 copay/prescription (retail and mail order) Covers up to a 90 day supply with multiple copays. Non-preferred brand drugs $45 copay/prescription (retail and mail order) $45 copay/prescription (retail and mail order) Covers up to a 90 day supply with multiple copays. Specialty drugs $45 copay/prescription (retail and mail order) $45 copay/prescription (retail and mail order) Coverage may include limitations and Preauthorization may be required. If you have outpatient surgery Facility fee ambulatory surgery center) 20% coinsurance 40% coinsurance Preauthorization required. Physician/surgeon fees 20% coinsurance 40% coinsurance Preauthorization required. If you need immediate medical attention Emergency room care $100 copay/visit, 20% coinsurance $100 copay/visit, 40% coinsurance Out-of-network services paid at In-network if Emergency medical condition. copay waived if admitted. none Emergency medical transportation 20% coinsurance 40% coinsurance Urgent care $30 copay/visit 40% coinsurance Does not apply to additional services. If you have a hospital stay Facility fee hospital room) 20% coinsurance 40% coinsurance Preauthorization required. Physician/surgeon fee 20% coinsurance 40% coinsurance Preauthorization required. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 2 of 8 ---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 have mental health, behavioral health, or substance abuse services none Outpatient services $30 copay/visit, 20% coinsurance for facility and other services 40% coinsurance Inpatient services 20% coinsurance 40% coinsurance Preauthorization required. If you are pregnant Office Visits 20% coinsurance 40% coinsurance For pregnancy services, cost sharing does not apply to certain preventive services. Depending on the type of services, a copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). none Childbirth/delivery professional services 20% coinsurance 40% coinsurance none Childbirth/delivery facility services 20% coinsurance 40% coinsurance If you need help recovering or have other special health needs Home health care 20% coinsurance 40% coinsurance Preauthorization required. ReHabilitation services 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max. Habilitation services 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max. Skilled nursing care 20% coinsurance 40% coinsurance Coverage is limited to 30 day annual max. Durable medical equipment 20% coinsurance 40% coinsurance Preauthorization required. Hospice services No charge. deductible does not apply. 40% coinsurance Preauthorization required. 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. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 3 of 8 ---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.) Private-duty nursing • Acupuncture • Bariatric surgery • • Routine eye care (Adult) Cosmetic surgery • • Routine foot care Dental care (Adult) • • Weight loss programs Dental check-up (Child) • Eye exam (Child) • • Glasses (Child) Hearing aids • • Infertility treatment Long-term care • Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Chiropractic care • Non-emergency care when traveling outside the U.S. • Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 4 of 8 ---PAGE BREAK--- Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month, you will have to make payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for the month. 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 initial 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 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. see examples of how this plan might cover costs for a sample medical situation, see the next Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 5 of 8 ---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) coinsurance n Other coinsurance Total Example Cost $12,731 In this example, Peg would pay: Deductible Copayments Coinsurance Limits or exclusions $60 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 coinsurance) 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. $2,000 $40 $1,500 $2,000 $30 20% 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) The total Peg would pay is Cost Sharing What isn't Covered Total Example Cost $7,389 In this example, Joe would pay: Deductible Copayments Coinsurance $2,000 $30 20% 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) 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 $1,930 In this example, Mia would pay: Deductible Copayments Coinsurance Limits or exclusions $2,000 $30 20% 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) The total Mia would pay is Cost Sharing What isn't Covered $0 $0 $1,525 $3,600 $1,700 $130 $1,340 $1,540 $160 $55 $0 About these Coverage Examples: n The plan's overall deductible n Specialist copay n Hospital (facility) coinsurance n Other coinsurance n The plan's overall deductible n Specialist copay n Hospital (facility) coinsurance n Other coinsurance The plan would be responsible for the other costs of these EXAMPLE covered services. Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 6 of 8 ---PAGE BREAK--- Nondiscrimination Statement: Discrimination is Against the Law 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’s Customer Service Department. Call 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]), 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 East Pine Avenue, Meridian, Idaho 83642 Telephone: (800) 274-4018 ext.3838, Fax: (208) 331-7493 Email: grievances&[EMAIL REDACTED] TTY: 1-[PHONE REDACTED] 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 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], 1-[PHONE REDACTED] (TTY). Complaint forms are available at . Reference: Questions: Call 1-[PHONE REDACTED] or visit us at www.bcidaho.com/SBC. City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 7 of 8 ---PAGE BREAK--- Language Assistance ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-[PHONE REDACTED] (TTY：1-[PHONE REDACTED])。 French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-[PHONE REDACTED] (ATS : 1-[PHONE REDACTED]). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]）まで、お電話にてご連絡ください。 Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED])번으로 전화해 주십시오. Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-[PHONE REDACTED] (телетайп: 1-[PHONE REDACTED]). Serbo-Croation OBAVJEŠTENJE: Ako govorite usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-[PHONE REDACTED] (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-[PHONE REDACTED]). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-[PHONE REDACTED] (телетайп: 1-[PHONE REDACTED]). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-[PHONE REDACTED] (TTY: 1-[PHONE REDACTED]). City of Burley I 10034229 I Large Group PPO I 2000 I 10/01/17 I PPO I 2017 I AHCR I SBC ID: 42184 Page 8 of 8