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1 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 or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? 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 this plan doesn t cover? $0 person/$0 family Level I & Level II PPO $500 person/$1,500 family Level II Non-PPO Copayments, prescriptions & preventive do not apply towards the deductible. No. Yes. $6,600 person/$13,200 family Level I & Level II PPO & Non-PPO Premiums; balance-billed charges; charges in excess of UCR (Usual, Customary & Reasonable); health care this plan doesn t cover and any noncompliance penalties. No. Yes, for physicians, independent lab/x-ray facilities, home health care and other providers (Level II). See or call for a list of participating physicians. No. You don t need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1 st ). See the chart starting on page 2 for how much you pay for covered after you meet the deductible. You don t have to meet deductibles for specific, but see the chart starting on page 2 for other costs for this plan covers. This out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered. This limit helps you plan for health care expenses. Even though you pay these expenses, they do not count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered, such as office visits. This plan treats providers the same in determining payment for the same. You can see the specialist you choose without permission from this plan. Some of the this plan doesn t cover are listed on page 5. See your plan document for additional information about excluded. 1

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance 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 payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered 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 Independent Medical Systems providers for Level II by charging you lower deductibles, copayments and amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Level I Level II PPO Level II Non- PPO N/A $20 copay/visit 40% Specialist visit N/A $20 copay/visit 40% Other practitioner office visit Preventive care/screening/ immunization Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) N/A $20 copay/visit 40% 0% ; deductible waived 0% ; deductible waived Not Covered 40% 40% Limitations & Exceptions applies to PPO office surgery, lab/ x-ray & allergy testing/serum/injections. 0% applies to PPO female sterilization & all PPO FDA approved female contraceptive methods. Non-PPO Chiropractic limited to $40 maximum per visit & 25 visits per calendar year. See your plan document for additional benefit information & limitations. Level I charges based on Allowable Claims Limits. 10% applies to Level I performed at University Medical Center. Level I charges based on Allowable Claims Limits. Non-PPO charges are subject to UCR fees. 2

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room Emergency medical transportation Level I Level II PPO Level II Non- PPO Copays: Retail $10 (30 days)/$0 (90 days Costco only)/mail Order $0 (90 days) Copays: Retail $25 (30 days)/$50 (90 days Costco only)/mail Order $50 (90 days) Copays: Retail $25 (30 days)/$50 (90 days Costco only)/mail Order $50 (90 days) Retail & Mail Order copays apply N/A N/A N/A 40% copay/visit then 30% copay/visit then 30% Deductible then Deductible then Limitations & Exceptions Covers a 30 day (all pharmacies) or 90 day supply (Costco only) for Retail/90 day supply for Mail Order/30 day supply for Specialty. Prior authorization required for Actiq, acne medications (cosmetic related) age 40 & older, ADD/ADHD drugs age 14 & older, growth hormones, injectable forms of legend drugs & specialty drugs. Excluded drugs include but are not limited to prescription vitamins except pediatric & prenatal, Stadol, fertility drugs, impotence/sexual dysfunction drugs, weight loss medications, immunization agents except as required by the Affordable Care Act, biological sera, blood or blood plasma, alopecia drugs and drugs labeled Caution-limited by Federal Law to Investigational use or experimental drugs. 10% applies to Level I performed at University Medical Center. UR notification required. Level I charges based on Allowable Claims Limits. Non-PPO charges are subject to UCR fees. 0% (copay waived) applies to Level I performed at University Medical Center. UR notification required if admitted inpatient. Level I charges based on Allowable Claims Limits. Non-PPO charges are subject to UCR fees. 10% (copay waived) applies to Level I performed at University Medical Center. Level I charges based on Allowable Claims Limits. 3

4 Common Medical Event Services You May Need Level I Level II PPO Level II Non- PPO Limitations & Exceptions Urgent care N/A $20 copay/visit 40% If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient Mental/Behavioral health inpatient Substance use disorder outpatient Substance use disorder inpatient Prenatal and postnatal care Delivery and all inpatient copay/admit then N/A N/A N/A 40% copay/visit then 30% copay/admit then copay/visit then 30% copay/admit then 40% 40% 40% 40% N/A 40% copay/admit then 40% 10% (copay waived) applies to Level I performed at University Medical Center. UR notification required. Level I charges based on Allowable Claims Limits. Non-PPO charges are subject to UCR fees. 10% (copay waived) applies to Level I performed at University Medical Center. See If you visit a health care provider s office or clinic for the office visit benefit. UR notification required for Inpatient admissions and day treatment. Level I charges based on Allowable Claims Limits. Office visit copayment applies to the initial visit only. Contact UR for coordination of care. Non-PPO charges are subject to UCR fees. 10% (copay waived) applies to Level I performed at University Medical Center. UR notification required. Level I charges based on Allowable Claims Limits. Non-PPO charges are subject to UCR fees. 4

5 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Home health care Rehabilitation Habilitation Skilled nursing care Durable medical equipment Hospice service Eye exam Level I copay/admit or visit then 30% N/A Level II PPO Level II Non- PPO 40% 0% ; deductible waived Not Covered Glasses N/A 0% 0% Dental check-up Not Covered Limitations & Exceptions Home Health Care Level I copay applies per series of treatment. 10% (copay waived) applies to Level I performed at University Medical Center. Services limited per calendar year to 90 visits for Home Health care & 100 days for Skilled Nursing Facilities. Hospice limited to 180 days per lifetime. Treatment of developmental delays may not be covered. See your policy or plan document for additional information. Contact UR for coordination of care for Outpatient Hospice & Home Health care. UR notification required for inpatient admission. Level I charges based on Allowable Claims Limits. Benefit applies to Annual Routine Vision Exam. Limited to $100 per calendar year for age 19 & older only. Coverage may be available if separate Dental Plan was elected. 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.) Acupuncture Care outside the U.S. when travel is specifically for medical care Charges not medically necessary Cosmetic Surgery Infertility Treatment Long Term Care Routine eye care Routine foot care Weight Loss Programs 5

6 Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered and your costs for these.) Bariatric surgery (morbid obesity only) Chiropractic Care Dental Care Hearing Aids (only for initial purchase if hearing loss is due to illness, accidental injury, congenital anomaly or surgical procedure) Medical Services incurred while traveling outside the U.S. only if a medical emergency, subject to medical necessity and approved AMA procedure Private Duty Nursing 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 You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or 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: or the Department of Labor, Employee Benefits Security Administration at EBSA (3272) or 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? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered. This is called the minimum value standard. 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 To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6

7 Coverage Examples Coverage for: Employee & Dependents Plan Type: Cost Plus About these Coverage Examples: These examples show how this plan might cover medical care in given 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 will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $4,990 Patient pays $2,550 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 $0 Copays $290 Coinsurance $2,110 Limits or exclusions $150 Total $2,550 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,350 Patient pays $1,050 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $560 Coinsurance $410 Limits or exclusions $80 Total $1,050 7

8 Coverage Examples Questions and answers about the Coverage Examples: Coverage for: Employee & Dependents Plan Type: Cost Plus 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 U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All 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 deductibles, copayments, and 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 in 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 copayments, deductibles, and. You should also consider 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. 8

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