BlueEssentials SM. Individual and Family Plans NEW INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

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1 BlueEssentials SM Individual and Family Plans NEW INSURANCE PLANS FROM BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

2 Important Enrollment Dates ENROLLMENT DATE EFFECTIVE DATE November 15 through December 15, 2014 January 1, 2015 December 16, 2014 through January 15, 2015 February 1, 2015 January 16 through February 15, 2015 March 1, 2015 Table of Contents Overview 3 Financial Assistance Value-Added Benefits 4 Enrollment Plan Essentials 5 Plan Benefits Member Tools 6-7 Exclusions Plan Networks 8-9 Glossary 49-50

3 Overview 3 TRUST IN BLUE BlueCross BlueShield of South Carolina is a company you trust. Ensuring access to quality health coverage is vital to the health and well-being of every community in our state. Having served South Carolina for almost 70 years, we re more than a recognized member of the community we re a strong and stable partner you know you can count on. Our goal is simple: provide the highest quality coverage at a reasonable price. Since there s no such thing as one size fits all, we now offer more options than ever before. The choices are numerous to make sure you have the right plan for your needs. And you ll love BLUE s large network of doctors, hospitals, specialists, pharmacies and other health care providers. Let us help you find the right health insurance. The Basics ESSENTIAL HEALTH S All of the new Affordable Care Act (ACA) health plans must include these Essential Health Benefits: Ambulatory patient services: services that can be completed during a single day and don t require a patient to be admitted to the hospital Emergency services: care that is given in a hospital emergency room Hospitalization: hospital stays Maternity and newborn care: care for pregnant women and newborn babies Mental health and substance dependency services Prescription drugs: medications prescribed by your doctor Rehabilitative and habilitative services and devices: services that help you recover lost abilities or services that help you gain functions so you can participate in daily life Routine wellness and preventive services and chronic disease management services

4 Value 4 Specials DISCOUNT AND VALUE-ADDED PROGRAMS Sometimes all you need to feel great is a little sprucing up. That s why our members enjoy discounts and value-added programs, such as: FITNESS AND WELLNESS Fitness Center Memberships Getting in shape is now more affordable than ever! We make it easy for our members to save on memberships to local fitness facilities and other exercise centers. Children s Fitness With My Gym Children s Fitness Center, choose from a variety of structured, age-appropriate classes that use music, dance, relays, games and more. Weight Management Enjoy discounts on weight-loss programs and services, including Jenny Craig. Plus, get one-on-one support to help you lead a healthy lifestyle. HEARING AND VISION Laser Vision Correction You ll see exclusive discounts on Lasik surgery offered through QualSight, a national network of credentialed Lasik surgeons. Eye Care Open your eyes to special savings from Vision One eye exams, designer frames, lenses and contacts. Hearing Care Hear that? With Blue, get great savings from TruHearing a leader in digital hearing aids and ranked No. 1 in customer service. Save on hearing exams and follow-up care, too. COSMETIC Cosmetic Surgery Lift your spirits with preferred rates on face-lifts, breast lifts, breast augmentation and reduction, tummy tucks, nose reshaping, ear pinning, even cheek and chin augmentation. Save on nonsurgical procedures, too. Hair Restoration Suffering from hair loss? You have everything to gain. As a member, you ll save 20 percent on a hair transplantation procedure. Allergy Relief You ll breathe easier thanks to special prices on products designed to reduce exposure to indoor allergies. Alternative Health Care Where does it hurt? With Natural Blue SM you can tap into an extensive network of credentialed acupuncturists, massage therapists, chiropractors, plus diet advisers all offering extensive discounts. BLUE365 As a BlueCross member, you have access to Blue365, a daily deal website with discounts on various wellness products and services. Blue365 complements your health coverage by making it easier and more affordable to make healthy choices. Visit: Blue365deals.com/BCBSSC for the deal of the day!

5 Essentials 5 Benefits WITHOUT BORDERS Members can rest easy knowing their BlueCross coverage travels beyond South Carolina s borders. The BlueCard and BlueCard Worldwide programs give members access to a network of participating doctors and hospitals across the country and around the world. PREVENTIVE SERVICES Services such as preventive screenings for children, women and men, including prostate screenings and lab work according to the American Cancer Society (ACS) guidelines, are provided at 100 percent when provided by a network provider. The American Cancer Society is an independent company that provides some health information on behalf of BlueCross BlueShield of South Carolina. We cover: U.S. Preventive Services Task Force (USPSTF) recommended Grade A or B screenings Immunizations as recommended by the Centers for Disease Control and Prevention (CDC) Screenings recommended for women and children by the Health Resources and Services Administration (HRSA) Prostate screenings according to the ACS. The USPSTF, CDC and HRSA are independent companies that provide some health information on behalf of BlueCross. For more information, visit (This link leads to a thrid party website. That company is solely responsible for the content and privacy policy on its site.) PHARMACY SERVICES RETAIL To receive benefits for prescription drugs, you must get them through our network. A network pharmacy has contracted with our pharmacy benefit manager to provide prescription drugs. When you buy drugs from a network pharmacy, you must show your BlueCross ID card. You can find a list of network pharmacies at under the pharmacy directory. Up to 31-day supply. MAIL ORDER Our mail-order pharmacy is one we have contracted with to provide prescription drugs. Our mail-order pharmacy information is located on our website under Prescription Drug Information. Up to 90-day supply. SPECIALTY DRUG Some drugs are designated as specialty medications and must be filled at Caremark Specialty Pharmacy. Caremark Specialty Pharmacy is an independent company that provides pharmacy services on behalf of BlueCross. You ll find the list of drugs that you must fill at Caremark on the BlueEssentials Covered Drug List. Up to 31-day supply.

6 Tools 6 Services MY HEALTH TOOLKIT We understand the importance of making the right health care decisions. These decisions affect the health of you and your family, and they impact your finances. That is why we created My Health Toolkit. My Health Toolkit is an online resource for tools and information to help you manage your benefits, treatments and financial decisions. Whether you need to locate an in-network doctor or want to research the cost of a specific surgery, My Health Toolkit has resources that can assist you. As more power is placed in your hands to manage your health care benefits, we are here to help you every step of the way. MANAGE YOUR S Claims Summary View claims status and an Explanation of Benefits (EOB). Eligibility and Benefits Read about your benefits and coverage information and check your eligibility. Ask Customer Service Send a secure message directly to the customer service area that handles your coverage for faster answers to your questions. Authorization Status Verify your authorization status for inpatient and outpatient visits. Deductible and Out-of-Pocket Statuses See how close you are to meeting your deductible and out-of-pocket maximum. Request a New ID Card. MAKE INFORMED HEALTH CARE DECISIONS Compare Hospital Quality Choose the hospital that is right for you by comparing up to 10 facilities on the number of patients treated, complication rates, average lengths of stay for certain conditions and procedures, and more. Plan Comparison Tool Compare which benefit plan is right for you and your family. Estimate Treatment Costs Research average costs and days of treatment for specific medical conditions or procedures. Compare Drug Costs Look up cost and consumer information about prescription drugs. Find a Doctor Find a network doctor or hospital across the country and around the world.

7 Tools 7 Services (Continued) IMPROVE YOUR WELLNESS Personal Health Record A confidential online tool providing a summary of all your health information, including doctors visits, prescriptions, lab results and much more. You also can keep track of upcoming medical appointments and print a copy of your medical history. Additional features are available, based on your benefit plan. Personal Health Assessment An online survey that helps identify risk factors and offers ways to improve your health based on your answers. Health Library This feature offers medical information, health calculators, self-care channels and nutrition guides to help improve and protect your health status. TO SET UP AN ACCOUNT: Go to On the home page, find the Member Login: My Health Toolkit box and click Register Now! Create your profile by entering your member information found on your insurance card. Follow the remaining steps to complete your profile.

8 Networks 8 Providers ALLOWED AMOUNT BlueEssentials NETWORK The BlueEssentials network provides access to a group of physicians, hospitals and other health care providers that agree to provide health care services to our members at a discounted rate, sometimes referred to as the allowed amount. What you pay for medical care is based on an allowed amount. This is a lower amount that BlueCross BlueShield of South Carolina has negotiated with in-network providers. See page 11 for more information. IN NETWORK To make the most out of your benefits, always choose providers who are in the BlueEssentials network, also known as an exclusive provider organization (EPO). Through this network, you ll receive a discounted rate for health care services. OUT OF NETWORK Refers to health care providers we have not contracted with and who do not participate in the BlueEssentials network. These providers may charge full price for medical care and you will be responsible for all charges, including those above the in-network allowed amount. We do not provide benefits when you visit providers outside the network, except in cases of emergency. in BlueCross makes an agreement with providers to provide services at a discounted rate In-network provider Lower cost to member Member out Out-of-network provider: benefits are not paid

9 Networks 9 Providers (Continued) PROVIDER NETWORK Our individual BlueEssentials plans come with access to our BlueEssentials Network, also known as an EPO. We only cover services provided by an in-network provider. We will not cover services given by an out-of-network provider unless a service is due to an emergency or is not available at an in-network provider. In this instance, we will cover the services an out-of-network provider offers at the in-network coinsurance amount. These providers can bill you for the difference in the allowed amount and their actual changes. IMPORTANT INFORMATION ABOUT PREAUTHORIZATION A preauthorization is also known as a prior authorization, prior approval or precertification. A preauthorized service is one that BlueCross determines to be medically necessary for a patient s condition. Preauthorization, however, does not guarantee we will pay benefits for the service. Contract limitations or exclusions may apply. Additionally, a preauthorization may only be for a specific period of time or number of visits or treatments. You or your doctor must get a preauthorization for certain categories of benefits. Failure to get a preauthorization will result in a denial of your benefits. We make our final benefit determination when we process your claims. In-network providers in South Carolina are familiar with this requirement and they will request any necessary preauthorization for you. If an in-network provider in South Carolina does not get a preauthorization, the provider cannot bill you for the services.

10 Financials 10 Eligibility ADVANCED PREMIUM TAX CREDIT (APTC) The APTC is a federal subsidy that assists qualifying individuals and families by reducing the monthly premium amount to make health insurance affordable. The amount of APTC an individual or family receives is based on the individual s or family s annual income compared to the Federal Poverty Level (FPL) and the cost of the second cheapest Silver plan available to that individual or family, in their service area. The individual or family can still choose any of our Gold, Silver or Bronze plans, however, and receive the APTC. EXAMPLE: A family of four has a household income of $47,100 a year. That places the family at 200 percent of the FPL. Per ACA guidelines, the percentage the family is responsible for is 6.3 percent of their income ($ per month). If the second cheapest Silver plan in the family s service area is $ per month, the APTC amount is the difference ($ ) = $ COST-SHARING REDUCTIONS Members who qualify for the APTC may also be eligible for lower out-of-pocket costs, or cost-sharing reductions (CSR). To receive CSR, the individual or family must choose a Silver plan. EXAMPLE: An individual selects BlueEssentials Silver 2. Normally, the Silver 2 plan s coinsurance is 40 percent, deductible is $2,000 and the out-of-pocket maximum is $6,350. Based on the individual s APTC eligibility and household income, the member also qualifies for CSR resulting in a reduced coinsurance of 20 percent, deductible of $200 and out-ofpocket maximum of $2,250. The same Silver plan s CSR may be higher or lower, depending on the individual s income. Copayments for office visits and drugs may also be reduced. EXAMPLE OF HOW A TAX CREDIT WORKS WITH A HEALTH PLAN: The monthly cost for a health plan (cost depends on which health plan you choose) Subtract the government tax credit (money paid to the insurance company) YOU WOULD PAY $ per month $ per month $ per month POVERTY LEVELS The FPL is a measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits. The amounts on the next page are 2014 numbers and used for calculating eligibility for APTC, Medicaid and the Children s Health Insurance Program (CHIP).

11 Financials 11 Eligibility (Continued) 2014 POVERTY GUIDELINES The following figures are the 2014 HHS poverty guidelines which were published in the Federal Register on January 22, ANNUAL GUIDELINES Family Size 100% 138% 150% 200% 250% 300% 350% 400% 1 $11,670 $16,105 $17,505 $23,340 $29,175 $35,010 $40,845 $46, ,730 21,707 23,595 31,460 39,325 47,190 55,055 62, ,790 27,310 29,685 39,580 49,475 59,370 69,265 79, ,850 32,913 35,775 47,700 59,625 71,550 83,475 95, ,910 38,516 41,865 55,820 69,775 83,730 97, , ,970 44,119 47,955 63,940 79,925 95, , , ,030 49,821 54,045 72,060 90, , , , ,090 55,324 60,135 80, , , , ,360 For a family of more than eight members, add $4,060 for each additional member. MONTHLY GUIDELINES Family Size 100% 138% 150% 200% 250% 300% 350% 400% 1 $972 $1,342 $1,458 $1,945 $2,431 $2,917 $3,404 $3, ,310 1,809 1,966 2,621 3,277 3,932 4,588 5, ,649 2,276 2,473 3,298 4,122 4,947 5,772 6, ,987 2,743 2,981 3,975 4,968 5,962 6,956 7, ,325 3,210 3,488 4,651 5,814 6,977 8,140 9, ,664 3,677 3,996 5,328 6,660 7,992 9,325 10, ,002 4,143 4,503 6,005 7,506 9,007 10,509 12, ,340 4,610 5,011 6,681 8,352 10,022 11,693 13,363 Produced by: CMCS/CAHPG/DEEO

12 Financials 12 Cost Sharing Plans COST SHARING PLANS See the FPL chart to determine your cost sharing level PLAN NAME BASE PLAN COST SHARE percent FPL COST SHARE percent FPL COST SHARE percent FPL Silver 1 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 50 percent $0/$0 $6,000/$9, percent $0/$0 $5,200/$8, percent $0/$0 $2,250/$3,500 5 percent $0/$0 $2,250/$3,050 Silver 2 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 40 percent $2,000/$3,650 $6,350/$11, percent $1,300/$2,400 $5,200/$9, percent $200/$350 $2,250/$4,100 5 percent $0/$0 $2,250/$2,950 Silver 3 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 20 percent $3,000/$5,700 $5,200/$9, percent $1,600/$3,050 $5,200/$9, percent $0/$0 $2,250/$3,700 5 percent $0/$0 $2,250/$3,250 Silver 4 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 30 percent $1,900/$3,450 $6,600/$12, percent $1,900/$3,450 $5,200/$9, percent $50/$50 $2,250/$3,750 5 percent $0/$0 $2,250/$3,100 HD Silver 5 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 20 percent $2,300/$4,300 $5,000/$9, percent $1,600/$3,050 $5,000/$9, percent $250/$450 $2,250/$4,150 5 percent $200/$400 $2,250/$4,150 HD Silver 6 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 0 percent $3,600/$6,900 $3,600/$6,900 0 percent $2,900/$5,800 $2,900/$5,800 0 percent $1,150/$2,600 $1,150/$2,600 0 percent $500/$1,250 $500/$1,250 Silver 7 Coinsurance Deductible (single/family) Out-of-pocket limit (single/family) 10 percent $6,000/$11,000 $6,500/$11, percent $3,250/$6,550 $5,200/$10, percent $500/$1,000 $2,000/$4, percent $200/$450 $500/$1,200

13 Enrollment 13 Sign Up WHEN CAN I ENROLL? BlueCross is here to help you understand how the health care reform law will impact you and your family. Once a year, individuals can apply for health insurance during the Open Enrollment Period (OEP). This year, OEP will be from November 15, 2014, to February 15, These dates are especially important as they indicate when your new policy will become effective: ENROLLMENT DATE EFFECTIVE DATE November 15 through December 15, 2014 January 1, 2015 December 16, 2014 through January 15, 2015 February 1, 2015 January 16 through February 15, 2015 March 1, 2015 NOTE: It s important to remember that a tax penalty may be charged to individuals who are uninsured for any period during the year. SPECIAL ENROLLMENT PERIOD (SEP) This is the time outside of the OEP during which you re allowed to buy health insurance, provided you have a qualifying life event (QLE). In most cases, you qualify for a SEP within 60 days following the QLE. WHAT IS A QUALIFYING LIFE EVENT? A QLE is a significant change in a person s circumstances. Here are some examples of QLEs: QUALIFYING EVENT ENROLLMENT PERIOD EVENT DATE APPLICATION SUBMISSION DATE Marriage Within 60 days after marriage July 4 July 28 August 1 Birth Within 60 days after birth April 20 May 6 April 20 EFFECTIVE DATE Loss of Minimum Essential Coverage Within 60 days before or after termination of other coverage November 1 November 21 December 1

14 Enrollment 14 The Plans Gold, Silver and Bronze aren t just the metals used for Olympic medalists. Along with Platinum, these metals denote the different levels of coverage mandated by the ACA. BLUE CROSS PLANS Here are some key things to know before you start to shop for a plan. BlueEssentials plans are divided into two categories: the metallic plans (Gold, Silver and Bronze) and the Catastrophic Plan. Anyone can buy a metallic plan, but only certain people qualify for a Catastrophic plan. The Gold, Silver and Bronze plans Each plan must cover the same set of minimum essential health benefits. While the range of benefits is the same among the plans, the value of the benefits will vary. This means the amount you pay yourself, such as a copayment, coinsurance or deductible, is different. These metal levels can help you compare plans, the monthly premiums and costs for services for things like doctors or hospital visits. The Catastrophic Plan Young adults and people for whom coverage is otherwise unaffordable can purchase a Catastrophic plan. A Catastrophic plan can be offered to an individual who: Is under age 30 before the plan year begins. Has received certification from the Marketplace stating he or she is exempt from the individual mandate because he or she does not have an affordable coverage option or qualifies for a hardship exemption. EPO An EPO plan offers comprehensive health services from participating health care providers. HIGH DEDUCTIBLE HEALTH PLAN (HDHP) This health care coverage puts you in control of your health care expenses by keeping your costs down while providing great benefits and options to make your dollar go farther. All of the HDHP plans have access to the EPO network.

15 15 Deductible* GOLD 1 (In Network Only) Single Coverage: $1,200 per member per benefit period Family Coverage: $1,200 per member and $2,350 per family per benefit period. The deductible applies to the out-of-pocket limit. Maximum Out of Pocket $4,200 per benefit period for single coverage and $8,250 per family per benefit period. Covered services will be paid at 100% of the allowable charges when you reach your single or family (whichever is applicable) maximum out of pocket. Primary Care Physician Services $15 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Preventive Services Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes prostate screening and lab work according to ACS. Specialist Visit $0 $30 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Outpatient Hospital Services Urgent Care Emergency Room Ambulance 2 2 $15 copayment per visit $300 copayment per visit, then 2 2 * This plan has an embedded family deductible. Once a family member meets the plan s individual deductible, the plan begins paying benefits for that member. Benefits are not payable for other family members until each member meets his or her own deductible individually, or until the members collectively satisfy the family deductible. Once the deductible and coinsurance combined reach the out-of-pocket maximum, allowable charges then are payable at 100 percent for all family members.

16 16 GOLD 1 (In Network Only) Mental Health and Substance Abuse: Office Services Outpatient Services Residential Treatment Center Prescription Drugs Covers up to a 31-day supply at retail pharmacy and 90-day supply at mail-order pharmacy Specialty Drugs (Tier 4) Covers up to a 31-day supply Pediatric Vision Care Eye Exam limited to one exam per benefit period Eyeglasses frames limited to once every two years and lenses every benefit period. Contacts only when medically necessary. Durable Medical Equipment $15 copayment per visit Retail: Tier 1: $10 Tier 2: $35 Tier 3: $100 30% $25 copayment $50 copayment 2 Mail Order: Tier 1: $14 Tier 2: $95 Tier 3: $270 Physical, Speech and Occupational Therapy and Habilitation Home Health Skilled Nursing Facility Hospice Transplants Lifetime Benefit Maximum 2 limited to 30 visits for physical, speech and occupational therapy 2 limited to 60 visits 2 limited to 60 days 2 limited to six months per episode 2 Unlimited

17 17 Deductible* GOLD 2 (In Network Only) Single Coverage: $800 per member per benefit period Family Coverage: $800 per member and $1,450 per family per benefit period. The deductible applies to the out-of-pocket limit. Maximum Out of Pocket $4,000 per benefit period for single coverage and $7,450 per family per benefit period. Covered services will be paid at 100% of the allowable charges when you reach your single or family (whichever is applicable) maximum out of pocket. Primary Care Physician Services $15 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Preventive Services Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes prostate screening and lab work according to ACS. Specialist Visit $0 $40 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Outpatient Hospital Services Urgent Care Emergency Room 3 3 $15 copayment per visit $300 copayment per visit, then 3 Ambulance 3 * This plan has an embedded family deductible. Once a family member meets the plan s individual deductible, the plan begins paying benefits for that member. Benefits are not payable for other family members until each member meets his or her own deductible individually, or until the members collectively satisfy the family deductible. Once the deductible and coinsurance combined reach the out-of-pocket maximum, allowable charges then are payable at 100 percent for all family members.

18 18 GOLD 2 (In Network Only) Mental Health and Substance Abuse: Office Services Outpatient Services Residential Treatment Center Prescription Drugs Covers up to a 31-day supply at retail pharmacy and 90-day supply at mail-order pharmacy Specialty Drugs (Tier 4) Covers up to a 31-day supply Pediatric Vision Care Eye Exam limited to one exam per benefit period Eyeglasses frames limited to once every two years and lenses every benefit period. Contacts only when medically necessary. Durable Medical Equipment $15 copayment per visit Retail: Tier 1: $6 Tier 2: $30 Tier 3: $100 30% $25 copayment $50 copayment 3 Mail Order: Tier 1: $9 Tier 2: $81 Tier 3: $270 Physical, Speech and Occupational Therapy and Habilitation Home Health Skilled Nursing Facility Hospice Transplants Lifetime Benefit Maximum 3 limited to 30 visits for physical, speech and occupational therapy 3 limited to 60 visits 3 limited to 60 days 3 limited to six months per episode 3 Unlimited

19 19 Deductible** HD GOLD 3 (In Network Only) Single Coverage: $2,000 per member per benefit period Family Coverage: $4,250 per family per benefit period. The deductible applies to the out-of-pocket limit. Maximum Out of Pocket $2,000 per benefit period for single coverage and $4,250 per family per benefit period. Covered services will be paid at 100% of the allowable charges when you reach your single or family (whichever is applicable) maximum out of pocket. Primary Care Physician Services Preventive Services Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes prostate screening and lab work according to ACS. Specialist Visit Outpatient Hospital Services Urgent Care Emergency Room Ambulance $0 ** This plan has an aggregate family deductible. Benefits are not payable for any family member until one member satisfies the family deductible, or until all family members collectively satisfy the family deductible whichever occurs first. If one or more family members satisfies the family maximum out of pocket, allowable charges are payable at 100 percent for all family members.

20 20 HD GOLD 3 (In Network Only) Mental Health and Substance Abuse: Office Services Outpatient Services Residential Treatment Center Prescription Drugs Covers up to a 31-day supply at retail pharmacy and 90-day supply at mail-order pharmacy Specialty Drugs (Tier 4) Covers up to a 31-day supply Retail and mail order Tier 1, Tier 2 and Tier 3: Pediatric Vision Care Eye Exam limited to one exam per benefit period Eyeglasses frames limited to once every two years and lenses every benefit period. Contacts only when medically necessary. Durable Medical Equipment Physical, Speech and Occupational Therapy and Habilitation Home Health Skilled Nursing Facility Hospice Transplants Lifetime Benefit Maximum $25 copayment $50 copayment limited to 30 visits for physical, speech and occupational therapy limited to 60 visits limited to 60 days limited to six months per episode Unlimited

21 21 SILVER 1 (In Network Only) Deductible Maximum Out of Pocket Single coverage: $0 per member per benefit period. Family coverage: $0 per member and $0 per family per benefit period. $6,000 per benefit period for single coverage and $9,200 per family per benefit period. Covered services will be paid at 100% of the allowable charges when you reach your single or family (whichever is applicable) maximum out of pocket. Primary Care Physician Services $30 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Preventive Services Covers only screenings recommended by USPSTF Grade A & B, HRSA and CDC. Also includes prostate screening and lab work according to ACS. Specialist Visit $0 $60 copayment per visit The copayment does not include surgery, outpatient lab and X-ray services (except for standard plain film X-rays), second surgical opinion, dialysis, chemotherapy, radiation therapy, specialty drugs, endoscopies and imaging. Outpatient Hospital Services Urgent Care 5 5 $30 copayment per visit Emergency Room $300 copayment per visit, then 50% after deductible Ambulance 5

22 22 SILVER 1 (In Network Only) Mental Health and Substance Abuse: Office Services Outpatient Services Residential Treatment Center Prescription Drugs Covers up to a 31-day supply at retail pharmacy and 90-day supply at mail-order pharmacy Specialty Drugs (Tier 4) Covers up to a 31-day supply Pediatric Vision Care Eye Exam limited to one exam per benefit period Eyeglasses frames limited to once every two years and lenses every benefit period. Contacts only when medically necessary. Durable Medical Equipment $30 copayment per visit Retail: Tier 1: $30 Tier 2: $60 Tier 3: 50% after deductible 5 $25 copayment $50 copayment 5 Mail Order: Tier 1: $42 Tier 2: $162 Tier 3: 50% after deductible Physical, Speech and Occupational Therapy and Habilitation Home Health Skilled Nursing Facility Hospice Transplants Lifetime Benefit Maximum 5 limited to 30 visits for physical, speech and occupational therapy 5 limited to 60 visits 5 limited to 60 days 5 limited to six months per episode 5 Unlimited

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