Southern Healthcare Agency Network Blue Summary of Benefits

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4 Southern Healthcare Agency Network Blue Summary of Benefits This summary is designed for the purpose of presenting general information only and is not intended as a guarantee of benefits. It is not a Summary Plan Description and in the event of a conflict between this document and the Benefit Plan, the terms of the Benefit Plan will prevail. The terms pay, paid, payment, and payable appear throughout this Summary of Benefits. These terms reference the benefits provided by Blue Cross & Blue Shield of Mississippi (hereinafter BCBSMS ), rather than an actual amount paid by BCBSMS. Actual benefits and the limitations, exclusions, terms, conditions and definitions to which such benefits are subject are contained in the Benefit Plan. Complete terms of the plan are contained in the Summary Plan Description. Important Terms Allowable Charge The lesser of the: (1) Covered Charges or (2) the amount established by BCBSMS as the maximum amount for Provider services covered under the terms of the Benefit Plan. Benefits The amount provided under the Benefit Plan for covered services. Benefits are based on the Allowable Charge minus any applicable Deductible Amount, Coinsurance or Copayment. Coinsurance - That portion of the Allowable Charge expressed as a percentage for which the Member is financially responsible under the Benefit Plan in addition to any applicable deductible and copay amounts. Copay (Copayment) That portion of the Allowable Charge expressed as an amount for which the Insured is financially responsible under this Benefit Plan, in addition to the Deductible Amount, where applicable. Covered Services A service or supply specified in the Benefit Plan for which Benefits are available when rendered by a Provider. A charge for a Covered Service is considered to have been incurred on the date the service or supply was provided to the Member. Deductible The amount the Member must pay each calendar year toward covered services. Medical and pharmacy deductibles are separate. Member A subscriber or an enrolled dependent. Max Out-of-Pocket Unreimburseable expenses incurred by a Member for Covered Services in a Benefit Period. Charges for non-covered services or any charges in excess of the Allowable Charge do not apply. Precertification/Certification A determination by BCBSMS that an admission or health care service is medically necessary as well as meets the utilization management requirements of the Benefit Plan. Primary Care Physician (PCP) A physician who practices under one of the following specialties: Family Practice, General Practice, Internal Medicine, Pediatrics or Obstetrics/Gynecology. Specialist A physician who practices under any one of a number of specialties from Allergy to Urology, not including the five specialties of Primary Care Physicians. Your Network Blue Benefit Plan includes Network Providers such as physicians, hospitals, pharmacies, and others. To ensure that you receive the highest level of benefits, you should always use Network Providers. Some services must be provided by Primary Care Physicians (PCPs) or Primary Care Health Professionals to receive the higher level of benefits, or to be covered at all. The benefits described below are for general information. You should refer to your Summary Plan Description for complete details regarding benefit maximums, limitations and exclusions, pre-certification requirements and penalties and non-covered services. Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

5 Register for myblue: Network Blue Summary of Benefits If you use Network Providers: You cannot be billed for any amount (other than your deductible, coinsurance or copay) over the allowable charge for covered services. Network Providers will file your claims for you. You will be responsible for paying copays as determined by your Benefit Plan. You will be responsible for paying any applicable deductibles, coinsurance and non-covered charges (unless otherwise noted below) as determined by your Benefit Plan. If you use Non-Network Providers: You may have to pay for charges that exceed the allowable charge. You may have to pay the provider the full amount during the visit and file a claim for reimbursement. Healthy You! wellness benefits are not covered. You may have to pay more for your health care. Your Benefit Plan includes the following: Network Non-Network Lifetime Maximum Unlimited Medical Deductible Per Calendar Year Individual: $5,000 Family: $10,000 Individual: $10,000 Family: $20,000 Prescription Drug Deductible Per Calendar Year Integrated with Medical Not Covered Maximum Out-of-Pocket Per Calendar Year Individual: $6,450 Family: $12,900 Outpatient Preventive/Wellness Services Physician Office Visits Healthy You! Other Services - For example: immunizations, wellness benefits apply mammography, pap smear, complete blood count, urinalysis, prostate specific antigen, stool for occult blood. Benefits/Coinsurance Physician (MD or DO) Office Visit Copay Applies to the office visit only. Pharmacy Copay - Community PLUS Pharmacy Network Member must satisfy Prescription Drug Deductible if applicable. Individual: No Limit Family: No Limit Not Covered 70% 50% Primary Care Physician (PCP): $35.00 Specialist: $50.00 Category 1: $15 Category 2: $35 Category 3: $75 Category 4: $100 Benefits/Coinsurance and Deductible Apply Not Covered Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

6 Helping You Be Healthy and Stay Healthy Helping you be as healthy as possible is at the core of our commitment to a healthier Mississippi. We encourage you to practice healthy lifestyle habits that will make a significant impact on your health. Eat healthy, exercise, be tobacco-free and see your healthcare provider each year. These habits can help you avoid chronic medical conditions like heart disease and diabetes, which can increase your healthcare costs and affect your quality of life. By taking care of yourself and your health, you can live a longer, healthier life. Healthy You! is your first step in taking ownership of your health. Healthy You! Is a wellness benefit that provides you and your covered dependents with an annual wellness visit with your Network Provider. This wellness benefit is paid at 100% with no deductible, copay or coinsurance when you use your Network Provider. Remember that Healthy You! is about helping you stay on track with a healthy lifestyle. If you are sick on the day of your Healthy You! visit, re-schedule your visit for a day that is more appropriate for you to discuss your health and wellness. If illness services are completed at your Healthy You! visit, please be aware that these services are not in the list of recommended wellness services and will apply to your medical benefits. Covered wellness screenings and immunizations are based on age and gender to ensure you receive the screenings you need to know your numbers and manage your health risks, both at an early age and as you get older. Register for the myblue website! We are pleased to provide you with secure, personalized access to your claims and benefit information online through our myblue website. Here s why you should register now: Registration is quick, easy, secure and useful. You have access to the health benefit information you want, when you want it. You can view claims history for the previous 15 months, including payments, copay and deductible amounts. You can go green and stop the mailing and delivery of paper EOBs. You can give us important information online at any time no need to call during business hours only. You can update your phone number or , and you can order a new ID card on myblue. Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company, is an independent licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

7 Mississippi Life & Health Inc SOUTHERN HEALTHCARE AGENCY, INC. HOURLY EMPLOYEE HEALTHCARE BENEFITS OPEN ENROLLMENT NOVEMBER 2014 EFFECTIVE DATE JANUARY 2015 ALL EMPLOYEES ELIGIBLE FOR INITIAL ENROLLMENT Future employees will have a first of the month following 60 days of employment to be eligible. If you do not enroll now for January 2015, you cannot enroll again until November of 2015 for January of 2016 unless there is a qualified event. BLUE CROSS BLUE SHIELD OF MS INSURANCE BENEFITS COST: Monthly Weekly Employee only $ $36.11 Employee children $ $81.28 Employee Spouse $ $ Employee family $ $ *In 2015 the penalty for not having Health Insurance is the greater of 2% of household income or $325 per adult plus $ per child. 327 Main Street Greenville Ms P. O. Box 1647 Greenville Ms Telephone Fax

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