7/1/2021 - 6/30/2022 Coverage Period: Summary of Benefits ...

1 Coverage Period: Summary of Benefits and Coverage :What this plan Covers & What You Pay For covered ServicesEmblemHealth :PPOC overage for:Individual/FamilyPlan Type:PPOOMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 20162501 of9 TheSummaryof BenefitsandCoverage(SBC) documentwillhelp andtheplanwouldsharethecost for :Information about thecost of thisplan(calledthepremium)willbeprovided moreinformationaboutyourcoverage,ortoget acopy ofthecompleteterms ofcoverage, definitionsofcommonterms, suchasallowedamount,balancebilling,coins urance,copayment,deductible,provider, orotherunderlinedterms seetheGlossary. YoucanviewtheGlossaryat or call1-800-624-2414to request a QuestionsAnswersWhy this Matters:Whatistheoveralldeductible?

2 $0, in network providers,$200 Individual / $500 Family out ofnetwork , you must pay all of the costs fromproviders up to thedeductible amount before thisplan begins to pay. If you have other family members on theplan, each family member must meettheir own individualdeductible until the total amount ofdeductible expenses paid by all familymembers meets the overall coveredbeforeyou meet yourdeductible?In network services are not subjectto a covers some items and services even if you haven t yet met thedeductible amount. Butacopayment orcoinsurance may apply. For example, thisplan covers certainpreventiveservices withoutcost-sharing and before you meet yourdeductible. See a list of coveredpreventive services at services ?Yes, $100 for durable must pay all of the costs for these services up to the specificdeductible amount before thisplan begins to pay for these in network providers $4,550 Individual / $9,100 limit is the most you could pay in a year for covered services .

3 If you have otherfamily members in thisplan,they have to meet their ownout-of-pocket limits until the overallfamilyout-of-pocket limit has been intheout-of-pocketlimit?Premiums, penalties, balanced-billcharges, and health care this plandoesn't though you pay these expenses, they don t count toward theout of pocket youpaylessifyou useanetworkprovider?Yes. See call 1-877-842-3625 for a list ofparticipating uses aprovider network. You will pay less if you use aprovider in theplan will pay the most if you use anout-of-networkprovider, and you might receive a bill from aprovider for the difference between theprovider s charge and what yourplan pays (balancebilling).Be aware, yournetwork provider might use anout-of-network provider for someservices (such as lab work).

4 Check with yourprovider before you get can see thespecialist you choose without youneed areferraltoseeaspecialist?No7/1/2021 - 6/30/2022 * For more information about limitations and exceptions, see the plan or policy document of9 Allcopaymentandcoinsurancecosts showninthischart areafteryourdeductiblehasbeenmet, EventServices You May NeedWhat You Will Pay*Limitations, Exceptions, & OtherImportant InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)If you visit ahealthcareprovider sofficeorclinicPrimary care visit to treatan injury or illnessPreferred: $0 co-pay per visitParticipating: $15 co-pay per visitAfter plan deductible is met,No charge-----None-----SpecialistvisitPrefe rred: $0 co-pay per visitParticipating.

5 $30 co-pay per visitAfter plan deductible is met,No chargeLower co-pay applies when a PreferredProvider refersPreventivecare/screening/immunizat ionNo chargeAfter plan deductible is met,No charge-----None-----If you have a testDiagnostic test(x-ray,blood work)$20 co-pay per visitAfter plan deductible is met,No charge-----None-----Imaging (CT/PET scans,MRIs)$50 co-pay per visitAfter plan deductible is met,No chargePre-certification requiredIf you need drugstotreat your illnessorconditionMore informationaboutprescriptiondrugcoverage is drugs (Tier 1)Not coveredNot covered -----None-----Preferred brand drugs(Tier 2)Not coveredNot coveredNon-preferred branddrugs (Tier 3)Not coveredNot coveredSpecialtydrugsNot coveredNot covered -----None-----If you have outpatientsurgeryFacility fee ( ,ambulatory surgerycenter)

6 Not coveredNot coveredPlease check with your feesCoveredAfter plan deductible is met,No charge-----None-----If you need immediatemedical attentionEmergency roomcareNot coveredNot covered -----None-----Emergencymedicaltra nsportationNot covered20% coinsuranceNo air ambulance or ambulette serviceUrgentcare$50 co-pay per visitAfter plan deductible is met,No charge-----None----- 7/1/2021 - 6/30/2022 * For more information about limitations and exceptions, see the plan or policy document of9 CommonMedical EventServices You May NeedWhat You Will Pay*Limitations, Exceptions, & OtherImportant InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)If you have a hospitalstayFacility fee ( , hospitalroom)Not coveredNot coveredPlease check with your feeCoveredAfter plan deductible is met,No charge-----None-----If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient servicesPreferred: $0 co-pay per visitParticipating: $15 co-pay per visitAfter plan deductible is met,No chargeNo prior approval requiredInpatient services $300 co-pay per admission/$750maximum per calendar year$500 co-pay peradmission/$1,250 maximumper calendar year.

7 20% tomax of $2,000 per person percalendar requiredIf you are pregnantOffice visitsNo chargeAfter plan deductible is met,No charge-----None-----Childbirth/deliveryp rofessional servicesNo chargeAfter plan deductible is met,No charge-----None-----Childbirth/delivery facilityservicesNo chargeAfter plan deductible is met,No chargeLimited to 48 hours for natural delivery and 96hours for caesarean delivery. Prior approvalrequiredIf you need helprecovering or haveother special healthneedsHome healthcareNo charge$50 deductible per episode;20% coinsurance insurance200 visits per member per plan : $0 co-pay per visitParticipating: $30 co-pay per visitAfter plan deductible is met,No chargeCoverage limited to 16 visits per calendaryear. Pre-certification required for additionalvisitsHabilitationservicesPref erred: $0 co-pay per visitParticipating: $30 co-pay per visitAfter plan deductible is met,No chargeSkilled nursingcareNot coveredNot covered -----None-----Durable medicalequipment$100 deductible$100 deductible.

8 50% of usualand customary chargePre-certification required on greater than$2,000 call NYC Healthline at coveredNot covered -----None-----If your child needsdental or eye careChildren s eye examNot coveredNot covered -----None-----Children s glassesNot coveredNot covered -----None-----Children s dental check-upNot coveredNot covered -----None----- 7/1/2021 - 6/30/2022 * For more information about limitations and exceptions, see the plan or policy document of9 Excluded services & Other covered services : services YourPlan Generally Does NOT Cover (Check your policy orplan document for more information and a list of any otherexcluded services .) Acupuncture Cosmetic surgery Dental care Hearing aids Long-term care Most Coverage provided outside the United States Non-emergency care when traveling outside the Routine foot care Weight loss programsOther covered services (Limitations may apply to these services .)

9 This isn t a complete list. Please see yourplan document.) Bariatric surgery (Prior Approval required) Chiropractic care Infertility treatment (Prior Approval required) Private-duty nursing Routine eye careYour Rights to Continue Coverage :There are agencies that can help if you want to continue your Coverage after it contact information for thoseagencies is:New York State Department of Financial services at 1-800-342-3736 , Department of Health and Human services at 1-877-267-2323 x1565 , Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 Other Coverage options may be available to you too, including buyingindividual insurance Coverage through the Health InsuranceMarketplace. For more information about theMarketplace, or Grievance and Appeals Rights:There are agencies that can help if you have a complaint against yourplan for a denial of complaint is called agrievance orappeal.

10 For more information about your right, look at the explanation of Benefits you will receive for that medicalclaim. Yourplandocuments alsoprovide complete information to submit aclaim, appeal, or agrievance for any reason to yourplan. For more information about your rights, this notice, or assistance,contact:EmblemHealthBy Phone:Please call the number on your ID writing:EmblemHealthGrievance and Appeals Box 2801 New York, NY10116-2807 All Coverage TypesNew York State Department of Financial ServicesBy Phone: 1-800-342-3736In writing:New York State Department of Financial ServicesConsumer Assistance UnitOne Commerce PlazaAlbany, NY12257 - 6/30/2022 * For more information about limitations and exceptions, see the plan or policy document of9 For HMO CoverageNew York State Department of HealthBy Phone: 1-800-206-8125In writing.