Summary of Benefits and Coverage ... - Robert Half …

1 Summary of Benefits and Coverage : What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 12/31/2018. Anthem Blue Cross Life and Health Insurance Company: Coverage for: Individual + Family | Plan Type: PPO +. Robert Half International: $2500 Deductible Plan with HSA Plan HSA. 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 this 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 , For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

2 You can view the Glossary at or call (844). 594-6178 to request a copy. Important Questions Answers Why This Matters: What is the overall $2,500/individual or Generally, you must pay all of the costs from providers up to the deductible amount before deductible? $5,000/family for In-Network this plan begins to pay. If you have other family members on the plan, the overall family Providers. $4,500/individual or deductible must be met before the plan begins to pay. $9,000/family for Out-of- Network Providers. Are there services Yes. Preventive care for In- This plan covers some items and services even if you haven't yet met the deductible amount. covered before you Network providers. But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible?

3 Services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of- $4,500/individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this $6,850/family for In-Network other family members in this plan, the overall family out-of-pocket limit must be met. plan? Providers. $9,000/individual or $13,700/family for Out-of- Network Providers. What is not included Premiums, balance-billing Even though you pay these expenses, they don't count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this limit? plan doesn't cover.

4 Will you pay less if Yes, Blue Card PPO. See This plan uses a provider network. You will pay less if you use a provider in the plan's you use a network network. You will pay the most if you use an out-of-network provider, and you might receive provider? or call (844) 594-6178 for a list a bill from a provider for the difference between the provider's charge and what your plan of network providers. 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. CA/L/A/RobertHalf,Inc/$2500 Deductible Plan with HSA/NA/1U68/NA/01-18. 1 of 10. Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

5 What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least). (You will pay the most). Primary care visit to treat an 30% coinsurance 50% coinsurance --------none-------- injury or illness If you visit a Specialist visit 30% coinsurance 50% coinsurance --------none-------- health care You may have to pay for services that provider's office aren't preventive. Ask your provider if or clinic Preventive care/screening/. No charge 50% coinsurance the services needed are preventive. immunization Then check what your plan will pay for. Diagnostic test (x-ray, blood 30% coinsurance 50% coinsurance --------none-------- If you have a test work). Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance --------none-------- 30% Coinsurance /Prescription for Retail 30% Coinsurance If you need drugs Tier 1 - Typically Generic 30% Coinsurance /Prescription for Retail to treat your /Prescription for Mail illness or order Covers up to a 30-day supply (retail condition 30% Coinsurance prescription); 31-90 day supply (mail More information /Prescription for Retail 30% Coinsurance order prescription).

6 About prescription Tier 2 - Typically Preferred /. 30% Coinsurance /Prescription for Retail Mail order is Not Covered for Out-of- drug Coverage is Brand /Prescription for Mail Network. available at: order Deductible is waived for preventive 30% Coinsurance drugs. or /Prescription for Retail 30% Coinsurance 1-844-604-9159 Tier 3 - Typically Non-Preferred 30% Coinsurance /Prescription for Retail / Specialty Drugs /Prescription for Mail order Facility fee ( , ambulatory If you have 30% coinsurance 50% coinsurance --------none-------- surgery center). outpatient surgery Physician/surgeon fees 30% coinsurance 50% coinsurance --------none-------- If you need Emergency room care 30% coinsurance Covered as In-Network --------none-------- immediate Emergency medical 30% coinsurance Covered as In-Network --------none-------- * For more information about limitations and exceptions, see plan or policy document at 2 of 10.

7 What You Will Pay Common Out-of-Network Limitations, Exceptions, & Other Services You May Need In-Network Provider Medical Event Provider Important Information (You will pay the least). (You will pay the most). medical attention transportation Urgent care 30% coinsurance 50% coinsurance --------none-------- Subject to utilization review for If you have a Facility fee ( , hospital room) 30% coinsurance 50% coinsurance Inpatient Service hospital stay Physician/surgeon fees 30% coinsurance 50% coinsurance --------none-------- Outpatient services 30% coinsurance 50% coinsurance --------none-------- If you need mental health, 30% coinsurance for Inpatient behavioral health, Physician Fee In-Network Providers. or substance Inpatient services 30% coinsurance 50% coinsurance 50% coinsurance for Inpatient abuse services Physician Fee Out-of-Network Providers.

8 Office visits 30% coinsurance 50% coinsurance Cost sharing does not apply for Childbirth/delivery professional preventive services. Maternity care If you are 30% coinsurance 50% coinsurance services may include tests and services pregnant Childbirth/delivery facility described elsewhere in the SBC ( 30% coinsurance 50% coinsurance ultrasound.). services 120 visits/calendar year including Home health care 30% coinsurance 50% coinsurance private duty nursing. If you need help Rehabilitation services 30% coinsurance 50% coinsurance recovering or have Habilitation services --------none-------- 30% coinsurance 50% coinsurance other special health needs Skilled nursing care 30% coinsurance 50% coinsurance 120 visits/calendar year Durable medical equipment 30% coinsurance 50% coinsurance --------none-------- Hospice services 30% coinsurance 50% coinsurance --------none-------- If your child Children's eye exam Not covered Not covered --------none-------- needs dental or Children's glasses Not covered Not covered eye care Children's dental check-up Not covered Not covered --------none-------- * For more information about limitations and exceptions, see plan or policy document at 3 of 10.

9 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 any other excluded services.). Cosmetic surgery Routine eye care Weight loss programs Dental care Non-emergency care when traveling outside Long- term care the Routine foot care Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.). Abortion Acupuncture Bariatric surgery Chiropractic care Hearing Aids Infertility treatment Private-duty nursing Most Coverage provided outside the United Autism spectrum disorder, including applied States. See behavioral analysis Gender reassignment surgery Your Rights to Continue Coverage : There are agencies that can help if you want to continue your Coverage after it ends.

10 The contact information for those agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), Other Coverage options may be available to you too, including buying individual insurance Coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a 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: ATTN: Grievances and Appeals, PO Box 54159, Los Angeles, CA 90054-0159.