Summary of Benefits and Coverage (SBC)

1 Pkg ID: 1909580645(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022)(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)1of7 Summary of Benefits and Coverage : What this Plan Covers & What You Pay For Covered ServicesIHC Bronze EPO HSA AmeriHealth Advantage $25/$50 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 , visit or by calling 1-888-YOUR-AH1 (TTY:711). 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 1-888-YOUR-AH1 (TTY:711) to request a QuestionsAnswersWhy This Matters:What is the overall deductible?For Tier 1 and Tier 2 Participating providers $6,000 person / $12,000 , you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family there services covered before you meet your deductible?Yes. Preventive care is covered before you meet your plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at there other deductibles for specific services?

3 Don't have to meet deductibles for specific is the out-of-pocket limit for this plan?For Tier 1 and Tier 2 Participating providers $7,050 person / $14,100 out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been is not included in the out-of-pocket limit?Premiums, out-of-network balance-billed charges, health care this plan doesn't cover, and penalties for failure to obtain precertification for though you pay these expenses, they don't count toward the out-of-pocket you pay less if you use a network provider?Yes. See or call 1-888-YOUR-AH1 (TTY:711) for a list of network pay the least if you use a provider in Tier 1. You pay more if you use a provider in Tier 2. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays(balance billing).

4 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 you need a referral to see a specialist? can see the specialist you choose without a referral.*For more information about limitations and exceptions, see plan or policy document at copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible You Will PayCommon Medical EventServices You May NeedIn-Network Tier 1(You will pay the least)In-Network Tier 2 Out-of-Network Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationIf you visit a health care provider's office or clinic Primary care visit to treat an injury or illness$25 is a covered benefit: See your benefit booklet for Coverage level at visit$50 is a covered benefit: See your benefit booklet for Coverage level at care/screening/immunizationNo charge. Deductible does not charge.

5 Deductible does not and frequency schedules may apply. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay you have a test Diagnostic test (x-ray, blood work)50% (CT/PET scans, MRIs)50% authorization is required. *See section "using services that require preapproval".If you need drugs to treat your illness or conditionMore information about prescription drug Coverage is available at Generic DrugsRetail/Mail Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% authorization may be required on some drugs. Covers up to a 30 day DrugsRetail/Mail Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% authorization may be required on some drugs.

6 Covers up to a 30 day supply.*For more information about limitations and exceptions, see plan or policy document at You Will PayCommon Medical EventServices You May NeedIn-Network Tier 1(You will pay the least)In-Network Tier 2 Out-of-Network Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationNon Preferred DrugsRetail/Mail Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% authorization may be required on some drugs. Covers up to a 30 day DrugsRetail/Mail Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% Order (1-30 days supply) 50% coinsurance. Mail Order (31-90 days supply) 50% applies to oral or injectable self-administered Specialty Drugs which are covered under the Prescription Drug Plan. Covers up to a 30 day supply. Prior authorization and/or dispensing limits may apply.

7 Other Specialty Drugs and infusion therapy drugs may be covered under your medical Benefits plan as stated within your Policy and/or Drug Rider information. A complete list of drugs requiring Prior authorization is available, *see section "Using services that require preapproval".If you have outpatient surgery Facility fee ( , ambulatory surgery center)30% authorization is required for certain services. *See section "using services that require preapproval".Physician/surgeon fees30% you need immediate medical attention Emergency room care30% at In-Network Tier 2 medical transportation50% at In-Network Tier 2 care30% at In-Network Tier 2 costs for urgent care are based on care received at a designated urgent care center or facility, not your physician's office. Costs may vary depending on where you receive you have a hospital stay Facility fee ( , hospital room)30% authorization is required. *See section "using services that require preapproval".

8 Physician/surgeon fees30% covered.*For more information about limitations and exceptions, see plan or policy document at You Will PayCommon Medical EventServices You May NeedIn-Network Tier 1(You will pay the least)In-Network Tier 2 Out-of-Network Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationIf you need mental health, behavioral health, or substance abuse services Outpatient services$50/Visit.$50 is a covered benefit. See your benefit booklet for Coverage level at services30% authorization may be required. *See section "using services that require preapproval".If you are pregnant Office visitsNo charge. Deductible does not charge. Deductible does not sharing does not apply for preventive services. Depending on the type of services a copayment and coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC ( ultrasound.)Childbirth/delivery professional services30% facility services30% notification you need help recovering or have other special health needs Home health care50% authorization is required.

9 *See section "using services that require preapproval".Rehabilitation services$50/Visit.$50 , Occupational, Speech, and Cognitive therapies: 30 visits each/Calendar Year. All tiers services$50/Visit.$50 , Occupational, Speech, and Cognitive therapies: 30 visits each/Calendar Year. All tiers combined. Visit limits do not apply for the treatment of nursing care30% authorization is required. *See section "using services that require preapproval".Durable medical equipment50% authorization is required for selected items. *See section "using services that require preapproval".Hospice services50% authorization is required. *See section "using services that require preapproval".*For more information about limitations and exceptions, see plan or policy document at You Will PayCommon Medical EventServices You May NeedIn-Network Tier 1(You will pay the least)In-Network Tier 2 Out-of-Network Provider (You will pay the most)Limitations, Exceptions, & Other Important InformationIf your child needs dental or eye care Children's eye examNo charge.

10 Deductible does not charge. Deductible does not benefit is administered by Davis Vision. Pediatric Vision; 1 exam(s)/Calendar 's glassesNo charge. Deductible does not charge. Deductible does not benefit is administered by Davis Vision. Lenses and Hardware are covered once/Calendar Year. Limit includes 1 pair(s) of frames from the select Davis Vision collection. There is a $150 allowance for non-collection 's dental check-upNot 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 Non-emergency care when traveling outside the Routine foot care Dental care (Adult) Routine eye care (Adult) Weight loss programs Long-term care Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Abortion, in the case of rape, incest, or for a pregnancy which, as certified by a physician, places the woman in danger of death unless an abortion is performed Chiropractic care Infertility treatment (limited to artificial insemination; requires pre approval) Acupuncture, when used as a substitute for other forms of anesthesia Hearing aids (covered for members 15 and younger) Private-duty nursing (covered under Home Health Care) Bariatric surgery*For more information about limitations and exceptions, see plan or policy document at Rights to Continue Coverage : There are agencies that can help if you want to continue your Coverage after it ends.