Summary of Benefits and Coverage: What this Plan …

1 Summary of Benefits and coverage : what this Plan Covers & what You Pay For Covered Services coverage Period: Beginning on or after 01/01/2018. Capital BlueCross1 Gold PPO 2000/10/20 STD coverage For: Individual and Family | Plan Type: PPO. 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 , go to or call 1-800-730-7219.

2 For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call 1-888-428-2566 to request a copy. Important Questions Answers Why this Matters: Generally, you must pay all the costs from providers up to the deductible amount before this plan $2,000 individual / $4,000 family what is the overall begins to pay. If you have other family members on the plan, each family member must meet their participating providers; $5,000 individual /.

3 Deductible? own individual deductible until the total amount of deductible expenses paid by all family members $10,000 family non-participating providers. meets the overall family deductible. Are there services this plan covers some items and services even if you haven't yet met the deductible amount. But a covered before you Yes. Professional services with copays or copayment or coinsurance may apply. For example, this plan covers certain preventive services meet your network preventive services. without cost-sharing and before you meet your deductible. See a list of covered preventive services at deductible?

4 Are there Yes, $75/person for pediatric dental. There You must pay all the costs for these services up to the specific deductible amount before this plan deductibles for are no other specific deductibles. begins to pay for these services. specific services? what is the out-of- For participating providers $7,350 individual The out-of-pocket limit is the most you could pay in a year for covered services. If you have other pocket limit for this / $14,700 family; for non-participating family members in this plan, they have to meet their own out-of-pocket limits until the overall family out- plan?

5 Providers $10,000 individual / $20,000 family. of-pocket limit has been met. what is not Pre-authorization penalties, premiums, included in the out- balance billing charges, and health care this Even though you pay these expenses, they don't count toward the out-of-pocket limit. of-pocket limit? plan doesn't cover. this plan uses a provider network. You will pay less if you use a provider in the plan's network. You Will you pay less if will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for Yes. For a list of participating providers, see you use a network the difference between the provider's charge and what your plan pays (balance billing).

6 Be aware or call 1-800-730-7219. provider? 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. Do you need a referral to see a No. You can see the specialist you choose without a referral. specialist? IND_Generic-8-18-17-6552501-01-SBC_v15-I J347RJ849D0128VJ140-45127PA2001301. 1 of 7. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. what You Will Pay Common Limits, Exceptions, & Other Important Services You May Need Participating Provider Non-participating Provider Medical Event Information (You will pay the least) (You will pay the most).

7 Primary care visit to treat an $20 copayment/visit 50% coinsurance None injury or illness Specialist visit $50 copayment/visit 50% coinsurance None If you visit a health Deductible does not apply to services at care provider's participating providers. You may have to Preventive care/screening/. office or clinic pay for services that aren't preventive. Ask immunization No charge 50% coinsurance your provider if the services you need are preventive. Then check what your plan will pay for. 10% coinsurance x-ray; $25. Deductible waived at independent clinical Diagnostic test (x-ray, blood copayment-independent clinical 50% coinsurance labs.)

8 Deductible applies at hospital/facility work) labs; $75 copayment- If you have a test owned labs. hospital/facility owned labs. *See preauthorization schedule attached to Imaging (CT/PET scans, MRIs) 10% coinsurance 50% coinsurance your certificate of coverage . $3 copayment/prescription (retail) $8 copayment/prescription (mail Generic drugs Deductible waived for generic drugs. order). If you need drugs to Generic substitution applies, see plan $25 copayment/prescription (retail) $63 copayment/prescription treat your illness or Preferred brand drugs documents for details & info on the (mail order).

9 Condition. More Advanced Choice network. No coverage for information about Non-preferred brand drugs $75 copayment (select non-preferred) (retail Rx) $188 copayment non-participating mail order prescriptions. prescription drug (select non-preferred) (mail order Rx). coverage is 40% coinsurance after available by calling deductible ($1,000 coinsurance Only select non-preferred drugs will be 1-800-730-7219 Specialty drugs maximum per script)(generic, No coverage for specialty drug covered. Generic Substitution Program preferred and select non- applies. prefered brand). Facility fee ( , ambulatory No coverage for services at non- 10% coinsurance 50% coinsurance If you have surgery center) participating ambulatory surgical facilities outpatient surgery *See preauthorization schedule attached to Physician/surgeon fees 10% coinsurance 50% coinsurance your certificate of coverage .

10 *For more information about preauthorization, see the Preauthorization Program information attached to your certificate of coverage at 2 of 7. what You Will Pay Common Limits, Exceptions, & Other Important Services You May Need Participating Provider Non-participating Provider Medical Event Information (You will pay the least) (You will pay the most). Emergency room care $300 copayment/service $300 copayment/service Copayment waived if admitted inpatient. If you need Emergency medical immediate medical 10% coinsurance 10% coinsurance None transportation attention Urgent care $75 copayment/service $75 copayment/service Deductible does not apply.