Transcription of SummaryofBenefitsandCoverage: …
1 TheSummaryofBenefitsandCoverage(SBC) cost for :Informationabout the cost of this plan(calledthe premium) willbe ,ortogetacopyofthecompletetermsofcoverag e, by generaldefinitionsof commonterms, suchas allowedamount, balancebilling, coinsurance,copayment,deductible,provide r, call 1-855-756-4448to requesta This Matters:AnswersImportantQuestionsSee the CommonMedicalEventschartbelow for your costsfor servicesthis plancovers.$0 What is the overalldeductible?You will have to meet the deductiblebefore the planpays for any meet yourdeductible?
2 You don thave to meet deductiblesfor there otherdeductiblesfor specificservices?The out-of-pocketlimitis the most you could pay in a year for you haveotherfamily membersin this plan, they have to meet their ownout-of-pocketlimitsuntil theoverall family out-of-pocketlimithas been met.$800 Individual/$2, is the out-of-pocketlimitfor this plan?Eventhoughyou pay theseexpenses,they don'tcounttowardthe healthcare thisplandoes not ,andyoumightreceiveabillfromYes. For a list of Participatingprovidersplease callWillyoupaylessifyouusea networkprovider?
3 Aproviderforthedifferencebetweentheprovi der schargeandwhatyourplanpays(balance1-888- 697-0683or ).Beawareyournetworkprovidermightuseanou t-of-networkproviderforsomeservices(such as lab work).Checkwith your providerbefore you get have a referralbefore you see the you need a referraltosee a specialist?Limitations,Exceptions,& Other ImportantInformationWhat You WillPayServicesYou May NeedCommonMedicalEventNon-ParticipatingP rovider(Youwillpaythemost)ParticipatingP rovider(You willpay the least)First two officevisits are at copaymentamount.
4 Coinsuranceapply for Covered$5/visitPrimarycare visit to treat aninjuryor illnessIfyouvisitahealthcareprovider sofficeorclinicNoneNot Covered30% coinsuranceSpecialistvisitBlue Crossand Blue Shield of Texas,a Divisionof Health Care ServiceCorporation,a Mutual Legal ReserveCompany,an IndependentLicenseeof the Blue Crossand Blue Shield Association1 of 6 Summaryof Benefitsand Coverage:What this Plan Covers& What You Pay For CoveredServicesCoveragePeriod:01/01/2018 -12/31/2018: Blue AdvantageSilverHMOSM205- Two $5 PCP VisitsCoveragefor:Individual/FamilyPlanT ype:HMOL imitations,Exceptions,& Other ImportantInformationWhat You WillPayServicesYou May NeedCommonMedicalEventNon-ParticipatingP rovider(Youwillpaythemost)ParticipatingP rovider(You willpay the least)You may have to pay for servicesthat aren' your providerif the servicesNot CoveredNo ChargePreventivecare/screening/immunizat ionyou need are planwill pay.
5 CoveredHospital 30%coinsuranceNon-Hospital 20%coinsuranceDiagnostictest(x-ray,blood work)If you have a testNot CoveredHospital 30%coinsuranceNon-Hospital 20%coinsuranceImaging(CT/PETscans,MRIs)L imitedto a 30-day supply at retail (or a90-day supply at a networkof selectretailNot CoveredRetail PreferredParticipating-NoChargeParticipa ting$10/prescriptionMail - No ChargePreferredgenericdrugsIf you need drugs totreat your illnessorconditionMoreinformationaboutpr escriptiondrugpharmacies).Up to a 90-day supply at mailorder. Specialtydrugslimited to a the differencebetweenthe costof a brand name drug and a genericNot CoveredRetail PreferredParticipating-$10/prescriptionN on-Preferedd$20/prescriptionMail - $30/prescriptionNon- also be requiredif a genericdrug CoveredRetail PreferredParticipating30% coinsuranceParticipating35% coinsuranceMail.
6 30% coinsurancePreferredbrand drugs2 of 6 Limitations,Exceptions,& Other ImportantInformationWhat You WillPayServicesYou May NeedCommonMedicalEventNon-ParticipatingP rovider(Youwillpaythemost)ParticipatingP rovider(You willpay the least)Not CoveredRetail PreferredParticipating35% coinsuranceParticipating40% coinsuranceMail: 35% coinsuranceNon-preferredbrand drugsNot Covered45% coinsurancePreferredspecialtydrugsNot Covered50% coinsuranceNon-PreferredspecialtydrugsEl ectiveabortionis not coveredexceptinlimited ;no CoveredHospital $100/visitplus30% coinsuranceNon-Hospital-$100/visitplus 20% coinsuranceFacilityfee ( ,ambulatorysurgerycenter)If you have outpatientsurgeryNot Covered30% coinsurancePhysician/surgeonfeesCopaymen tis waived if admitted.
7 $500/visitplus 30%coinsurance$500/visitplus 30%coinsuranceEmergencyroomcareIf you need immediatemedicalattentionNone30% coinsurance30% coinsuranceEmergencymedicaltransportatio nNot Covered$10/visitUrgentcarePreauthorizati onrequired; Covered$250/admitplus30% coinsuranceFacilityfee ( ,hospitalroom)If you have a hospitalstayNoneNot Covered30% coinsurancePhysician/surgeonfeesPreautho rizationrequired; Covered30% coinsuranceOutpatientservicesIf you need mentalhealth,behavioralNot Covered$250/admitplus 30%coinsuranceInpatientserviceshealth,or substanceabuse servicesCopaymentappliestofirstprenatalv isit(perpregnancy)ifoneoffirsttwoofficev isitsperNot Covered$5/visitOfficevisitsIf you are pregnantNot Covered30% coinsuranceChildbirth/deliveryprofession alservicesbenefitperiod; coinsuranceapply notNot Covered$250/admitplus 30%coinsuranceChildbirth/deliveryfacilit yservicesapply to the type of services,coinsurancemay apply.
8 Maternitycare may3 of 6 Limitations,Exceptions,& Other ImportantInformationWhat You WillPayServicesYou May NeedCommonMedicalEventNon-ParticipatingP rovider(Youwillpaythemost)ParticipatingP rovider(You willpay the least)includetests and servicesdescribedelsewherein the SBC ( ultrasound).Inpatient:Preauthorizationre quired; visit maximumper Covered30% coinsuranceHomehealthcareIf you need helprecoveringor have35visitmaximumpercalendaryearcombine dwith Chiropracticcare. Preauthorizationrequired;no Covered30% coinsuranceRehabilitationservicesother specialhealthneedsNot Covered30% coinsuranceHabilitationservices25 day maximumper Covered30% coinsuranceSkillednursingcarePreauthoriz ationrequired; Covered30% coinsuranceDurablemedicalequipmentNoneNo t Covered30% coinsuranceHospiceservicesOne visit per year.
9 *See CoveredNo Charge;deductibledoesnotapplyChildren seye examIf your childneedsdentalor eye careOne pair of glassesper year. *See benefitbookletfor CoveredNo Charge;deductibledoesnotapplyChildren sglassesNoneNot CoveredNot CoveredChildren sdental check-upExcludedServices& Other CoveredServices:ServicesYour PlanGenerallyDoes NOT Cover (Checkyour policyor plandocumentfor more informationand a list of any other excludedservices.)Private-dutynursing(Un lessmedicallynecessary)Dental Care (Adult and Child)Abortions(Exceptwhereapregnancyist heresultof rape or incest,or for a pregnancywhich,ascertifiedby a physician,places the womanindangerofdeathunlessanabortionispe rformed)Routineeye care (Adult)Infertilitytreatment(Diagnosisand treatmentcovered.)
10 In vitro not covered)Routinefootcare (Exceptin connectionwithdiabetes,circulatorydisord ersof the lowerextremities,peripheralvasculardisea se,peripheralneuropathy,or chronicarterial or venousinsufficiency)Long-termcareAcupunc tureNon-emergencycare (Exceptfor the correctionofcongenitaldeformitiesorforco nditionsresultingfrom accidentalinjuries,scars, )Weightloss programs*Formoreinformationaboutlimitati onsandexceptions, of 6 Other CoveredServices(Limitationsmay apply to these isn t a completelist. Pleasesee your plandocument)Hearingaids (Limitedto two hearingaids everythree years)Chiropracticcare ( visits/year)Your Rightsto may also contactyour state insurancedepartmentat coverageoptionsmay be availableto you too,includingbuyingindividualinsuranceco veragethroughthe Health InsuranceMarketplace.
