SummaryofBenefitsandCoverage: WhatthisPlanCovers ...

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018. SM. : Blue Advantage Silver HMO 205 - Two $15 PCP Visits Coverage for: Individual/Family Plan Type: HMO. 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.

2 For more information about your coverage, or to get a copy of the complete terms of coverage, visit 2018 or by calling 1-888-697-0683. 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 Reports-and-Other-Resources/ or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall $0 Generally, you must pay all of the costs from providers up to the deductible amount before deductible?

3 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 deductible. Are there services covered No. You will have to meet the deductible before the plan pays for any services. before you meet your deductible? Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of-pocket $2,450 Individual/$4,900 Family.

4 The out-of-pocket limit is the most you could pay in a year for covered services. If you have limit for this plan? 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 met. What is not included in the Premiums and health care this Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? plan does not cover. Will you pay less if you use Yes. For a list of Participating This plan uses a provider network.

5 You will pay less if you use a provider in the plan's network. a network provider? providers please call You will pay the most if you use an out-of-network provider, and you might receive a bill from 1-888-697-0683 or see www. a provider for the difference between the provider's charge and what your plan 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. Do you need a referral to Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if see a specialist?

6 You have a referral before you see the specialist. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 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 Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most).

7 Primary care visit to treat an $15/visit Not Covered First two office visits are at copayment injury or illness amount; coinsurance apply for subsequent visits. If you visit a health care Specialist visit 40% coinsurance Not Covered None provider's office or clinic Preventive care/screening/ No Charge Not Covered You may have to pay for services that aren't immunization preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood Hospital 40% Not Covered work) coinsurance Non-Hospital 30%.

8 Coinsurance If you have a test Preauthorization required; no member penalty. Imaging (CT/PET scans, MRIs) Hospital 40% Not Covered coinsurance Non-Hospital 30%. coinsurance If you need drugs to Preferred generic drugs Retail Preferred Not Covered treat your illness or Participating - No Charge condition Participating Limited to a 30-day supply at retail (or a $10/prescription 90-day supply at a network of select retail More information about Mail - No Charge prescription drug pharmacies). Up to a 90-day supply at mail Non-preferred generic drugs Retail Preferred Not Covered order.

9 Specialty drugs limited to a 30-day coverage is available at Participating - supply. Payment of the difference between $10/prescription the cost of a brand name drug and a generic com/content/dam/. Non-Preferedd may also be required if a generic drug is prime/memberportal/. $20/prescription available. forms/AuthorForms/. Mail - $30/prescription HIM/2018/TX_6T_EX. pdf 2 of 7. What You Will Pay Common Participating Provider Non-Participating Limitations, Exceptions, & Other Important Services You May Need Medical Event (You will pay the least) Provider (You will pay the Information most).

10 Preferred brand drugs Retail Preferred Not Covered Participating 30% coinsurance Participating 35% coinsurance Mail: 30% coinsurance Non-preferred brand drugs Retail Preferred Not Covered Participating 35% coinsurance Participating 40% coinsurance Mail: 35% coinsurance Preferred specialty drugs 45% coinsurance Not Covered Non-Preferred specialty drugs 50% coinsurance Not Covered Facility fee ( , ambulatory Hospital $100/visit plus Not Covered surgery center) 40% coinsurance Elective abortion is not covered except in If you have outpatient Non-Hospital - $100/visit limited circumstances.