SummaryofBenefitsandCoverage: WhatthisPlanCovers ...

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019. SM. : Blue Choice Preferred Bronze PPO 202 Coverage for: Individual/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, visit or by calling 1-800-541-2768. 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 https://. or call 1-855-756-4448 to request a copy. Important Questions Answers Why This Matters: What is the overall Individual: Participating $3,150 Generally, you must pay all of the costs from providers up to the deductible amount before deductible?

2 Non-Participating $15,000 this plan begins to pay. If you have other family members on the plan, each family member Family: Participating $9,450 must meet their own individual deductible until the total amount of deductible expenses paid Non-Participating $45,000 by all family members meets the overall family deductible. Are there services covered Yes. In-Network Preventive Health This plan covers some items and services even if you haven't yet met the deductible amount. before you meet your is covered before you meet your But a copayment or coinsurance may apply. For example, this plan covers certain preventive deductible? deductible. 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-pocket Individual: Participating $6,650 The out-of-pocket limit is the most you could pay in a year for covered services.

3 If you have limit for this plan? Non-Participating Unlimited other family members in this plan, they have to meet their own out-of-pocket limits until the Family: Participating $13,300 overall family out-of-pocket limit has been met. Non-Participating Unlimited What is not included in the Premiums, balance-billed Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? charges, and health care this plan doesn't cover. Will you pay less if you use Yes. See or call This plan uses a provider network. You will pay less if you use a provider in the plan's network. a network provider? 1-800-541-2768 for a list of You will pay the most if you use an out-of-network provider, and you might receive a bill from Participating Providers. 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.

4 Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO IND-2019 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 Information (You will pay the most). Primary care visit to treat an 40% coinsurance 50% coinsurance Virtual Visits: 40% coinsurance. See your injury or illness benefit booklet* for details. If you visit a health care Specialist visit 40% coinsurance 50% coinsurance None provider's office or Preventive care/screening/ No Charge; deductible 50% coinsurance You may have to pay for services that aren't clinic immunization does not apply preventive.

5 Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood Freestanding Facility: 50% coinsurance work) 30% coinsurance Hospital: 40% coinsurance Preauthorization may be required; see your If you have a test Imaging (CT/PET scans, MRIs) Freestanding Facility: 50% coinsurance benefit booklet* for details. 30% coinsurance Hospital: 40% coinsurance *For more information about limitations and exceptions, see the plan or policy document at 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 Information (You will pay the most). Preferred generic drugs Preferred - Retail - 25% coinsurance 20% coinsurance Non-Preferred - Limited to a 30-day supply at retail (or a If you need drugs to 25% coinsurance 90-day supply at a network of select retail treat your illness or Non-preferred generic drugs Preferred - Retail - 30% coinsurance pharmacies).

6 Up to a 90-day supply at mail condition 25% coinsurance order. Specialty drugs limited to a 30-day Non-Preferred - supply. Payment of the difference between More information about 30% coinsurance the cost of a brand name drug and a generic prescription drug coverage is available at Preferred brand drugs Preferred - Retail - 35% coinsurance may also be required if a generic drug is 30% coinsurance available. All Out-of-Network prescriptions com/content/dam/ Non-Preferred - are subject to a 50% additional charge after prime/memberportal/ 35% coinsurance the applicable copay/coinsurance. Additional forms/AuthorForms/ Non-preferred brand drugs Preferred - Retail - 40% coinsurance charge will not apply to any deductible or HIM/2019/2019_IL_6T_ 35% coinsurance out-of-pocket amounts. You may be eligible Non-Preferred - to synchronize your prescription refills, please 40% coinsurance see your benefit booklet* for details. Preferred specialty drugs 45% coinsurance 45% coinsurance Non-Preferred specialty drugs 50% coinsurance 50% coinsurance Facility fee ( , ambulatory Freestanding Facility: $1,500/visit plus 50%.)

7 Surgery center) $600/visit plus 30% coinsurance Preauthorization may be required. Abortion coinsurance is not covered except in limited If you have outpatient Hospital: circumstances. surgery $600/visit plus 40%. For Outpatient Infusion Therapy, see your coinsurance benefit booklet* for details. Physician/surgeon fees $200/visit plus 40% 50% coinsurance coinsurance *For more information about limitations and exceptions, see the plan or policy document at 3 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 Information (You will pay the most). Emergency room care $1,000/visit plus 40% $1,000/visit plus 40%. None coinsurance coinsurance If you need immediate Emergency medical 40% coinsurance 40% coinsurance Preauthorization may be required for medical attention transportation non-emergency transportation; see your benefit booklet* for details. Urgent care 40% coinsurance 50% coinsurance None Facility fee ( , hospital $850/visit plus 40% $1,500/visit plus 50% Preauthorization required.

8 Preauthorization If you have a hospital room) coinsurance coinsurance penalty: $1,000 or 50% of the eligible charge stay Physician/surgeon fees 40% coinsurance 50% coinsurance In-Network, $500 Out-of-Network. If you need mental Outpatient services 40% coinsurance 50% coinsurance Outpatient: Preauthorization may be required;. health, behavioral Inpatient services $850/visit plus 40% $1,500/visit plus 50% see your benefit booklet* for details. Inpatient: health, or substance coinsurance coinsurance Preauthorization required. abuse services Office visits 40% coinsurance 50% coinsurance Cost sharing does not apply to certain Childbirth/delivery professional 40% coinsurance 50% coinsurance preventive services. Depending on the type of If you are pregnant services services, coinsurance may apply. Maternity Childbirth/delivery facility $850/visit plus 40% $1,500/visit plus 50% care may include tests and services described services coinsurance coinsurance elsewhere in the SBC ( ultrasound).

9 Home health care 40% coinsurance 50% coinsurance If you need help Rehabilitation services 40% coinsurance 50% coinsurance recovering or have Habilitation services 40% coinsurance 50% coinsurance Preauthorization may be required. other special health Skilled nursing care 40% coinsurance 50% coinsurance needs Durable medical equipment 40% coinsurance 50% coinsurance Hospice services 40% coinsurance 50% coinsurance Children's eye exam No Charge; deductible Not Covered One visit per year. See your benefit booklet*. does not apply for details. If your child needs Children's glasses No Charge Not Covered One pair of glasses per year. See your benefit dental or eye care booklet* for details. Children's dental check-up Not Covered Not Covered None *For more information about limitations and exceptions, see the plan or policy document at 4 of 7. 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.)

10 Abortion (Except where a pregnancy is the result Long-term care Routine eye care of rape or incest, or for a pregnancy which, as Non-emergency care when traveling outside the Weight loss programs certified by a physician, places the woman in danger of death unless an abortion is performed). Acupuncture Dental Care (Adult). Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document). Bariatric surgery Hearing aids (Two covered every 36 months for Private-duty nursing (With the exception of Chiropractic care (Limited to 25 visits per calendar children or bone anchored) inpatient private duty nursing). year.) Infertility treatment (Covered for 4 procedures per Routine foot care (Only in connection with Cosmetic surgery (Only for the correction of benefit period) diabetes). congenital deformities or conditions resulting from accidental injuries, scars, tumors, or diseases). Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends.