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 Preferred Gold PPO 205 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 1-866-520-2507. 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 Network: $200 Individual/$600 Generally, you must pay all of the costs from providers up to the deductible amount before deductible?

2 Family this plan begins to pay. If you have other family members on the plan, each family member Out-of-Network: $600 must meet their own individual deductible until the total amount of deductible expenses paid Individual/$1,800 Family 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 and some prescription drugs are But a copayment or coinsurance may apply. For example, this plan covers certain preventive deductible? covered before you meet your services without cost-sharing and before you meet your deductible. See a list of covered deductible. 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 Network: $7,900 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? Individual/$15,800 Family other family members in this plan, they have to meet their own out-of-pocket limits until the Out-of-Network: Unlimited overall family out-of-pocket limit has been met. Individual/Unlimited Family 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. For a list of network This plan uses a provider network. 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 1-866-520-2507 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).

4 Check with your provider before you get services. 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 Oklahoma, 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 Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most). Primary care visit to treat an 40% coinsurance 50% coinsurance Virtual Visits are available. See your benefit injury or illness 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 30% 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) 20% 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. 20% 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 Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most). Preferred generic drugs Retail - Preferred - No Retail - $10/prescription;. Charge deductible does not apply Non-Preferred - $10/prescription Mail - No Charge;. If you need drugs to deductible does not apply Limited to a 30-day supply at retail (or a treat your illness or Non-preferred generic drugs Retail - Preferred - Retail - $20/prescription; 90-day supply at a network of select retail condition $10/prescription deductible does not apply pharmacies).

6 Up to a 90-day supply at mail Non-Preferred - order. Specialty drugs limited to a 30-day More information about $20/prescription supply. Payment of the difference between prescription drug Mail - $30/prescription; the cost of a brand name drug and a generic coverage is available at deductible does not apply may also be required if a generic drug is com/content/dam/ Preferred brand drugs Preferred - Retail - 25% coinsurance available. All Out-of-Network prescriptions prime/memberportal/ 20% coinsurance are subject to a 50% additional charge after forms/AuthorForms/ Non-Preferred - the applicable copay/coinsurance. Additional HIM/2019/2019_OK_6T_ 25% coinsurance charge will not apply to any deductible or Non-preferred brand drugs Preferred - Retail - 40% coinsurance out-of-pocket amounts. 35% coinsurance Non-Preferred - 40% coinsurance 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) $300/visit plus 20% coinsurance Preauthorization may be required. If you have outpatient coinsurance For Outpatient Infusion Therapy, see your surgery Hospital - $300/visit plus benefit booklet* for details. 40% coinsurance Physician/surgeon fees 40% coinsurance 50% coinsurance *For more information about limitations and exceptions, see the plan or policy document at 3 of 7. What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most). Emergency room care $950/visit plus 40% $950/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 $400/visit plus 40% $1,500/visit plus 50% Preauthorization required.

8 Preauthorization If you have a hospital room) coinsurance coinsurance penalty: $500. See your benefit booklet* for stay Physician/surgeon fees 40% coinsurance 50% coinsurance details. If you need mental Outpatient services 40% coinsurance 50% coinsurance Outpatient: Preauthorization may be required;. health, behavioral Inpatient services $400/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 $400/visit plus 40% $1,500/visit plus 50% care may include tests and services described services coinsurance coinsurance elsewhere in the SBC ( ultrasound). *For more information about limitations and exceptions, see the plan or policy document at 4 of 7.

9 What You Will Pay Common Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most). Home health care 40% coinsurance 50% coinsurance 30 visits/year. Preauthorization may be required. Rehabilitation services 40% coinsurance 50% coinsurance Preauthorization may be required. Outpatient: Habilitation services 40% coinsurance 50% coinsurance Combined 25 visit limit per benefit period for physical, speech, occupational therapy and If you need help muscle manipulation. Inpatient: 30 day recovering or have maximum per benefit period. Preauthorization other special health penalty: $500. needs Skilled nursing care 40% coinsurance 50% coinsurance 30 days/year. Preauthorization may be required. Inpatient Preauthorization penalty: $500. Durable medical equipment 40% coinsurance 50% coinsurance Preauthorization may be required. Hospice services 40% coinsurance 50% coinsurance Preauthorization may be required.

10 Inpatient Preauthorization penalty: $500. 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; deductible Not Covered One pair of glasses per year. See your benefit dental or eye care does not apply booklet* for details. Children's dental check-up Not Covered Not Covered None 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.). Abortion (Unless the life of the mother is Dental Care (Adult and Child) Routine eye care (Adult). endangered) Infertility treatment Routine foot care (Except for diabetic subscribers). Acupuncture Long-term care Weight loss programs Bariatric surgery (For weight loss purposes) Non-emergency care when traveling outside the Cosmetic surgery (With exception of accidental injury repair and some instances for physiological functioning improvement of a malformed body member).