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 Advantage Gold PPO 309 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.

2 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: $1,200 Generally, you must pay all of the costs from providers up to the deductible amount before deductible? Individual/$3,600 Family this plan begins to pay. If you have other family members on the plan, each family member Out-of-Network: $3,600 must meet their own individual deductible until the total amount of deductible expenses paid Individual/$10,800 Family by all family members meets the overall family deductible. Are there services covered Yes. In-Network Preventive This plan covers some items and services even if you haven't yet met the deductible amount.

3 Before you meet your Health, services with a copay, and But a copayment or coinsurance may apply. For example, this plan covers certain preventive deductible? some prescription drugs are services without cost-sharing and before you meet your deductible. See a list of covered covered before you meet your preventive services at 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 Network: $7,900 The out-of-pocket limit is the most you could pay in a year for covered services. 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.

4 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).

5 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 $25/visit; deductible does 30% coinsurance Virtual Visits are available.

6 See your benefit injury or illness not apply booklet* for details. If you visit a health care Specialist visit 25% coinsurance 30% 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. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, bloodFreestanding Facility: 30% coinsurance work) 15% coinsurance Hospital: 25% coinsurance Preauthorization may be required; see your If you have a test Imaging (CT/PET scans, MRIs) Freestanding Facility: 30% coinsurance benefit booklet* for details.

7 15% coinsurance Hospital: 25% 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 - Retail - $10/prescription;. $5/prescription deductible does not apply Non-Preferred - $10/prescription Mail - $15/prescription;. deductible does not apply Non-preferred generic drugs Retail - Preferred - Retail - $20/prescription;. If you need drugs to $10/prescription deductible does not apply Limited to a 30-day supply at retail (or a treat your illness or Non-Preferred - 90-day supply at a network of select retail condition $20/prescription pharmacies).

8 Up to a 90-day supply at mail Mail - $30/prescription; order. Specialty drugs limited to a 30-day More information about deductible does not apply supply. Payment of the difference between prescription drug coverage is available at Preferred brand drugs Retail - Preferred - Retail - $70/prescription; the cost of a brand name drug and a generic $50/prescription deductible does not apply may also be required if a generic drug is com/content/dam/ Non-Preferred - available. All Out-of-Network prescriptions prime/memberportal/ $70/prescription are subject to a 50% additional charge after forms/AuthorForms/ Mail - $150/prescription; the applicable copay/coinsurance. Additional HIM/2019/2019_OK_6T_ deductible does not apply charge will not apply to any deductible or Non-preferred brand drugs Retail - Preferred - Retail - $120/prescription; out-of-pocket amounts.

9 $100/prescription deductible does not apply Non-Preferred - $120/prescription Mail - $300/prescription;. deductible does not apply Preferred specialty drugs 45% coinsurance 45% coinsurance Non-Preferred specialty drugs 50% coinsurance 50% coinsurance Facility fee ( , ambulatory Freestanding Facility: 15% $1,500/visit plus 30%. surgery center) coinsurance coinsurance Preauthorization may be required. If you have outpatient Hospital: 25% For Outpatient Infusion Therapy, see your surgery coinsurance benefit booklet* for details. Physician/surgeon fees 25% coinsurance 30% 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).

10 Emergency room care $950/visit plus 25% $950/visit plus 25%. None coinsurance coinsurance Emergency medical 25% coinsurance 25% coinsurance Preauthorization may be required for If you need immediate transportation non-emergency transportation; see your medical attention benefit booklet* for details. Urgent care 25% coinsurance 30% coinsurance Office visit copayment may apply instead of coinsurance. Facility fee ( , hospital $400/visit plus 25% $1,500/visit plus 30% Preauthorization required. Preauthorization If you have a hospital room) coinsurance coinsurance penalty: $500. See your benefit booklet* for stay Physician/surgeon fees 25% coinsurance 30% coinsurance details. If you need mental Outpatient services 25% coinsurance 30% coinsurance Outpatient: Preauthorization may be required.