Summary Of Benefits And Coverage: What This Plan Covers .

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesState of Connecticut: POS Medical Benefit PlanCoverage Period: 10/01/2020 – 06/30/2021Coverage for: Individual/Family Plan Type: POSThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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, anDoceff1012016updt9132016.pdf. For general definitions of common terms, such as allowed amount, balance billing,coinsurance, copay, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at http://www.cciio.cms.gov or call Anthem BlueCross and Blue Shield at 800-922-2232 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible?In-network: 350/individual; 1,400/family. Waivedfor HEP Members and pre-October 2, 2011retireesOut-of-network: 300/individual; 900/familyGenerally, you must pay all of the costs from providers up to the deductibleamount before this plan begins to pay. Once you or a family member meets theindividual deductible amount, the plan begins to pay for you or that family member.If you have other family members on the plan, each family member must meettheir own individual deductible until the total amount of deductible expenses paidby all family members meets the overall family deductible.Yes. Primary care and specialist office visits,Are there servicespreventive care, prescription drugs, emergency roomcovered before youcare, urgent care, mental health and substancemeet your deductible? abuse outpatient services, and eye exams arecovered before you meet your deductible.Are there otherdeductibles forNo.specific services?What is the out-ofMedical: 2,000/individual; 4,000/familypocket limit for thisPrescription drugs: 4,600/individual; 9,200/familyplan?What is not includedin the out-of-pocketlimit?Out-of-network deductible and cost sharing,premiums, balance-billing charges, penalties forfailure to obtain prior authorization for services andhealth care this plan doesn’t cover.This plan covers some items and services even if you haven’t yet met thedeductible amount. But a copay or coinsurance may apply. For example, this plancovers certain preventive services without cost sharing and before you meet yourdeductible. See a list of covered preventive services are-benefits/You don’t have to meet deductibles for specific services.The out-of-pocket limit is the most you could pay in a year for covered services. Ifyou have other family members in this plan, they have to meet their own out-ofpocket limits until the overall family out-of-pocket limit has been met.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.Chat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.1 of 9

Important QuestionsAnswersWhy This Matters:Will you pay less ifyou use a networkprovider?Yes. See www.anthem.com/statect or call 800-9222232 for a list of network providers.This plan uses a provider network. You will pay less if you use a provider in theplan’s network. You will pay the most if you use an out-of-network provider, andyou might receive a bill from a provider for the difference between the provider’scharge and what your plan pays (balance billing). Be aware your network providermight use an out-of-network provider for some services (such as lab work). Checkwith your provider before you get services.Do you need a referralto see a specialist?No.You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommonMedical EventServices YouMay NeedPreferred In-NetworkProvider(You will pay the least)Primary care visitNo charge. Deductibleto treat an injury ordoes not apply.illnessIf you visit ahealth careprovider’s officeor clinicIf you have atestIn-Network Provider 15 copay/visitPre-1999 Retirees: 5copay/visitDeductible does not apply. 15 copay/visitPre-1999 Retirees: 5copay/visitDeductible does not apply.Out-of-NetworkProvider(You will pay themost)Limitations, Exceptions, & OtherImportant Information20% coinsuranceNone.Specialist visitNo charge. Deductibledoes not apply.Preventivecare/screening/immunizationNo charge. Deductibledoes not apply.No charge.Deductible does not apply.20% coinsuranceYou may have to pay for services thataren’t preventive. Ask your provider ifthe services needed are preventive.Then check what your plan will pay for.Diagnostic test (xray, blood work)No charge.20% coinsurance40% coinsuranceNone.Imaging (CT/PETscans, MRIs)No charge.20% coinsurance40% coinsurancePrior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Chat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.20% coinsurance2 of 9

What You Will PayCommonMedical EventServices YouMay NeedGeneric drugsIf you needdrugs to treatyour illness orconditionMore informationaboutprescriptiondrug coverage isavailable rred branddrugsNon-preferredbrand drugsSpecialty drugsPreferred In-NetworkProvider(You will pay the least)In-Network ProviderPreferred generic - Non-Maintenance: 5 copay/retail;Preferred generic - Maintenance: 5 copay/ mail orderor Maintenance drug pharmacy. Non-preferredgeneric: Non-Maintenance: 10 copay/retail; Nonpreferred - Maintenance: 10 copay/mail order orMaintenance drug pharmacy. Retired July 2, 2009 –October 1, 2011: Non-Maintenance: 5 copay/retail;Maintenance: 0 copay/initial fill/mailorder/maintenance drug pharmacy. Pre-July 1, 2009retirees: Non-maintenance: 3 copay/retail;Maintenance: 0 copay/initial fill/mailorder/Maintenance drug pharmacyNon-Maintenance: 25 copay/retail; Maintenance: 25copay/initial fill/mail order/Maintenance drugpharmacy. Retired July 2, 2009 – October 1, 2011:Non-Maintenance: 10 copay/retail; Maintenance: 25copay/initial fill; 25 copay mail order/ Maintenancedrug pharmacy. Pre-July 1, 2009 retirees: NonMaintenance: 6 copay/retail; Maintenance: 0copay/initial fill; 0 copay/mail order/Maintenancedrug pharmacy.Non-Maintenance: 40 copay/retail; Maintenance: 40copay/initial fill/mail order/Maintenance drugpharmacy. Retired July 2, 2009 – October 1, 2011:Non-Maintenance: 25 copay/retail; Maintenance: 0copay/initial fill/mail order/ maintenance drugpharmacy. Pre-July 1, 2009 retirees: NonMaintenance: 6 copay/retail; Maintenance: 0copay/initial fill/mail order/maintenance drugpharmacySame as non-preferred brand drugsChat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.Out-of-NetworkProvider(You will pay themost)20% coinsurance fornon-participatingpharmacy.20% coinsurance fornon-participatingpharmacy.20% coinsurance fornon-participatingpharmacy.Limitations, Exceptions, & OtherImportant InformationDeductible will not apply to prescriptiondrug coverage. No charge for FDAapproved contraceptives (or brandname contraceptives if a generic ismedically inappropriate).See details ofyour coverage for slightly adjustedcopays for persons retired between July1, 2009 and October 1, 2011, andpersons retired after October 1, 2011.Check the details enance drugs must be filled bymail order or maintenance drugpharmacy after first initial retail fill.Penalty may apply if brand name drugis requested when a generic isavailable.Prescription drugs purchased at a retailpharmacy are limited to a maximum ofa 30-day supply; prescription drugspurchased through mail order ormaintenance drug pharmacy are limitedto a maximum of a 90-day supply.For some prescription drugs, priorauthorization may be required.Prescription drug coverage isseparately administered.Same as non-preferredbrand drugs3 of 9

What You Will PayCommonMedical EventIf you haveoutpatientsurgeryIf you needimmediatemedicalattentionIf you have ahospital stayIf you needmental health,behavioralhealth, orsubstanceabuse servicesServices YouMay NeedFacility fee (e.g.,ambulatorysurgery center)Physician/surgeonfeesPreferred In-NetworkProvider(You will pay the least)In-Network ProviderOut-of-NetworkProvider(You will pay themost)Limitations, Exceptions, & OtherImportant InformationNo charge20% coinsuranceNo charge20% coinsurance 35 copay/visitEmergency roomcare 250 copay/visit.Retired October 2, 2011 – October 1, 2017: 35copay/visitPre-October 2, 2011 Retirees: No chargeDeductible does not apply.EmergencymedicaltransportationNo chargeNo chargeNone.Urgent care 15 copay/visitPre-1999 Retiree: 5 copay/visitDeductible does not apply.20% coinsuranceNone.Pre-October 2, 2011Retirees: No chargePrior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Copay waived if admitted or if actualemergency.Prior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.No coverage in excess of cost of asemi-private room unless medicallynecessary.Prior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Facility fee (e.g.,hospital room)No charge20% coinsurancePhysician/surgeonfeesNo charge20% coinsuranceOutpatientservices 15 copay/visitPre-1999 Retirees: 5 copay/visitDeductible does not apply.20% coinsuranceNone.20% coinsurancePrior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Inpatient servicesNo chargeChat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.4 of 9

What You Will PayCommonMedical EventServices YouMay NeedPreferred In-NetworkProvider(You will pay the least)In-Network ProviderOut-of-NetworkProvider(You will pay themost)Office visits 15 copay/first visit onlyPre-1999 Retiree: 5 copay/initial visit onlyDeductible does not apply.20% No charge20% coinsuranceChildbirth/deliveryfacility servicesNo charge20% coinsuranceIf you arepregnantChat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.Limitations, Exceptions, & OtherImportant InformationCost sharing does not apply forpreventive care services.Depending on the type of services, acopay, coinsurance, or deductible mayapply.Maternity care may include tests andservices described within anothersection (i.e., ultrasound).Prior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.5 of 9

What You Will PayCommonMedical EventServices YouMay NeedHome health careIf you need helprecovering orhave otherspecial healthneedsPreferred In-NetworkProvider(You will pay the least)In-Network ProviderNo chargeOut-of-NetworkProvider(You will pay themost)Limitations, Exceptions, & OtherImportant Information20% coinsuranceLimit: 200 visits/calendar year.RehabilitationservicesNo charge20% coinsurancePrior authorization required (except forpre-1999 retirees) to avoid penalty oflesser of 500 or 20% of coveredservices.In-network speech therapy limit: 30visits/calendar year. Limit does notapply to treatment resulting fromautism, stroke, tumor removal, injury orcongenital anomalies of oropharynx.Out-of-network physical, occupational,chiropractic, speech & autism therapylimit: 30 visits/condition/calendar year.HabilitationservicesNo charge20% coinsuranceNone.Skilled nursingcareNo charge20% coinsuranceDurable medicalequipmentNo charge20% coinsuranceHospice servicesNo charge20% coinsuranceChat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.Out-of-network services limit: 60days/calendar year.Prior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Prior authorization required to avoidpenalty of lesser of 500 or 20% of costof services.Out-of-network in-home hospice limit:200 visits/calendar year.Out-of-network inpatient hospice limit:60 days/calendar year.Prior authorization required for inpatientservices to avoid penalty of lesser of 500 or 20% of cost of services.6 of 9

What You Will PayCommonMedical EventIf your childneeds dental oreye careServices YouMay NeedPreferred In-NetworkProvider(You will pay the least)In-Network ProviderOut-of-NetworkProvider(You will pay themost)Children’s eyeexam 15 copay/visitDeductible does not apply.50% coinsuranceChildren’s glassesNot coveredNot coveredChildren’s dentalcheck-upNot coveredNot coveredLimitations, Exceptions, & OtherImportant InformationLimit: 1 visit/calendar year.Copay waived for HEP members inalternate years.You must pay 100% of this service,even in-network.You must pay 100% of this service,even in-network.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.) Children’s dental check-up Dental care (adult) Routine foot care Children’s glasses Long-term care Cosmetic surgery Non-emergency care outside the U.S. (urgent care Weight loss programs (except as required by law)covered).Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgery (prior authorization required) Infertility treatment (prior authorization required) Acupuncture (covered only if medically necessary Chiropractic care (limit: 30 out-of-networkfor osteoarthritis or nausea and vomitingvisits/year) Private duty nursing (prior authorization required)associated with surgery, chemotherapy or Hearing aid (limit: 1 set per 36 month period; prior Routine eye care (Adult) (limit: 1 exam/year)pregnancy)authorization may be required for bone-anchoreddevices)Chat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.7 of 9

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agenciesis: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 877-267-2323 x61565 or http://www.cciio.cms.gov.Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more informationabout the Marketplace, visit www.HealthCare.gov or call 800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also providecomplete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:Anthem Blue Cross and Blue Shield108 Leigus RoadWallingford, CT 06492800-922-2232CVS/CaremarkPrescription Claim Appeals MC109P.O. Box 52084Phoenix, AZ 85072-2084Fax: 866-443-1172Additionally, a consumer assistance program can help you file your appeal. Contact the Connecticut Office of the Healthcare Advocate at 866-466-4446.Does this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month.Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Para obtener asistencia en Español, llame al 800-922-2232.Kung kailangan ninyo ang tulong sa Tagalog tumawag sa ��这个号码 800-922-2232.Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' ��–––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next ––––––––Chat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.Or, use the online chat tool by clicking the Health Navigator button on CareCompass.Ct.Gov.8 of 9

About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will bedifferent depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharingamounts (deductibles, copays and coinsurance) and excluded services under the plan. Use this information to compare the portion ofcosts you might pay under different health plans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natal care and ahospital delivery) The plan’s overall deductible Specialist copayment Hospital (facility) Other 350 15 0 0This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example CostIn this example, Peg would pay:Cost SharingDeductiblesCopaysCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Peg would pay isManaging Joe’s type 2 DiabetesMia’s Simple Fracture(a year of routine in-network care of a wellcontrolled condition) The plan’s overall deductible Specialist copayment Hospital (facility) Other(in-network emergency room visit and followup care) 350 15 0 0This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter) 12,800 350 20 0 60 430Total Example CostIn this example, Joe would pay:Cost SharingDeductiblesCopaysCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Joe would pay is The plan’s overall deductible Specialist copayment Hospital (facility) Other 350 15 0 0This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy) 7,400 70 235 0 60 365Total Example CostIn this example, Mia would pay:Cost SharingDeductiblesCopaysCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Mia would pay is 1,900 350 310 0 0 660NOTE: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program,you may be able to reduce your cost. For more information about the wellness program, please visit http://www.osc.ct.gov/benefits.htm.The plan would be responsible for the other costs of these EXAMPLE covered services.9 of 9

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2020 – 06/30/2021 State of Connecticut: POS Medical Benefit Plan Coverage for: Individual/Family Plan Type: POS Chat with a professional Health Navigator 24 hours a day, seven days a week at (866) 611-8005.

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