Swarthmore College Keystone 15 HMO

Medical Benefit HighlightsSwarthmore College Keystone 15 HMOCovered ServicesBenefits per Calendar YearDeductibleIndividual/FamilyOut-of-Pocket Maximum (Embedded)1Individual/FamilyCoinsurancePreventive ServicesPreventive CarePreventive ColonoscopyPreventive Plus ProvidersHospital BasedNutritional Counseling (6 visits/year)Physician ServicesPrimary Care Physician (PCP) Office VisitOffice VisitTelemedicine VisitSpecialist Office VisitOffice VisitTelemedicine VisitRetail Health Clinic VisitUrgent Care VisitVirtual Care2Telemedicine (through MDLive )TeledermatologyTelebehavioral HealthTherapy ServicesPhysical Therapy (60 consecutivedays/year)3FreestandingHospital BasedOccupational Therapy (60 consecutivedays/year)3FreestandingHospital BasedSpeech Therapy (60 consecutivedays/year)3Emergency ServicesEmergency Room (copay waived ifadmitted)Emergency AmbulanceNon-Emergency AmbulanceReferredYour Costs (You pay)Out-of-Network 0/ 0Not covered 1,000/ 2,0000%Not coveredNot coveredReferredOut-of-NetworkNo chargeNo chargeNo chargeNot coveredNot coveredNot coveredReferredOut-of-Network 15 15Not coveredNot covered 25 25 15 105Not coveredNot coveredNot coveredNot coveredReferredOut-of-NetworkNo chargeNot covered 5 15 15Not coveredNot coveredNot coveredReferredOut-of-NetworkNo chargeNo chargeNot coveredNot coveredNo chargeNo chargeNo chargeNot coveredNot coveredNot coveredReferredOut-of-NetworkNo chargeNo chargeCovered at In-Network levelNot covered 150Covered at In-Network levelReference ID: 10045140PS01012022

Hospital ServicesInpatient Hospital ServicesObservation Services (copay waived ifadmitted)Maternity Hospital ServicesReferred 100/Day; max of 5 copays peradmission 150Out-of-NetworkNot coveredNot covered 100/Day; max of 5 copays peradmissionNo chargeNot coveredOutpatient SurgeryReferredOut-of-NetworkOutpatient DiagnosticsReferredOut-of-NetworkNo chargeNo chargeNot coveredNot coveredNo chargeNo chargeNot coveredNot coveredOutpatient Lab and PathologyReferredOut-of-NetworkOther Medical ServicesReferredOut-of-NetworkNo chargeNo chargeNo chargeNo chargeNo chargeNo chargeNo chargeNo charge 25Not coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot covered 100/Day; max of 5 copays peradmission 25Not coveredInpatient Professional Services (includesMaternity)FreestandingHospital BasedOutpatient Professional ServicesDiagnostic Medical (EKG)Routine Radiology (X-Ray)FreestandingHospital BasedAdvanced Imaging (MRI/MRA,CT/CTAScan, PET Scan)FreestandingHospital BasedFreestandingHospital BasedSpinal Manipulations (60 visits/year)Acupuncture (18 visits/year)Standard InjectablesAllergy InjectionsBiotech/Specialty isSkilled Nursing Facility (180 days/year)Home HealthHospiceDurable Medical Equipment (DME)Mental Health – Outpatient (includesserious mental illness and substanceabuse)Mental Health – Inpatient (includes seriousmental illness and substance abuse)Routine Eye Care1 50 50No chargeNo chargeNo chargeNo chargeNo charge 25No chargeNo chargeNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredEmbedded out-of-pocket maximum: Each covered family member only needs to satisfy his or her individual out-of-pocket maximum, not the entirefamily out-of-pocket maximum.Reference ID: 10045140PS01012022

2Telemedicine is provided by a designated telemedicine provider, please visit www.ibx.com/findcarenow.3Physical Therapy, Occupational Therapy, and Speech Therapy combined visit limit.Keystone is a Health Maintenance Organization (HMO). This is a managed care program. Coverage is available when your care is provided or referredby a Keystone primary care physician (PCP). Your Keystone PCP may also refer you to other Keystone providers for care, if needed.Designated Site – PCPs are required to choose one radiology, physical therapy, occupational therapy, and laboratory provider where they will send theirKeystone members. You can view the sites selected by your PCP at www.ibx.com.This summary represents only a partial listing of benefits and exclusions of the Medical Program described in this summary. If your employer purchasesanother program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, thismanaged care plan may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms,limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.ibx.com/LGBooklet or call 1-800-ASK-BLUE (TTY: 711).Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations.Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorization,please log on to http://www.ibx.com/preapproval or call the phone number that is listed on the back of your identification card.Benefits underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Cross - Independent licensees of the BlueCross and Blue Shield Association. www.ibx.comReference ID: 10045140PS01012022

Drug Benefit HighlightsSwarthmore College Select Rx 15/ 35/ 50 KeystoneCovered ServicesBenefits per Calendar YearIn-NetworkDeductibleOut-of-Pocket MaximumFormulary 0/ 0Combined with MedicalSelect 0/ 0Combined with MedicalRetail PharmacyIn-NetworkOut-of-NetworkTier 1 Generic DrugsTier 2 Preferred BrandTier 3 Non-Preferred DrugsDispensing Limits 15 35 5030 day supply max30% Reimbursement30% Reimbursement30% Reimbursement30 day supply maxMail Order PharmacyAvailable for maintenance drugsIn-NetworkOut-of-NetworkTier 1 Generic DrugsTier 2 Preferred Brand DrugsTier 3 Non-Preferred DrugsDispensing Limits 30 70 10090 day supply maxNot coveredNot coveredNot coveredNot coveredDrug dCoveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredCoveredCoveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredDrugs1ACA PreventiveCompound MedicationsContraceptivesDiabetic Supplies (i.e., test strips)Glucometers (no copayment/coinsurance requiredat participating pharmacies)InsulinInsulin Needles and SyringesLancets (no copayment/coinsurance required atparticipating pharmacies)Prescribed Tobacco Cessation Drugs (RX and OTC)Retin-A (up to Age 35)Allergy SerumBiologicals, Investigational/Experimental DrugsBlood, Blood PlasmaDrugs used for Cosmetic PurposesImmunization AgentsInjectable Fertility DrugsNon-Federal Legend DrugsOver-The-Counter Drugs (Non-Prescription)Your Costs (You pay)Out-of-NetworkReference ID: 1003499501012020

Weight Control Drugs1Not coveredNot coveredCertain designated preventative medications will not be subject to any cost-sharing or deductibles, but will be subject to the terms and conditionsof your benefits contract. Refer to your summary of benefits, member handbook, and/or benefit booklet to determine if your plan includes 100percent coverage for in-network preventive services.This summary represents only a partial listing of benefits and exclusions of the Prescription Drug Program described in this summary. If your employerpurchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by pharmacy policy. As aresult, this program may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing ofterms, limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visitwww.ibx.com/LGBooklet or call 1-800-ASK-BLUE (TTY: 711).Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician's originalorder are not covered. Devices or supplies except those specifically listed under covered drugs are not covered. Drugs used to treat hemophilia arenot covered.All covered self-administered specialty medications except insulin will be provided through the convenient Specialty Pharmacy Program for theappropriate cost sharing indicated above. Benefits are available for up to a thirty (30) days supply.FutureScripts network includes more than 65,000 retail pharmacies. You can locate a participating pharmacy near you on www.ibx.com byselecting the Find a Participating Pharmacy feature.FutureScripts is an independent company providing pharmacy benefit management service.Benefits underwritten or administered by Keystone Health Plan East, a subsidiary of Independence Blue Cross - Independent licensees of the BlueCross and Blue Shield Association. www.ibx.comReference ID: 1003499501012020