Summary Of Benefits And Coverage: What This Covers & What You Pay . - IU

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: 08/01/2021– 07/31/2022Anthem Blue Cross and Blue ShieldCoverage for: Individual Family Plan Type: PPOIndiana University SHIP: International Students/Scholars Blue Access (PPO)The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and theplan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) willbe provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete termsof coverage, . For general definitions of common terms, such as allowed amount, balancebilling, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call (844) 412-0752 to request a copy.Important QuestionsWhat is the overalldeductible?Are there servicescovered before youmeet your deductible?Are there otherdeductibles forspecific services?What is the out-of pocket limit for thisplan?What is not includedin the out-of-pocketlimit?Will you pay less ifyou use a networkprovider?Answers 500/person for In-NetworkProviders. 750/person forNon-Network Providers.Yes. Preventive care for InNetwork Providers. Dental andVision for In-NetworkProviders.No. 2,000/person or 4,000/familyfor In-Network Providers. 2,000/person or 4,000/familyfor Non-Network Providers.Non-Network TransplantServices, Premiums, balancebilling charges, and health carethis plan doesn't cover.Yes, Blue Access. rdirectory/searchcriteria?planstate IN&plantype NETWORK&planname Blue Access orcall (844) 412-0752 for a list ofnetwork providers.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay.This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment or coinsurance may apply. For example, this plan covers certain preventiveservices without cost-sharing and before you meet your deductible. See a list of coveredpreventive services at e-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. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.This plan uses a provider network. You will pay less if you use a provider in the plan’snetwork. You will pay the most if you use an out-of-network provider, and you might receivea bill from a provider for the difference between the provider’s charge and what your planpays (balance billing). Be aware your network provider might use an out-of-network providerfor some services (such as lab work). Check with your provider before you get entsPPOStudHeWStHC-PPO/NA/02QFJ/ NA/08-21Page 1 of 11

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.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessSpecialist visitWhat You Will PayIn-Network ProviderNon-Network Provider(You will pay the least)(You will pay the most)PCP 25/visitHealth Center50% coinsurance 15/visit deductible doesnot applyPCP 25/visitHealth Center50% coinsurance 15/visit deductible doesnot applyIf you visit ahealth careprovider’s officeor clinicPreventive care/screening/immunizationIf you have a testDiagnostic test (x-ray, bloodwork)Imaging (CT/PET scans, MRIs)If you need drugsto treat yourTier 1 - Typically GenericNo charge50% coinsurance 20/visit50% coinsurance 20/visit 10/prescription (retail)and 20/prescription(home delivery)50% coinsurance50% coinsurance (retail)Limitations, Exceptions, & OtherImportant Prescribed FDA approvedcontraceptives are not subject to costshares.Immunizations for children prior totheir 6th birthday have no cost sharefor In-Network and Non-Networkcharges.Non-Network preventive care servicesfor children prior to their 6th birthdayhave no deductible.You may have to pay for services thataren't preventive. Ask your provider ifthe services needed are preventive.Then check what your plan will payfor.Costs may vary by site of service.Includes coverage for BreastTomosynthesis.Costs may vary by site of service.*See Prescription Drug section* For more information about limitations and exceptions, see plan or policy document at .Page 2 of 11

CommonMedical Eventillness orconditionMore informationabout prescriptiondrug coverage isavailable es You May NeedTier 2 - Typically Preferred /BrandTier 3 - Typically Non-Preferred/ Specialty DrugsTier 4 - Typically Specialty(brand and generic)What You Will PayIn-Network ProviderNon-Network Provider(You will pay the least)(You will pay the most) 40/prescription (retail)and 80/prescription50% coinsurance (retail)(home delivery) 60/prescription (retail)and 120/prescription50% coinsurance (retail)(home delivery)Limitations, Exceptions, & OtherImportant InformationNot ApplicableNot Applicable 100/visit50% coinsuranceCosts may vary by site of service. 50/visit50% coinsurance 100/visitCovered as In-Network0% coinsuranceCovered as In-Network 50/visit50% coinsuranceFacility fee (e.g., hospital room) 200/admission50% coinsurancePhysician/surgeon fees 25/visitOffice Visit 25/visitOther Outpatient 25/visit 200/admission 25/pregnancy50% coinsuranceOffice Visit50% coinsuranceOther Outpatient50% coinsurance50% coinsurance50% coinsurance 25/visit50% coinsurance 200/admission50% coinsurance--------none-------Copay waived if admitted.No charge for Emergency RoomPhysician Fee.Non-emergency non-networkAmbulance Services are limited to 50,000 per trip.--------none-------60 days/benefit period forInpatient physical medicine,rehabilitation including dayrehabilitation programs.--------none-------Office Visit--------none-------Other e copayment per pregnancy forboth office visits andchildbirth/delivery professionalservices. Maternity care may includetests and services described elsewherein the SBC (i.e. ultrasound).National Drug ListIf you haveoutpatient surgeryFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency room careIf you needimmediatemedical attentionEmergency medicaltransportationUrgent careIf you have ahospital stayIf you needmental health,behavioral health,or substanceabuse servicesIf you arepregnantOutpatient servicesInpatient servicesOffice visitsChildbirth/delivery professionalservicesChildbirth/delivery facilityservices* For more information about limitations and exceptions, see plan or policy document at .Page 3 of 11

CommonMedical EventIf you need helprecovering or haveother specialhealth needsIf your childneeds dental oreye careServices You May NeedHome health careRehabilitation servicesHabilitation servicesWhat You Will PayIn-Network ProviderNon-Network Provider(You will pay the least)(You will pay the most)0% coinsurance0% coinsurance 15/visit50% coinsurance 15/visit50% coinsuranceSkilled nursing care 200/admission50% coinsuranceDurable medical equipment20% coinsurance20% coinsuranceHospice servicesChildren’s eye examChildren’s glassesChildren’s dental check-up 15/visitNo chargeNo chargeNo charge50% coinsurance50% coinsurance50% coinsurance50% coinsuranceLimitations, Exceptions, & OtherImportant Information100 visits/benefit period.*See Therapy Services section90 days limit/benefit period for skillednursing services.*See Durable Medical EquipmentSection--------none-------*See Vision Services section*See Dental Services sectionExcluded 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 excludedservices.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (adult) Hearing aids Infertility treatment Long- term care Routine foot care unless you have been Weight loss programsdiagnosed with diabetes.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care 12 visits/benefit period. Most coverage provided outside the United Private-duty nursing 35 visits/benefit period.States. See www.bcbsglobalcore.com Routine eye care (adult) 1 exam/benefitperiod to age 19.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 thoseagencies is: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395,www.in.gov/idoi/3008.htm. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323x61565, www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the HealthInsurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.* For more information about limitations and exceptions, see plan or policy document at .Page 4 of 11

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 iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments also provide complete 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:ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, 1-877-267-2323 x61565, www.cciio.cms.govState of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395,www.in.gov/idoi/3008.htmDoes this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for thepremium tax credit.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.––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––* For more information about limitations and exceptions, see plan or policy document at .Page 5 of 11