Summary Of Benefits And Coverage Completed Example - Moda Health

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesModa Health Plan, Inc.: Connexus Platinum 500Coverage Period: 01/01/2022-12/31/2022Coverage for: Family Plan Type: PPOThe 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, contact Moda Health atwww.modahealth.com or by calling 1-888-217-2363. 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 www.healthcare.gov/sbc-glossary or call 1-888-217-2363 to request acopy.Important QuestionsWhat is the overalldeductible?Are there services coveredbefore you meet yourdeductible?AnswersWhy This Matters:Generally, you must pay all of the costs from providers up to the deductible amountFor network providers 500 individual / 1,000before this plan begins to pay. If you have other family members on the plan, eachfamily; for out-of-network providers 1,500 individualfamily member must meet their own individual deductible until the total amount of/ 3,000 family.deductible expenses paid by all family members meets the overall family deductible.Yes. In-network preventive care, primary care,specialist, urgent care, virtual care visits, office visitsThis plan covers some items and services even if you haven’t yet met the deductiblefor outpatient mental health and chemicalamount. But a copayment or coinsurance may apply. For example, this plan coversdependency, outpatient diagnostic testing, outpatientcertain preventive services without cost sharing and before you meet yourrehabilitation services and habilitation services, anddeductible. See a list of covered preventive services atchildren’s vision care as well as in and out of ive-care-benefits/.prescription medications are covered before youmeet your deductible.Are there other deductiblesNo.for specific services?For network providers 3,250 individual / 6,500What is the out-of-pocketfamily; for out-of-network providers 9,750 individuallimit for this plan?/ 19,500 family.Premiums, balance-billing charges, expensesWhat is not included in theincurred due to brand substitution and health careout-of-pocket limit?this plan doesn’t cover.Will you pay less if you use Yes. See www.modahealth.com or call 1-888-217a network provider?2363 for a list of network providers.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.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, and youmight receive a bill from a provider for the difference between the provider’s chargeand what your plan pays (balance billing). Be aware, your network provider mightuse an out-of-network provider for some services (such as lab work). Check withyour provider before you get services.Page 1 of 7

Important QuestionsAnswersWhy This Matters:Do you need a referral tosee 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.Common MedicalEventServices You MayNeedPrimary care visit totreat an injury orillnessIf you visit a healthcare provider’s officeor clinicSpecialist visitPreventive care /screening /immunizationIf you have a testDiagnostic test (xray, blood work)Imaging (CT/PETscans, MRIs)What You Will PayNetwork Provider(You will pay the least) 15 copay/office visit, 5 copay/virtual care visit;No charge/CirrusMD virtual visit;deductible does not apply 30 copay/office visit, 5 copay/virtual care visit,No charge/CirrusMD virtual visit; 15 copay/acupuncture andspinal manipulation visits, 45 copay/hearing exam visit;deductible does not applyNo charge for most services. 15copay/visit or 10% coinsurancefor remaining services.Deductible does not apply.10% coinsurance; deductibledoes not apply to outpatient /office setting10% coinsuranceLimitations, Exceptions, & Other ImportantInformationOut-of-NetworkProvider(You will pay the most)50% coinsuranceNone50% coinsuranceOffice visits by naturopaths, acupuncturists andchiropractors are specialist visits. Naturopathicsubstances are not covered. Calendar year maximumof 12 visits for acupuncture and 20 visits for spinalmanipulation. Prior authorization is required for somespinal manipulation. Failure to get prior authorizationresults in denial.Not covered for mostservices. 50%coinsurance forremaining services.You may have to pay for services that aren’tpreventive. Ask your provider if the services neededare preventive. Then check what your plan will pay for.50% coinsuranceIncludes other tests such as EKG, allergy testing andsleep study.50% coinsurancePrior authorization is required for many services.Failure to get prior authorization results in denial.* For more information about limitations and exceptions, see the plan or policy document at www.modahealth.com.Page 2 of 7

Common MedicalEventServices You MayNeedValue tierIf you need drugsto treat yourillness or conditionMore informationabout prescriptiondrug coverage isavailable atwww.modahealth.com/pdlIf you haveoutpatient surgerySelect tierPreferred tierLimitations, Exceptions, & Other ImportantInformationCovers up to a 30-day supply (retail pharmacy) and90-day supply (mail order and participating retailpharmacies). One copay for each 30-day supply. Priorauthorization may be required. Mail order at a ModaHealth designated mail order pharmacy only. 75 maximum cost share 30-day supply and 225maximum cost share 90-day supply for insulin,deductible does not apply.Covers up to a 30-day supply for most specialty. Priorauthorization may be required. Moda Healthdesignated pharmacy only.Non-preferred tier50% coinsurance, deductible doesnot apply50% coinsurance,deductible does not applySpecialty tier25% coinsurance for preferred,50% coinsurance for non-preferreddeductible does not applyNot covered10% coinsurance50% coinsurance10% coinsurance50% coinsurance 200 copay/visit, then 10%coinsurance, deductible does notapply 200 copay/visit, then10% coinsurance,deductible does not applyCopay waived if hospital admission immediatelyfollows. In-network out-of-pocket limit applies.10% coinsurance10% coinsuranceIn-network deductible and out-of-pocket limit apply.50% coinsuranceNoneFacility fee (e.g.,ambulatory surgerycenter)Physician/surgeonfeesEmergency roomcareIf you needimmediate medicalattentionWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 2 copay/retail prescription, 2 copay/retail 6 copay/90-day retail and mailprescription, deductibleorder prescription;does not applydeductible does not apply 10 copay/retail prescription, 10 copay/retail 30 copay/90-day retail and mailprescription, deductibleorder prescription;does not applydeductible does not apply 25 copay/retail prescription, 25 copay/retail 75 copay/90-day retail and mailprescription, deductibleorder prescription;does not applydeductible does not applyEmergency medicaltransportationUrgent care 30 copay/office visit, 5 copay/virtual care visit,No charge/CirrusMD virtual visit;deductible does not applyCost sharing for anticancer medication is 10%.Prior authorization may be required. Failure to get priorauthorization results in denial.* For more information about limitations and exceptions, see the plan or policy document at www.modahealth.com.Page 3 of 7

Common MedicalEventServices You MayNeedIf you have ahospital stayFacility fee (e.g.,hospital room)Physician/surgeonfeesIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesIf you are pregnantIf you need helprecovering or haveother specialhealth needsWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)10% coinsurance50% coinsurance10% coinsurance50% coinsuranceLimitations, Exceptions, & Other ImportantInformationPrior authorization is required for many services.Failure to get prior authorization results in denial.Outpatient services 15 copay/office visit, 5 copay/virtual care visit,No charge/CirrusMD virtual visit;deductible does not apply.10% coinsurance for otheroutpatient services.50% coinsurancePrior authorization is required for some outpatientbehavioral health services. Failure to obtain priorauthorization results in denial.Inpatient services10% coinsurance50% coinsurancePrior authorization is required. Failure to obtain priorauthorization results in denial.Office birth/deliveryfacility servicesHome health care10% coinsurance50% coinsurance10% coinsurance50% coinsurance10% coinsurance50% coinsurance10% coinsurance 30 copay/outpatient visit,deductible does not apply.10% coinsurance for inpatient50% coinsuranceRehabilitationservices50% coinsuranceHabilitation services 30 copay/outpatient visit,deductible does not apply.10% coinsurance for inpatient50% coinsuranceSkilled nursing care10% coinsurance50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services, a copay,coinsurance or deductible may apply. Maternity caremay include tests and services described elsewhere inthe SBC (i.e., ultrasound).Calendar year maximum of 140 out-of-network visits.Calendar year maximum of 30 sessions for outpatientrehabilitation and habilitation; and up to 60rehabilitation sessions to treat neurologic conditions.Calendar year maximum of 30 days for inpatientrehabilitation and habilitation and 60 daysrehabilitation for head or spinal cord injury. Limitsapply separately to rehabilitative and habilitativeservices. Prior authorization may be required. Failureto get prior authorization results in denial.Calendar year maximum of 60 days.* For more information about limitations and exceptions, see the plan or policy document at www.modahealth.com.Page 4 of 7