I_2178607866_20220101_SBC

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2022 - 12/31/2022


Highmark Coverage Advantage:Together Blue EPO Gold 0 Coverage for: Individual/Family Plan Type: EPO
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, www.highmarkbcbs.com or call 1-833-585-
7337. 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 1-833-585-7337 to request a copy.
Important Questions Answers Why This Matters:
What is the overall $0 individual/$0 family network. See the Common Medical Events chart below for your costs for services this plan
deductible? covers.
Are there services No This plan covers some items and services even if you haven’t yet met the deductible
covered before you meet amount. But a copayment or coinsurance may apply. For example, this plan covers
your deductible? certain preventive services without cost-sharing and before you meet your deductible.
See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles No. You don’t have to meet deductibles for specific services.
for specific services?
What is the out-of-pocket limit $7,500 individual/$15,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you
for this plan? network. have other family members in this plan, they have to meet their own out-of-pocket
limits until the overall family out-of-pocket limit has been met.
What is not included in the Premiums, balance-billed charges, and Even though you pay these expenses, they don't count toward the out-of-pocket limit.
out–of–pocket limit? health care this plan doesn't cover.
Will you pay less if you Yes. See www.highmarkbcbs.com/find- This plan uses a provider network. You will pay less if you use a provider in the plan’s
use a network provider? a-doctor/ or call 1-833-585-7337 for a list network. You will pay the most if you use an out-of-network provider, and you might
of network providers. receive a bill from 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). Check with your provider before you get services.
Do I need a referral to see a No. You can see the specialist you choose without a referral.
specialist?

All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.

A copy of your agreement can be found at https://shop.highmark.com/sales/#!/sbc-agreements. 1 of 10


Together Blue EPO Gold 0 ONX Base Jan
I_2178607866_20220101_SBC
What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you visit a health Primary care visit to treat an injury or illness $20 copay/visit Not covered You may have to pay for services that
care provider’s Specialist visit $20 copay/visit Not covered aren’t preventive. Ask your provider if
office or clinic Preventive care/screening/Immunization No charge for Not covered the services needed are preventive.
preventive care Then check what your plan will pay for.
services
Please refer to your preventive schedule
for additional information.
If you have a test Diagnostic test (x-ray, blood work) $35 copay/visit Not covered Precertification may be required.
Imaging (CT/PET scans, MRIs) $400 copay/visit Not covered Precertification may be required.
If you need drugs Tier 1 No charge Not covered Up to 31/60/90-day supply retail
to treat your illness per prescription pharmacy.
or condition (retail)
No charge Up to 90-day supply maintenance
More information per prescription prescription drugs through mail order.
about prescription (mail order)
drug coverage is Tier 2 $30/$60/$90 copay Not covered This plan uses an Essential Formulary.
available at per prescription
https://www.highmar (retail)
kbcbs.com/find-a- $60 copay
doctor/#/drug per prescription
(mail order)
Tier 3 $150/$300/$450 Not covered
copay
per prescription
(retail)
$300 copay
per prescription
(mail order)

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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
Tier 4 50% coinsurance Not covered
$250/$500/$750
minimum
$1,000/$2,000/$3,000
maximum
per prescription
(retail)
50% coinsurance
$500 minimum
$2,000 maximum
per prescription
(mail order)
If you have Facility fee (e.g., ambulatory surgery center) $250 copay/visit Not covered Precertification may be required.
outpatient surgery Physician/surgeon fees $250 copay/visit Not covered Precertification may be required.
If you need Emergency room care $300 copay/visit $300 copay/visit Copay waived if admitted as an
immediate medical Deductible does not inpatient.
attention apply.
Emergency medical transportation 30% coinsurance 30% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not
apply.
Urgent care $40 copay/visit $40 copay/visit −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not
apply.
If you have a Facility fee (e.g., hospital room) $500 copay/visit Not covered Precertification may be required.
hospital stay Physician/surgeon fees 30% coinsurance Not covered Precertification may be required.
If you have mental Outpatient services $20 copay/visit Not covered Precertification may be required.
health, behavioral
health, or
Inpatient services $500 copay/visit Not covered Precertification may be required.
substance abuse
services

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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you are pregnant Office visits 30% coinsurance Not covered Cost sharing does not apply for
preventive services.
Depending on the type of services, a
copayment, coinsurance, or deductible
may apply.
Childbirth/delivery professional services 30% coinsurance Not covered Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound.)
Network: The first visit to determine
pregnancy is covered at no charge.
Childbirth/delivery facility services $500 copay/visit Not covered Please refer to the Women’s Health
Preventive Schedule for additional
information.
Precertification may be required.
If you need help Home health care 30% coinsurance Not covered Network: 60 visits per benefit period,
recovering or have aggregate with visiting nurse.
other special health Precertification may be required.
needs Rehabilitation services $45 copay/visit Not covered Network: combined habilitation and
Habilitation services $45 copay/visit Not covered rehabilitation services.
Network: 30 combined physical
medicine and occupational therapy visits
and 30 speech therapy visits per benefit
period.
Limit does not apply to habilitation
services for the treatment of a mental
health or substance use disorder
diagnosis.
Precertification may be required.
Skilled nursing care $500 copay/visit Not covered Network: 120 days per benefit period.
Precertification may be required.
Durable medical equipment 30% coinsurance Not covered Precertification may be required.
Hospice services 30% coinsurance Not covered Network: Respite care limit of 7 days
every six months.
Precertification may be required.
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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If your child needs Children’s eye exam No charge Not covered Network: One eye exam per 12 month
dental or eye care period up to age 19.
Children’s glasses No charge Not covered Network: One pair frames/lenses every
12 months.
Children’s dental check-up No charge Not covered Network: One exam every 6 months.

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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.)
 Abortion, except where a pregnancy is the  Bariatric surgery  Non-emergency care when traveling outside
result of rape or incest, or for a pregnancy the U.S.
which, as certified by a physician, places the  Cosmetic surgery  Private-duty nursing
life of the woman in danger unless an
abortion is performed.  Dental care (Adult)  Routine eye care (Adult)
 Hearing aids  Routine foot care
 Acupuncture  Long-term care  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

 Chiropractic care  Infertility treatment

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
agencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or at https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-
question/ask-ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other options to continue coverage are
available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
http://www.HealthCare.gov or call 1-800-318-2596.

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 a
grievance 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
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:
 Highmark, Inc. at 1-833-585-7337.
 Additionally, a consumer assistance program can help you file your appeal. Contact the Pennsylvania Department of Consumer Services at 1-877-881-6388.

Does this plan provide Minimum Essential Coverage? Yes


Minimum 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 the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes


If 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.––––––––––––––––––––––

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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 be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

The plan’s overall deductible $0 The plan’s overall deductible $0 The plan’s overall deductible $0
Specialist copayment $20 Specialist copayment $20 Specialist copayment $20
Hospital (facility) copayment $500 Hospital (facility) copayment $500 Hospital (facility) copayment $500
Other coinsurance 30% Other coinsurance 30% Other coinsurance 30%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $1,000 Copayments $700 Copayments $600
Coinsurance $1,200 Coinsurance $200 Coinsurance $400
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $2,260 The total Joe would pay is $920 The total Mia would pay is $1,000

The plan would be responsible for the other costs of these EXAMPLE covered services.

Highmark Blue Cross Blue Shield is an independent corporation operating under licenses from the Blue Cross and Blue Shield Association.
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Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Coverage
Advantage or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association.

To find more information about Highmark’s benefits and operating procedures, such as accessing the drug formulary or using network providers,
please go to DiscoverHighmark.com; or for a paper copy, call 1-855-873-4106.

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