I_2178607866_20220101_SBC
I_2178607866_20220101_SBC
I_2178607866_20220101_SBC
All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.
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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.)
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.
–––––––––––––––––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.