x0000x0000SI G10461868 69 70 71 72 73 74 75 Effective 08012019 SBC - PDF document

1 ��SI G_10461868, 69, 70, 7
��SI G_10461868, 69, 70, 71, 72, 73, 74, 75 _ Effective 08/01/2019 _ SBC _ Version Effective 04/01/20171 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For C overed Services - 08overage for:Allverage LevelsPlan Type:PPO University ofMinnesota Graduate Assistants and Dependent lan 1 The Summ a ry o f Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan w uldare the cost for covered health care services.NOTE: Information about the cost of this plan(called the premiu l 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, visit www.bluecrossmnonline.com or call toll - free 18668735943. For general definitins of common term, su as allowed amountbalance billingcoinsurancecopaymentdeductibleprovider , or other underlinedterms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbcglossary call tollfree 18668735943to reqest a copy Impotant Questions Answers What is the overall deductible ? $200 individual medical Out - of - Network $600family medical OutNetwork Generally, you must pay all the costs from providers up to the deductible amount before hisplanbegins to pay. If you have other family members on the plan, each deductibleexpenses paid by all family members meets the overall family deductible Are there se rvices covered before you meet yourdeductible Yes. Out of network Well - c hild care, prenatal care, Emergency room services, Emergencymedical transportationand Durablemedical equipmentservicesare coered before you meet y ou r deductible . This plan covers some items and services even if you haven’t yet met the de d uctible amount. But a copayment or coinsurancemay apply. For example, this plan covers rtain preventive serviceswithout costsharing d before you meet your at https://www.healthcare.gov/coverage/preventivecarebenefits/ . Are there other ded u ctibles for specific services? No You don’t have to m eet deductible s for specific services. What is the ou t – of – pocket limit for this plan? $2,500 individual medical combined Network a

2 nd OutNetwork, None Family Pharmacy: $
nd OutNetwork, None Family Pharmacy: $300 individual The out - of - pocket l i mit is the most you could pay in a year for covered serv ices. ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of What is not included in the out – pocket limit Premiums , balance - billed charges, and health care thplandoesn't cover. Even though you pay these expenses, they don't count toward the out - of - pocket limit Will you pay less if you use a networkovider Yes. S ee https://www.bluecrossmn.com/ umngaor call tofree 18668735943 for a list of Network providers T his p lan uses a provid er network . You will pay less if you u s e a provider in the plan’s network . You will pay the most if you use an outnetworkproviderand you might rceive a bill from a providerfor the difference between the provider’scharge and what your planpays (balancbillingBe aware your network provider mightse outnetwoprovideror some services (such as lab work). Check with your provider before you get services . Do y ou need a referral to see a specialist No. You can see the s pecialist you choo se without a referral . All copaymeand coinsurancosts shown in this chart are after yourdeductiblehas been met, if a deductible applies. Common MedicEvent Services You May Need W h at Y ou Will Pay mitationsExceptions, & Other Important Information Network Provider (You w ill pay the least) OutNetworkProvider (You will pay the most) If you visit a health care ovider’soffice or clinic Pr im ary care visit to treat an inj $10 office visi t co pay per visit ; Convenience Clinicopay no charge for all other services 20% coinsurance −−−−−−−−−−none−−−−−−−−−− 匀瀀攀挀楡汩猀琀 瘀楳楴 ␱〠潦昀椀挀攀 瘀椀猀椀琀  挀潰慹 瀀攀爀⁶楳楴 湯⁣栀慲来 昀潲⁡氀氀 潴栀敲⁳敲瘀椀挀敳 挀潩湳畲慮挀攀 −−−−−−−−−−none−−−−−−−−−− 倀爀敶敮琀椀瘀攀 挀愀牥 敥渀椀湧 浭甀渀椀稀楯渀 一漠挀桡爀 ㈰─  挀潩湳畲慮挀攀 昀潲⁡搀畬琀  灲敶敮琀椀瘀攀獥爀癩捥猀 一漠挀桡爀æ

3 œ€æ” æ˜€æ½²â·æ•¬æ°€æŒ€æ¡©æ°€æ æŒ€æ…²æ”
œ€æ” æ˜€æ½²â·æ•¬æ°€æŒ€æ¡©æ°€æ æŒ€æ…²æ”  獥爀癩捥猀 挀潩湳畲慮挀攀景爀  倀爀敶敮琀椀瘀攀挀愀牥Ⰰ㈰─  潩湳畲慮挀攀 昀潲琀栀敲⁳敲瘀椀挀敳 夀潵  礀⁨慶攠琀漀⁰慹⁦潲  猀敲瘀椀挀敳⁴桡琀⁡爀攀溒琀 灲敶敮琀椀瘀攀 䄀獫⁹漀甀爀 灲潶椀椀昀⁴栀攀攀爀癩捥猠 湥攀摥搀 慲攠灲敶敮琀椀瘀攀⸀⁔桥渠 捨攀捫⁷栀愀琀⁹漀 瀀氀慮 睩汬⁰愀礀  昀漀爮 If you have a test Diagnostic test ( x - ray, blood work) No charge 0% coinsurance ; deductible d oes not ap ply −−−−−−−−none−−−−−−−−−− 䤀洀慧椀湧
䌀吀⼀倀䔀吀⁳挀慮猀Ⰰ⁍刀䤀猀⤀ 一漠挀桡爀最攀 ㈰─  挀潩湳畲慮挀攀 ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of Common MedicEvent Services You May Need W h at Y ou Will Pay mitationsExceptions, & Other Important Information Network Provider (You w ill pay the least) OutNetworkProvider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myprime.co Pre ferre d g en eric drugs $10.00 copay /retail $20.00 copaymail service $20.00 copay90dayRx Retail Deductib l e does not apply $10.00 copay /retail Deductibdoes not apply Covers up to 3 4 - da y supply (retail prescription) day supply (mail order or 90dayRx Retailprescription) No coverage forail order and 90dayRx Retailservices from networkproviders Preferred b rand drugs $25.00 copay /retail $50.00 copay/mail service .00 copay/90dayRx Retail Deductib l e does not apply $25.00 copay /retail Deductibdoes not apply Non - p ref erred drugs Non - preferred generic drugs: $50.00 copay/retail $100.00 copay/mail service $100.00 copay/90dayRx Retail Nonpreferred brand drugs: $50.00 copay/retail $100.00 copay/mail service $100.00 copay90dayRx Retail Deductibe does not apply Non - pre ferred generic drugs: $50.00 copay/retail Nonpreferred brand drugs: $50.00 copay/retail Deductibedoes not apply Specialty drugs Formulary : $10 copay/prescription, Brand: $25 copay/90

4 day prescription, Nonformulary: $50 co
day prescription, Nonformulary: $50 copay/prescription. 100% coverage after copay for all. Deductible does not apply. Not covered Covers up to 3 4 - day supply ecialty Pharmacy Network Supplierprescription) No coverage for services from network providers If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 0% coinsurance ; deductible does not apply −−−−−−−−−−none−− −−−−−−−− 倀桹猀椀挀椀慮⼀猀畲来漀渠昀敥猀 一漠挀桡爀最攀 挀潩湳畲慮挀攀 −−−−−−−−−−none−−−−−−−−−− If you nee d immediate medical attention Emergency room care $40.00 copay /visit $40.00 copay /visit ; deductible does not a pply −−−−−−−−−−none −−−−−−−−−− Emergency medi cal transportation 20% coinsurance 20% coinsurance ; deductible does not apply −none−−−− −−−−−− ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of Common MedicEvent Services You May Need W h at Y ou Will Pay mitationsExceptions, & Other Important Information Network Provider (You w ill pay the least) OutNetworkProvider (You will pay the most) Urgent care $10 office visit copay per visit ; 0% coinsurancefor all other services 20% coinsurance −−−−no ne−− −−−−−−−− If you have a hos pital stay Facility fee (e.g., hospital room) No charg e 0 % coinsurance ; dedu ctib le does not apply −−−−−−−−−−none−−−−−−−−−− Physician/surgeon fee No charge 20% coinsurance none−−−−−− −−−− If you ne ed mental health, behavioral health, o substance abuse services O utpatient services $10 off ice visit copay per vis it ; no charge for all other services 20% coinsurance Services for marriage/couples counseling are not cover ed. I npat ient services N o charge 0% coinsur ance ; deductible does not apply −−−−−−−−−−none−−−−−−− If you are p regnant Office visits N o ch arge 0% coinsurance ; deductib

5 le does not apply Cost sharing d
le does not apply Cost sharing does not apply for preventive servicesepending on the type of services, deductiblecopaymenor coinsurancemay apply. Maternity care may include tests avices described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge 2 2 22 0% coinsurancedeductible does not apply C hildbirth/delivery facility service No charge 0% coinsurance ; dedu ctible s not apply If you need help reco vering or have other special health needs Home health care No charge 0% co insurance ; deductible does not apply Limit of 120 visits per benefi t periodwhen you use Netwo Providers Limitsits per benefit eriowhen you use Network P rovi ders . Rehabilitation services $10 offi ce visit copay pe r visit for occupational therapyNo charge for therapies$10 office vis copayper visit for ical therapy; No charge for therapies$10 office visit copay per visit for speech therap No charge for therapies 20% coinsurance for occupational thera 20% coinsuranceor physical therapy 0% coinsurancefor speec therapy −−none−−−−−−−−−− ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of Common MedicEvent Services You May Need W h at Y ou Will Pay mitationsExceptions, & Other Important Information Network Provider (You w ill pay the least) OutNetworkProvider (You will pay the most) Habilitation services $10 office visit copay pe r visit for occupational therapy; No charge for therapies$10 office visitcopaper visit for physica erapy; No charge for therapies $10 office visit copayper visit for speech therap; No charge for therapies 20% coinsurance for occupational thera 20% coinsuranfor physical therapy 20% coinsuranfor sech therapy Skilled nursing care No charge 0% coinsurance ; deductible does not apply Combined Network and out - of - network120 daysper Plan Year . Durable medical equ ipment 20% co insuran ce ; deductible does not apply 20% coins urance ; deduct ible not apply Limited to o ne wig per year for Alopecia Areata Hospice service N o charge 20 % coinsurance −−−−−−−âˆ

6 ’−−none−−−−−−−−− I
’−−none−−−−−−−−− If your child needs dental or eye care Children’s eye exam No charge 0% coinsurance ; deduct ible d oes not a pp ly −−−−no ne−−−−−−−−−− 楬搀爀攀渀鉳  杬慳猀敳 一漠挀桡爀最攀 一潴⁣潶敲攀搀 伀湥  灡椀爀昀  敹攀杬慳猀敳爀  挀潮琀慣琀猀 灥爀⁢攀湥昀椀琀⁰敲椀潤 䐀敮琀慬⁣桥挀欀 一漠挀桡爀最攀 乯琀⁣漀 攀爀敤 匀攀爀癩捥猠瀀爀漀癩搀 攀搀⁥硣氀甀獩癥氀礠 琀桲潵最栠䈀䠀匀⁄敮琀愀楣⸀† 䌀潶敲慧攀⁰爀漀瘀楤戀礀⁄攀汴愀  䐀敮琀愀 潦⁍椀湮敳潴愀 Excluded Services & Other Covered Services: Services Your PlanGenerally DoesCover (Thisisn’t a complete list. heck your policy or planocument or other cluded services Cosmetic surg ery (u nless for r emoval of po rt wine stain, reconstructive surgery) Longterm careRoutine foot care Dental care (Adult)Privatey nursinWeight loss programs ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plandocument.) Acupunct ure for treatment of chronic pain (defined as a duration of at least six months) or for the prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy. Bariatric su rgery Hearing aidlimited to oneexternal hearing aid for each ear every three years)emergency care when travelingoutside the U.S. Chiropr actic care Infe rtility treatment Ro utine eye care (Adul t) Your Rights to Continue Coverage:There areagencies that can help if you want to continue your coverafterit ends. Thecontact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 18772672323,extension 61565 or www.cciio.cms.g Other options to continue coverage are available to you too, including buying individualinsurancecoverage through the Health Insurance MarketplaceFor more information aboutthe rketplacevisit http://www.HealthCare.gov or call 1-800-318-2596. our Grievance and Appeals Rights: Ther

7 e are agencies that can helpif you have
e are agencies that can helpif you have a complaint against your planfor a denial of a claim . This complaint is called a grievanceor appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents als provide complete information to submit a claimappealor agrievanceor any reason to your plan For more information about your rights, this notice, or assistance, contact: your Claims Administrator by calling tollfree 8735943or ifu are covered under a planoffered by the State Health Plan, a city, county, school district, or Service Coop, you may contact the Department of Health and Human Services Health Insurance team at 8883932789. Does this plan vide Minimum Essentiaoverage? Yes.If you don’t have MinimumEssential Coverag for month, you’ll haveto make a payment when you file your tax returnunless you qualify for an exemption from the requirementthat you have health coverage for thatmonth. es this planeet Minimum Value StandardYes.f your plandoesn’t meet the Minimum Value Standards, you may be eligible for a premium tax creditto help you pay for a plan through the Marketplace Language Access Services: ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of –––––––––––––––––To see examples of how this planmight cover costs for a sample medical situation, see tsection––––––––––––––––––––– ��SI G_10461868, 69, 70, 71, 72, 73, 74, 75Effective 08/01/2019SBC _ Version Effective 04/01/2017of About these Coverage Example This is not a cost estimator.Treatments shown are just examples of how this planmight cover medical care. Your actual costs will be ifferent depending on the actual care you receive, e prices your oviderscharge, and many other factors. Focus othe costsharing amounts (deductiblescopaymentsand oinsurance) and excludedservicesunder the plan. Use this information to compare the portion of costs you might pay under different hlth plans. Pleae note these coverage

8 examples are based on selonly coverage.
examples are based on selonly coverage. Peg is Having a Baby (9 months of network prenatal care an hospital delivery) Managing Joe’s type 2 Diabetes (a year ofroutine etwork care of a well controlled condition) Mia’s Simle Fracture network emergency room visitnd follow up care) 吀桥  灬慮鈀猀 潶敲慬氀  摥摵挀琀 楢氀攀 Specialistcopaymen Hospital (facility) coinsurance Other coinsurance $0 $10 0% 20% 吀桥  灬慮鈀猀 潶敲慬氀  摥摵挀琀椀扬攀 Specialistcopaym Hospital (faility) coinsurance Other coinsurance $0 $10 0% 20% 吀桥  灬慮鈀猀 潶敲慬氀  摥摵挀琀椀扬攀 Specialistcopayment Hospital (facility) coinsurance Other coinsurance $0 $10 0% 20% This EX A MPLE event in cludes services like: Specialist office visits (prenatl care) Childbirth/Delivery Professional rvices Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event inc ludes services like: Primary care physician office visits (includingdisease education) Diagnostic tests (bld work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (includingdical suppliesDiagnostic test ray) Durable medical equipment utches) Rehabilitation services (phycal therapy) Total Example Cost $12,800 Tot al Example Cost $7,400 T otal Example Cost $1,900 In this example, Peg would pay: In t his example, J oe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing D eductibles $0 Deductibles $0 Deductibles $0 Copa yments $ 6 0 Copayments $ 700 Copayments $ 200 Coinsurance $ 0 Coinsurance $ 400 Coi nsurance $ 200 What isn’t c overed What isn’t covered What isn’ t covered Limits or exclusions $60 Limits or exclusi on s $60 Limits or exclusions $0 The t otal Peg would pay is $ 120 The total Joe would pay is $ 1 , 1 6 0 The total Mia would pay i s $ 400 The plan would be respo nsible for the ot h er costs of t hese EXAMPLE covered se rv ice