2016-2017 Medical Plan Options

WOLFCHASE HONDA-NISSAN2016-2017 Medical Plan Options

Plan #1 Plan #2 Plan #3--- --- ---PJanName PPO 5000/6000 PPO 3500/5000 PPO 5000/6600

Plan Type PPO PPO PPO

IN-NETWORK BENEfiTS:Provider Network Network S Network S Network S

Provider Directory Website www.bcbst.com www.bcbst.com www.bcbst.comMethodist, St. Francis, Methodist, St. Francis, Methodist, St. Francis,

Locol Hospitals LeBonheur, Regional Medical leBonheur, Regional Medical leBonheur, Regional MedicalCenter St. Jude Center St. Jude Center St. Jude

WeI/ness SO; deductible waived $0; deductible waived $0; deductible waived

Primary Core Office Visit 30%; deductible waived 30%; deductible waived 30%; deductible waived

Specialist Office Visit 30%; deductible waived 30%; deductible waived 30%; deductible waived

Walk In Clinics 30%; deductible waived 30%; deductible waived 30%; deductible waived

Diagnostic Lab, In Physicion Office 30%; deductible waived 30%; deductible waived 30%; deductible waived

Diagnostic X-ray, In Physician Office 30%; deductible waived 30%; deductible waived 30%; deductible waived

24 Hour Telehealth (MDLive) $38 co-pay; deductible waived $38 co-pay; deductible waived $38 co-pay; deductible waived

Urgent Care, Physician Charges 30%; deductible waived 30%; deductible waived 30%; deductible waived

Emergency Room $250; deductible waived $250; deductible waived $250; deductible waived

Prescription Drugs:

Generic $8 co-pay; deductible waived $8 co-pay; deductible waived $10 co-pay; deductible waived

Pre/erred Brand $40 co-pay; deductible waived $40 co-pay; deductible waived $75 co-pay; deductible waived

Non-Pre/erred Brand $60 co-pay; deductible waived $60 co-pay; deductible waived $150 co-pay; deductible waived

Specialty $120 co-pay; deductible waived $120 co-pay; deductible waived $300 co-pay; deductible waived

Complex Imaging (MR1, CAT Scans, etc.) 30%; after deductible 30%; after deductible 30%; after deductible

Surgery 30%; after deductible 30%; after deductible 30%; after deductible

In / Outpatient Hospital 30%; after deductible 30%; after deductible 30%; after deductible

Deductible $5,000 $3,500 $5,000

Deductible, Maximum for Family x2 x2 x2

BlueCross Coinsurance 70% 70% 70%

Annual Out-oj-Pocket Maximum$6,000 $5,000 $6,600

(Includes deductible, coinsurance & co-pays)

Out-oj-Pocket, Maximum for Family x2 x2 x2

Bene/it Year Period Calendar Year Calendar Year Calendar Year

$10,000 Deductible; 50% $7,000 Deductible; 50% $10,000 Deductible; 50%OUT-Of-NETWORK BENEfiTS: coinsurance; $18,000 Out-of- coinsurance; $15,000 Out-of- coinsurance; $19,800 Out-of-

Pocket Pocket Pocket

Weeklv Employee Contributions

Single Coverage $32.01 $40.30 $24.03

Employee & Spouse Coverage $124.35 $141.75 $107.57

Employee & Children Coverage $101.68 $116.85 $87.07

Employee & Family Coverage $202.83 $227.99 $178.59All Payroll Deductions are befare-taK via our

Section 125 Cafeteria Plan

MUST ENROLL NOW OR WAIT UNTIL OPEN ENROLLMENT (MAY 1ST} UNLESS QUALIFYING FOR SPECIAL ENROLLMENT

This is a brief ovefll;ew only. Refer to your BlueCross Evidence of Coverage or the Summary of Benefits and Comparison for details.

BlueCross BlueShield of TN - Ne~o.rk 5Walk-In Clinics and Urgent Care Clinics

As of 04/7/16; bcbsl.com

Walk-In ClinicsThe Little Clinic (Kroger)11630 Highway 51 S.Atoka, TN 38004\0.(901) 837-5020

The Little Clinic (Kroger)7615 US Highway 70Memphis, TN 38133••••(901) 969-1773

The Little Clinic (Kroger)9025 Highway 64Arlington, TN 38002\0. (901) 387-2998

The Little Clinic (Kroger)11635 US Highway 70Arlington, TN 38002\0. (901) 290-9270

The Little Clinic (Kroger)1675 N Germantown PkwyCordova, TN 38016••••(901) 969-1405

The Little Clinic (Kroger)3444 Plaza AveMemphis, TN 38111••••(901) 730-4204

TakeCare Clinic (Walgreens)43 Tabb DrMunford, TN 38058\0.(855) 925-4733

TakeCare Clinic (Walgreens)6697 Stage RdMemphis, TN 38134\0. (855) 925-4733

TakeCare Clinic (Walgreens)8046 Macon RdCordova, TN 38018\0. (855) 925-4733

TakeCare Clinic (Walgreens)1863 Union AveMemphis, TN 38104\0. (855)925-4733

TakeCare Clinic (Walgreens)4680 Poplar AveMemphis, TN 38117\0. (855) 925-4733

TakeCare Clinic (Walgreens)8001 Winchester Rd,Memphis, TN 38125\0.(855) 925-4733

MinuteClinic (CVS Rx)6670 Stage RdMemphis, TN 38134\0.(866) 389-2727

MinuteClinic (CVS Rx)786 N Germantown Pkwy #TN005Cordova, TN 38018\0. (866) 389-2727

TakeCare Clinic (Walgreens)6958 Goodman RdOlive Branch, MS 38654\0.(855) 925-4733

TakeCare Clinic (Walgreens)1501 Goodman Rd WestHorn Lake, MS 38637\0. (855) 925-4733

Urgent Care ClinicsMedpost Urgent Care1520 Bonnie LaneCordova, TN 38016\0.(901) 791-9060

Methodist LeBonheurUrgent Care8035 Club PkwyCordova, TN 38016\0.(901) 758-6000

LeBonheur Urgent Care8093 Club PkwyCordova, TN 38016\0.( (901) 758-6000

LeBonheur Urgent Care50 N Dunlap StreetMemphis, TN 38103\0.( (901) 287-6756

LeBonheur Urgent Care848 Adams AvenueMemphis, TN 38103\0.( (901) 287-5437

LeBonheur Urgent Care806 Estate PlaceMemphis, TN 38120\0.( (901) 287-4000

Methodist LeBonheurUrgent Care8071 Winchester RoadMemphis, TN 38125\0.( (901) 759-2030

MedPost Urgent Care1941 S Germantown Rd,#103Germantown, TN 38138\0.(901) 624-6055

., of Tennessee

We're Here to HelpNURSELINENo question is too big or too small -

'Call us 24 hours a day, 7 days a week.

Health questions come up at all times during the day and night. Ifs noteasy to predict when you might get sick or injured. but with Nurseline.part of your BlueCross BlueShield of Tennessee health plan. nurses areavailable 24/7/365 at no cost to you.

Answers to all your medical questions are just a phone call away.Or if you prefer. connect with Nurseline via live online chat.

Advice When You Need ItNo matter what the health concern - a cut finger, child's fever, possible foodpoisoning, skin rash and sprained ankle - an experienced, caring nurse willhelp you decide what kind of care you need.

Our nurses also provide support and guidance for majorhealth care decisions.If you are thinking about surgery or facing a major health decision, youdon't have to make a decision alone. A nurse can help you make thebest choice for you and your family.

BlueHealthSOL UTI 0 N S-

++

+ + ++ ++ + ++

+PEACE OF MIND

IS JUST APHONE CALLA WAY

~

CALL NURSEUNE1-800-818-8581(OPTION 1)

1-888-308-7231 (TTY)

eCHAT ONUNEII!I log in to BtueAccess .••••

- on bcbst.com to

chat with a nurse.

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THE DOCTOR IS INON YOUR PHONE, TABLETOR COMPUTERMDLlVE,powered by BlueHealth Solutions, connectsyou with doctors 24 hours a day, 7 days a week.

Use telehealth to avoid the hassle of scheduling timewith your doctor or spending hours in an ERor UrgentCare waiting room. All you need is a telephone,smartphone, tablet or computer:

BlueHealthSOL UTI 0 N S'

LIVE

+

++ ++$38 MDLive Consultation Fe't

SAVING YOU MONEY

You pay less using telehealth thanyou would visiting an Urgent Careor Emergency Room.

• Average Urgent Care visit costs $150

• Average Emergency Room visit costs $750

LEARNMORE ABOUT HOW TOCONNECT TO A DOCTOR 24/7

When Should I Use Telehealth?

• When it's not an emergency

• When it's not easy to schedule with your doctor

• When you're traveling

• When you're too busy to go to your doctor's office

•Visit bcbst.com/blueaccessand select the My Health andWellness tab.

Or call 888-283-6691

What Common ConditionsCan Telehealth Doctors Treat?

Common PediatricConditions Include:'"

• Allergies

• Asthma• Bronchitis• Cold & flu• Ear infections

• Fever• Infections

• Sinus infections

• Respiratory infections• Skin infections• Sore throat• Sports injuries

• Urinary Tract infections• And more"

• Cold & flu• Constipation

• Ear infections

• Fever• Nausea• Pink eye• Vomiting

• Some stale exckNons apply

•.Some state laws require that a doctor can only prescribe medicationin certain situations and can be subject to certain bmitation~ &IueCfCKSrnerrtl>m should ha~e their presaiptions flUed at a networil pharmacyIn compllaoc(' with the 81ue{rms drug formulary.

-Children under the age of 2 with a fever wiUbe automatically sentto the pediatridan on call.

• tJof Tennessce

How Do IUse Telehealth?

You can connect with a doctor via the phone or the internet.

Registering for MDLlVE is simple. Be sure to have the primarysubscriber's birthday and Social Security Number handy.

• Visit bcbst.comjblueaccess• Complete and confirm your medical history

(this can be completed before your consultation)

• Request a consultation• Stand by for your doctor to contact you for

your consultation

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50% after DeductibleNot Covered

50% after Deductlble50% after Deductlble50% after Deductlble50% after Deductlble50% after Deductlble50% after Deductible

$250 Copay70% after Deductlble

50% after Deductlble50% after Deductlble50% after Deductible50% after Deductlble50% after Deductlble50% after Deductlble50% after Deductible

50% after Deductible50% after Deductible70% after Deductible

50% after Deductlble

50% after Deductlble50% after Deductible50% after Deductlble50% after Deductlble50% after Deductlble50% after Deductible

50% after Deductible50% after Deductible

$10,000$20,000

$18,000$36,000

50% after Deductible

50% after Deductlble50% after Deductible50% after Deductible

To age 26Not Included

Qt-d-Netv.a1< Benefits

70% after deductible70%

58/$401$60 Copays$120 Co a

70% after Deductible100%

70'% after Deductible

70%70%

70% after Deductible70%

70% after Deductible$120 Co a

70% after Deductible70% after Deductible70% after Deductible

Netv.a1<Benefits


$5,000$10,000

$6,000$12,000


70% after Deductible70% after Deductible

70%70% after Deductible70% after Deductible70% after Deductible

$250 Copay70% after Deductible

100%100%100%100%100%100%100%

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BlueCross BiueShield ot Tennessee, Inc., an Independent licensee of the BlueCross BlueShleld AssociationiIil Registered Marks of the BlueCross BlueStlleld Association, an Association of Independent BiueCross BlueShield Plans

Preventive Health ServicesCovered at 100% In-NetvI.o1<

IIHleIv.ori<p-evenlille selVices that are COIIeJ"l!d""th no cost share include:• Prirrnry care selVices \lith an Aor B recaiiieldalion by the United Slates PreIIenliIleServices Task Face (USPSTF)• Irmunizations recorrrrended by the Advisay Cormittee on Irnnrization Practices that haYe been adorted by the

Centers for Disease Cortrol and PreIIenlion (CDC)• Briftlt FUltres recomrendations for inflrts, chil<t"enand adolescents that lre supported by the HeaJth Resolrces and

Services A<hiristration (!-RiA)• PreIIenliIlecare and screening for\Wr1"el1as provided in the gidelines supported by fflSA

The folloMng preventive care services are CXl'Jered.Coverage of some services rmy depend on age and'or risk expo5U'e.A111VmiJels:

• Q1e.a.year p-evenliIIe health exams. More freq.Jent preventille exam; are COIIeJ"l!dfor clil<t"en up to age 3• Allstandard imrunizations adop:ed by the CDC• Screening for coIorecta1 cancer (age 50--<5), hig, cholesterol and lipids, hig, blood pressure, obesity, dabeles, and

dep"ession• Screening for HV and certain sexually transrritted dseases, and COUlSeIingfor the prevention d sexually transrriIted

dseases• Screening and counseling in prirmry care setting for alcohol nisuse and tOOaccouse; tOOaccocessation COUlSeIingin

the primary care setting ""II be lillited to eiftlt visits per~• Dietary COUlSeIingfor aWIts \lith hyper1ipidenia, hypertension, Type 2 diabetes, obesity, coronary atei)' disease and

congestille heart faih.ll!; lillited to six visits per ~1rbre1:

• ArrwI v.el1.......,.,..",visit, including anruaI sexuallytransrritted infection (sn) oounseling and amuaI dorrestic violencescreening &COUlSeIing

• Cervical Cancer Screening• Screening d ~ \Wr1"eI1for anenia, iron deficiency, bacteriuia, hepatitis B virus, Rh factor i,m. p3tibility,

gestational dabetes• Breaslfeedng Sl4JIXlrfIoounseling& supplies (om lactation consultant visit and rranuallreast Plfill in conjunction \lith

each birth)• Counseling \Wr1"eI1at high risk d Ireast cancerfor d e, Cpievention, inclucing risks and benefits• Mil iii ll!JIapliy screening at age 40 and wer, and evaluation for genetic testing for BRCAIreast cancer gene• Osteqxrosis screening (age 60 or older)• ff'V testing once I!IIeI"Y3 years, begnring at age 30• ArrwI HV screening and oounseling• FIJA.apJrcM!d contraceptille rmthods and oounseling

Mrlcal plan: Injectable or inpantable honnoo"" ca Ibaeepives and barrier rTEthods, sterilization for \Wr1"eI1Rx plan: Generic oral & irjectable contraceptives, vagnal contraceptive, patch, prescription enegellcycaltlaeepion

M>n:

• Prostate cancer saeening at age 50 and older• Abdorrinal aortic aneu-ysm saeening at age 65 --<5 (for men v..hohaYefNer"srroked)

Q1i1cren:• Nev.bom screening for hearing, phenylketoruia (PKU),thyroid dsease, siclde cell anenia, and cystic fibrosis• Delle/oprrent delays and autism screening• Iron deficiency saeening• Vision screening• Screening for rmjor depressiYe disorders

BlueCross BlueShield of Tennessee, Inc., an Independent Lic8nS&8 of !he BlueCross BlueShiekl Association€l Regis!ered MalitS of the BluGCross BlueShield Association, an Association ollndepeodenl BlueCross BlueShield Plans

~lijorTcnncssec:Wolfchase Honda-Nissan Medical (OPT#l)Summary of Benefits & Coverage: What this Plan Covers & What it Costs

Coveraf.:e Period: 05/01/2016 - 04/30/2017Coverage for: Individual or Family I Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the coveragedocument at www.bcbst.com or by calling 1-800-565-9140. Coverage documcnts are not available until after the effective date of yourcoverage, but you may obtain a sample at http://www.bcbst.com/samplepolicy/2016/LG.This sample may not match your benefitsexactly, so you should review your coverage document once it is available.Contributions made by you and/or your employer to health savings accounts (HSAs), flexible spending arrangements (FSAs), or healthreimbursement arrangements (HRAs) may help pay Yo.!lrdeductible or other out-of-pocket expenses.

Important Questions I Answers I Why this Matters:In-network: $5,000 person/$10,000 You must pay all the costs up to the deductible amount before this plan beginsfamily

What is the overall Out-of-network: $10,000 to pay for covered services you use. Check your policy or plan document to see

deductible? person/$20,000 family when the deductible starts over (usually, but not always, January Ist). See the

Doesn't apply to preventive care. chart starting on page 2 for how much you pay for covered services after you

Copays do not apply to the deductible. meet the deductible.

Arc there otherYou don't have to meet deductibles for specific services, but see the chartdeductibles for specific No.

services? starting on page 2 for other costs for services this plan covers.

Is there an out-of- Yes. In-network: $6,000 The out-of-pocket limit is the most you could pay during a coverage periodpocket limit ou my person/$12,000 family (usually one year) for your share of the cost of covered services. This limit heIpsexpenses? Out-of-network: $18,000 you plan for health care expenses.oerson/$36,000 familyWhat is not included in Premium, balance-billed charges, Even though you pay these expenses, they don't count toward the out-of-pocketthe out-of-pocket penalties, and health care this plan limit.limit? doesn't cover.Is there an overall

The chart starting on page 2 describes any limits on what the plan will pay forannual limit on what No.~planEYs? specific covered services, such as office visits.

Yes. This plan uses Network S. For a If you use an in-network doctor or other health care provider, this plan will pay

Docs this plan usc a list of iu-network providers, see some or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use thenetwork of providers? www.bcbst.com or call 1-800-565- term in-network, preferred, or participating for providers in their network. See9140.the chart starting on page 2 for how this plan pays different kinds of oroviders.

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.Questions: Call 1-800-565-9140 or visit us at www.bcbst.com.If you aren't clear about any of the underlined tenns used in this fonn, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 1-800-565-9140 to request a copy.

1 of 8(G'1,#/Q#B47/HCR)

You can sec the specialist you choose without pennission from this plan.

Some of the services this plan doesn't cover arc listed on page 5. See your policyor Ian document for additional infonnation about excluded services.

I Why this Matters:. ..

Yes.•

Important Questions I Answers

• •00 I need a referral tosec a s ecialist?Arc there services this)Ian doesn't cover?

• Copayments arc fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Co-insurance is your share of the costs ofa covered service, calculated as a percent of the allowed amount for the service. For example,

if the plan's allowed aJllount for an overnight hospital stay is $1,000, your co-insurance payment 01'20% would be $200. This maychange if you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stayand the allowed aJllount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to usc in-network providers by charging you lower deduetibles, eo-pavments and co-insurance amounts.

CommonServices You May Need ~ L1ml"fl",&.""llomMedical Event

Primary care visit to treat an 30% co-insurance 50% co-insurance none~.!11)' or illness

If you visit a health Specialist visit 30% co-insurance 50% co-insurance none

care provider's Therapy visits limited to 20 per lype per

office or clinic Other practitioner office visit 30% co-insurance 50% co-insurance year. Cardiac/Pulmonary Rehab visitslimited to 36 per type per year.

Preventive care / screening / No Charge 50% co-insurance noneimmunizationDiagnostic test (x-ray, blood 30% co-insurance 50% co-insurance nonework)

If you have a test Imaging (CT/PET scans, Prior Authorization required. Your costMRIs) 30% co-insurance 50% co-insurance share mav increase to 60% if not obtained.

If you need drugs to 30-day supply retail; up to 90 day supplytreat your illness or Generic drugs $8 co-pay 50% co-insurance home delivery or Select90 network. Co-condition pay per 30-day supply.More infonnation 30-day supply retail; up to 90 day supplyabout prescription Preferred brand drugs $40 co-pay 50% co-insurance home delivery or Select90 network. Co-drug coverage is pay per 30-day supply. When a Brand Drugavailable at is chosen and a Generic Drug eauivalent is

03/301201605:50 PM 2or8

CommonI s,~,~,y"M., N""

I

Your cost if you lise a

I Lim''''',", & E"'p",m---

iOut-Of-NetworkMedical Event In-Network I'rovider Provideravailable, Your eost share will increase by

www.bcbst.com. Non-preferred brand drugs $60 co-pay 50% co-insurance the difference between the cost of theBrand Drug and the Generic Drug.

Self-Administered Specialty $120 co-pay at specialty Not Covered Up to a 30 day supply. Must use adrugs pharmacy network pharmacv in Specialty pharmacy network.

Facility fee (e.g., ambulatory Prior Authorization required for certain30% co-insurance 50% co-insurance outpatient procedures. Your cost share

If you have surgery center)may increase to 60% if not obtained.

outpatient surgery Prior Authorization required for certainPhysician/surgeon fees 30% co-insurance 50% co-insurance outpatient procedures. Your cost share

may increase to 60% if not obtained.Emergency room services $250 co-pay/visit $250 co-pay/visit nonc

If you need Emergency medical30% co-insurance 30% co-insurance none

immediate medical transportation

attention See Limitations & See Limitations & Urgent Care benefits are determined byUrgent care

Exceptions Exceptions place of service, such as physician's officeor ER.

If YOIl have a Facility fee (e.g., hospital 30% co-insurance 50% co-insurance Prior Authorization required. Your costroom) share may increase to 60% if not obtained.hospital stayPhysician/surgeon fee 30% co-insurance 50% co-insurance none

Mental/Behavioral health Prior Authorization required for electro-

outpatient services 30% co-insurance 50% co-insurance convulsive therapy (ECT). Your cost sharemay increase to 60% if not obtained.

If you have mental MentallBehavioral health 30% co-insurance 50% co-insurance Prior Authorization required. Your costhealth, behavioral inpatient services share may increase to 60% if not obtained.health, or substance

Substance use disorder Prior Authorization required for electro-abuse needs


Substance use disorder 30% co-insurance 50% co-insurance Prior Authorization required. Your costinpatient services share may increase to 60% if not obtained.Prenatal and postnatal care 30% co-insurance 50% co-insurance none

If you are pregnant Delivery and all inpatient 30% co-insurance 50% co-insuranceservices nonc

03/30/201605:50 PM 30f8

I

I Your cost if YOIllise a ICommon ,

, - -

I -Ollt-Of-NetworkMedical EvcntI Services YOIIMay Necd I

III-Network ProvidcrLimitations & Exceptions

II

Provider -__J__________________ J J_ .. - . - .- . . ,~ .. ... ----Home health care 30% co-insurance 50% co-insurance Limited to 60 visits.Rehabilitation services 30% co-insurance 50% co-insurance Therapy limited to 20 visits per type per

Habilitation services 30% co-insurance 50% co-insurance year. Cardiac/Pulmonary Rehab limited to36 visits per year.

If you need help Skilled nursing care 30% co-insurance 50% co-insurance Skilled Nursing and Rehabilitation Facility

recovering or have limited to 60 days/year combined.

other special health Prior Authorization may be required for

needs Durable medical equipment 30% co-insurance 50% co-insurance certain durable medical equipment. Yourcost share may increase to 60% if notobtained.Prior Authorization required for Inpatient

Hospice service No Charge 50% co-insurance Hospice. Your cost share may increase to60% if not obtained.

Eye exam Not Covered Not Covered noneIf your child needs

Glasses Not Covered Not Covered nonedental or eye careDental check-up Not Covered Not Covered none

03/30/201605:50 PM 40£8

Excluded Serviccs & Other Covercd Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture • Hearing aids for adults • Routine eye care (Adult)• Bariatric surgery • Infertility treatment • Routine eye care (Children)• Cosmetic surgery • Long-term care • Routine foot care for non-diabetics• Dental care (Adult) • Private-duty nursing • Weight loss programs• Dental care (Children)

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for theseservices.)

• Chiropractic care • Hearing aids for children under 18 • Non-emergency care when traveling outsidethe U.S.

Your Rights to Continue Covel'age:If you lose coverage under the plan, then, depending upon the circumstances. Federal and State laws may provide protections that allow you to keephealth coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than thepremium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-565-9140. You may also contact your state insurancedepartment, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa. or the U.S.Department of Health and Human Services at 1-877-267-2323 x61565 or www.ccHo.ems.gov.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appcal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact:

• Your Plan at 1-800-565-9140 or www.bcbst.eom.• The Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.• Consumer Insurance Services within the Tennessee Department of Commerce and Insurance at 1-800-342-4029 or visit

www.tn. govIi ns \I ra neelconsnmer Res.sh tm I.Additionally, a consumer assistance program can hclp you file your appeal. Contact the Tennessee Department of Commerce and Insurance (TDCI)at 1-800-342-4029, https:llsbs-tn.naic.org/Lion-W eb/serv let/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanish Version=N , or emailthem at [email protected]. You may also write them at 500 James Robe11sonPkwy, Davy Crockett Tower, 6th Floor, Nashville, TN37243.

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policydoes provide minimum essential coverage.

03/301201605:50 PM 50r8

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of bene fits of a health plan. The minimum value standard is 60% (actuarial value).This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:Spanish (Espanol): Para obtener asistencia en Espanol, llame al 1-800-565-9140.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140.Chinese (tf'::X::): froJIHm~tf'::x::i¥J'/iIiJlh, i1ft£:jJ~l'i'}li!!1-800-565-9140.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-565-9140.

---------To seeexamplesofhowthisplanmightcovercostsfor asamplemedicalsitl/ation,seethenextpage.--------

03/30/201605:50 PM 6 of 8

About these CoverageExamples:

Having a baby(normal delivery)

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

• Amount owed to providers: $5,400• Plan pays $3,700• Patient pays $1,700

SamJlle care costs:--Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100I Total $5,400

Patient pays:Deductibles-----------y---=$::-O

Copays $1,400Co-insurance $300Limits or exclusions $01T0tai $1,700J

$5,000$50$700$30

$5,7S0J


Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40

!cTotal $7,540

Patient p~ys:'----------,--,----DeductiblesCo~sCo-insuranceLimits or exclusionsiTotal

This isnot a costestimator.

Don't use these examples toestimate your actual costsunder this plan. The actualcare you receivewillbedifferent from theseexamples, and the cost ofthat care willalso bediffcrcnt.

See the next page forimportant information aboutthese examples.

These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, how muchfinancial protection a sample patient might getif thcy are covered under different plans.

03/301201605:50 PM 7 of8

~~onbnnosscc:Wolfchase Honda-Nissan Medical (OPT#l)Coverage Examples

Coverage Period: 05/01/2016 - 04/30/2017Coverage for: Individual or Family I Plan Type: PPO

8of8

Can I use Coverage Examples tocompare plans?

v'"Yes. When you look at the Summary ofBenefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the"Patient Pays" box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider whcn comparing plans?

v'"Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you'll pay in out-of-pocket costs, such as copayments,deductibles, and co-insurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.

-

Does the Coverage Example predictmy future expenses?

Does the Coverage Example predictmy own care needs?

X No. Treatments shown are justexamples. The care you would receive forthis condition could be different based onyour doctor's advice, your age, howserious your condition is, and many otherfactors.

For each treatment situation, the CoverageExample helps you sec how deductibles,copavments, and co-insurance can add up.It also helps you sec what expenses might beleft up to you to pay because the service ortreatment isn't covered or payment islimited.

Costs don't include premiums .Sample care costs arc based on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren't specific to aparticular geographic area or healthplan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based onlyon treating the condition in theexample.The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have beenhigher.

•

•

•

•

•

••

X No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Questions: Call 1.800-565-9140 or visit us at www.bcbst.com.(fyou aren't clear about any of the underlined terms used in this form, sec the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1.800-565-9140 to request a copy.

Questions and answers about the Coverage Examl!les:-----What are some of the assumptions What does a Coverage Examplebehind the Coverage Examples? show?

Wifd1ase t-trda-NSS<r1tIeclca Aa18",_55'11al16

GroupN1me:Netv.ak:E1fectiw Date:+.~lIIueCIll" llIucShlcld

r.•' M of1clHll"SS<.'C. .A ~iJrrntl' rlmBI eC pJ ~ 'uw>.;' ." , •••.~lU~'CO') " ,~.~ 'Ii'll"" >II:Cktioo tuTber. 2PPO BenefitsBeneIiI Feabres Nel1Mx1<PrcMders Q.t-of-Nelv.ak PrcMders [21Arn.JaIlJeWdible

Irm;o..a $3,500 $7,000Fari~ $7,000 $14,000

....-..a Q.i-<t __ Maxim.mAm:llrtIrd-.rlJa $5,000 $15,000Fari~ $10,000 $30,000

Dependert />g> UITit To age 264th Q.JartB" DedJctibie Pt'cMsim Not IncludedIlenefits fa' CcNered Services Nel1Mx1<Ilenefits OJI-of-Nelv.ak Benefits f2I~oner afire Services

f\'irmy CareO'lire"sits 70% 50% after DeductibleSI>rii", O'lireI.isits 70% 50% after DeductibleO'lirefug6y [4151[6] 70% after Deductible 50% after DeductibleFb..OreDagmic lID, X-Ray,& I 'ediors 70% 50% after Deductible

l<Mrarl-do;i":t ~~[~?b'?1 70% after Deductible 50% after DeductibleFm,;OO'-Mri~sl_' 1 $120 CODay 50% after Deductible

--., filaIth Care SeniicesIIIlJIOild Care(to<ge6) 100% 50% after DeductibleI>mJa IIIlJIWnm Born 100% 50% after Deductible.Arn..a Wa iii OJ ap ryScrea1rg - cgl: 40+- 100% 50% after DeductibleI>mJa Cffi,;caQrca- Sae<nrg 100% 50% after DeductibleI>mJa _e Qrca- Sae<nrg - '9' 50+ 100% 50% after DeductiblelrrTTlJ"izaicrs(~"f~, 100% 50% after DeductibleIIIlJICareSe;;= 6 a-d on\f141 100% 50% after Deductible

Seniices Receiwd at a Facility(includes ~essIooaI aldfacility __ )lrp3lieriSe;;= [3][51 70% after Deductible 50% after DeductibleQ.lpfu1 fug6y [4151[6] 70% after Deductible 50% after DeductibleFb..OreDagmic~eri 70% 50% after DeductibleI<Mrarl Raidq;jca l"..,grg{).jpatieri [3][5][7] 70% after Deductible 50% after Deductible_-Mri~_ ~atyCl1..gs(12] 70% after Deductible 50% after DeductibleCltffC>.ll>iieri-(8) 70% after Deductible 50% after Deductible

~Ccre=~, $250 Copay $250 CopayCare 'cal 70% after Deductible 70% after Deductible

MrlcaJ Eq..ipmrtDra1le tIeclca EqjIJTlrt 70% after Deductible 50% after Deductible- 70% after Deductible 50% after DeductibleOth:iiC:-';;:"ia'02S 70% after Deductible 50% after Deductible

BehavIoralfilaIth1rp3liert:~irritedd<r,sp"caff'da' ana _ p<ricd 70% after deductible 50% after Deductible

, '~irrit<rlcJa.:S "" caErda' ana _ ooiod 70% 50% after Deductible1herapeliic Seniices [9]'~'"' ~"'Io20J6""" •......•_""""" 70% after Deductible 50% after Deductible

Skilledtusirg Facility& _litaIia1 FacilitySeniices [3][5JUnitedtooo"""'-o::rrtired 70% after Deductible 50% after Deductible

Ibn> ~ Seniices [3]Urritedtooo"",ts P"a-na _t ooriod 70% after Deductible 50% after Deductible

Seniices 100% 50% after DeductibleArrtU<I1C8 Service 70% after Deductible 70% after DeductiblePIaTmcy

Fresai~ ~J;~li\ $8/$401$60 Copay. 50% after Deductible, 11 1 1 $120 CODay Not Covered

Noles,1. Urritaticns cr.dExdl..SO'ls.1l'ese ~&.mT'EIize tte t:tnIitsd ~ heath cae p.n Ya.r E\rtdm:;ed C'o.e'age(EO:) 8"d ridl:rsaiine ttefUJ term>cn::la::rdli<ns in gettEI'dEtal. SoJd <nj QJESicnsaise cx::ro:rrinJ t:xn3its, t!"eEo::: '.'.ingMm Fa a CXJ'I"Pa.eliS.d lirritaicns cr.dOOl.Scn>. pease mer 10'PI' ECC.

2. OJ-d-ll£tV.ak benefrtp:rynu1 t:esed00 Bl.lEOt:ssBueSield cITErreSSee ITQlCirnrn alcwije ctage. Yw a-e resp:n::itle fa p:r,1rg<nj a'TO.J'tem:e::Irg t!"errmoirnrnalo.o.<tJe daga

3. Req..irespia a.ttoizatial.4. Cert<inQ1pEfut SJg;Jies arl'a ~ rrey rEQ.irepia a.At'o1zaicn5. If pia a.Jh:rizaicn is req..ired,vJol usirg ru....ak po.ms o.Sda TEn'ESSOO cr.d~ w-d-rev.ak ~ t:uaitswll be red.J:::a:llo4Q%ifpia aJtDizaIia1 is n:t ctlanOO

cr.d ~ a-e rTBicaIly f"'IfmSS'r\j. If SENces a-e n:t 1Tl':rl~ na::essaryro bn3its Vollibe !XMdErl6. SJp;riEs ird..I:E irrisicns, e>tisials, ticpges, ir;oc1ia1 trearra1s, fra:ru-e!rfWm1S. <qjiCOOcn>cIcastscr.d~irts, sAI.res, cr.d i~d<qx;asticsm1ces (e.g., cx:kn:a:J:py',

-"" """"""',7, CAT seem, PET Seem..~s. Mea- nmdne cn::lcther siniJa-ta:trdcges.a IrdLdesse"kes 9..dlas d aid! ai4'Y, r;:d<ti(ntha'apf, 8"d rem dayjs.9. R¥;ica, spa9l::t\ nmpJaiw, m:j ~ ~ a-e tinited to2:lvisits p3f It'ltr.'Vit)pe p:r an.£lI bendit p;rio:i Cadaccr.d pJ~l"Ehb!itali\.-e ~es lYe linited

1036_ ,.,. """'" twa,.,. •.•.•.••_ JHiad1QCquj, if WIC3je, v.ffied if a:tritle:f totn;pta.11.500a:taetaj ridErfa A"'aTmcy exr::lusicr"6crd ~ D'uJ V9"d:rs.12.Rda- IoINNN.txbsto:mfa ~ A"'aTmcy D'uJ Usl..13.Cq»J perp-esa;l1icn lPlo3:lday s..q1y.14.St:rV£esrou:1e: an.a jh,.9oi. ctil<fn:)j i~ lOCO III a dOOa:Ut irrm..rizalia's. W;im cn:l hDirg SO'8I'rirg.:; p2tf(lTT'8j IJt th3p'lySiciM dJirg the p-evErive I"eMh

""""B1ueCross BJueShield 01 Tennessee, Inc., an Independent Licensee 01 the BlueCross BlueShiekl Assodallon

@)RegisteredMarksoltheBlueCross Blue$hield Association, an Associatlon of Independent BlueCross Blue5hleld Plans

Preventive Health SelvicesCovered at 100% In-Netv..ak

1n-netv.a1<I=fflII'!IlliwsefVices that are ~ Yoithno cost share include:• Plirmry care sefVices Y.ithan Aor B meal "" idatioo by the lkIited States PreIIentiw Services Task Force (USPSTF)• lll1lU1izalioos mea Iii" ided by the Advisay ComTitlee onlmnrization Practices that have been ador'ed by theCenter.>for Disease CortroI and PreIIention (CDC)

• Bri\tll Fultres mea.lI •• idatioos for inf<rts, chilcrenand adolescents that are supported by the Health ResarcesandServices Atiriristratlon (H'lSA)

• PreIIentiw <:<reand saeening forworren as provided in the glidelines supported by IflSA

The fo/leMing preventive care services are covered.Coverage of SOITI:l services rrny depend on age and/or risk expo5lre.AllrIeniJefs:• Ole-a-year prl!IIOO!iwhealth exams. M:Jre~ prewntive exams are ~ for chilcren up to age 3• Allstandard imrunizalioos ador'ed by the CDC• Screening for coIorecla1 cancer (age 50-75), hig, cholesterol ard lipids, hig, blood pressure, obesity, dabetes, anddepression

• Screening for HVand certain sexuallytransrritled dseases, and eo<nseIing forthe prewrtion d sexually transrritleddseases

• Screening and coonseIing in prirmry <:<resetting for a1coho1llisuse and tobacco use; tobacco cessation eo<nseIing inthe prirmry <:<resetting Yoillbe Iillited to ei\tll visits per year

• Dielafy eo<nseIing for aWIts Y.ithhyper1ipidenia, hypertension, Type 2 diabetes, obesity, coronary artE!IYdisease andcongestiIIe heM failu-e; Iirrited to six visits per year

\I\bren:• Arn.JaI ".,II"'MJrTB1lvisit, including annual sexually transrritled infection (sn) coonseIing and annuaJ dorrestic violencesaeening &eo<nseIing

• Cervical Qn:er Screering• Screening d ~worrenfor anerria, iron deficiency, bacterilJia, hepatitis Bvirus, Rhfaclori, kX>lpatibility,gestational dabeles

• Breaslfeedng 54JPOf'lIcoonseIing &supplies (ore lactalionlXll1SUltantvisit and rranual treast fUll' in conjLnClionYoitheach birth)

• Counselingworren at high riskdtreast cancerfor d •• ""pol!llelllion, includng risks and benefits• W•• ill "!Jiapl ryscreening at age 40 and wel", and evaluation for genetic testing for BRCAtreast cancer gere• Osteoporosis saeening (age 60 or older)• If'Iftesting once every 3 years, beginring at age 30• Arn.JaI HV saeening and coonseIing• fDA.arJl:rowd contracertiw rrethocIs and coonseIingWedicalplan: Injectable or implantable 1•• 11•• "" COlltaceptives and banier rrethods, sterilization for worrenRx plan: GenericoraJ &irjectabie ~ vaginal contracertiw, patch, presaijXionell"gelicycolll1aceplion

1Ven:

• Prostate cancer screening at age 50 and older• AI:xlaTinalaortic 3I'leU)'SI11saeening at age 65-75 (for rren v.no have ever sm:lked)O1ilcren:• iIIeI.Ibomsaeening for hearing, phenylketonuria (PKU),thyroid dsease, sickle ceil anerria, and cystic fibrosis• DeYeloprrent delays and autism screening• Iron deficiency screening• Vision saeening• Screening for rmjor depressiw dsorders

BlueCrass BlueShield of Tennessee, Inc., an Independent Llcen~ or the BlueCross BlueShield Association~ Registered MarKs althe BlueCross BlueShield Association, an AssociatiOn of Independenl BlueCrnss BlueSh1e1d Plans

. 'rm~OfTennCSScc:Wolfchase Honda-Nissan Medical (OPT#2)Summary of Benefits & Coverage: What this Plan Covers & What it Costs


This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the coveragedocument at www.hehst.com or by calling 1-800-565-9140. Coverage documents arc not available until after the effective date of yourcoverage, but you may obtain a sample at http://www.bchst.colll/salllplepolicy/2016/LG.This sample may not match your benefitsexactly, so you should review your coverage document once it is available.Contributions made by you and/or your cmploycr to hcalth savings accounts (HSAs), flcxiblc spcnding arrangemcnts (FSAs), or hcalthreimbursement arrangcments (HRAs) may help pay your deductible or other out-of-pocket expenses.

Important Questions I Answers I Why this Matters:In-nctwork: $3,500 person/$7,000

You must pay all the costs up to the deductible amount before this plan beginsfamilyWhat is the overall Out-of-network: $7,000 to pay for covered services you usc. Check your policy or plan document to sec

deductible? person/$14,000 family when the deductible starts over (usually, but not always, January Ist). Sec the

Doesn't apply to preventive care. chart starting on page 2 for how much you pay for covered services after you

Copays do not apply to the deductible. meet the deductible.

Arc there otherYou don't have to meet deductibles for specific services, but see the chartdeduetibles for specific No. starting on page 2 for other costs for services this plan covers.services?

Is there an out-of- Yes. In-network: $5,000 The out-of-pocket limit is the most you could pay during a coverage periodperson/$IO,OOOfamilypocket limit on my Out-of-network: $15,000 (usually one year) for your share of the cost of covcrcd scrviccs. This limit hclpsexpenses? oerson/$30,000 family you plan for health carc expenses.

What is not included in Premium, balance-billed charges, Even though you pay these expenses, they don't count toward the out-of-pocketthe out-of-pocket penalties, and health care this plan limit.limit? doesn't cover.Is there an overall The chart starting on page 2 describes any limits on what the plan will pay forannual limit on what No.the ohm ~s? specific covered services, such as office visits.

Yes. This plan uses Network S. For a If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orDoes this plan use a list of in-network providers, sec hospital may usc an out-of-network provider for some services. Plans use thenetwork of providers? www.bcbst.com or call 1-800-565- tenn in-network, preferred, or participating for providers in their network. Sec9140. the chart starting on page 2 for how this plan pays different kinds of nroviders.

BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.Questions: Call 1-800-565-9140 or visit us at www.hcbst.colll.If you aren't clear about any of the underlined tenns used in this fonn, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossal.y.pdfor call 1-800-565-9140 to request a copy.

1 of 8(Grp#/Q#B48/HCR)

Important Questions I Answers I Why this Matters:Do T need a referral to No. You don't need a referral to see a

You can sec the specialist you choose without permission from this plan.see a snecialist? specialist.Are there services this Yes. Some of the services this plan doesn't cover are listed on page 5. See your policyplan doesn't cover? or plan document for additional infonnation about excluded services.

• Copavments are fixed dollar amounts (for example, $15) you pay for covered health care, usually whcn you rcceive the service.• Co-insurance isYOllr share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example,

ifthc plan's allowed amount for an ovcmight hospital stay is $1,000, your co-insurance paymcnt of20% would bc $200. This maychange if you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an ovemight stayand the allowed amonnt is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in-network providers by charging you lowcr deductibles, co-pavments and co-insurance amounts.

Common IS'NI~ y" M.,N,,' ~ Limli.",,,& E,"pli'"Mcdical Evcnt

Primary care visit to treat an 30% co-insurancc 50% co-insurance nonelJ!1j~1)'or illness


care provider's Therapy visits limitcd to 20 per type per

office or clinic Other practitioner office visit 30% co-insurance 50% co-insurance ycar. CardiacfPulmonary Rehab visitslimited to 36 per !)'pe per year.

Preventive eare / screening / No Charge 50% co-insurance noncimmunizationDiagnostic test (x-ray, blood 30% co-insurance 50% co-insurance nonework)

If you have a test Imaging (CT/PET scans, Prior Authorization required. Your costMRls) 30% co-insurance 50% co-insurance share may increase to 60% if not obtained.

If you need drugs to 30-day supply retail; up to 90 day supplytreat your illness or Generic dmgs $8 co-pay 50% co-insurance home delivery or Select90 network. Co-condition pay per 30-day supply.More information 30-day supply retail; up to 90 day supplyabout prescription Preferred brand drugs $40 co-pay 50% co-insurance home delivery or Select90 network. Co-drug coverage is pay per 30-day supply. When a Brand Drugavailable at - is chosen and a Generic Dmg equivalent is

03/301201605:51 PM 2 of 8

I '<IT"" Yo. M" N«dYour cost if ou use a

CommonLimitations & ExceptionsMedical Event In-Network Provider Out-Of-Network

Provider

available, Your cost sharc will incrcasc bywww.bcbst.com. Non-prefcrrcd brand dmgs $60 co-pay 50% co-insurance the differencc bctween the cost of the

Brand Dmg and the Gcncric Drug.Sclf-Administered Specialty $120 co-pay at specialty Not Covcrcd Up to a 30 day supply. Must use adrul!s pharmacy network pharrnacy in Specialty pharmacy network.

Facility fee (e.g., ambulatory Prior Authorization required for ccrtain30% co-insurance 50% co-insurancc outpaticnt procedurcs. Your cost sharc

If you have surgcry center)may_increase to 60% ifnot obtained.

outpatient surgery Prior Authorization required for certainPhysician/surgcon fees 30% co-insurance 50% co-insurancc outpatient procedures. Your cost share

may increase to 60% if not obtaincd.Emcrgcncy room scrviccs $250 co-pay/visit $250 co-pay/visit nonc

Tfyou need Emcrgency medical 30% co-insurancc 30% co-insurance noncimmediate medical transportation

attention See Limitations & See Limitations & Urgcnt Care benefits arc detemlincd byUrgent care Execptions Execptions place of service, such as physician's office

or ER.

If you have aFacility fee (e.g., hospital 30% co-insurance 50% co-insurancc Prior Authorization required. Your costroom) share may increase to 60% if not obtained.hospital stayPhysician/surgeon fee 30% co-insurance 50% co-insurance none

Mcntal/Behavioral health Prior Authorization required for electro-


If you have mental MentallBehavioral health 30% co-insurance 50% co-insurance Prior Authorization required. Your costhealth, behavioral inpatient services share may incrcase to 60% ifnot obtained.health, or substance Substance usc disorder Prior Authorization required for electro-abuse needs outpatient serviccs 30% co-insurancc 50% co-insurance convulsive thcrapy (ECT). Your cost share

may increasc to 60% if not obtained.Substance use disorder 30% co-insurancc 50% co-insurancc Prior Authorization required. Your costinpatient serviccs share may increasc to 60% ifnot obtained.Prenatal and postnatal care 30% co-insurance 50% co-insurance none

Tfyou are pregnant Delivery and all inpatient 30% co-insurancc 50% co-insurancc noncservices

03/30/201605:51 PM 3 of 8

II Your cost if you use a I

Common I - - ,M d' I E I Services You May Need , Out-Of-Network : Limitations & Exceptionse Ica vent In-Network Provider Provider L_____----------- ------ ,- ,- -

Home health care 30% co-insurance 50% co-insurance Limited to 60 visits.Rehabilitation services 30% co-insurance 50% co-insurance Therapy limited to 20 visits per type per


If you need help Skilled nursing care 30% co-insurance 50% co-insurance Skilled Nursing and Rehabilitation Facilityreeovering or have limitcd to 60 days/year combined.

other special health Prior Authorization may be required forneeds Durable medical equipment 30% co-insurance 50% co-insurance certain durable medical equipment. Your

cost share may increase to 60% if notobtained.Prior Authorization required for Inpatient

Hospice service No Charge 50% co-insurance Hospice. Your cost share may increase to60% if not obtained.

Eye exam Not Covered Not Covered noneIf your child needsGlasses Not Covered Not Covered nonedental or eye careDental check-up Not Covcrcd Not Covercd none

03/30/201605:51 PM 40f8

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture • Hearing aids for adults • Routine eye care (Adult)• Bariatric surgery • Infertility treatment • Routine eye care (Children)• Cosmetic surgery • Long-term care • Routine foot care for non-diabetics• Dental care (Adult) • Private-duty nursing • Weight loss programs• Dental care (Children)


• Chiropractic care • Hearing aids for children under 18 • Non-emergency care when traveling outsidethe U.S.

Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keephealth coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than thepremium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-565-9140. You may also contact your state insurancedepartment, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa. or the U.S.Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact:

• Your Plan at 1-800-565-9140 or www.bcbst.com.• The Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.• Consumer Insurance Services within the Tennessee Department of Commerce and Insurance at 1-800-342-4029 or visit

www.tn.gov/insuranee/eonsumerRes.shlm I.

Additionally, a consumer assistance program can help you file your appeal. Contact the Tennessee Department of Commerce and Insurance (TDCI)at 1-800-342-4029, https:llsbs-tn.naic.org/Lion- Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spallish Version=N , or emailthem at [email protected]. You may also write them at 500 James Robertson Pkwy, Davy Crockett Tower, 6th Floor, Nashville, TN37243.

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policydoes provide minimum essential coverage.

03/30/201605:51 PM 50f8

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits ofa health plan. The minimum value standard is 60% (actuarial value).This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:Spanish (Espaiiol): Para obtencr asistcncia en Espaiiol,llame al 1-800-565-9140.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140.Chinese (9=')(): .!m*fr7i~9=')(I¥Jr1I!JJiJ, ~Utn~l'{}li!!J 1-800-565-9140.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-565-9140.

-------- To see examples of how Ihis plall mighl cover cosls for a sample medical sill/alioll, see Ihe lIexl page.

03/30/201605:51 PM 60f8


Having a baby(normal del".cry)

Managing type 2 diabetes(routI1H: maintc:nancl:' of


$0$1,400$300$0

$1,700 I

t


Sample care cos s:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100(Total $5,400 IPatient pays:DeductiblesCopaysCo-insuranceLimits or exclusions( Total

$3,500$50

$1,100$30

$4,680 I


S

Patient I!!!~s:----------.----=:-::-::-::-:c-DeductiblesCopaysCo-insuranceLimits or exclusionsITotal

ample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40notal $7,5401


See the next page forimportant information aboutthese examples.

Don't use these examples toestimate your actual costsunder this plan. The actualcare you receivewillbedifferent from theseexamples, and the cost ofthat carewill also bedifferent.

These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, how muchfinancial protection a sample patient might getif they are covered under different plans.

03/30/201605:51 PM 70fS

~lg) of Tennessee :Wolfchase Honda-Nissan Medical (OPT#2)Coverage Examples

Covel'age Pel'iod: 05/01/2016 - 04/30/2017Coverage for: Individual or Family I Plan Type: PPO

80£8


."....Yes. When you look at the Summary ofBenefits and Coverage for other plans,you'll find the same Covcrage Examples.When you compare plans, check the"Paticnt Pays" box in each example. Thcsmaller that number, the more coveragethc plan provides.

Are there other costs I shouldconsider when comparing plans?

."....Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, thc more you'll pay in out-of-pocket costs, such as copavments,deductibles, and co-insurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or hcalth reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.

x No. Treatmcnts shown arc justexamples. The care you would rcceivc forthis condition could be different based onyour doctor's advice, your agc, howserious your condition is, and many otherfactors.



For each treatment situation, the CoverageExample hclps you see how deductiblcs,copayments, and co-insurance can add up.It also helps you sce what expenses might belell up to you to pay because the service ortreatmcnt isn't covercd or payment islimited.

Costs dOIl't include premiums .Samplc carc costs arc bascd on nationalaverages supplied by the U.S.Department of Health and HumanServices, and aren't specific to aparticular geographic arca or healthplan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andcndcd in thc same eoveragc pcriod.There arc no other medical expenses forany member covercd undcr this plan.Out-of-pocket expenses are based onlyon treating the condition in theexample.The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would havc bccnhigher.

•

•

•

•

•

•

•

Questions and answers about the Coverage Examples:What are some of the assumptions What does a Coverage Examplebehind the Coverage Examples? show?

x No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition.They are for comparative purposes only.Your own costs will bc diffcrcntdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Qucstions: Call 1-800-565-9140 or visit us at www.bcbst.com.If you aren't clcar about any of the undcrlincd tcrms used in this fonn, sce the Glossary. You can view thc Glossaryat ,~vw.dol.gov/cbsa/pdf/SBCUnirorIl1Glossary.pdf or call 1-800-565-9140 to request a copy.

mfchase 1-lTd<>NSS>lM:rl<:a AirBoo~S5'1tal16

Glll.\J tore:Netv.a1<:8fecti", Dale:

-'-"- ~ 1l111L'C",,, B111cShldd~ M ()r~lennl"Ss('C• •A ~ U., """" ~1\S~••H,flhe mucCr~~1lI~l\biddAU"'o:iMi""

..•••01ia1 f'UTIJer. 3PPO BeneIItsBenefit Feam!s _ Providers o.4-Netv.a1< Providers f21knJaIlJeclJctibie

[nct.idJa $5.000 $10.000Fmily $10.000 $20.000

knJaI Oi-of_ MaxinunArrnlrt[nct.idJa $6.600 $19.800Fmily $13.200 $39.600

lJependert />g3 Lirrit To age 264th CWrter lJeclJctibie AvJision Not IncludedBenefits for Covered Services _Benefits o.4-Netv.a1< Benefits f21Practitioner alice Services

PriJTHyQre O!ioe \lSts 70% 50% after Deductible~isl OIice \1si1s 70% 50% after DeductibleOIice &rge!y [4][51[6] 70% after Deductible 50% after DeductibleR:Uire Dagnslic L3b, )(Ray. & i~edicns 70% 50% after DeductibleAMrre:l Ra1d09ca1 [rngrg [3}[5If7J.

'?1 70% after Deductible 50% after Deductible

PttMdff.MTi~sl_. 1 $300 Conav 50% after DeductibleA1Mrti~ t-mIth cae Servicesm[ QjkjQre (10'9' 6) 100% 50% after Deductiblekrui ml Wnm 80m 100% 50% after DeductibleHn..a Wdl i IOJep iy Screa1rg - a;}34Of- 100% 50% after Deductiblekrui Cer.1ca1On:..- S7eerirg 100% 50% after Deductiblekrui Prostae On:..- S7eerirg - age 50+ 100% 50% after DeductibleIrrmrizaicns (to age 6) 100% 50% after Deductiblem[ Qre Sm.1resT";':' 6 ad' ~H141 100% 50% after Deductible

Services Received at a Facmly (includes pdesslornl Md facility cI-<rges)IrpaIi••.• Sm.1ces 13J151 70% after Deductible 50% after DeductibleQlp<iie-t &rge!y[4][51[6j 70% after Deductible 50% after DeductibleR:Uire D<glJ5tic Sm.1ce&OJlpalj••.• 70% 50% after DeductibleAMrre:l Ra:ld09ca1lrTe9rg-{)..<p3ti ••.• [3][5][7) 70% after Deductible 50% after Deductible_.Mri~slerOO ~aty I:hgs [12] 70% after Deductible 50% after DeductibleCIrEr Qlp<iie-t Sm.1res [8] 70% after Deductible 50% after Deductible&r&-gero{ Qre Sm.1res !~, $250 Copay $250 Capay

Qre AMrre:l -call 70% after Deductible 70% after DeductibleMrlca Eq,jprrert

70% after Deductible 50% after Deductiblel1r.tJe Mdcal EQ.i~Pn:JsltEIia; 70% after Deductible 50% after DeductibleOth:iicA;...iares 70% after Deductible 50% after Deductible

I3eI1<McraI-.tIirpalilrt Uilnitoo~~..m ana _ \':'~ 70% after deductible 50% after Deductible

. : LHinitEd caam an..a OO"efit . 70% 50% after Deductible1her.lpeUic Services [9J

•.••..•• "",it....vvl> 70% after Deductible 50% after Deductible'nitooto2).J6 \otsitsS<illoo ~rg Facility & Rehal:ilitalioo Facility Services [3][5]

United 1000%: o:rrtined 70% after Deductible 50% after DeductibleHam -.tI SeMces [3]

Uniloo 1060 liSts -:..-..a _t rorinoi 70% after Deductible 50% after Deductiblece Services 1000 50% after Deductible

Arrhia'x:e Service 70% after Deductible 70% after DeductiblePhaTmcy

Ptesai<1iOO~,1;1JJ;~ $101$75/$150 50% after Deductible- 111 1 $300 Conav Not Covered

""""1. Urrrtaicns a""dBa:lusialS. "Thesep:qJS9JTlTlI'izette I::e'ditsd}OJ I'1ealtlcae Pm Ycu EWBnd Co.eage (ECC)wd ri<i:.rs~netre hli tem6a""d ardtims in gmudEtail.SnJd <nf~aisean::arir9 bEr'dits, the EOCwl ga.Em Fa a D:r"!"P€te6s dlirritalcns cn::IE!lId..Sms.pease rd€£to}OJEOC.

2. OJ~ bErdrt p:!'yfT01l:Bse:l01BueO'a;s BlB9ieId d T~ rraxirrun <ik:w:tie ctage. YOJae ~~e fer pa'ylrg<nj <rTU.r1elIDn1rg the rre:xmm"",""",duge.

3. Pa:J,..irespier a..ch:malkn4. 02rtan OJ;aiert &rgaies arl'cr ~ lTB'frEQ.irepier a..dh:ri2aimS. If pier aJtni2:aial is req..irErl,Yh20wrg ne:v.ak ~ o.JSdeTuressee wd allCU<i~ ~ l:6'eti1SWli be re:iJ::a:j to 400/0if p'icr aJtoizai01 is ret d1ailOO

a-d SI:J'\K.esa-e rre:i::aly ra::1i!SSa'j. If sa'\4ceswe ret rm:tcaly ra::1i!SSa'j In t:uaits wll be ~6. $..rgt:riesi~ rosicns, elrisicns, ticpsies, lriedicn trearra1IS. fra1l.re trearTa1S. ~io:D:n; d castswd spirts, sA!..ns. al:l il'M9ve c:iag"cSicSEJ"'kes(e.g.,c:dalcBx:pJ,

-""~7. CAT sr:::cr6,F£TS:als, ~s. ru::lea'"l'l'Eddne a"d ett'a" simla' 1e::tTdc:ges.8. lrdi..des S£fVkesSl..dla:; del dle"">,, ra:iai01~, al:l ruaI d<iysis.9. ~,speech, nmpjOOw, an ~au ~ ae linit8::l to 3)'olSts P'J"~tpe p:!f a'Tl..Ii ~ I=EricdCada:al:l pJfTD'la'Y rd'l.D[itaIi\e~esae lirrilf:d

to 33 'olsilSP'J"thEJ<W't')-pep:!f aTl.B tJen:ft perb::I.1QCq:ay, if~ic3je, YBved if a7ritted to~.1'.See <tta::tlOOride' fer Rmm:::y eldlOO"6 a-d ~ty ~ \6rl:rs..12RSEt" toWNN.txb;t.cun fer sp;riaty A-am.::q 01.JJUst.13.Cq:ayp:!f ~pm, LPto:Dc2j s.wy.14.&rv;ces irdl.de: an..a~, dliktnxl il'1TTUizrocn5, lto:J IIIe dt:d ari.it irrrn.ri2alicrs ..00, <n:l heairg SO'&'rirgi pErlarTHj bt lh3 ~ dJirg the ~ t"iIE9th

"""BlueCross BlueShleld of Tennessee, Inc., an Independent licensee 01 the BIiJeCross BlueShield AssociatiOn

ilY Registered Mal1<s of the BlueCross BlueShield Assoclatlon, an Association of Independent 61ueCross BlueShield Plans

,Preventive Health ServicesCovered at 100% 1n-Netv.a1<

IIHlelv.ork pwentiw services that are covered wth no cost share include:• Prirmry care services Wth an Aor B 'ea>' i '" idation by the lAlitedStates PreIienlive Services Task Fcn:e (USPS'TF)• Inrn.mizalions recorrrmnded by the Advisory Connitlee on IlTITlrizalion Practices that haw been adorted by theCenters for Disease Cor1rol and PreI.oention(a:x::)

• Brigrt FUlIres recoo'i'" idations for inf<rts, child"en and adolescents that are supported by the Health Resolrces andServices Mrinstralion (!RiA)

• PreI.oentiwcare and saeening forv.aren as provided in the g..idelines supported by I-RSA.

The follcmng prevertive care services are covered.Coverage of sare services may depend on age and'or risk expose reoAllMerrbefs:• Qle.a-year preIIeIlliw hea/th exams. Morefreq.Jenl pwentiw exam; are covered for ctild"en up to age 3• Allstandard inrn.mizalions adcJr.tedbythea:x::• Screening for coIorecta1cancer (age 50 -75), hig, cholesterol and lipids, tog, blood pressure, obesity, dabetes, anddepression

• Screening for HVand certain sexuallytransrritled dseases, and cornseIing forthe prevertion eXsexually transrritteddseases

• Screening and coonseIing in prirmry care sel!ingfor alcohol rrisuse and tobacco use; tobacco cessation cornseIing inthe prirmry care setting wll be lirrited to eigrt visi1s per year

• Dietary cornseIing for adul1sWth hypeo1ipiderria,hypertension, Type 2 diabetes, obesity, ca 01""Y artery disease andca rgestiw heart failLre; Iirrited to six visi1s per year

\I\bren:• AmuaJ \WII-v.arm visi~ including annual sexuaJlytransrritled infection (5n) coonseIing and annuaJ dorreslic violencesaeening &cornseIing

• Cervical Qn::er Screening• Screening eXIJ1lg13rt v.aren for aneoia, iron deficiency, bacteri..;a, hepatitis B virus, Rh factor incorrpalibility,gestational dabetes

• Breastfeedng 5LWlJI1/coonseIing&supplies (ore laclalion consultant visit and rranuaJ Ireast IJlITP in conjl>1Clionwtheach birth)

• Counseling IMlfreI1at high risk eXIreast cancer for chen cpoevenlion, including risks and benefits• ria li'll!JIaphy saeening at age 40 and <Ner,and evaluation for genetic testing for BRCAIreast cancer gene• Osteoporosis saeening (age 60 or older)• H'IItesting once every 3 years, be9ming at age 30• AmuaJ HV saeening and cornseIing• fDA.app'oYed ca ,bacertiw rrelhods and counselingMedicalplan: Injectable or ifll'lanlable hOI"o "" contracepti\ll!S and bani ••.mathods, sterilization for IMlfreI1Rx plan: Generic oral &irjectablecartJacertives, vaginal contracej1ive, patch, presaiplion ••,..getlcycontraception

Men:• Prostate cancer saeening at age 50 and older• AIxIorrinal aortic anelO)'SI'Tlsaeening at age 65 -7S (for rren "'"" haw evet' srmked)Qlild"en:• NeY.bomsaeening for hearing, phenylketon..;a (PKlJ),thyroid dsease, sickle ceil aneoia, and cy.;tic fibrosis• Dewloprrent delays and autism saeening• Iron deficiency saeening• \Ilsion saeening• Screening for rrnjor depressiIII! disorders

BlueGrass BlueShield 01 Tennessee, Inc .• an Independent Licensee of the BlueCross Blue5hiekl Association~ Registered Marks 01 the BlueCross BlueShield Association, an Associatioo of Independent Bluecross 8tueShiekl Plans

• •~~ofTcnncsscc:Wolfchasc Honda-Nissan Medical (OPT#3)Summary of Benefits & Coverage: What this Plan Covers & What it Costs


This is only a summary. If you want more detail about your coverage and costs, you can get the complete tenus in the coveragedocument at www.bcbst.com or by calling 1-800-565-9140. Coverage documents are not available until after the effective date of yourcoverage, but you may obtain a sample at http://www.bcbst.eom/samplepoliey/2016/LG.This sample may not match your benefitsexactly, so you should review your coverage document once it is available.Contributions made by you and/or your employer to health savings accounts (HSAs), flexible spending arrangemcnts (FSAs), or healthreimbursement arrangements (HRAs) may help pay your deductible or other out-of-pocket expenses.

Important Questions IAnswers Why this Matters:In-network: S5,000 person/SI 0,000 You must pay all the costs up to the deductible amount before this plan beginsfamily to pay for covered services you use. Check your policy or plan document to seeWhat is the overall Out-of-network: SIO,OOO when the deductible starts over (usually, but not always, January Ist). See thedeductible? person/S20,000 family chart starting on page 2 for how much you pay for covered services after youDoesn't apply to preventive care. meet the deductible.Copays do not apply to the deductible.

Arc there other You don't have to meet deductibles for specific services, but see the chartdeductibles for specific No. starting on page 2 for other costs for services this plan covers.services?

Is there an out-of- Yes. In-network: $6,600 The out-of-pocketlimil is the most you could pay during a coverage periodpocket limit on my person/S13,200 family (usually one ycar) for your share of the cost of covered serviccs. This limit helpsOut-of-network: S19,800expenses? person/$39,600 family you plan for health care expenscs.

What is not included in Premium, balance-billcd charges, Even though you pay these expenses, they don't count toward the out-of-pocketthe out-of-pocket penalties, and health care this plan limit.limit? doesn't cover.Is there an overall The chart starting on pagc 2 describes any limits on what the plan will pay forannual limit on what No.~l!lan ays? specific covered services, such as office visits.

Yes. This plan uses Network S. For a If you usc an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orDoes this plan use a list of in-network providers, sec hospital may use an out-of-network provider for some services. Plans use the

network of providers? www.bcbst.com or call 1-800-565- term in-network, preferred, or participating for providers in their network. See9140. the chart starting on page 2 for how this plan pays different kinds of providers.

BlueCross B1ueShield of Tennessee, Inc., an Independent Licensce orthe BlueCross BlueShield Association.Questions: Call 1-800-565-9140 or visit us at www.bebst.com.If you aren't clear about any ofthc underlined tenus used in this fonu, sec the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdIYSBCUniformGlossary.pdf or call 1-800-565-9140 to request a copy.

lofS(Grp#/Q#B49/IICR)

Important Questions Answers Why this Matters:Do I need a referral to No. You don't need a referral to sec a

You can see the specialist you choose wilhout pennission from this plan.see a sDecialist? sDeeialist.Arc there services this Yes. Some of the services this plan doesn't cover arc listed on page 5. See your policyplan doesn't cover? or plan document for additional information about excluded services.

• Copavments arc fixcd dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.• Co-insurance isyollr share of the costs ofa covered service, calculated as a percent of the allowed amount for the service. For example,

if the plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This maychange if you haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than theallowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stayand the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in-network providers by charging you lower dedllctibles, co-pavments and co-insurance amounts.

Common I ""I,,, Y,," M,yN,""Your cost if you use a

Medical Event In-Network Provider Out-Of-Network Limitations & ExceptionsProvider

Primary care visit to treat an 30% co-insurance 50% co-insurance noncJ!]j.!:!!X or illness


eare provider's Therapy visils limited to 20 per type per

office or clinic Other practitioner office visit 30% co-insurance 50% co-insurance year. Cardiac/Puhnonary Rehab visitslimited to 36 per ly.££.~year.

Preventive care 1screening 1 No Charge 50% co-insurance noneimmunizationDiagnostic test (x-ray, blood 30% co-insurance 50% co-insurance nonc

If you bave a test work)Imaging (CT/PET scans, Prior Authorization required. Your costMRls) 30% co-insurance 50% co-insurance

share may_increase to 60% ifnot obtained.If yon need drngs to 30-day supply retail; up to 90 day supplytreat your illness or Generic drugs $10 co-pay 50% co-insurance home delivery or Select90 network. Co-condition pay per 30-day supply.More infonnation 30-day supply retail; up to 90 day supplyabout prescription Preferred brand drugs $75 co-pay 50% co-insurance home delivery or Sclect90 network. Co-drug coverage is pay per 30-day supply. When a Brand Drugavailable at is chosen and a Generic Drug equivalent is

03/30/201605:53 PM 2 of 8

IS""I~ Y,. M.,N••d Your cost if ou use aCommon

Limitations & ExceptionsMedical Event In-Network Provider

available, Your cost share will increasc bywww.bcbst.com. Non-preferred brand drugs $150 co-pay 50% co-insurance the difference between the cost of the

Brand Drug and the Generic Drug.Self-Administered Specialty $300 co-pay at specialty Not Covered Up to a 30 day supply. Must use adrugs pharmacy network pharmacy in Specialty pharmacy network.

Facility fee (e.g., ambulatory Prior Authorization required for certain30% co-insurancc 50% co-insurance outpatient procedures. Your cost share

If you have surgery centcr)max increase to 60% ifnot obtained.

outpatient surgery Prior Authorization required for certainPhysician/surgeon fees 30% co-insurance 50% co-insurance outpatient procedures. Your cost share

may increase to 60% ifnot obtained.Emergency room services $250 co-pay/visit $250 co-pay/visit none

If you need Emergency medical 30% co-insurance 30% co-insurance nonctransportationimmediate medicalUrgent Care benefits are detennined byattention See Limitations & See Limitations &Urgent care Exceptions Exceptions place of service, such as physician's officeor ER.

If you have aFacility fee (e.g., hospital 30% co-insurance 50% co-insurance Prior Authorization required. Your costroom) share max increase to 60% ifnot obtained.hospital stay Physician/surgeon fcc 30% co-insurance 50% co-insurance none

Mental/Behavioral health Prior Authorization required for electro-

outpatient services 30% co-insurance 50% co-insurance convulsive therapy (ECT). Your cost sharemax increase to 60% if not obtained.

If you have mental MentallBehavioral health 30% co-insurance 50% co-insurance Prior Authorization required. Your costhealth, behavioral inpatient services share max increase to 60% if not obtained.health, or substance Substance use disorder Prior Authorization required for electro-abuse needs outpatient services 30% co-insurance 50% co-insurance convulsive therapy (ECT). Your cost share

may increase to 60% if not obtained.Substance use disorder 30% co-insurance 50% co-insurance Prior Authorization required. Your costinpatient services share may increase to 60% ifnot obtained.Prenatal and postnatal care 30% co-insurance 50% co-insurance none

If you are pregnant Delivery and all inpatient 30% co-insurance 50% co-insurance noneservices

03/30/201605:53 PM 30rS

.•.

•• I

. ,

•• I Limitations & Exceptions

-Home health care 30% co-insurance 50% co-insurance Limited to 60 visits.Rehabilitation services 30% co-insurance 50% co-insurance Therapy limited to 20 visits per type per


If you need help Skilled nursing care 30% co-insurance 50% co-insurance Skilled Nursing and Rehabilitation Facilityrecovering or have limited to 60 day~ear combined.other special health Prior Authorization may be required forneeds Durable medical equipment 30% co-insurance 50% co-insurance certain durable medical equipment. Your

cost share may increase to 60% if notobtained.Prior Authorization required for Inpatient

Hospice service No Charge 50% co-insurance Hospice. Your cost share may increase to60% ifnot obtained.

Eye exam Not Covered Not Covered noneIf your child needsGlasses Not Covered Not Covered nonedental or eye careDental check-up Not Covered Not Covered none

03/30/201605:53 PM 40fS

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other cxcluded scrvices.)

• Acupuncture • Hearing aids for adults • Routine eye care (Adult)• Bariatric surgery • Infertility treatment • Routine eye care (Children)• Cosmetic surgery • Long-tenn carc • Routine foot carc for non-diabetics• Dental care (Adult) • Private-duty nursing • Weight loss programs• Dental care (Childrcn)


• Chiropractic care • Hearing aids for children under 18 • Non-emergency care when traveling outsidethc U.S.

Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keephealth coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than thepremium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more infonnation on your rights to continue coverage, contact the plan at 1-800-565-9140. You may also contact your state insurancedepartment, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.govfebsa. or the U.S.Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. Forquestions about your rights, this notice, or assistance, you can contact:

• Your Plan at 1-800-565-9140 or www.bcbst.com.• The Department of Labor's Employee Benefits Security Administration at 1-866-444-3272 or www.dol.govfebsafhealthreform.• Consumcr Insurance Scrvices within the Tennessee Department of Commerce and Insurance at 1-800-342-4029 or visit

www.tn.gov finsura ncefconsumerRes.sh tml.

Additionally, a consumer assistance program can help you file your appeal. Contact the Tennessce Department ofCommcrce and Insurance (TDCI)at 1-8()O-342-4()29,https:ffsbs-tn.naic.orgfLion- Webfservletforg.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanish Version=N , or emailthcm at [email protected]. You may also write them at 500 Jamcs Robertson Pkwy, Davy Crockett Tower, 6th Floor, Nashville, TN37243.

Does this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifics as "minimum essential coverage." This plan or policydoes provide minimum essential coverage.

03/30/201605:53 PM 5of8

Does this Coverage Meet the Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value).This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:Spanish (Espanol): Para obtener asistencia en Espanol,llamc al 1-800-565-9140.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-565-9140.Chinese ('PX): ~D*fIi'i~'Pxi¥JfflJl}J. ifH£:rri!l'{}~1-800-565-9140.Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-565-9140.

---------To seeexamplesathol\'thisplallmightcovercostsfor asamplemedicalsitl/atioll,seethenextpage.--------

03/30/201605:53 PM 60f8


Having a baby(normal delivery)

Managing type 2 diabetes(routine maintenance of


Patient p~ys:Deductibles-----------.---::$-=-O

Copays $2,300Co-insurance $300Limits or exclusions $0Total $2,600


SamJlle care costs:--Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400

$5,000$60$700$30

$5,790 I


SamJlle care costs:--Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40•Total $7,540 I

Patient ays:----------,----DeductiblesCopaysCo-insuranceLimits or exclusionsl Total


Don't use these examples toestimate your actual costsunder this plan. 'n,e actualcare you receivewillbedifferent from theseexamples, and the cost ofthat care willalso bedifferent.

Sec the next page forimportant information aboutthese examples.

These examples show how this plan mightcover medical care in given situations. Usethese examples to see, in general, how muchfinancial protection a sample patient might getif they are covered under different plans.

03/30/201605:53 PM 70r8

~lfJ.J~rTcnncsscc:WOlfchaseHonda-Nissan Medical (OPT#3)Coverage Examples

Cove.-age Period: 05/01/2016 - 04/30/2017Coverage for: Individual or Family I Plan Type: PPO

S ofS


./ Yes. When you look at the Summary ofBenefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the"Patient Pays" box in each example. Thesmaller that number, the more coveragethe plan provides.

Are there other costs I shouldconsider when comparing plans?

./ Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you'll pay in out-of-pocket costs, such as eopavments,deduetibles, and co-insurance. Youshould also consider contributions toaccounts such as health savings accounts(HSAs), flexible spending arrangements(FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocketexpenses.

x No. Treatments shown are justexamples. The care you would receive forthis condition could be different based onyour doctor's advice, your age, howserious your condition is, and many otherfactors.



For each treatment situation, the CoverageExample helps you sec how deduetibles,eopayments, and co-insurance can add up.It also helps you sec what expenses might beleft up to you to pay because the service ortreatment isn't covered or payment islimited.

o Costs don't include premiums.o Sample care costs arc based on national

averages supplied by the U.S.Department of Health and HumanServices, and aren't specific to aparticular geographic area or healthplan.

o The patient's condition was not anexcluded or preexisting condition.

o All services and treatments started andended in the same coverage period.

o There arc no other medical expenses forany member covered under this plan.

o Out-of-pocket expenses are based onlyon treating the condition in theexample.

o The patient received all care from in-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have beenhigher.

x No, Coverage Examples arc not costestimators. You can't use the examples toestimate costs for an aeomi condition.They arc for comparative purposes only.Your own costs will be differentdepending on the care you receive, theprices your providers charge, and thereimbursement your health plan allows.

Questions: Call 1-800-565-9140 or visit us at www.bebst.eom.If you aren't clear about any of the underlined terms used in this form, sec the Glossary. You can view the Glossaryat www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdfor call 1-800-565-9140 to request a copy.

Questions and answers about the Coverage ExamIJles:What are some of the assumptions What does a Coverage Examplebehind the Coverage Examples? show?

2016-2017 Medical Plan Options

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Transcript of 2016-2017 Medical Plan Options