Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community...

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1 of 16 Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX (Base Plan) Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy. A copy of your agreement can be found at https://shop.highmark.com/sales/#!/sbc-agreements. WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbs.com or by calling 1-800-544-6679. Important Questions Answers Why this Matters: What is the overall deductible? $1,000 individual/$2,000 family preferred value network, $1,500 individual/$3,000 family enhanced value network, $2,500 individual/$5,000 family standard value network. All in-network services are credited to the preferred, the enhanced, and the standard value deductibles. Preferred and Enhanced deductibles do not apply to office visits, preventive care services, diagnostic services, urgent care, emergency room services, inpatient facility fee, inpatient maternity, mental health services, substance abuse services, rehabilitation services, habilitation services, pediatric dental, pediatric vision, and prescription drug expenses. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 4 for how much you pay for covered services after you meet the deductible.

Transcript of Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community...

Page 1: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

1 of 16

Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.A copy of your agreement can be found at https://shop.highmark.com/sales/#!/sbc-agreements.

WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX BaseI_2110145614_20170101_SBC

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at www.highmarkbcbs.com or by calling 1-800-544-6679.

Important Questions Answers Why this Matters:

What is the overalldeductible?

$1,000 individual/$2,000 familypreferred value network,$1,500 individual/$3,000 familyenhanced value network,$2,500 individual/$5,000 familystandard value network.

All in-network services are creditedto the preferred, the enhanced, andthe standard value deductibles.

Preferred and Enhanceddeductibles do not apply to officevisits, preventive care services,diagnostic services, urgent care,emergency room services, inpatientfacility fee, inpatient maternity,mental health services, substanceabuse services, rehabilitationservices, habilitation services,pediatric dental, pediatric vision,and prescription drug expenses.

You must pay all the costs up to the deductible amount before this planbegins to pay for covered services you use. Check your policy or plandocument to see when the deductible starts over (usually, but not always,January 1st). See the chart starting on page 4 for how much you pay forcovered services after you meet the deductible.

Page 2: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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Standard deductible does not applyto preventive care services,emergency room services, mentalhealth services, substance abuseservices, pediatric dental, pediatricvision, and prescription drugexpenses.

Copayments and coinsuranceamounts don't count toward thenetwork deductible.

Are there other deductiblesfor specific services?

No. You don't have to meet deductibles for specific services, but see the chartstarting on page 4 for other costs for services this plan covers.

Is there an out–of–pocketlimit on my expenses?

Network: $6,500 individual/$13,000family combined preferred,enhanced, and standard value out-of-pocket limits.

All in-network services are creditedto the preferred, the enhanced, andthe standard value out-of-pocketlimits.

The out-of-pocket limit is the most you could pay during a coverage period(usually one year) for your share of the cost of covered services. This limithelps you plan for health care expenses.

What is not included in theout–of–pocket limit?

Premiums, balance-billed charges,and health care this plan doesn'tcover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Is there an overall annuallimit on what the planpays?

No. The chart starting on page 4 describes any limits on what the plan will payfor specific covered services, such as office visits.

Page 3: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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Does this plan use anetwork of providers?

Yes. For a list of networkproviders, seewww.highmarkbcbs.com or call1-800-544-6679.

If you use an in-network doctor or other health care provider, this plan willpay some or all of the costs of covered services. Be aware, your in-networkdoctor or hospital may use an out-of-network provider for some services.Plans use the term in-network, preferred, or participating for providers intheir network. See the chart starting on page 4 for how this plan paysdifferent kinds of providers.

Do I need a referral to seea specialist?

No. You can see the specialist you choose without permission from this plan.

Are there services this plandoesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed in the ExcludedServices & Other Covered Services section. See your policy or plandocument for additional information about excluded services.

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a 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 coinsurance payment of 20% would be $200.This may change 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 network providers by charging you lower deductibles, copayments and coinsurance amounts.

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you visit ahealth careprovider’soffice or clinic

Primary care visitto treat an injury orillness

$10 copay/visit $40 copay/visit 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

Specialist visit $30 copay/visit $55 copay/visit 50% coinsurance Not covered −−−−−−−−none−−−−−−−− Other practitioneroffice visit

$30 copay/visitfor chiropractor

$55 copay/visitfor chiropractor

50% coinsurancefor chiropractor

Not covered Combined all networktiers: 20 visits per benefitperiod.

Preventive careScreeningImmunization

No chargefor preventivecare services

No chargefor preventivecare services

No chargefor preventivecare services

No coveragefor preventivecare services

Please refer to yourpreventive schedule foradditional information.

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you have atest

Diagnostic test (x-ray, blood work)

$15 copay fornon-hospital,$30 copay/visitfor hospital

$55 copay/visit 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

Imaging (CT/PETscans, MRIs)

$40 copay fornon-hospital,$80 copay/visitfor hospital

$165 copay/visit 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you needdrugs to treatyour illness orcondition

Moreinformationaboutprescriptiondrug coverageis available at1-800-544-6679.

Formulary LowCost Generic drugs

15% coinsurance$3/$6/$9minimum/$10/$20/$30maximum perprescription(retail)15% coinsurance$6 minimum/$20 maximum perprescription(mail order)

15% coinsurance$3/$6/$9minimum/$10/$20/$30maximum perprescription(retail)15% coinsurance$6 minimum/$20 maximum perprescription(mail order)

15% coinsurance$3/$6/$9minimum/$10/$20/$30maximum perprescription(retail)15% coinsurance$6 minimum/$20 maximum perprescription(mail order)

Not covered Up to 31/60/90-day supplyretail pharmacy.

Up to 90-day supplymaintenance prescriptiondrugs through mail order.

Specialty drugs up to 31-day supply.

Certain participating retailpharmacy providers mayhave agreed to makemaintenance prescriptiondrugs available at the samecost-sharing and quantitylimits as the mail servicecoverage.

This Plan has EssentialFormulary.

FormularyMedium CostGeneric & LowCost Brand drugs

25% coinsurance$20/$40/$60minimum/$75/$150/$225maximum perprescription(retail)25% coinsurance$40 minimum/$150 maximumper prescription(mail order)

25% coinsurance$20/$40/$60minimum/$75/$150/$225maximum perprescription(retail)25% coinsurance$40 minimum/$150 maximumper prescription(mail order)

25% coinsurance$20/$40/$60minimum/$75/$150/$225maximum perprescription(retail)25% coinsurance$40 minimum/$150 maximumper prescription(mail order)

Not covered

Page 7: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

7 of 16

Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you needdrugs to treatyour illness orcondition

Moreinformationaboutprescriptiondrug coverageis available at1-800-544-6679.

Formulary HighCost Generic,Medium, & HighCost Brand drugs

35% coinsurance$70/$140/$210minimum/$250/$500/$750maximum perprescription(retail)35% coinsurance$140 minimum/$500 maximumper prescription(mail order)

35% coinsurance$70/$140/$210minimum/$250/$500/$750maximum perprescription(retail)35% coinsurance$140 minimum/$500 maximumper prescription(mail order)

35% coinsurance$70/$140/$210minimum/$250/$500/$750maximum perprescription(retail)35% coinsurance$140 minimum/$500 maximumper prescription(mail order)

Not covered Up to 31/60/90-day supplyretail pharmacy.

Up to 90-day supplymaintenance prescriptiondrugs through mail order.

Specialty drugs up to 31-day supply.

Certain participating retailpharmacy providers mayhave agreed to makemaintenance prescriptiondrugs available at the samecost-sharing and quantitylimits as the mail servicecoverage.

This Plan has EssentialFormulary.

Formulary HighestCost Generic,Highest CostBrand, & Specialtydrugs

50% coinsurance$150/$300/$450minimum/$1,000/$2,000/$3,000 maximumper prescription(retail)50% coinsurance$300 minimum/$2,000 maximumper prescription(mail order)

50% coinsurance$150/$300/$450minimum/$1,000/$2,000/$3,000 maximumper prescription(retail)50% coinsurance$300 minimum/$2,000 maximumper prescription(mail order)

50% coinsurance$150/$300/$450minimum/$1,000/$2,000/$3,000 maximumper prescription(retail)50% coinsurance$300 minimum/$2,000 maximumper prescription(mail order)

Not covered

Page 8: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

8 of 16

Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you haveoutpatientsurgery

Facility fee (e.g.,ambulatorysurgery center)

No charge fornon-hospital,$200 copay/visitfor hospital

30% coinsurance 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

Physician/surgeonfees

10% coinsurance 30% coinsurance 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

If you needimmediatemedicalattention

Emergency roomservices

$200 copay/visit $200 copay/visit $200 copay/visit $200 copay/visit Copay waived if admittedas an inpatient.Out-of-network: Notsubject to deductible.

Emergencymedicaltransportation

10% coinsurance 10% coinsurance 10% coinsurance 10% coinsurance All tiers: Subject topreferred value networkdeductible.

Urgent care $80 copay/visit $80 copay/visit 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

If you have ahospital stay

Facility fee (e.g.,hospital room)

$300 copay/dayper admission,3 day copaymaximum

$800 copay/dayper admission, 3day copaymaximum

50% coinsurance Not covered Precertification may berequired.

Physician/surgeonfee

10% coinsurance 30% coinsurance 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

Page 9: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you havemental health,behavioralhealth, orsubstance abuseneeds

Mental/Behavioralhealth outpatientservices

$30 copay/visit $30 copay/visit $30 copay/visit Not covered −−−−−−−−none−−−−−−−−

Mental/Behavioralhealth inpatientservices

$300 copay/dayper admission,3 day copaymaximum

$300 copay/dayper admission,3 day copaymaximum

$300 copay/dayper admission,3 day copaymaximum

Not covered Precertification may berequired.

Substance usedisorder outpatientservices

$30 copay/visit $30 copay/visit $30 copay/visit Not covered −−−−−−−−none−−−−−−−−

Substance usedisorder inpatientservices

$300 copay/dayper admission,3 day copaymaximum

$300 copay/dayper admission,3 day copaymaximum

$300 copay/dayper admission,3 day copaymaximum

Not covered Precertification may berequired.

If you arepregnant

Prenatal andpostnatal care

10% coinsurance 30% coinsurance 50% coinsurance Not covered Network: The first visit todetermine pregnancy iscovered at no charge.Please refer to theWomen’s HealthPreventive Schedule foradditional information.

Delivery and allinpatient services

$300 copay/dayper admission,3 day copaymaximum

$800 copay/dayper admission,3 day copaymaximum

50% coinsurance Not covered Precertification may berequired.

Page 10: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

If you need helprecovering orhave otherspecial healthneeds

Home health care 10% coinsurance 30% coinsurance 50% coinsurance Not covered Combined all networktiers: 60 visits per benefitperiod.

Rehabilitationservices

$30 copay/visit $55 copay/visit 50% coinsurance Not covered Combined all networktiers: 30 physical medicinevisits, 30 combined speechtherapy, and occupationaltherapy visits per benefitperiod.

Habilitationservices

$30 copay/visit $55 copay/visit 50% coinsurance Not covered Combined all networktiers: 30 physical medicinevisits, 30 combined speechtherapy, and occupationaltherapy visits per benefitperiod.

Skilled nursingcare

10% coinsurance 10% coinsurance 50% coinsurance Not covered Combined all networktiers: 120 days per benefitperiod.Enhanced value network:Subject to preferred valuenetwork deductible.

Durable medicalequipment

10% coinsurance 30% coinsurance 50% coinsurance Not covered −−−−−−−−none−−−−−−−−

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11 of 16

Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

CommonMedical Event

Services YouMay Need

Your Cost ifYou Use a

Preferred Value(Network)Provider

Your Cost ifYou Use an

Enhanced Value(Network)Provider

Your Cost ifYou Use a

Standard Value(Network)Provider

Your Cost ifYou Use an

Out-of-NetworkProvider

Limitations & Exceptions

Hospice service 10% coinsurance 30% coinsurance 50% coinsurance Not covered Combined all networktiers: Respite care limit of7 days every 6 months.

If your childneeds dental oreye care

Eye exam No charge No charge No charge Not covered Network: One routine eyeexam every 12 months.

Glasses No charge No charge No charge Not covered Network: One pairframes/lenses every 12months.

Dental check-up No charge No charge No charge Not covered Network: One exam every6 months.

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12 of 16

Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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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.)

Abortions, except where a pregnancy isthe result of rape or incest, or for apregnancy which, as certified by aphysician, places the life of the womanin danger unless an abortion isperformed.

Dental care (Adult)

Hearing aids

Long-term care

Private-duty nursing

Routine eye care (Adult)

Routine foot care

Weight loss programs

Acupuncture

Bariatric surgery

Cosmetic surgery

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

Coverage provided outside the UnitedStates. See www.bcbsa.com

Infertility treatment Non-emergency care when travelingoutside the U.S.

Page 13: Highmark Blue Cross Blue Shield: my Connect Blue …...WPAHM my Connect Blue EPO 1000G, a Community Blue Flex Plan OFFX Base I_2110145614_20170101_SBC This is only a summary. If you

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

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Your Rights to Continue Coverage:Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium.There are exceptions, however, such as if:

You commit fraud. The insurer stops offering services in the State. You move outside the coverage area.

For more information on your rights to continue coverage, contact the insurer at 1-800-544-6679. You may also contact your state insurancedepartment at The Pennsylvania Department of Consumer Services at 1-877-881-6388.

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:

The Pennsylvania Department of Consumer Services at 1-877-881-6388. Additionally, a consumer assistance program can help you file your appeal. Contact the Pennsylvania Department of Consumer Services at

1-877-881-6388.

Does this 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 policy doesprovide minimum essential coverage.

To obtain language assistance, call 1-800-544-6679.SPANISH (Español): Para obtener asistencia en Español, llame al 1-800-544-6679.TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-544-6679.

CHINESE (中文): 如果需要中文的帮助, 请拨打这个号码 1-800-544-6679.

NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-544-6679.

–––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Coverage Examples Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.

I_2110145614_20170101_SBC

Having a baby(normal delivery)

Managing type 2 diabetes(routine maintenance of

a well-controlled condition)

About these Coverage 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.

This isnot a costestimator.

Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.

See the next page forimportant information aboutthese examples.

Amount owed to providers: $7,540 Plan pays $6,140 Patient pays $1,400

Sample care costs:Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:Deductibles $1,000

Copays $400

Coinsurance $0

Limits or exclusions $0

Total $1,400

Amount owed to providers: $5,400 Plan pays $3,940 Patient pays $1,460

Sample care costs:Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:Deductibles $1,000

Copays $400

Coinsurance $60

Limits or exclusions $0

Total $1,460

You should also con sider contribution s to accounts such as health savings accounts (HSAs), flex ible spend ing arrangements (FSAs) or health reimbursement accounts (HRAs) that help y ou pay out-of-pocket ex penses.

You should also consider contributions to accounts such as health savings accounts(HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts(HRAs) that help you pay out-of-pocket expenses.

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Highmark Blue Cross Blue Shield: my Connect Blue EPO 1000G, aCommunity Blue Flex Plan OFFX (Base Plan)

Coverage Period: 01/01/2017 - 12/31/2017

Coverage Examples Coverage for: Individual/Family | Plan Type: EPO

Questions: Call 1-800-544-6679 or visit us at www.highmarkbcbs.com.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform and www.HealthCare.gov or call 1-800-544-6679 to request a copy.Highmark Blue Cross Blue Shield is an independent corporation operating under licenses from the Blue Cross and Blue Shield Association.

I_2110145614_20170101_SBC

Questions and answers about the Coverage Examples:

What are some of the assumptionsbehind the Coverage Examples? Costs don’t include premiums. Sample care costs are based on national

averages supplied by the U.S. Departmentof Health and Human Services, and aren’tspecific to a particular geographic area orhealth plan.

The patient’s condition was not an excludedor 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 only ontreating the condition in the example.

The patient received all care from networkproviders. If the patient had received carefrom out-of-network providers, costswould have been higher.

What does a Coverage Example show?For each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn’t covered or payment is limited.

Does the Coverage Example predictmy own care needs?

No. Treatments shown are just examples.The care you would receive for this conditioncould be different based on your doctor’sadvice, your age, how serious your conditionis, and many other factors.

Does the Coverage Example predictmy future expenses?

No. Coverage Examples are not costestimators. You can’t use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Your owncosts will be different depending on the careyou receive, the prices your providerscharge, and the reimbursement your healthplan allows.

Can I use Coverage Examples tocompare plans?

Yes. When you look at the Summary ofBenefits and Coverage for other plans, you’llfind the same Coverage Examples. Whenyou compare plans, check the “Patient Pays”box in each example. The smaller thatnumber, the more coverage the planprovides.

Are there other costs I should considerwhen comparing plans?

Yes. An important cost is the premium youpay. Generally, the lower your premium,the more you’ll pay in out-of-pocket costs,such as copayments, deductibles, andcoinsurance. You should also considercontributions to accounts such as healthsavings accounts (HSAs), flexible spendingarrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.

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Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark CoverageAdvantage or Highmark Health Insurance Company, all of which are independent licensees of the Blue Cross and Blue Shield Association.

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

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Discrimination is Against the Law

The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you speak English, language assistance services, free of charge, are available to you. Call 1-800-876-7639.

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