There’s a plan in here with

your name all over it.

Your guide to finding just the right Individual or Family plan for you.

For Benefit Period: January 1 to December 31, 2021 Go ahead. Get picky about your plan.

With lots of great coverage options from Highmark, this book will help you find the plan, the product, and the network access that matters most to you.

Looking for something in particular? You can easily navigate through the guide by clicking on the headings in the Table of Contents.

Why choose Highmark?...... 3

Affordable Care Act basics...... 8

Financial help info...... 10

Enrollment dates...... 12

Enrollment checklist...... 13

Product and network highlights...... 14

Plan details by county ...... 26

Helpful health insurance definitions...... 39

Legal info ...... 40 Why choose Highmark?

Why choose a Highmark health plan? Woah. So many reasons. Here are three big ones right off the top of our heads.

1 Expert care, close to home. With Highmark, you’re covered here, there, just about everywhere with a network that gives you access to in-network facilities throughout Pennsylvania, as well as select facilities in Maryland, New Jersey, New York, Ohio, and West Virginia.

2 Coast-to-coast coverage with BlueCard®. All of our plans come with BlueCard coverage, giving you access to the largest physician and hospital networks in the U.S. with over 1.7 million providers, including 95% of all hospitals.* BlueCard gives you access to routine,** urgent, and emergency care, no matter where you are. Traveling abroad? You’re also covered in 190 countries.

3 No red tape. Lose the timewasting of going to an appointment just to get another appointment. See whichever in-network doctors you want to see — no referral. Or call 1-888-BLUE-428, and we’ll find a specialist for you. No hoops, no hoopla.

And that’s just for starters. Turn the page for even more reasons to choose Highmark.

* According to the Blue Cross and Blue Shield Association. ** Certain services may require you to work with your BlueCard participating provider to obtain prior authorization. 3 How easy do we make it to find care and get care? Almost too easy.

4 DENTAL AND VISION COVERAGE All your care, all in one plan. Healthy eyes and teeth are important parts of your overall health and regular check-ups can help you stay ahead of potential problems down the road. That’s why many of our plans come with adult dental and vision benefits included. No need to purchase separate plans.

TELEMEDICINE Face to face with a doctor, 24/7. Need to see a doctor but don’t want to leave your couch? Get a diagnosis, treatment plan, or prescription any time, right from your phone or computer. Best of all — telemedicine services provided by Amwell are free with many of our plans. Just call the number on the back of your ID card for details. That’s laid-back-in-a-recliner easy.

BLUE DISTINCTION℠ See specialists who get proven results. Only doctors who consistently deliver safe, effective treatments make our Blue Distinction list. When you use our Find a Doctor tool, a special logo will be by their name, so you can cherry-pick a top-performing specialist for any care you need

JOHNS HOPKINS MEDICINE COLLABORATION Expert teamwork for advanced care. We collaborate with some of the best minds, like Johns Hopkins Medicine, for cancer research. That lets us bring the latest innovative medical breakthroughs right to your neighborhood.

5 How simple is it for you to get answers and reach your goals? Super simple.

6 THE HIGHMARK APP AND MEMBER WEBSITE Your entire plan at your fingertips. No more searching for old files or waiting on snail mail. Your digital ID card, Find a Doctor tool, deductible progress, and claims status are all available via the Highmark Plan app (available on Google Play or in the Apple App Store) or online at highmarkblueshield.com.

MY CARE NAVIGATORSM Your appointments, booked for you. It’s as simple as calling 1-888-BLUE-428. We’ll help you find the in-network doctor you need and reserve some space on their calendar for a checkup. Which means less on-hold music for you.

BLUES ON CALLSM Answers from a health pro, 24/7. Medical concerns during off hours? Just call 1-888-BLUE-428 to get support from a registered nurse or a health coach any time and put your worries to bed.

WELLNESS Personalized support for health goals. Looking to lose weight? Quit smoking? Be more active? Get guidance based on your lifestyle, trackers to measure your progress, resources like Sharecare®, and access to experienced wellness coaches to make healthy choices and keep you motivated. Once you’re enrolled, visit mycare.sharecare.com.

BLUE365® Discounts to help you stay healthy and active. From workout gear to gym memberships to healthy meal services, we’ll take a little off the top while you’re taking a little off your middle. Member-only deals are at blue365deals.com.

7 Affordable Care Act basics

Before we get much further, let’s cover some Affordable Care Act (ACA) essentials.

8 ACA basics Metal levels ACA plans are broken into four categories based on how you and your plan share the costs of your health care.

Just so you know, metal levels reflect cost-sharing differences only — which means you get the same quality of care at any level.

Description CATASTROPHIC BRONZE SILVER GOLD

Premium low medium high highest Out-of-Pocket Costs highest high medium low

Never use health care Use health care services services unless it’s Don’t use a lot of Are eligible for CSR somewhat frequently Makes sense an emergency. health care services or want to balance and/or want low if you: Only available and/or want to keep premiums with out-of-pocket costs if you’re under 30 premium payments low. out-of-pocket costs. for most commonly or have a hardship. used services.

ACA also includes Platinum level plans; however, Highmark does not offer these types of plans in Pennsylvania. Ways to save Good news: There are two ways to Even better news: Premiums will decrease, on average, by about $50 per person per save available for Affordable Care month, because premium tax credits are Act (ACA) enrollees. increasing. Four out of five Marketplace enrollees will be able to find a plan for $10 or less a month with premium tax credits, and over half will be able to find a Silver plan for $10 or less with tax credits.

Advanced Premium Tax Credits (APTC), which may be applied — in advance — to lower what you pay each month for your premium on any level Marketplace plan except Catastrophic.

Cost-Sharing Reductions (CSR) will lower out-of-pocket costs that you may pay at the time of service for doctor visits, lab tests, drugs, and other covered services. CSR plans also offer lower deductibles. You can only get these savings if you enroll in an Extra Savings Silver plan.

* Based on on-exchange Highmark enrollment during 2020 OEP.

9 Financial help info

See if you qualify To see if you’re eligible for financial help, locate your qualifying income and household size on the chart below. Then refer to the Standard or Extra Savings plans for your county to find the plans that will reduce how much you pay for care. If you don’t qualify for Cost-Sharing Reductions, you may be eligible for Advanced Premium Tax Credits. Please refer to the Standard plan options for your county.

What is the income for those covered under this health plan?

Eligible for Eligible for Eligible for Who Needs Medicaid CSRs and APTCs APTCs Coverage? Silver Extra Savings plans Standard Medicaid Eligible Range (100-138% or less FPL) 138-149% 150-199% 200-249% 250% or more CSR plans CSR plans CSR plans

Single Less than $17,607 $17,608 - $19,139 $19,140 - $25,519 $25,520 - $31,899 $31,900 or more

Family of 2 Less than $23,790 $23,791 - $25,859 $25,860 - $34,479 $34,480 - $43,099 $43,100 or more

Family of 3 Less than $29,792 $29,973 - $32,579 $32,580 - $43,439 $43,440 - $54,299 $54,300 or more

Family of 4 Less than $36,155 $36,156 - $39,299 $39,300 - $52,399 $52,400 - $65,499 $65,500 or more

Family of 5 Less than $42,337 $42,338 - $46,019 $46,020 - $61,359 $61,360 - $76,699 $76,700 or more

Family of 6 Less than $48,519 $48,520 - $52,739 $52,740 - $70,319 $70,320 - $87,899 $87,900 or more

Family of 7 Less than $54,702 $54,703 - $59,459 $59,460 - $79,279 $79280 - $99,099. $99,100 or more

Family of 8 Less than $60,884 $60,885 - $66,179 $66,180 - $88,239 $88,240 - $110,299 $110,300 or more

* Most individuals and families with household incomes 100% or more of the FPL will qualify for premium tax credits. These credits help lower the cost of health insurance coverage and are based on the second-lowest-cost Silver plan available in your area on the Pennsylvania Insurance Ex- change. The second-lowest-cost Silver plan is also known as the “benchmark plan.” Premium tax credits vary by income. Households with incomes 150% or less of the FPL will pay no premium for the benchmark plan. Those households with annual incomes 400% or more of the FPL will pay no more than 8.5% of their household income on health insurance premiums for the benchmark plan. * Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based only on your income. * American Indians and Alaska Natives who are members of federally recognized tribes are eligible for cost-sharing reductions at alternative dollar thresholds. This chart is only applicable for coverage in 2021 and in the 48 contiguous states and the District of Columbia. For families/households with more than 8 persons, add $4,480 for each additional person. HHS Poverty Guidelines for 2020 (January 31, 2020). Retrieved from https://aspe.hhs.gov/poverty-guidelines.

Check to see if you qualify for one or both types of help. Call 855-400-9159.

10 ACA plans vs. short-term plans In addition to the availability of APTC and CSR, all ACA plans provide coverage for preexisting conditions and the ten essential health benefits (see page 13). Short-term plans — which are plans that come with a fixed, limited term — do not. Short-term plans can seem like a cheaper alternative to ACA coverage but often come with hidden costs and exclusions that can make them more expensive in the long run.

Other types of hidden costs in short-term plans:

Description SHORT-TERM PLANS ACA PLANS

Capped out-of-pocket spending not covered covered

10 Essential Health Benefits not covered covered

No limits on covered doctor visits not covered covered

No dollar limits on covered benefits not covered covered

No limits on prescription drug coverage not covered covered

11 Enrollment dates

Next, enrollment dates.

There are two different ways you can be eligible to enroll in or change your ACA coverage. One is for a fixed period during the year, and the other is for special cases that can happen any time.

COVID-19 ENROLLMENT PERIOD February 15, 2021 – August 15, 2021 Your coverage will start on the first of the following month regardless of when you enroll. For example, for coverage that begins June 1, you have until May 31 to sign up for a plan.

SPECIAL ENROLLMENT PERIODS Can happen any time throughout the year Outside the COVID-19 Enrollment Period, you can only get or change coverage if you have a qualifying life event. Examples include losing your existing coverage, a new addition to the family, getting married, or moving to a new area where you can’t keep your current plan. A Special Enrollment Period only lasts 60 days from the qualifying life event.

If you think you’re eligible for a Special Enrollment Period, you may be asked to submit documents to prove it. You can go to discoverhighmark.com for more information.

12 Enrollment checklist

Finally, your ACA Enrollment Checklist. Here’s the info you’ll need for each person who will be covered on your plan.

• Date of birth

• Social Security number (or legal immigrant documents)

• Income documentation for all household members, even if they won’t be covered by the plan (pay stubs, W-2 forms, or wage and tax statements)

• Current health insurance policy numbers (if applicable)

• Info on any health insurance you or your family could get from your job

All set? Great. Let’s dig into the details for 2021 — and find you the plan with the benefits and features that matter most to you.

13 Product and network highlights

2021 Highmark product and network highlights

Now that we’ve gotten the preliminaries out of the way, let’s take a look at the products and networks available in your area in 2021.

14 Cue the highlight reel. With Highmark, you get all the essentials — and so much more. First, you get access to But Highmark goes the ten essential health above and beyond. benefits — plus coverage Here are just some of the awesome for preexisting conditions. benefits you’ll find for the 2021 plan year.* They include: Go ahead. Start circling the ones you want.

• Outpatient care • Low office visit copay ® • Emergency services • Free telemedicine through Amwell • Hospitalization (like surgery • $0 prescription copays for Tier 1 drugs and overnight stays) • Free preventive vaccines,** tests, • Pregnancy, maternity, and screenings*** and newborn care • Adult dental and vision coverage • Mental health and substance • Predictable copays that start day 1, use disorder services no deductible to meet • Prescription drugs • Prescription drug coverage that • Rehabilitative and habilitative starts day 1, no deductible to meet services and devices • Enhanced resources for managing • Laboratory services chronic conditions • Preventive and wellness services • 2 free mental health visits and chronic disease management • 2 free substance abuse disorder visits • Pediatric services, including dental • Potential tax-free savings with and vision care a Health Savings Account**** – Money can go in tax-free and lower your taxable income – Money comes out tax-free when used for qualified medical expenses – Interest and earnings on any unused money grows tax-free – Unused money rolls over from year to year

* Not all plans include these benefits. The availability of benefits depends on your selected plan. ** As listed on the Highmark Preventive Schedule when given at a participating pharmacy. *** As presented on the Highmark Preventive Schedule. To check the preventive schedule for covered care, visit https://www.highmarkblueshield.com/pdffiles/Highmark_Preventive_Schedule_2020.pdf. **** Please note: Qualified High Deductible Health Plans may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA. If you have questions, please check with your financial advisor.

15 my Direct Blue EPO Enjoy in-network access to top-quality care throughout central Pennsylvania and the Lehigh Valley, plus full BlueCard access coast to coast.

With my Direct Blue EPO plans, it’s very simple: providers are either in network or out of network. You can even see most specialists with no need for referrals. Even better, the BlueCard program gives you access to the majority of hospitals and doctors nationwide — so you’ll be covered for routine, urgent, and emergency care wherever you go.

16 To see if your provider is in network, visit highmarkblueshield.com and click Find a Doctor or Pharmacy. my Direct Blue EPO plans are available for residents of the counties highlighted below.

17 my Direct Blue EPO In-Network Hospitals

ALLEGHENY BLAIR • Penn Medicine – Chester • AHN Allegheny General • Conemaugh Nason Medical County Hospital Hospital Center CLARION • AHN Allegheny Valley Hospital • Tyrone Hospital • BHS Clarion Hospital • AHN Brentwood • UPMC Altoona Neighborhood Hospital CLINTON BRADFORD • AHN Forbes Hospital • Bucktail Medical Center • Guthrie Robert Packer Hospital • AHN Jefferson Hospital • UPMC Susquehanna • Guthrie Towanda Memorial • AHN McCandless Lock Haven Neighborhood Hospital Hospital • AHN West Penn Hospital • Guthrie Troy Community COLUMBIA Hospital • Heritage Valley Kennedy • CHS Berwick Hospital Center • Heritage Valley Sewickley BUCKS CRAWFORD • St. Clair Hospital • Doylestown Hospital • Meadville Medical Center • The Children’s Home • Jefferson Health – • Titusville Area Hospital of Pittsburgh Bucks Hospital • The Children’s Institute CUMBERLAND of Pittsburgh BUTLER • Geisinger Holy Spirit Hospital • UPMC Children’s Hospital of • BHS Butler Memorial Hospital • UPMC Carlisle Pittsburgh CAMBRIA • UPMC Western DAUPHIN • Conemaugh Memorial Psychiatric Hospital • Penn State Health Medical Center Children’s Hospital ARMSTRONG • Conemaugh Miners • Penn State Health Milton • Armstrong County Memorial Medical Center S. Hershey Medical Center Hospital • Select Specialty Hospital – Johnstown DELAWARE BEAVER • Crozer-Chester Medical Center • Heritage Valley Beaver CARBON • Delaware County • St. Luke’s Hospital – Memorial Hospital BEDFORD Lehighton Campus • UPMC Bedford • Main Line Health – CENTRE Riddle Hospital BERKS • Mount Nittany Medical Center ERIE • Penn State Health St. Joseph Medical Center CHESTER • AHN Saint Vincent Hospital • Surgical Institute of Reading • Main Line Health – Bryn Mawr • Corry Memorial Hospital Rehab Hospital • Millcreek Community Hospital • Main Line Health – • Select Specialty Hospital - Erie Paoli Hospital

18 FAYETTE LUZERNE • Main Line Health – • Highlands Hospital • CHS Wilkes-Barre Lankenau Medical Center • Uniontown Hospital General Hospital NORTHAMPTON • Geisinger Wyoming Valley FRANKLIN Medical Center • Lehigh Valley Hospital – Coordinated Health Bethlehem • WellSpan Chambersburg • Lehigh Valley Hospital – Hospital Hazleton PHILADELPHIA • WellSpan Waynesboro Hospital LYCOMING • Children’s Hospital of Philadelphia GREENE • Geisinger Jersey Shore • Einstein Medical • Washington Health System • UPMC Susquehanna Muncy Center Philadelphia Greene • UPMC Susquehanna • Jefferson Health – Williamsport LACKAWANNA Frankford Hospital • UPMC Susquehanna • Jefferson Health – • CHS Moses Taylor Hospital Williamsport DP Campus • CHS Regional Hospital Methodist Hospital of Scranton MCKEAN • Jefferson Health – Thomas Jefferson University Hospital • Geisinger Community • Bradford Regional Medical Medical Center Center • Jefferson Health – Torresdale Hospital • UPMC Kane LANCASTER • Jefferson Health – WillsEye • Lancaster General Hospital MERCER Hospital • Lancaster General Hospital • AHN Grove City • Penn Medicine – Hospital of Women & Babies • Edgewood Surgical Hospital the University of Pennsylvania • Lancaster Surgery Center • Sharon Regional Health System • Penn Medicine – Penn Presbyterian Medical Center • UPMC Horizon – Greenville LAWRENCE • Penn Medicine – • UPMC Horizon – Shenango • Lawrence County Surgery Pennsylvania Hospital Valley Center of Edgewood Surgical • Temple Health – Fox Chase Hospital MONROE Cancer Center • UPMC Jameson • Lehigh Valley Hospital – • Temple Health – Temple University Hospital LEBANON Pocono • St. Luke’s Hospital – • WellSpan Good Samaritan POTTER Monroe Campus Hospital • UPMC Cole MONTGOMERY LEHIGH SCHUYLKILL • Lehigh Valley Hospital – • Einstein Medical Center Elkins Park • Lehigh Valley Hospital – 17th Street Schuylkill E. Norwegian Street • Lehigh Valley Hospital – • Einstein Medical Center Montgomery • Lehigh Valley Hospital – Cedar Crest Schuylkill S. Jackson Street • Lehigh Valley Hospital – • Holy Redeemer Hospital Coordinated Health Allentown and Medical Center SOMERSET • Lehigh Valley Hospital – • Jefferson Health – • Conemaugh Meyersdale Muhlenberg Abington Hospital Medical Center • Lehigh Valley Reilly • Jefferson Health – • UPMC Somerset Children’s Hospital Abington-Landsdale Hospital • Main Line Health – Bryn Mawr Hospital

19 SUSQUEHANNA • Barnes-Kasson Hospital IN-NETWORK ACCESS TO THESE • Endless Mountains Health OUT-OF-STATE HOSPITALS * Systems THROUGH BLUECARD

TIOGA MARYLAND • UPMC Susquehanna Wellsboro • Meritus Medical Center • The Johns Hopkins Hospital UNION • University of Maryland • Evangelical Community Medical Center Hospital • UPMC Western Maryland • WVU Medicine – Garrett VENANGO Regional Medical Center • UPMC Northwest NEW YORK WARREN • AHN Westfield • Warren General Hospital Memorial Hospital • Guthrie Corning Hospital WASHINGTON • Olean General Hospital • Advanced Surgical Hospital • UR Medicine – Jones • AHN Canonsburg Hospital Memorial Hospital • Monongahela Valley Hospital • UR Medicine – Strong • Washington Hospital Memorial Hospital

WAYNE OHIO • Wayne Memorial Hospital • Cleveland Clinic

WESTMORELAND WEST VIRGINIA • AHN Hempfield • Weirton Medical Center Neighborhood Hospital • WVU Medicine – • Excela Health Frick Hospital Children’s Hospital • Excela Health Latrobe Hospital • WVU Medicine – J.W. Ruby • Excela Health Westmoreland Memorial Hospital Hospital • Select Specialty Hospital – Laurel Highlands

WYOMING • CHS Tyler Memorial Hospital

*In addition, my Direct Blue EPO plans provide in-network access to out-of-state providers that participate with local Blue Plans through the BlueCard program. Please refer to the provider directory for additional out-of-state hospitals. You can find the provider directory at highmarkblueshield.com under the Find a Doctor or Pharmacy tab.

20 my Blue Access EPO Your choice for comprehensive in-network access throughout central Pennsylvania and the Lehigh Valley.

With my Blue Access EPO plans, you have in-network access to high-quality, cost-effective care from more than 9,800 physicians and 50 community hospitals in western and central Pennsylvania. You can even see in-network specialists with no need for referrals. Even better, the BlueCard program gives you access to the largest physician and hospital networks in the U.S. with over 1.7 million providers, including 95% of all hospitals* — so you’ll be covered for routine, urgent, and emergency care wherever you go. To see if your provider is in network, visit highmarkblueshield.com and click Find a Doctor or Pharmacy.*

* According to the Blue Cross Blue Shield Association my Blue Access EPO plans are available for residents of the counties highlighted below.

21 my Blue Access EPO In-Network Hospitals

ADAMS • UPMC St. Margaret BUTLER • WellSpan Gettysburg Hospital • UPMC Western Psychiatric • BHS Butler Memorial Hospital Hospital ALLEGHENY • UPMC Passavant – Cranberry • AHN Allegheny General ARMSTRONG CAMBRIA Hospital • Armstrong County Memorial • Conemaugh Memorial Medical • AHN Allegheny Valley Hospital Hospital Center • AHN Brentwood BEAVER • Conemaugh Miners Medical Neighborhood Hospital • Curahealth Hospital Center • AHN Forbes Hospital Heritage Valley • Select Specialty Hospital – • AHN Jefferson Hospital • Heritage Valley Beaver Johnstown • AHN McCandless BEDFORD CARBON Neighborhood Hospital • UPMC Bedford • St. Luke’s – Lehighton Campus • AHN West Penn Hospital CENTRE • Curahealth Pittsburgh BERKS • Mount Nittany Medical Center • Heritage Valley Kennedy • Penn State Health St. Joseph • Heritage Valley Sewickley Medical Center CHESTER • LifeCare Behavioral Health • Surgical Institute of Reading • Main Line Health – Bryn Hospital of Pittsburgh • Tower Health – Mawr Rehab Hospital • Select Specialty Hospital – Reading Hospital • Main Line Health – Paoli McKeesport BLAIR Hospital • Select Specialty Hospital – • Conemaugh Nason • Penn Medicine – Chester Pittsburgh UPMC Medical Center County Hospital • St. Clair Hospital • Tyrone Hospital • Tower Health – Brandywine Hospital • The Children’s Home • UPMC Altoona of Pittsburgh • Tower Health – Jennersville • The Children’s Institute BRADFORD Hospital of Pittsburgh • Guthrie Robert Packer Hospital • Tower Health – Phoenixville • UPMC Children’s Hospital • Guthrie Towanda Memorial Hospital Hospital of Pittsburgh CLARION • Guthrie Troy Community • UPMC East • BHS Clarion Hospital • UPMC Magee-Womens Hospital CLEARFIELD Hospital BUCKS • Penn Highlands Clearfield • UPMC McKeesport • Doylestown Hospital • Penn Highlands DuBois • UPMC Mercy • Jefferson Health – • UPMC Montefiore Bucks Hospital CLINTON • UPMC Passavant – • St. Luke’s Hospital – • Bucktail Medical Center McCandless Quakertown Campus • UPMC Susquehanna Lock • UPMC Presbyterian • St. Luke’s Hospital – Haven • UPMC Shadyside Upper Bucks Campus

22 COLUMBIA GREENE • St. Luke’s Hospital – • CHS Berwick Hospital Center • Washington Health System Allentown Campus • Geisinger Bloomsburg Hospital Greene • St. Luke’s Hospital – Sacred Heart Campus HUNTINGDON CRAWFORD • St. Luke’s University Hospital – • Meadville Medical Center • Penn Highlands Huntingdon Bethlehem • Titusville Area Hospital INDIANA LUZERNE CUMBERLAND • Indiana Regional Medical • CHS Wilkes-Barre • Geisinger Holy Spirit Hospital Center General Hospital • Select Specialty Hospital – JEFFERSON • Geisinger Wyoming Valley Camp Hill • Penn Highlands Brookville Medical Center • UPMC Carlisle • Punxsutawney Area Hospital • Lehigh Valley Hospital – • UPMC Pinnacle West Shore Hazleton LACKAWANNA DAUPHIN • CHS Moses Taylor Hospital LYCOMING • Geisinger Jersey Shore Hospital • Penn State Health Children’s • CHS Regional Hospital Hospital of Scranton • UPMC Susquehanna Muncy • Penn State Health Milton S. • Geisinger Community • UPMC Susquehanna Hershey Medical Center Medical Center Williamsport • UPMC Pinnacle Community • UPMC Susquehanna LANCASTER Osteopathic Williamsport Divine • Lancaster General Hospital • UPMC Pinnacle Harrisburg Providence Campus • Lancaster General Hospital DELAWARE Women & Babies MCKEAN • Bradford Regional Medical • Crozer-Chester Medical Center • Lancaster Surgery Center Center • Delaware County Memorial • UPMC Lititz • UPMC Kane Hospital • WellSpan Ephrata Community • Main Line Health – Hospital MERCER Riddle Hospital • AHN Grove City LAWRENCE • Edgewood Surgical Hospital ELK • Lawrence County Surgery • Penn Highlands Elk Center of Edgewood Surgical • Sharon Regional Health System Hospital • UPMC Horizon – Greenville ERIE • UPMC Horizon – Shenango • AHN Saint Vincent Hospital • UPMC Jameson Valley • Corry Memorial Hospital LEBANON • Millcreek Community Hospital • WellSpan Good Samaritan MIFFLIN • Select Specialty Hospital – Erie Hospital • Geisinger Lewistown Hospital • UPMC Hamot LEHIGH MONROE FAYETTE • Lehigh Valley Hospital – • Lehigh Valley Hospital – Pocono 17h Street • Highlands Hospital • St. Luke’s Hospital – Monroe • Lehigh Valley Hospital – Campus • Uniontown Hospital Cedar Crest MONTGOMERY FRANKLIN • Lehigh Valley Hospital – • Einstein Medical Center • WellSpan Chambersburg Coordinated Health Allentown Elkins Park Hospital • Lehigh Valley Hospital – • Einstein Medical Center • WellSpan Waynesboro Hospital Muhlenberg Montgomery • Lehigh Valley Reilly FULTON Children’s Hospital • Holy Redeemer Hospital • Fulton County Medical Center and Medical Center

23 • Jefferson Health – PHILADELPHIA POTTER Abington Hospital • Children’s Hospital • UPMC Cole • Jefferson Health – of Philadelphia SCHUYLKILL Abington-Landsdale Hospital • Einstein Medical • Main Line Health – Bryn Mawr Center Philadelphia • Geisinger St. Luke’s Hospital Hospital • Jefferson Health – Frankford • Lehigh Valley Hospital - • Main Line Health – Lankenau Hospital Schuylkill E. Norwegian Street Medical Center • Jefferson Health – Methodist • Lehigh Valley Hospital - • Tower Health – Pottstown Hospital Schuylkill S. Jackson Street Hospital • Jefferson Health – Thomas • St. Luke’s Hospital – Miners Campus MONTOUR Jefferson University Hospital • Geisinger Jane Weis • Jefferson Health – Torresdale SOMERSET Children’s Hospital Hospital • Chan Soon-Shiong Medical • Geisinger Medical Center • Jefferson Health – WillsEye Center at Windber Hospital • Conemaugh Meyersdale NORTHAMPTON • Penn Medicine – Hospital of Medical Center • Leigh Valley Hospital – the University of Pennsylvania • UPMC Somerset Coordinated Health Bethlehem • Penn Medicine – Penn • St. Luke’s Hospital – Anderson Presbyterian Medical Center SUSQUEHANNA • Barnes-Kasson Hospital Campus • Penn Medicine – Pennsylvania • St. Luke’s Hospital – Hospital • Endless Mountains Health Systems Easton Campus • Temple Health – Fox Chase NORTHUMBERLAND Cancer Center TIOGA • Geisinger Shamokin Area • Temple Health – Temple • UPMC Susquehanna Community Hospital University Hospital Wellsboro • Tower Health – Chestnut UNION Hill Hospital • Evangelical Community Hospital

24 VENANGO • UPMC Northwest IN-NETWORK ACCESS TO THESE OUT-OF-STATE HOSPITALS WARREN THROUGH BLUECARD* • Warren General Hospital MARYLAND WASHINGTON • Meritus Medical Center • Advanced Surgical Hospital • The Johns Hopkins Hospital • AHN Canonsburg Hospital • University of Maryland • Monongahela Valley Hospital Medical Center • Washington Hospital • UPMC Western Maryland WAYNE • WVU Medicine – Garrett Regional Medical Center • Wayne Memorial Hospital • Westmoreland NEW YORK • AHN Hempfield • AHN Westfield Memorial Neighborhood Hospital Hospital • Excela Health Frick Hospital • Guthrie Corning Hospital • Excela Health Latrobe • Olean General Hospital Hospital • UR Medicine – Jones Memorial • Excela Health Westmoreland Hospital Hospital • UR Medicine – Strong • Select Specialty Hospital – Memorial Hospital Laurel Highlands OHIO WYOMING • Cleveland Clinic • CHS Tyler Memorial Hospital WEST VIRGINIA YORK • Weirton Medical Center • OSS Orthopaedic Hospital • WVU Medicine – • UPMC Hanover Children’s Hospital • UPMC Memorial • WVU Medicine – J.W. Ruby • WellSpan York Hospital Memorial Hospital

*In addition, my Blue Access EPO plans provide in-network access to out-of-state providers that participate with local Blue Plans through the BlueCard program. You can find the provider directory at highmarkblueshield.com under the Find a Doctor or Pharmacy tab.

25 Plan details by county

Now, let’s dig into plan details.

26 To make it easier, we’ve sorted them by what’s available where you live. Just find your county and jump to that section.

Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties Standard plan options...... 28 Extra Savings plan options ...... 30

Adams, Centre,* Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties Standard plan options...... 32 Extra Savings plan options ...... 34

Adult Vision and Dental Benefits...... 36

* If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805, 16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875, 16877, or 16882

You’ll see plan summaries here. If you want any plan’s full benefit list, visit SBCsHighmark2021.com or get a paper copy by calling 1-833-484-2113 (TTY/TDD 711).

27 1

deductible $90 copay after deductible copay after$140 deductible $750 copay after deductible after10% deductible $0/$30/$150/50% after deductible No Silver HSA 3450 my DirectBlue EPO my Blue Access EPO Individual: $3,450 $6,900 Family: Individual: $6,900 $13,800 Family: copay$70 after deductible copay$70 after deductible copay$70 after deductible copay$70 after

1

50% after deductible $100 copay 50% after deductible 50% after deductible 50%/50%/50%/50% after deductible Yes Bronze 3800 my DirectBlue EPO my Blue Access EPO Individual: $3,800 $7,600 Family: Individual: $8,500 $17,000 Family: copay$60 50% after deductible First 2 visits free, then 50% after deductible 50% after deductible 1

$0 after deductible $0 after deductible $0 after deductible $0 after deductible $0/$0/$0/$0 after deductible No Bronze HSA 6900 my DirectBlue EPO my Blue Access EPO Individual: $6,900 $13,800 Family: Individual: $6,900 $13,800 Family: $0 after deductible $0 after deductible $0 after deductible $0 after deductible 1

$0 after deductible $0 after deductible $0/$0/$0/$0 after deductible No $0 after deductible $0 after deductible $0 after deductible $0 after deductible $0 after deductible my DirectBlue EPO my Blue Access EPO Individual: $8,550 $17,100 Family: Individual: $8,550 $17,100 Family: First 3 visits free, then $0 after deductible Coverage Level Coverage Catastrophic 8550 3

5

4 Includes Adult Dental Adult Includes Option Vision and Maternity) Pharmacy Summary Services Inpatient Hospital (including Urgent Care Urgent Emergency Lab Services X-ray) / (Diagnostic Physical & Physical Occupational Therapy/Chiropractic Outpatient Mental Substance and Health Abuse Visits Specialist Visit Specialist Pocket Maximum Pocket Primary Care Visit In-Network Deductible In-Network In-Network, Out-of- Plan Availability Plan Description Standard plan options plan Standard

Plan summaries – Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties 28 Coverage Level Description Silver Silver Silver Gold 800 Gold 0 2900 2600 HSA 1850

my Direct Blue EPO1 my Direct EPO1* my Direct Blue EPO1* my Direct Blue EPO1 my Direct Blue EPO1 Plan Availability my Blue Access EPO my Blue Access EPO* my Blue Access EPO* my Blue Access EPO my Blue Access EPO

Individual: $1,850 In-Network Individual: $2,900 Individual: $2,600 Individual: $800 Individual: $0 Family: $3,700 Deductible Family: $5,800 Family: $5,200 Family: $1,600 Family: $0 [Non-embedded]2

In-Network, Individual: $7,800 Individual: $8,500 Individual: $6,900 Individual: $6,000 Individual: $7,500 Out-of-Pocket Family: $15,600 Family: $17,000 Family: $13,800 Family: $12,000 Family: $15,000 Maximum

Primary Care Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay

Specialist Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay

Outpatient Mental Health and $50 copay $40 copay 30% after deductible $15 copay $20 copay Substance Abuse Visits

Physical & Occupational $75 copay $40 copay 30% after deductible $40 copay $45 copay Therapy/Chiropractic3

Lab Services $75 copay $65 copay 30% after deductible $30 copay $35 copay (Diagnostic / X-ray)

Urgent Care $100 copay $80 copay 30% after deductible $30 copay $40 copay

Emergency $750 copay after 30% after deductible 30% after deductible $250 copay $300 copay Services deductible

Hospital Inpatient 30% after deductible 30% after deductible 30% after deductible 20% after deductible 40% after deductible (including Maternity)

Pharmacy 30%/30%/30%/30% $0/$30/$150/50% $0/$30/$150/50% $0/$25/$75/50% $0/$30/$150/50% Summary4 after deductible

Includes Adult Dental Yes Yes No Yes No and Vision Option5

* These plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced Premium Tax Credits or Cost-Sharing Reductions. 1 Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO 2 This plan has a Non-Embedded deductible. See Disclosures page for more info. 3 Limit of 30 combined physical and occupational therapy visits per benefit period. 4 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier. 5 See page 36 for Adult Dental and Vision benefit details.

29 Extra savings plan options Plan summaries – Income Level

138%-149% FPL 150-199% FPL Description Coverage Level

Silver 100 Silver 0 Silver 700

1 1 1 Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Perry, Northampton, and Schuylkill Counties Plans Savings Extra my Direct Blue EPO my Direct Blue EPO my Direct Blue EPO Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO

Individual: $100 Individual: $0 Individual: $700 In-Network Deductible Family: $200 Family: $0 Family: $1,400

In-Network, Out-of- Individual: $1,400 Individual: $1,200 Individual: $2,850 Pocket Maximum Family: $2,800 Family: $2,400 Family: $5,700

Primary Care Visit $5 copay $1 copay $25 copay

Specialist Visit $5 copay $1 copay $25 copay

Outpatient Mental Health and Substance $5 copay $1 copay $25 copay Abuse Visits

Physical & Occupational $5 copay $5 copay $25 copay Therapy/Chiropractic2

Lab Services $15 copay $5 copay $45 copay (Diagnostic / X-ray)

Urgent Care $10 copay $5 copay $50 copay

Emergency Services $150 after deductible $75 copay $300 after deductible

Hospital Inpatient 10% after deductible 10% after deductible 10% after deductible (including Maternity)

Pharmacy Summary3 $0/$5/$15/50% $0/$5/$15/50% $0/$10/$50/50%

Includes Adult Dental Yes No Yes and Vision Option4

30 Income Level

150-199% FPL 200-249% FPL Description Coverage Level

Silver 0 Silver 2100 Silver 1050

my Direct Blue EPO1 my Direct Blue EPO1 my Direct Blue EPO1 Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO

Individual: $0 Individual: $2,100 Individual: $1,050 In-Network Deductible Family: $0 Family: $4,200 Family: $2,100

In-Network, Out-of- Individual: $2,800 Individual: $6,800 Individual: $5,800 Pocket Maximum Family: $5,600 Family: $13,600 Family: $11,600

Primary Care Visit $15 copay $50 copay $60 after deductible

Specialist Visit $15 copay $50 copay $60 after deductible

Outpatient Mental Health and Substance $15 copay $50 copay $60 after deductible Abuse Visits

Physical & Occupational $30 copay $75 copay $60 after deductible Therapy/Chiropractic2

Lab Services $25 copay $75 copay $75 after deductible (Diagnostic / X-ray)

Urgent Care $30 copay $100 copay $120 after deductible

Emergency Services $275 copay $750 after deductible $750 after deductible

Hospital Inpatient 10% after deductible 30% after deductible 10% after deductible (including Maternity)

Pharmacy Summary3 $0/$10/$50/50% $0/$30/$150/50% $0/$30/$150/50% after deductible

Includes Adult Dental No Yes No and Vision Option4

1 Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO 2 Limit of 30 combined physical and occupational therapy visits per benefit period. 3 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier. 4 See page 36 for Adult Dental and Vision benefit details.

31 Standard plan options Plan summaries – Coverage Level Description Catastrophic Bronze Bronze Silver 8550 HSA 6900 3800 HSA 3450

Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO my Blue Access EPO

Individual: $8,550 Individual: $6,900 Individual: $3,800 Individual: $3,450 Adams, Centre In-Network Deductible Family: $17,100 Family: $13,800 Family: $7,600 Family: $6,900

In-Network, Out-of- Individual: $8,550 Individual: $6,900 Individual: $8,500 Individual: $6,900 Pocket Maximum Family: $17,100 Family: $13,800 Family: $17,000 Family: $13,800

First 3 visits free, Primary Care Visit $0 after deductible $60 copay $70 after deductible then $0 after deductible ** , Fulton, Columbia, Montour, Juniata, Mifflin, Snyder,Northumberland, andUnion, Counties York Specialist Visit $0 after deductible $0 after deductible 50% after deductible $70 after deductible

Outpatient Mental First 2 visits free, then Health and Substance $0 after deductible $0 after deductible $70 after deductible 50% after deductible Abuse Visits

Physical & Occupational $0 after deductible $0 after deductible 50% after deductible $70 after deductible Therapy/Chiropractic2

Lab Services $0 after deductible $0 after deductible 50% after deductible $90 after deductible (Diagnostic / X-ray)

Urgent Care $0 after deductible $0 after deductible $100 copay $140 after deductible

Emergency $0 after deductible $0 after deductible 50% after deductible $750 after deductible Services

Hospital Inpatient (including $0 after deductible $0 after deductible 50% after deductible 10% after deductible Maternity)

Pharmacy $0/$0/$0/$0 $0/$0/$0/$0 50%/50%/50%/50% $0/$30/$150/50% Summary3 after deductible after deductible after deductible after deductible

Includes Adult Dental No No Yes No and Vision Option4

32 Coverage Level Description Silver 2900 Silver Silver Gold 800 Gold 0 2600 HSA 1850

Plan Availability my Blue Access EPO my Blue Access EPO* my Blue Access EPO* my Blue Access EPO my Blue Access EPO

Individual: $1,850 Individual: $2,900 Individual: $2,600 Individual: $800 Individual: $0 In-Network Deductible Family: $3,700 Family: $5,800 Family: $5,200 Family: $1,600 Family: $0 [Non-embedded]1

In-Network, Out-of- Individual: $7,800 Individual: $8,500 Individual: $6,900 Individual: $6,000 Individual: $7,500 Pocket Maximum Family: $15,600 Family: $17,000 Family: $13,800 Family: $12,000 Family: $15,000

Primary Care Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay

Specialist Visit $50 copay $40 copay 30% after deductible $15 copay $20 copay

Outpatient Mental Health and Substance $50 copay $40 copay 30% after deductible $15 copay $20 copay Abuse Visits

Physical & Occupational $75 copay $40 copay 30% after deductible $40 copay $45 copay Therapy/Chiropractic2

Lab Services $75 copay $65 copay 30% after deductible $30 copay $35 copay (Diagnostic / X-ray)

Urgent Care $100 copay $80 copay 30% after deductible $30 copay $40 copay

Emergency $750 after deductible 30% after deductible 30% after deductible $250 copay $300 copay Services

Hospital Inpatient (including 30% after deductible 30% after deductible 30% after deductible 20% after deductible 40% copay Maternity)

Pharmacy 30%/30%/30%/30% $0/$30/$150/50% $0/$30/$150/50% $0/$25/$75/50% $0/$30/$150/50% Summary3 after deductible

Includes Adult Dental Yes Yes No Yes No and Vision Option4

* Plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced Premium Tax Credits or Cost-Sharing Reductions. ** If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805, 16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875, 16877, or 16882 1 This plan has a Non-Embedded deductible. See Disclosures page for more info. 2 Limit of 30 combined physical and occupational therapy visits per benefit period. 3 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier. 4 See page 36 for Adult Dental and Vision benefit details.

33 Extra savings plan options Plan summaries – Plan summaries Income Level

138%-149% FPL 150-199% FPL Description Coverage Level

Silver 100 Silver 0 Silver 700

Adams, Centre Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO

Individual: $100 Individual: $0 Individual: $700 In-Network Deductible Family: $200 Family: $0 Family: $1,400

In-Network, Out-of- Individual: $1,400 Individual: $1,200 Individual: $2,850 ** Pocket Maximum Family: $2,800 Family: $2,400 Family: $5,700 , Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties Extra Savings Plans Savings Extra and Counties Snyder,York Union, Montour,Northumberland, Mifflin, Juniata, Fulton, , Columbia,

Primary Care Visit $5 copay $1 copay $25 copay

Specialist Visit $5 copay $1 copay $25 copay

Outpatient Mental Health and Substance $5 copay $1 copay $25 copay Abuse Visits Physical & Occupational $5 copay $5 copay $25 copay Therapy/Chiropractic1 Lab Services $15 copay $5 copay $45 copay (Diagnostic / X-ray)

Urgent Care $10 copay $5 copay $50 copay

Emergency Services $150 after deductible $75 copay $300 after deductible

Hospital Inpatient 10% after deductible 10% 10% after deductible (including Maternity)

Pharmacy Summary2 $0/$5/$15/50% $0/$5/$15/50% $0/$10/$50/50%

Includes Adult Dental Yes No Yes and Vision Option3

34 Income Level

150-199% FPL 200-249% FPL Description Coverage Level

Silver 0 Silver 2100 Silver 1050

Plan Availability my Blue Access EPO my Blue Access EPO my Blue Access EPO

Individual: $0 Individual: $2,100 Individual: $1,050 In-Network Deductible Family: $0 Family: $4,200 Family: $2,100

In-Network, Out-of- Individual: $2,800 Individual: $6,800 Individual: $5,800 Pocket Maximum Family: $5,600 Family: $13,600 Family: $11,600

Primary Care Visit $15 copay $50 copay $60 after deductible

Specialist Visit $15 copay $50 copay $60 after deductible

Outpatient Mental Health and Substance $15 copay $50 copay $60 after deductible Abuse Visits Physical & Occupational $30 copay $75 copay $60 after deductible Therapy/Chiropractic1 Lab Services $25 copay $75 copay $75 after deductible (Diagnostic / X-ray)

Urgent Care $30 copay $100 copay $120 after deductible

Emergency Services $275 copay $750 after deductible $750 after deductible

Hospital Inpatient 10% 30% after deductible 10% after deductible (including Maternity)

Pharmacy Summary2 $0/$10/$50/50% $0/$30/$150/50% $0/$30/$150/50% after deductible

Includes Adult Dental No Yes No and Vision Option3

** If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805, 16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875, 16877, or 16882 1 Limit of 30 combined physical and occupational therapy visits per benefit period. 2 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier. 3 See page 36 for Adult Dental and Vision benefit details.

35 Adult Dental and Vision Benefits Adult Benefits Vision For all plans with Adult Dental and Vision — these are your vision benefits.

In-network Vision Benefits Frequency - Once Every:

Eye Examination (including dilation when professionally indicated) 12 months

Spectacle Lenses 12 months

Frame 12 months

Contact Lenses (in lieu of eyeglass lenses) 12 months

Copayments

Eye Examination $0

Spectacle Lenses $0

Contact Lens Evaluation, Fitting, and Follow-Up Care n/a

Eyeglass Benefit - Frame Average Retail Value

Non-Collection Frame Allowance (Retail): Up to $130 Up to $60

Fashion level Up to $125 Included

1 Davis Vision Frame Collection Designer level Up to $175 $20 copayment (in lieu of Allowance): Premier level Up to $225 $40 copayment

Eyeglass Benefit - Spectacle Lenses Average Retail Value Member Charges

Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx) $60-$120 Included

Oversize Lenses $20 Included

Tinting of Plastic Lenses $20 $11

Scratch-Resistant Coating $25-$40 Included

Scratch Protection Plan Single Vision $60-$120 $20

Scratch Protection Plan Multifocal $60-$120 $40

Polycarbonate Lenses2 $60-$75 $0 or $30

Ultraviolet Coating $25-$30 $12

Standard Anti-Reflective (AR) Coating $50-$70 $35

Premium AR Coating $65-$90 $48

Ultra AR Coating $100-$125 $60

Standard Progressive Lenses $150-$195 $50

Premium Progressives (Varilux®, etc.) $195-$225 $90

Ultra Progressive Lenses $225-$300 $140

Intermediate-Vision Lenses $150-$175 $30

High-Index Lenses $90-$150 $55

Polarized Lenses $95-$110 $75

Plastic Photosensitive Lenses $95-$150 $65

36 Contact Lens Benefit (in lieu of eyeglasses)

Non-Collection Contact Lenses: Materials Allowance Up to $85

Disposable Covered In Full Collection Contact Lenses1 Planned Replacement Covered In Full in lieu of Allowance): Materials Evaluation, Fitting, and Follow-up Care Included

Medically Necessary Contact Materials, Evaluation, Fitting, and Follow-Up Care Included Lenses (with prior approval)

1 Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and multifocals.

2 Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater.

One-year eyeglass breakage warranty included.

Adult Vision benefits utilize the Davis Vision Network. There is no out-of-network coverage. Davis Vision is a separate company that administers Highmark vision benefits.

To find a provider in the Davis Vision Network, visit highmarkblueshield.com and select the Find a Doctor or Pharmacy tab.

37

Find a Doctor or and select the 6 Months None 6 Months 6 Months 6 Months 6 Months 6 Months 6 Months None 6 Months 6 Months 6 Months None None None None Elimination Period None None None None None None 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% $50 Per Calendar Year Per Calendar$150 Year $1,250 Out of Network 0% 0% 0% 0% 0% 0% highmarkblueshield.com 0% 100% 0% 50% 50% 80% 50% 50% 50% 50% 50% 80% 100% 100% 100% 100% 100% 80% 80% 80% 50% Policy Pays In Network 100% tab.

Consultations Orthodontics Adjustments and Repairs of Prosthetics of Repairs and Adjustments ServicesImplant Surgical PeriodonticsSurgical Inlays,Crowns, Onlays Dentures) Dentures, Partial (Fixed Prosthetics Nonsurgical Periodontics Nonsurgical Maintenance Periodontal Endodontics (Root canals, etc.) canals, (Root Endodontics and/or Oxide Nitrous and/or Anesthesia General SedationIV Surgical Extractions Surgical Surgery Oral Complex Basic Restorative (Fillings, etc.) Basic Restorative Extractions Simple Space Maintainers Space Partial Fixed Onlays, Inlays, Crowns, of Repairs Dentures and Dentures, Prophylaxis (Cleanings) Prophylaxis (Emergency) Treatment Palliative Sealants Oral Evaluations (Exams) Evaluations Oral X-Rays) (All Radiographs Covered Services: Covered Annual Deductible Per Insured Person Insured Per Deductible Annual Family Insured Deductible Per Annual Person Insured Per Maximum Annual Dental Benefits Dental Pharmacy provider. There is Out-of-Network no coverage for this benefit.United Concordia Companies, Inc., is a separate company that administers pediatric dental benefitsfor Highmark members. find a dental providerTo in the AdvantageNetwork, visit as payment in full. Adult Dental benefitsutilize Unitedthe Concordia AdvantageNetwork. Membersmust Uniteduse a Concordia The percentage in the Policy Pays column is the percentage the of plan allowance that the Policy will pay for Covered Services provided by a Participating Dentist. Participating Dentists accept the Maximum Allowable Charge

these are your dental benefits. dental your are these For all plans with Adult Dental and Vision — Vision and Dental Adult with plans all For

Adult Dental Benefits 38 Helpful health insurance definitions

Health care lingo, translated. When you’re choosing plans, you’re bound to see certain terms over and over. Here’s a cheat sheet for a few of the most important ones.

BlueCard® HIGH-DEDUCTIBLE HEALTH PREMIUM A program that connects independent PLAN (HDHP) The monthly amount paid for coverage. Blue Plans across the country. It A plan that usually comes with a lower PREVENTIVE CARE SERVICES gives Blue Plan members access to premium because you pay more for Routine care like screenings and in-network coverage while outside health care services up front before the checkups that help you healthy. Refer to their plan area. The level of coverage insurance company starts to pay. These the Highmark Preventive Schedule for depends on your chosen plan. plans are often combined with a health the list of preventive care services. savings account. COINSURANCE PRIMARY CARE PROVIDER (PCP) The percentage of total cost of IN-NETWORK PROVIDER The medical professional you see for care you may owe for certain A provider that has an agreement most of your basic care, like yearly covered services after reaching your with the plan and will accept plan preventive visits and screenings. deductible. For example, if your plan allowance plus member copay or pays 80%, you pay 20%. coinsurance as payment in full. QUALIFIED HEALTH PLAN (QHP) A plan that has been certified by the COPAY OUT-OF-NETWORK PROVIDER Health Insurance Marketplace and The set amount you pay for certain A provider that does not have an meets all ACA requirements. That covered services, could be $20 for a agreement with the plan and does includes providing the 10 essential doctor visit or $30 for a specialist visit. not have to accept plan allowance health benefits and staying inside the If you owe a copay, you must pay it as payment in full. limits for deductibles, copays, and when you check in for your visit. OUT-OF-POCKET MAXIMUM out-of-pocket maximums. DEDUCTIBLE The most you’d pay for covered REHABILITATIVE SERVICES The set amount you pay for covered care in a benefit period or year. Care that helps you keep, get back, health services or drug costs before If you reach this amount, your or improve skills and functioning your plan starts paying. plan pays 100% after that. after you were sick, hurt, or disabled. EMERGENCY SERVICES PLAN ALLOWANCE RETAIL CLINIC Care for a condition needing The set amount an in-network Walk-in centers for less complex health immediate attention to avoid provider has agreed to accept for a needs, generally open in the evenings severe harm. covered health care service. Member and on weekends. responsibility for the service can FORMULARY be found in the Outline of Coverage. TELEMEDICINE A list of drugs selected by the plan The plan pays the difference between Telemedicine is health care that you get based on certain clinical factors. the plan allowance and the member from a doctor in real time via a smart The list of medicines is sorted responsibility. If an out-of-network device, computer, or telephone. by tier. Lower tiers usually mean provider bills for more than the lower copays. plan allowance, you may have to URGENT CARE CENTER A walk-in center for when you have a HABILITATIVE SERVICES pay the difference. If your plan does not condition that’s serious enough to need Health care services that help you include out-of-network coverage and care right away, but not serious enough keep, acquire, or improve skills and you receive care, other than emergency for a trip to the emergency room. functioning for daily living following or urgent care, you may be responsible disease, illness, or injury. for the entire cost. VIRTUAL VISIT A type of telemedicine that you receive HEALTH SAVINGS ACCOUNT (HSA) from a PCP or specialist via email or An account to set aside pre-tax money online videoconferencing. to pay for qualified medical expenses. You can only have an HSA if you have a Qualified High-Deductible Health Plan.

39 Legal info

There’s a whole lot of legalese around these plans. We put it all in one place for you.

HIGHMARK DISCLOSURES Important Benefit Details *Non-Embedded Family Deductible: For an agreement covering more than one Pediatric vision benefits utilize the Davis Vision Network. Pediatric dental (1) family member, the family deductible must be satisfied before the plan will benefits utilize United Concordia’s Advantage Network. begin to pay benefits for covered services for any covered family member. When Essential Formulary prescription drug cost covers a 90-day (Mail Order) or 31- the family deductible has been satisfied, the family deductible will be considered day (Retail) supply. All plans have a four-tier closed formulary prescription drug to have been satisfied for all family members, the plan will begin to pay benefits structure. for covered services for all covered family members for the remainder of the benefit period (January 1, 2021– December 31, 2021). The family deductible can Qualified High Deductible Health Plans may be coupled with a Health be met by one family member or a combination of members. Savings Account (HSA). However, certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance **Blue Distinction Centers (BDC) met overall quality measures, developed with Marketplace are not intended to be used with an HSA. If you have questions, input from the medical community. A Local Blue Plan may require additional please check with your financial advisor. criteria for providers located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that BlueCard coverage is available for emergency or urgent care for all plans when address consumers’ need for affordable healthcare. Each provider’s cost of care you are away from home. Routine care is also covered for some plans. Consult is evaluated using data from its Local Blue Plan. Providers in CA, ID, NY, PA, and your plan documents for additional information. WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost BlueCard is a registered mark of the Blue Cross and Blue Shield Association, an of care; and their own Local Blue Plans decide whether one or both cost of care association of independent Blue Cross and Blue Shield Plans. evaluation(s) must meet BDC+ national criteria. Blue Distinction Total Care (“Total Highmark Blue Shield is a Qualified Health Plan insurer in the Health Insurance Care”) providers have met national criteria based on provider commitment to Marketplace. deliver value-based care to a population of Blue members. Total Care+ providers also met a goal of delivering quality care at a lower total cost relative to other Please note that information regarding the Patient Protection and Affordable providers in their area. Program details are displayed on www.bcbs.com. Care Act of 2010 (a.k.a. “PPACA”, “Affordable Care Act”, “ACA”, and/or “Health Individual outcomes may vary. For details on a provider’s in-network status or Care Reform”), as amended, and/or any other law, does not constitute legal or your own policy’s coverage, contact your Local Blue Plan and ask your provider tax advice and is subject to change based upon the issuance of new guidance before making an appointment. Neither Blue Cross Blue Shield Association and/or change in laws. This information is intended to provide general nor any Blue Plans are responsible for noncovered charges or other losses or information only and does not attempt to give you advice that relates to your damages resulting from Blue Distinction or other provider finder information or specific circumstances. The information regarding any health plan will be care received from Blue Distinction or other providers. subject to the terms of the applicable health plan benefit agreement. Any review of materials, request for information, or application does not obligate Aggregate/Embedded Family Deductible Plans: For an Agreement covering you to enroll for coverage. Please request the Outline of Coverage for details on more than one (1) family member, as each Member satisfies their individual benefits, conditions, and exclusions. Providing your information is voluntary. Deductible, the Plan will begin to pay benefits for Covered Services for that Member for the remainder of the Benefit Period (January 1, 2021– December To find more information about Highmark’s benefits and operating procedures, 31, 2021), whether or not the entire family Deductible has been satisfied. such as accessing the drug formulary or using network providers, please go to When the family Deductible has been satisfied, the family Deductible will be DiscoverHighmark.com/QualityAssurance; or for a paper copy, call 1-855-873- considered to have been satisfied for all remaining covered family members. 4108 (TTY/TDD 711). Not every individual member must meet the individual deductible for the family Blue Distinction Centers (BDC) met overall quality measures for patient safety deductible to be met and no individual member may satisfy the entire family and outcomes, developed with input from the medical community. A Local Deductible. Blue Plan may require additional criteria for providers located in its own service You are responsible for out-of-pocket costs each benefit period (January 1, 2021 area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) – December 31, 2021) up to the maximum amount shown. Thereafter, the plan also met cost measures that address consumers’ need for affordable healthcare. pays 100% of the Plan Allowance. During the remainder of the benefit period. Each provider’s cost of care is evaluated using data from its Local Blue Plan. This amount does not include amounts in excess of the plan allowance. Providers in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans Diagnostic Lab services include Laboratory and Pathology. Diagnostic Lab decide whether one or both cost of care evaluation(s) must meet BDC+ national services require one copay (or, for some plans, coinsurance after deductible) per criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. date of service and type of service. Individual outcomes may vary. For details on a provider’s in-network status or Basic Diagnostic Services include Diagnostic X-ray, diagnostic medical and your own policy’s coverage, contact your Local Blue Plan and ask your provider allergy testing. Basic diagnostic services require one copay (or, for some plans, before making an appointment. Neither Blue Cross and Blue Shield Association coinsurance after deductible) per date of service and type of service. nor any Blue Plans are responsible for non-covered charges or other losses or Advanced Imaging services include, but are not limited to, CAT scan, CTA, MRI, damages resulting from Blue Distinction or other provider finder information or MRA, PET scan, and PET/CT Scan. Advanced Imaging services require one copay care received from Blue Distinction or other providers. (or, for some plans, coinsurance after deductible) per date of service and type of Blue Distinction is a registered mark of the Blue Cross and Blue Shield service. Association, an association of independent Blue Cross and Blue Shield Plans. Blue365 is a registered mark of the Blue Cross Blue Shield Association. Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. You can file a grievance in person You should confirm the network status of a provider prior to receiving services. or by mail, fax, or email. If you need help filing a grievance, the Civil Rights You can call My Care Navigator at 1-888-Blue-428 to confirm if a doctor or facility Coordinator is available to help you. You can also file a civil rights complaint will be in network in 2021. with the U.S. Department of Health and Human Services, Office for Civil Rights American Well is an independent company that provides telemedicine services. electronically through the Office for Civil Rights Complaint Portal, available at American Well does not provide Blue Cross and/or Blue Shield products or https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: services and it is solely responsible for its telemedicine services. U.S. Department of Health and Human Services Sharecare, RealAge Test and AskMD are registered trademarks of Sharecare, 200 Independence Avenue, SW LLC., an independent and separate company that provides a consumer care Room 509F, HHH Building engagement platform for Highmark members. Sharecare is solely responsible Washington, D.C. 20201 for its programs and services, which are not a substitute for professional medical 1-800-368-1019, 800-537-7697 (TDD) advice, diagnosis or treatment. Sharecare does not endorse any specific product Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. service or treatment. Health care plans and the benefits thereunder are subject to the terms of the applicable benefit agreement. My Care Navigator is a service mark of Highmark Inc. Highmark Blue Shield is an independent licensee of the Blue Cross Blue Shield Association. Discrimination is Against the Law The Claims Administrator/Insurer 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 Claims Administrator/Insurer 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 Claims Administrator/Insurer 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 Claims Administrator/Insurer 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 Claims Administrator/Insurer: • 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 Claims Administrator/Insurer 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, Notes

42 Highmark, a member of the Blue Cross Blue Shield Association,* has been providing secure and stable health care coverage for over 80 years. With one in three Americans covered by a Blue Cross and/or Blue Shield plan, when you’re with Highmark, you’re in good company.

*The Blue Cross Blue Shield Association is an association of independent Blue Cross Blue Shield plans. Ready to (en)roll? Cool. Here’s how to do it: • By phone: 1-855-400-9159 • Online: Highmark2021Plans.com • By contacting your agent or broker • At a Highmark Direct store or walk-in center near you

The Shops at Cedar Point Mill Creek Square 305 South Cedar Crest Boulevard 2350 Lincoln Highway East Allentown, PA 18103 Lancaster, PA 17602 484-773-1669 717-400-9809 Colonial Commons Silver Spring Square Shopping Center 6416 Carlisle Pike 5072 Jonestown Road Mechanicsburg, PA 17050 Harrisburg, PA 17112 717-516-1978 717-678-6442 Lower Nazareth Commons 3770 Dryland Way Easton, PA 18045 610-881-6525

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