Excluded Services & Other Covered Services

Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

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 1-800-241-5704.

Important Questions Answers Why this Matters: What is the overall $0 individual/$0 family enhanced You must pay all the costs up to the deductible amount before this plan deductible? value network. begins to pay for covered services you use. Check your policy or plan $100 individual/$200 family document to see when the deductible starts over (usually, but not always, standard value network. January 1st). See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Network deductible does not apply to office visits, preventive care services, emergency room services, urgent care, and prescription drug benefits. ‍ Copayments, coinsurance amounts don't count toward the network deductible. Are there other deductibles No. You don't have to meet deductibles for specific services, but see the chart for specific services? starting on page 3 for other costs for services this plan covers. Is there an out–of–pocket Enhanced value network: $0 The out-of-pocket limit is the most you could pay during a coverage period limit on my expenses? individual/$0 family. (usually one year) for your share of the cost of covered services. This limit Standard value network: $400 helps you plan for health care expenses. individual/$800 family. Up to a $6,600 individual/$13,200 family, combined enhanced and standard value total maximum out- of-pocket.

Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 1 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO What is not included in the Enhanced value and Standard value Even though you pay these expenses, they don't count toward the out-of- out–of–pocket limit? network: Premiums, balance-billed pocket limit. charges, and health care this plan doesn't cover do not apply to your total maximum out-of-pocket. Is there an overall annual No. The chart starting on page 3 describes any limits on what the plan will pay for limit on what the plan specific covered services, such as office visits. pays? Does this plan use a Yes. For a list of network If you use a network doctor or other health care provider, this plan will pay network of providers? providers, see some or all of the costs of covered services. Be aware, your network doctor www.highmarkbcbs.com or hospital may use an out-of-network provider for some services. Plans use or call 1-800-241-5704. the term ‍in-network, preferred or participating for providers in their network. See the chart starting on page 3 for how this plan pays different kinds of providers. Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist? Are there services this plan Yes. Some of the services this plan doesn’t cover are listed in the Excluded doesn’t cover? Services & Other Covered Services section. See your policy or plan document for additional information about excluded services.

 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 c oinsurance 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 the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and 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.

Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 2 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Your Cost if You Limitations & Exceptions Medical Event Use an Enhanced Use a Standard Use an Out-of- Value (Network) Value (Network) Network Provider Provider Provider If you visit a Primary care visit to treat ‍No charge $10 copay/visit‍ Not covered ‍‍−−−−−−−−−−−none−−−−−−−−−− health care an injury or illness provider’s office Specialist visit ‍$10 copay/visit‍ $25 copay/visit‍ Not covered −−−−−−−−−−−none−−−−−−−−−− or clinic Other practitioner office $25 copay/visit $25 copay/visit Not covered ‍‍−−−−−−−−−−−none−−−−−−−−−− visit for chiropractor for chiropractor Preventive care No charge for No charge for Not covered Please refer to your preventive Screening preventive care preventive care schedule for additional Immunization services services information. If you have a test Diagnostic test (x-ray, No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− blood work) Imaging (CT/PET scans, No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− MRIs)

Common Services You May Need Your Cost if You Your Cost if You Your Cost if You Limitations & Exceptions Medical Event Use an Enhanced Use a Standard Use an Out-of- Value (Network) Value (Network) Network Provider Provider Provider If you need drugs ‍Generic drugs $8 copay $8 copay Not covered Up to 34-day supply retail to treat your (retail) (retail) pharmacy. illness or $12 copay $12 copay Up to 90-day supply maintenance condition prescription drugs through mail (mail order) (mail order) order. More information Formulary Brand drugs $35 copay $35 copay Not covered Certain participating retail about prescription (retail) (retail) pharmacy providers may have drug coverage is $50 copay $50 copay agreed to make maintenance available at (mail order) (mail order) prescription drugs available at the www.highmarkbcb same cost-sharing and quantity s.com. limits as the mail service coverage. Non-Formulary Brand $60 copay $60 copay Not covered ‍drugs (retail) (retail) $90 copay $90 copay (mail order) (mail order)

If you have Facility fee (e.g., No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− outpatient ambulatory surgery center) surgery Physician/surgeon fees No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− If you need Emergency room services $100 copay/visit $100 copay/visit Not covered Copay waived if admitted as an immediate inpatient. medical attention Emergency medical No charge ‍‍ No charge ‍‍ Not covered −−−−−−−−−−−none−−−−−−−−−− transportation Urgent care ‍$10 copay/visit‍ $20 copay/visit‍ Not covered −−−−−−−−−−−none−−−−−−−−−− Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 4 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Your Cost if You Limitations & Exceptions Medical Event Use an Enhanced Use a Standard Use an Out-of- Value (Network) Value (Network) Network Provider Provider Provider If you have a Facility fee (e.g., hospital No charge ‍‍ 20% coinsurance Not covered ‍‍‍‍Precertification may be required. hospital stay room) Physician/surgeon fee No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− If you have Mental/Behavioral health No charge ‍‍ No charge ‍‍ Not covered −−−−−−−−−−−none−−−−−−−−−− mental health, outpatient services behavioral health, Mental/Behavioral health No charge ‍‍ No charge ‍‍ Not covered ‍Precertification may be required. or substance inpatient services abuse needs Substance use disorder No charge ‍‍ No charge ‍‍ Not covered −−−−−−−−−−−none−−−−−−−−−− outpatient services Substance use disorder No charge ‍‍ No charge ‍‍ Not covered ‍‍‍‍‍‍‍‍Precertification may be required. inpatient services If you are Prenatal and postnatal care No charge ‍‍ 20% coinsurance Not covered Network: The first visit to pregnant determine pregnancy is covered at no charge. Please refer to the Women’s Health Preventive Schedule for additional information. Delivery and all inpatient No charge ‍‍ 20% coinsurance Not covered Precertification may be required. services

Common Services You May Need Your Cost if You Your Cost if You Your Cost if You Limitations & Exceptions Medical Event Use an Enhanced Use a Standard Use an Out-of- Value (Network) Value (Network) Network Provider Provider Provider If you need help Home health care No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− recovering or Rehabilitation services No charge ‍‍ No charge Not covered −−−−−−−−−−−none−−−−−−−−−− have other special Habilitation services ‍‍Not covered ‍‍Not covered Not covered ‍‍−−−−−−−−−−−none−−−−−−−−−− health needs Skilled nursing care No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− Durable medical No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− equipment Hospice service No charge ‍‍ 20% coinsurance Not covered −−−−−−−−−−−none−−−−−−−−−− If your child Eye exam ‍‍Not covered ‍‍Not covered ‍‍Not covered −−−−−−−−−−−none−−−−−−−−−− needs dental or Glasses ‍‍Not covered ‍‍Not covered ‍‍Not covered −−−−−−−−−−−none−−−−−−−−−− eye care Dental check-up Not covered Not covered Not covered −−−−−−−−−−−none−−−−−−−−−−

Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 6 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO Excluded Services & Other Covered Services:

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

 Acupuncture  Habilitation services  Routine eye care (Adult)  Cosmetic surgery  Hearing aids  Routine foot care  Dental care (Adult)  Long-term care  Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)  Bariatric surgery  Coverage provided outside the United  Non-emergency care when traveling States. See www.bcbsa.com outside the U.S.  Chiropractic care  Infertility treatment  Private-duty nursing

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

For more information on your rights to continue coverage, contact the plan at 1-800-241-5704. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact:  Your plan administrator/employer.

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 [does / does not] provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage [does / does not] meet the minimum value standard for the benefits it provides.

To obtain language assistance, call 1-800-241-5704. SPANISH (Español): Para obtener asistencia en Español, llame al 1-800-241-5704. TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-241-5704. CHINESE (中文): 如果需要中文的帮助，请拨打这个号码 1-800-241-5704. NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-241-5704.

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

Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 8 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Coverage Examples Coverage for: Individual/Family | Plan Type: EPO

About these Coverage Examples: Managing type 2 diabetes Having a baby (routine maintenance of These examples show how this plan might (normal delivery) a well-controlled condition) cover medical care in given situations. Use these examples to see, in general, how much  Amount owed to providers: $7,540  Amount owed to providers: $5,400 financial protection a sample patient might get  Plan pays $7,520  Plan pays $5,000 if they are covered under different plans.  Patient pays $20  Patient pays $400

Sample care costs: Sample care costs: This is Hospital charges (mother) $2,700 Prescriptions $2,900 not a cost Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 estimator Hospital charges (baby) $900 Office Visits and Procedures $700 . Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 Don’t use these examples to Prescriptions $200 Vaccines, other preventive $100 estimate your actual costs Radiology $200 Total $5,400 under this plan. The actual Vaccines, other preventive $40 care you receive will be Total $7,540 Patient pays: different from these Deductibles $0 examples, and the cost of Patient pays: Copays $400 that care will also be Deductibles $0 Coinsurance $0 different. Copays $20 Limits or exclusions $0 Coinsurance $0 Total $400 See the next page for important information about Limits or exclusions $0 these examples. Total $20

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. Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 9 of 10 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 1-800-241-5704 to request a copy. Allegheny County Schools Health Insurance Consortium:‍ Coverage Period: 07/01/2015 - 06/30/2016 Community Blue Flex EPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Questions and answers about the Coverage Examples:

What are some of the assumptions What does a Coverage Example show? Can I use Coverage Examples to behind the Coverage Examples? For each treatment situation, the Coverage compare plans?  Costs don’t include premiums. Example helps you see how deductibles, copayments, and coinsurance can add up. It Yes. When you look at the Summary of  Sample care costs are based on national Benefits and Coverage for other plans, you’ll averages supplied by the U.S. Department also helps you see what expenses might be left up to you to pay because the service or find the same Coverage Examples. When of Health and Human Services, and aren’t you compare plans, check the “Patient Pays” specific to a particular geographic area or treatment isn’t covered or payment is limited. box in each example. The smaller that health plan. number, the more coverage the plan  The patient’s condition was not an excluded Does the Coverage Example predict provides. or preexisting condition. my own care needs?  All services and treatments started and  No. Treatments shown are just examples. The Are there other costs I should consider ended in the same coverage period. care you would receive for this condition when comparing plans?  There are no other medical expenses for could be different based on your doctor’s any member covered under this plan. advice, your age, how serious your condition Yes. An important cost is the premium you  Out-of-pocket expenses are based only on is, and many other factors. pay. Generally, the lower your premium, treating the condition in the example. the more you’ll pay in out-of-pocket costs,  The patient received all care from network such as copayments, deductibles, and providers. If the patient had received care Does the Coverage Example predict coinsurance. You should also consider from out-of-network providers, costs my future expenses? contributions to accounts such as health would have been higher. No. Coverage Examples are not cost savings accounts (HSAs), flexible spending estimators. You can’t use the examples to arrangements (FSAs) or health estimate costs for an actual condition. They reimbursement accounts (HRAs) that help are for comparative purposes only. Your own you pay out-of-pocket expenses. costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-241-5704 or visit us at www.highmarkbcbs.com. 10 of 10 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 1-800-241-5704 to request a copy.