Summary of Benefits and Coverage: What This Plan Covers & What

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2021 – 3/31/2022 GUILD-TIMES BENEFITS FUND: Choice I – Hospital & Major Medical PPO Coverage for: Individual, Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, [insert contact information]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-646-237-1670 to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount In-Network: $250/Individual or $500/Family before this plan begins to pay. If you have other family members on the plan, each What is the overall family member must meet their own individual deductible until the total amount of deductible? Out-of-Network: $500/Individual or $1,000/Family deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the Are there services deductible amount. But a copayment or coinsurance may apply. For example, this Yes. Preventive care is covered before you meet covered before you meet plan covers certain preventive services without cost-sharing and before you meet your deductible. your deductible? your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other Yes. $50 for prescription drug coverage (retail You must pay all of the costs for these services up to the specific deductible deductibles for specific only). There are no other specific deductibles. amount before this plan begins to pay for these services. services? Medical – For network providers $3,675 Individual / $7,350 Family; for out-of-network The out-of-pocket limit is the most you could pay in a year for covered services. If What is the out-of-pocket providers $5,000 Individual / $10,000 Family you have other family members in this plan, they have to meet their own out-of- limit for this plan? Prescription Drug – For network providers pocket limits until the overall family out-of-pocket limit has been met. $3,675 Individual / $7,350 Family What is not included in Premiums, balance-billing charges, and health Even though you pay these expenses, they don’t count toward the out–of–pocket the out-of-pocket limit? care this plan doesn’t cover. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and Will you pay less if you Yes. See www.anthem.com or call 1-800-810- you might receive a bill from a provider for the difference between the provider’s use a network provider? BLUE (2583) for a list of network providers. charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. 1 of 6 Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common What You Will Pay Limitations, Exceptions, & Other Services You May Need Network Provider Out-of-Network Provider Medical Event Important Information** (You will pay the least) (You will pay the most) 35% coinsurance after Primary care visit to treat an $25 copayment/visit then deductible *plus any amount None injury or illness deductible applies in excess of reasonable and customary (R&C) charges. Copayment applies to chiropractic, If you visit a health outpatient mental health, and physical, care provider’s office $40 copayment/visit then 35% coinsurance after occupational, and speech therapy visits. or clinic Specialist visit deductible applies deductible * Coverage for physical, occupational, and speech therapy is limited to 30 visits per calendar year. Preventive care/screening/ 35% coinsurance after No charge None immunization deductible * Diagnostic test (x-ray, blood 35% coinsurance after No charge after deductible None work) deductible * If you have a test 35% coinsurance after Imaging (CT/PET scans, MRIs) No charge after deductible Pre-certification required. deductible * [** For more information about limitations and exceptions, see the plan or policy document at guild.candrdirect.com.] 2 of 6 Common What You Will Pay Limitations, Exceptions, & Other Services You May Need Network Provider Out-of-Network Provider Medical Event Important Information** (You will pay the least) (You will pay the most) Retail: $50 deductible. Greater of $10 or 25% Generic drugs copayment/prescription. Not covered Mail Order: $20 Covers up to a 30-day supply (retail); copay/prescription. up to a 90-day supply (mail order). Prior authorization is required for certain drugs. Retail: $50 deductible. If you need drugs to If a Brand name drug is purchased when Greater of $15 or 25% treat your illness or a generic is available, you will pay the Preferred brand drugs copayment/prescription. Not covered condition difference between the Generic and Mail Order: $40 More information about Brand drug cost plus 25% of the drug copayment/prescription. prescription drug cost. coverage is available at www.express- Retail: $50 deductible. The mail order program is mandatory scripts.com Greater of $40 or 40% after two refills of maintenance drugs. Non-preferred brand drugs copayment/prescription. Not covered Mail Order: $60 copayment/prescription. Retail: $50 deductible. Specialty drugs are available only Greater of $15 or 25% Specialty drugs Not covered through Express Scripts’ specialty copayment/prescription. pharmacy. No mail order. Facility fee (e.g., ambulatory 35% coinsurance after No charge after deductible None If you have outpatient surgery center) deductible * surgery 35% coinsurance after Physician/surgeon fees No charge after deductible None deductible * $250 copayment/visit then $250 copay/visit then Copayment waived if admitted to the Emergency room care deductible applies deductible applies* same hospital within 24 hours. If you need immediate Emergency medical 35% coinsurance after No charge after deductible None medical attention transportation deductible * $50 copayment/visit then 35% coinsurance after Urgent care None deductible applies deductible * 35% coinsurance after Facility fee (e.g., hospital room) No charge after deductible Pre-certification required. If you have a hospital deductible * stay 35% coinsurance after Physician/surgeon fees No charge after deductible None deductible * [** For more information about limitations and exceptions, see the plan or policy document at guild.candrdirect.com.] 3 of 6 Common What You Will Pay Limitations, Exceptions, & Other Services You May Need Network Provider Out-of-Network Provider Medical Event Important Information** (You will pay the least) (You will pay the most) If you need mental $40 copayment/visit then 35% coinsurance after Outpatient services None health, behavioral deductible applies deductible * health, or substance 35% coinsurance after Inpatient services No charge after deductible Pre-certification required. abuse services deductible * 35% coinsurance after Office visits No charge after deductible None deductible * Childbirth/delivery professional 35% coinsurance after If you are pregnant No charge after deductible None services deductible * Childbirth/delivery facility 35% coinsurance after No charge after deductible Pre-certification required. services deductible * Pre-certification required. 35% coinsurance after Home health care No charge after deductible deductible * Coverage limited to 200 visits per calendar year. Coverage is limited to 30 visits per $40 copayment/visit then 35% coinsurance after Rehabilitation services calendar year (combined home, office, or deductible applies deductible * outpatient facility). If you need help $40 copayment/visit then 35% coinsurance after recovering or have Habilitation services None deductible applies deductible * other special health Pre-certification required. needs 35% coinsurance after Skilled nursing care No charge after deductible deductible * Coverage is limited to 60 days per calendar year. 35% coinsurance after Durable medical equipment No charge after deductible None deductible * 35% coinsurance after Pre-certification required. Coverage is Hospice services No charge after deductible deductible * limited to 210 days per lifetime. Children’s eye exam No charge None If your child needs Excess over network Children’s glasses No charge None dental or eye care allowable charge Children’s dental check-up No charge None [** For more information about limitations and exceptions, see the plan or policy document at guild.candrdirect.com.] 4 of 6 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Bariatric surgery Long-term care Private-duty nursing Cosmetic surgery Non-emergency care when traveling outside the Routine foot care Hearing aids U.S. Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture Chiropractic care Dental care (Adult) Routine eye care (Adult) Coverage provided outside the United States. Infertility treatment See www.empireblue.com. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: U.S.

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