Summary of Benefits and Coverage Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020 - 12/31/2020 Anthem ® BlueCross Coverage for: Individual + Family | Plan Type: EPO Anthem Silver 70 EPO 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, https://eoc.anthem.com/eocdps/ca/49ZHIND01012020 . 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.healthcare.gov/sbc-glossary/ or call (855) 634-3381 to request a copy. Important Questions Answers Why This Matters: What is the overall $4,000/person or $8,000/family Generally, you must pay all of the costs from providers up to the deductible amount before deductible? for In-Network Providers. this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services Yes. Primary Care Specialist This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Visit Preventive Care for In- But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? Network Providers. Dental services without cost-sharing and before you meet your deductible. See a list of covered Vision for In-Network preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Providers. Are there other Yes. $300/person or You must pay all of the costs for these services up to the specific deductible amount before deductibles for $600/family for Prescription this plan begins to pay for these services. specific services? Drugs In-Network Providers. There are no other specific deductibles. What is the out-of- $7,800/person or The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this $15,600/family for In-Network other family members in this plan, they have to meet their own out-of-pocket limits until the plan? Providers. overall family out-of-pocket limit has been met. What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this limit? plan doesn't cover. Will you pay less if Yes, Pathway X – EPO. See This plan uses a provider network. You will pay less if you use a provider in the plan’s you use a network www.anthem.com/ca or call network. You will pay the most if you use an out-of-network provider, and you might receive provider? (855) 634-3381 for a list of a bill from a provider for the difference between the provider’s charge and what your plan network providers. pays (balance billing). Be aware your network provider might use an out-of-network provider CA/IND/Anthem Silver 70 EPO/49ZH/01-20 1 of 12 for some services (such as lab work). Check with your provider before you get services. Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Limitations, Exceptions, & Services You May Need In-Network Provider Non-Network Provider Medical Event Other Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $40/visit deductible does not Not covered --------none-------- injury or illness apply $80/visit deductible does not If you visit a Specialist visit Not covered --------none-------- apply health care You may have to pay for services provider’s office that aren't preventive. Ask your or clinic Preventive care/screening/ No charge Not covered provider if the services needed immunization are preventive. Then check what your plan will pay for. Lab – Office $40/service, deductible does Lab – Office Diagnostic test (x-ray, blood not apply Not covered --------none-------- work) If you have a test X-Ray – Office X-Ray – Office $85/service, deductible Not covered does not apply $325/service, deductible does Imaging (CT/PET scans, MRIs) Not covered --------none-------- not apply If you need drugs $16/prescription, Prescription to treat your Drug deductible applies Not covered (retail and home illness or Tier 1 - Typically Generic (retail) and $32/prescription, delivery) Most home delivery is 90-day condition Prescription Drug deductible supply. *See Prescription Drug More information applies (home delivery) section of the plan or policy about prescription $60/prescription, Prescription document (e.g. evidence of drug coverage is Tier 2 - Typically Preferred Drug deductible applies Not covered (retail and home coverage or certificate). available at Brand & Non-Preferred (retail) and $150/prescription, delivery) http://www.anthe Generic Drugs Prescription Drug deductible m.com/pharmacyi applies (home delivery) nformation/ Select Drug List * For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/ca/49ZHIND01012020. 2 of 12 What You Will Pay Common Limitations, Exceptions, & Services You May Need In-Network Provider Non-Network Provider Medical Event Other Important Information (You will pay the least) (You will pay the most) $90/prescription, Prescription Drug deductible applies Tier 3 - Typically Non-Preferred Not covered (retail and home (retail) and $225/prescription, Brand and Generic drugs delivery) Prescription Drug deductible applies (home delivery) 20% coinsurance up to $250/prescription, Prescription Drug deductible Tier 4 - Typically Preferred applies (retail) and 20% Not covered (retail and home Specialty (brand and generic) coinsurance up to delivery) $750/prescription, Prescription Drug deductible applies (home delivery) Facility fee (e.g., ambulatory 20% coinsurance deductible If you have Not covered --------none-------- surgery center) does not apply outpatient 20% coinsurance deductible surgery Physician/surgeon fees Not covered --------none-------- does not apply Cost share except deductible $400/visit deductible does not waived if admitted. No charge Emergency room care Covered as In-Network apply for Emergency Room Physician If you need Fee. immediate Emergency medical $250/trip deductible does not medical attention Covered as In-Network --------none-------- transportation apply $40/visit deductible does not Urgent care Covered as In-Network --------none-------- apply Facility fee (e.g., hospital room) 20% coinsurance Not covered --------none-------- If you have a 20% coinsurance deductible hospital stay Physician/surgeon fees Not covered --------none-------- does not apply Office Visit $40/visit deductible does not If you need Office Visit Office Visit apply mental health, Not covered --------none-------- Outpatient services Other Outpatient behavioral health, Other Outpatient Other Outpatient 20% coinsurance deductible or substance Not covered --------none-------- does not apply, up to a $40 abuse services maximum Inpatient services 20% coinsurance Not covered 20% coinsurance deductible does * For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/ca/49ZHIND01012020. 3 of 12 What You Will Pay Common Limitations, Exceptions, & Services You May Need In-Network Provider Non-Network Provider Medical Event Other Important Information (You will pay the least) (You will pay the most) not apply for Inpatient Physician Fee In-Network Providers. No Coverage for Inpatient Physician Fee Non-Network Providers. Office visits No charge Not covered Cost sharing does not apply for Childbirth/delivery professional 20% coinsurance deductible preventive services. $40/visit Not covered services does not apply deductible does not apply for Postnatal In-Network Providers. If you are In-Network preventative pregnant prenatal and postnatal services Childbirth/delivery facility 20% coinsurance Not covered are covered at 100%. Maternity services care may include tests and services described elsewhere in the SBC (i.e. ultrasound). 100 visits/year for Home Health $45/visit deductible does not and Private Duty Nursing Home health care Not covered apply combined for In-Network Providers. $40/visit deductible does not Rehabilitation services Not covered If you need help apply *See Therapy Services section. recovering or $40/visit deductible does not Habilitation services Not covered have other special apply health needs 100 days/benefit period for Skilled nursing care 20% coinsurance Not covered skilled nursing services for In- Network Providers. 20% coinsurance deductible *See Durable Medical Durable medical equipment Not covered does not apply Equipment Section Hospice services No charge Not covered --------none-------- $0/visit, deductible does not Children’s