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What This Plan Covers & What You Pay for Covered Services Coverage

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What This Plan Covers & What You Pay for Covered Services Coverage Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021 – 12/31/2021 Insurance Company of Scott and White: Gold PPO copayment 0 7000 – 37755TX0130012 Coverage for: Member/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, call 800-321-7947 or visit us at swhp.org. 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 healthcare.gov/sbc-glossary or call 800-321-7947 to request a copy. Important Questions Answers Why This Matters: $0 per member / $0 per family for a Generally, you must pay all of the costs from providers up to the deductible amount before this What is the overall participating provider and $3,500 plan begins to pay. If you have other family members on the plan, each family member must deductible? per member / $7,000 per family for meet their own individual deductible until the total amount of deductible expenses paid by all a non-participating provider. family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. Are there services Yes. Preventive care and ACA But a copayment or coinsurance may apply. For example, this plan covers certain preventive covered before you meet preventive drugs are covered services without cost sharing and before you meet your deductible. See a list of covered your deductible? before you meet your deductible. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No You don’t have to meet deductibles for specific services. services? $7,000 per member / $14,000 per family for a participating provider The out-of-pocket limit is the most you could pay in a year for covered services. If you have What is the out-of-pocket and $21,000 per member / other family members in this plan, they have to meet their own out-of-pocket limits until the limit for this plan? $42,000 per family for a non- overall family out-of-pocket limit has been met. participating provider. Premiums, balance billing charges, What is not included in and health care this plan doesn’t Even though you pay these expenses, they don’t count toward the out–of–pocket limit. the out-of-pocket limit? cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Yes. See swhp.org or call You will pay the most if you use an out-of-network provider, and you might receive a bill from a Will you pay less if you 800-321-7947 for a list of network provider for the difference between the provider’s charge and what your plan pays (balance use a network provider? providers. 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. Do you need a referral to No You can see the specialist you choose without a referral. see a specialist? 092020 Page 1 of 7 (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Non-Participating Limitations, Exceptions, & Other Important Common Medical Event Services You May Need Participating Provider Provider Information (You will pay the least) (You will pay the most) Adult: $15 copayment per visit Primary care visit to treat an 50% coinsurance after Pediatric: injury or illness deductible No charge None (Age 0 through 18) If you visit a health care 50% coinsurance after Specialist visit $50 copayment per visit provider’s office or deductible clinic 50% coinsurance after deductible You may have to pay for services that aren’t Preventive care/screening/ preventive. Ask your provider if the services No Charge No charge for child immunization needed are preventive. Then check what immunizations through your plan will pay for. the 6th birthday. $150 copayment per visit Diagnostic test (X-ray, blood 50% coinsurance after for X-rays, $50 copayment None work) deductible per visit for Labs If you have a test Failure to obtain preauthorization of benefits, Imaging (CT/PET scans, 50% coinsurance after $250 copayment per visit other than emergency care, will result in a MRIs) deductible penalty of the lesser of $500 or 50%. 50% coinsurance after If you need drugs to ACA preventive drugs No charge Copayments are per 30-day supply. treat your illness or deductible Maintenance drugs are allowed up to a 90- $15 copayment per 50% coinsurance after condition Tier 1: Generic drugs day supply for three (3) copayments if More information about prescription deductible obtained through a Baylor Scott & White prescription drug $55 copayment per 50% coinsurance after Pharmacy or participating pharmacy. Mail Tier 2: Preferred brand drugs coverage is available at prescription. deductible Order: Available for a 1- to 90-day supply. https://swhp.org/en- $150 copayment per 50% coinsurance after Non-maintenance drugs obtained through Tier 3: Non-preferred drugs us/members/manage- prescription. deductible mail order are limited to a 30-day supply your-plan/pharmacy- Tier 4: Specialty drugs and $500 copayment per 50% coinsurance after maximum. Some specialty drugs may require information. oral anticancer medications prescription. deductible preauthorization. 30-day supply only. * For more information about limitations and exceptions, see the plan or policy document at swhp.org. Page 2 of 7 What You Will Pay Non-Participating Limitations, Exceptions, & Other Important Common Medical Event Services You May Need Participating Provider Provider Information (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory 50% coinsurance after $300 copayment per visit Failure to obtain preauthorization of benefits, If you have outpatient surgery center) deductible other than emergency care, will result in a surgery 50% coinsurance after Physician/surgeon fees $150 copayment per visit penalty of the lesser of $500 or 50%. deductible Emergency room copayment waived if $750 copayment per Emergency room care $750 copayment per visit episode results in hospitalization for the visit same condition within 24 hours. If you need immediate Emergency medical $750 copayment per $750 copayment per medical attention transportation service service None $50 copayment per Urgent care $50 copayment per visit visit Facility fee (e.g., hospital $500 copayment per day 50% coinsurance after Failure to obtain preauthorization of benefits, If you have a hospital room) (not to exceed $2,500) deductible other than emergency care, will result in a stay $500 copayment per day 50% coinsurance after Physician/surgeon fees penalty of the lesser of $500 or 50%. (not to exceed $2,500) deductible $15 copayment per office Failure to obtain preauthorization of partial visit, $300 copayment per 50% coinsurance after hospitalization benefits, other than Outpatient services If you need mental visit for all other outpatient deductible emergency care, will result in a penalty of the health, behavioral services. lesser of $500 or 50%. health, or substance Failure to obtain preauthorization of abuse services $500 copayment per day 50% coinsurance after residential treatment benefits, other than Inpatient services (not to exceed $2,500) deductible emergency care, will result in a penalty of the lesser of $500 or 50%. Cost sharing does not apply for preventive care. Depending on the type of services, a 50% coinsurance after copayment, coinsurance, or deductible may Office visits $15 copayment per visit deductible apply. Maternity care may include tests and If you are pregnant services described elsewhere in the SBC (i.e., ultrasound). Childbirth/delivery $500 copayment per day 50% coinsurance after Inpatient care for the mother and newborn professional services (not to exceed $2,500) deductible child in a health care facility is covered for a * For more information about limitations and exceptions, see the plan or policy document at swhp.org. Page 3 of 7 What You Will Pay Non-Participating Limitations, Exceptions, & Other Important Common Medical Event Services You May Need Participating Provider Provider Information (You will pay the least) (You will pay the most) minimum of 48 hours following an Childbirth/delivery facility $500 copayment per day 50% coinsurance after uncomplicated vaginal delivery and 96 hours services (not to exceed $2,500) deductible following an uncomplicated delivery by caesarean section. Limited to 60 visits per plan year. Failure to 50% coinsurance after obtain preauthorization of benefits, other than Home health care 10% of charges deductible emergency care, will result in a penalty of the lesser of $500 or 50%. 50% coinsurance after Limited to 35 visits for rehabilitation services Rehabilitation services $15 copayment per visit deductible and 35 visits for habilitation services per plan year. Limit is combined for physical therapy, occupational therapy, speech therapy, and, and chiropractic care. Limits may not apply for therapies for children with developmental 50% coinsurance after If you need help Habilitation services $15 copayment per visit delays, autism spectrum disorder and mental recovering or have deductible health services. Failure to obtain other special health preauthorization of benefits, other than needs emergency care, will result in a penalty of the lesser of $500 or 50%.
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