Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 08/19/18 – 08/18/19 Commercial Casualty Insurance Company: Otis College of Art and Design Coverage for: 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, www.chpstudenthealth.com or calling toll free (877) 657-5030. 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 1-800-318-2596 to request a copy. Important Questions Answers Why This Matters: Network: $250 Individual/ Generally, you must pay all of the costs from providers up to the deductible amount before this What is the overall Family $500 plan begins to pay. If you have other family members on the policy, the overall family deductible deductible? Non-Network: $750 Individual/ must be met before the plan begins to pay. Family $1,500 Yes. In-Network Preventive services, Physician and Specialist This plan covers some items and services even if you haven’t yet met the deductible amount. But Are there services office visits, Urgent Care visits, a copayment or coinsurance may apply. For example, this plan covers certain preventive covered before you meet Prescription drugs and Student services without cost-sharing and before you meet your deductible. See a list of covered your deductible? Health and Wellness Center preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Services are covered before you meet your deductible. Are there other deductibles for specific No You don’t have to meet deductibles for specific services. services? Network: $5,900 Individual/ The out-of-pocket limit is the most you could pay in a year for covered services. If you have other What is the out-of-pocket Family $11,800 family members in this plan, they have to meet their own out-of-pocket limits until the overall limit for this plan? Non-Network: $12,700 Individual/ family out-of-pocket limit has been met. Family $25,400 Premiums, balance-billing What is not included in charges, and health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out-of-pocket limit? doesn’t cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Yes. For Cigna Open Access Plan 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 (OAP), see www.cigna.com or call provider for the difference between the provider’s charge and what your plan pays (balance use a network provider? 1-877-657-5030 for a list of billing). Be aware, your network provider might use an out-of-network provider for some services network providers. (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? OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016 Otis College of Art and Design SBC (2018) 1 of 7 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Limitations, Exceptions, & Other Important What You Will Pay Information Common Services You May Need Non-Network Medical Event Network Provider Provider (You will pay the least) (You will pay the most) Primary care visit to treat an $20 copay/visit 50% coinsurance Deductible waived. injury or illness If you visit a health Specialist visit $20 copay/visit 50% coinsurance Deductible waived. care provider’s office or clinic You may have to pay for services that aren’t Preventive care/screening/ preventive. Ask your provider if the services you No Charge 50% coinsurance immunization need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood Deductible Waived if Student Health Center 20% coinsurance 50% coinsurance work) Referral If you have a test Imaging (CT/PET scans, Deductible Waived if Student Health Center 20% coinsurance 50% coinsurance MRIs) Referral If you need drugs to Generic drugs $15 copay/prescription (retail) Not Covered Copayment waived for Generic Contraceptives treat your illness or and brand-name contraceptives for which there condition Preferred brand drugs $30 copay/prescription (retail) Not Covered are no therapeutic equivalent. Up to a 12-month More information about Non-preferred brand drugs $70 copay/prescription (retail) Not Covered supply of contraceptives may be dispensed with prescription drug a single prescription order. coverage is available Specialty drugs $200 copay/prescription (retail) Not Covered at www.berxplan.com Deductible waived. If two or more surgical procedures are performed through the same incision or in Facility fee (e.g., ambulatory immediate succession at the same operative 20% coinsurance 50% coinsurance surgery center) session, We will pay a benefit equal to the If you have outpatient benefit payable for the procedure with highest surgery benefit value. Physician/surgeon fees 20% coinsurance 50% coinsurance –––––––––––none––––––––––– Otis College of Art and Design SBC (2018) 2 of 7 Limitations, Exceptions, & Other Important What You Will Pay Information Common Services You May Need Non-Network Medical Event Network Provider Provider (You will pay the least) (You will pay the most) 20% coinsurance, $150 20% coinsurance, Emergency room care Copayment waived if admitted. If you need copay/visit $150 copay/visit immediate medical Emergency medical 20% coinsurance 50% coinsurance Ground and/or air/water transportation attention transportation Urgent care $20 copay/visit 50% coinsurance Deductible waived. Pre-Certification is required. Pre-Certification is not required for medical emergency, Urgent Care or Hospital confinement for maternity care prior to the initial Facility fee (e.g., hospital 48 hours following vaginal delivery/96 hours 20% coinsurance 50% coinsurance If you have a hospital room) following cesarean section or for in-patient stay length of state following mastectomy and reconstructive surgery where the length of stay is determined by the physician or surgeon in consultation with the patient. Physician/surgeon fees 20% coinsurance 50% coinsurance Pre-Certification is required. First 15 visits for Mental Health/Substance If you need mental Abuse 100% of the Network Provider Allowance health, behavioral Outpatient services 20% coinsurance 50% coinsurance First 15 visits for Mental Health/Substance health, or substance Abuse 100% of the Non-Network Provider abuse services Allowance Inpatient services 20% coinsurance 50% coinsurance –––––––––––none––––––––––– $20 copay/visit and 20% Preventive Services associated with Prenatal Office visits 50% coinsurance coinsurance Care and the First Postpartum Appointment will Childbirth/delivery be covered with no Cost sharing. 20% coinsurance 50% coinsurance professional services Depending on the type of services, coinsurance may apply. Maternity care may include tests If you are pregnant and services described elsewhere in the SBC Childbirth/delivery facility (i.e. ultrasound). 20% coinsurance 50% coinsurance services Up to 48 hours for normal vaginal delivery and 96 hours (not including the day of surgery) for a caesarean section delivery. Otis College of Art and Design SBC (2018) 3 of 7 Limitations, Exceptions, & Other Important What You Will Pay Information Common Services You May Need Non-Network Medical Event Network Provider Provider (You will pay the least) (You will pay the most) Up to 100 visits per Policy Year Home health care 20% coinsurance 50% coinsurance (separate visit limits apply for Habilitative and Rehabilitative Services) Habilitation and Rehabilitation Therapy includes $20 copay/visit and 20% $20 copay/visit and cardiac rehabilitation, pulmonary rehabilitation, Rehabilitation services coinsurance 50% coinsurance Physical Therapy, occupational therapy and speech therapy. Deductible waived. Network: For Outpatient Physical Therapy and $20 copay/visit and 20% $20 copay/visit and Habilitation services Occupational Therapy, Pre-Certification coinsurance 50% coinsurance required after the 5th visit. If you need help recovering or have Pre-Certification is required. Skilled nursing care 20% coinsurance 50% coinsurance other special health Up to 100 days per Policy Year needs Excludes comfort and convenience items, equipment that increases residence’s value, Durable medical equipment 20% coinsurance 20% coinsurance and exercise equipment. For home use and Prosthetic/Orthotic devices Hospice services 20% coinsurance 50% coinsurance –––––––––––none––––––––––– Otis College of Art and Design SBC (2018) 4 of 7 Limitations, Exceptions, & Other Important What You Will Pay Information Common Services You May Need Non-Network Medical Event Network Provider Provider (You will pay the least) (You will pay the most) Preventive: Limited to one exam/Policy year to Children’s eye exam No Charge the end of the month in which the Insured Person turns age 19. Limited to one set of frames/glasses/lenses per Policy year to the end of the month in which the Insured Person turns age 19. No Charge Either prescription lenses for eyeglass frames or prescription contact lenses are covered but If your child needs Children’s glasses not both. dental or eye care Optional lenses and treatments. Either prescription lenses for eyeglass frames 50% coinsurance or prescription contact lenses are covered but not both. Preventive: Limited to one exam/six months to Children’s dental check-up No Charge the end of the month in which the Insured Person turns age 19.