533 D ccreaenee: Corporate Flight Management, I Coverage Period: OOV2017- 12172017 ‘Summary of Benefits & Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family | Plan Type: PPO This is only a summary. Ifyou want mare detail about your coverage and cess, youcan get the complete tems in the coverage |. document at yy etstcoin ary calling 1+Si0-5659 4. Coverage document are not available until ater the effective date of your coverage, but you may obtain a sample at hitip:/wdpcbst.com/samplepolicy/2017/L.G «This sample may not match your benefits A crabs sooou Soul reve your Covage docment cnt ava Contributions made by you andor your employer to health savings accounts (HSAs), flexible spending arrangements (FSAS), or health reimbursement arangements (HRAS) may help pay your deductible or other outof-pocket expen. In-network: $2,500 person $5,000 ‘Youmust pay all the coss up to the deductible amount before this plan begins family ; top for covered servos yo use Check yur policy or plan document 0 soe een SIO ey ‘whe the deductible tars over (usually, bltnot alas, amry Is) Se the ‘eductbi? “ a ‘Ghat sting cm page? for how much you pay farcovered services afer you Does apply to preventive cae. erting cn Copays donot apply to the deductible. Arediereotier ‘Yous fave w met datas er sie servos but tee ‘eduetinies for specific | No. starting on page 2 far other ost for serves ths pln cover. servis? Is there an out-of ar ut-of-packet mit is the most you could py’ during coverage pried Yes ngsver: $400 The ‘he could pay Docket limit onmy — | Pree 13,000 (usually one year) for your share of the cast of covered services. This limit helps expenses? network: you plan for health cave expenses. pperson/$24,000 fail ‘What is notineluded in| Premium, balance-illed charzes, theoutof-pocket ——_penaltics, and health care this plan Even hough you pay these expenses they don't count toward the auof-packet limit? doesn't covers Wstiereanoverst | ‘Teche seringcn page 2 describes anys on wha the pln wil ay er the plan pays? * specific covered services, such as office visits. ‘If you use an in-network doctor or other health care provider. this plan will pay: Designs EE een ae se Ustworof ravi? | wots con/NeSPor cal 1-800 | en ae a oy - ‘the chart starting on page 2 for how this plan pays different kinds of providers. ‘Yes. This plan uses Network S, Fora BlueCross BlueShield of Temessee, Inc. an Independent Licensee ofthe BlueCross BlueShield Association, Questions: Cal 1-800-565-9140 or visit us at wrwsbebstcon IF you aren*t clear about any ofthe underlined tems used in this fom, see the Glossary. You can view the Glossy toto at wwwvalolgov/ebsx/paSBCUniformGlossary.paf or call 1-800-505-9140 to requesta copy. (Gaps#116101/Q2381/HCR)Do Lneed a referral to No, You dont nea somal 0528 yo can sete spas you chose wit pension fem hs ln Are there services this, ‘Some ofthe services thisplan doest cover ave liste on page 5, See you policy plan doesn't cover? Corplan document for ational information about gycudke servis “a: Copavments are fixed dollar amounts (for example, $15) you pay for covered health care, usally when you reocive the service. ‘Corinsurance is jour share of the costs ofa 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 eo-insurance payment of 20% would be $200. This may cnge if you haven'tmet your deductible. © Theamount theplan pays for covered services is based on the allowed amount. If an out-oFnetwerk 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 ovemight 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 in-network providers by charging you lower deductibles, co-payments and co-insuranes amounts. fom Medical Event Seo NTT rear’ ea Primary eae vst to tet fice surgery subject to injury oriliness S25 copay/visit APocornsuranee | Getuctbkelcoinsurance. (Office surgery subject to a Spacalist vist S40 copay/isit 4orcorinsurance | OTHE surety subject ‘care provider's “Therapy visis limited w 20per bpe por office or cline Other practitioner office vist | 20%en-insurance ——-4(Poorinsurance year. Cardia’ Pulmonary Rehab visits limited © 36per pe per year. Preventive care / screening / : = NoCharge 40P% coinsurance | sons Riagiestic testy: Ble No Charge 4o%ooorinsurance | Not subject othe deductible Myoubaveatest ngeing CHPETSANS, | a¢p cg: ane Prior Authorization requined. Your cost MRIs fo surance | hare may increase © 50% i not cbained ‘Af you need drugs to 30-day supply retail; up to 90 day supply treat your illness or Generic dnes Sl0copay 40% coinsurance home dlivay or Pus60 network. Co-pay condition per 30eday sippy. 10272016 1:11 AM. 20f10a eee ed ‘30-day supply real; up t0 90 day supply hhame delivery or Pix90 network. Co-pay Preferred brand drugs S35 copay $076 cose ey Whewa Band Diet chosen area Generic Drug esuivalent is availabe, You will pay a Penalty forthe Nompreferredbranddnes | $S0copay 40Pcornsurance | difference benveen the oost of the Brand ‘Dneand the Generic Drug. SelfsAdministered Specialty S100 copay at PECially 4 Cex) ‘Uptoa30 day supply. Must use a rugs pharmacy network Pharmacy in Specialty pharmacy network. Prior Authorization ruined for certain Facility fe (Bo ambulalony ep ,c.insurance | 4%covinsurance—_ctpatent Your cost share Ityouhave ‘argery cer) ‘may increase 10 50% ifn obtained, ‘outpatient surgery Prior Authorization required for certain Piysiciavsrgeon fies | 20Peorinsurance | 4% covinsurance _cutpatent Your cost share ‘may increase t 50's ifnot obtained, Emergency roomservices | 2ecrinswrance | 20% eorinsurane | sis you need ee et Arocoinsamee | Wscornsrmee | —___a00» Immediate medical ESE cae Uyantare SerLimintcns & | SeLininins | Sees aha aca iat plas svi ‘Ifyou haye a ae hespital" 2or6co-insurance 40% co-insurance 2a eee ar room) ‘may increase to 50% = Pyscian/suracon foe WPocorinsurance | AP% cominsurance | Ifyou have mental S35 copays for health, behavioral | MentalBchavioral health | office visits and 20% op co TC Reneue heat or substance cate servos cove fret Te | ey nae eo ce stare ‘Merial Behavior health 6p, ws Prior Authorization roquined. Your ost ‘inpatient services couse SOMSURINGS | share may increase to 30% if not obtained. neat Pic Ain aif lt ra once toroner A77Coinsanee covubivetieany (ECT You cs sere outpatient services SCE SS 10272016 1:11 AM. 3 0f10Aryou are pregnant one 40% coninsurance Hons ksalth eare Wi coeinsumarce Limits te 60 visits. Therepy limited to 20 viss per type per yeer. Cardiac Pulmozary Reba limited to $e visls per ype per year. Hoabilitstion: services ‘Troy lid 0 20 vs pet pe Pe Skilled masing care Durtble medical equipment asen ay increase 1 (P6 if rot No Charge Pre Ahriaen query Hospice. Your cost share may increase to ete if not bial’. nom aon L2TOO6 ULL AM 40F10Eacluded Services & Other Covered Services: > © Hearing aids for adulls © Infeniy treatment + Longtemcers # Privatzeduty nursing Other Covered Services (This n't a complete st, Cheek your pollcy or plan decument for other covered services and your eosts for these services) © Chiropractic care © Hearing as for children uncer 18 rey be sin fly hh than he ‘else apply, 2 #lso conlast your stale insurance uty Administration 2 1866463272 of ywynidod.cov/ebs9, oF the LS. Department of Healia end Haman Servs 505 or nwwsedinams.gov. ‘Your Grievance and Appeals Rights ity Administration a 1-865~ the Teraesee Depenttets of Consmerce an i i thems cumple Sasa ‘You may also wre tem a 30 dames aborts Ph, Davy Crock Tver, 6h Flooe Nall TN a. Does this Coverage Provide Minimum Essential Coverage? ‘The Affdable Care Act requires most people to have health cee coverage tit qualifies #5 “minimum essential coverage.” This plan or policy sdges provide minimum essential coverage, 19272016 1:11 AM 5010Does this Coverage Meet the Minimum Value Standard? ‘The Affordable Care \ct esteblshes a minimum value stanczrd of betetits ofa health plac. ‘The minittm. value staan is 60% (ectuarial value). 1927206 1:11 AM Sof 10About these Coverage Prarie herr Examples: ‘hese cups sow bow this pln mig rovlders: $7,540 Amount owed to providers: $5,100 ‘m Plan pays $3,890 Patient pays $1,600 ifthe ae covered wer ferent pans. ‘Sample care costs: ‘Sample care costs; ‘Hospital charges (mother Preseriptions Routine obstetric cere Medicel Equipent ars Supplies Thisis W2TQO:6 ULL AM 7oF100) ar remenee ;Corporate Flight Management, I Coverage Examples Questions and answers about the Coverage Examples: ‘What are some of the assumptions ‘What does a Coverage Example behind the Coverage Examples? show? + Costs don’t include presniums. * Sample sae cons ae este rat ©The patient's cossition was at an or preexisting corition, Does the Coverage Example predict my own care needs? sevious your condition i, ang. meay other ‘actos. ‘mrs, 20s wold have been Docs the Coverage Example predict higher. my future expenses? ‘Coverage for Individual or F Coverage Period: 0 Can T use Coverage Examples to ‘compare plans? v'Yes, ay okt he Say of Ave there other costs I should consider when comparing plans? (Fatsrorheainrombusanen sce mis (HRAS) that help you pey cut-olspacket expenses, lossary. You can view tle Glossary BorlaNondiscrimination Notice BlueCross BtueSniokd of Dasis of race, color, nation 3508 (BlueCross) complies with applicable Federal civil rights laws and does not discririnate on the in, age, dsanilty o” Sax, BlueCross does not exclude peonie or treat then differently because of race, BlueCross: ‘emillgn information in ekner languages. Ifyou need tnese servizes, contact a consuTie” advisor at the number on the back of your Member ID card or call 1-800-565-9140 CITY: 1-800-848-0298 oF 711), Ifyou believe tat BlueCross nas falled to oravide these services or discriminatad in another way on the basis of rao2, color, national ‘or pealonee Kote SM Foam S08F, HHH Bulla. Was 4-8004368-1019, 309-537-7697 (TDD), Complaint fms are avaiable at btn the Glossary. You can Porto 40 request a copy.Language Access Services: ATENCION:si habla spare as Sssicin servis grits assess Ini, Lame al -S00-56S9MOCTTY; 00-48-0005 Guo B, Bot £2) 1-900.555.9.40 (TTY 18008484098) LT CHE CY, sa LSS ar Ses 8400054 pes ATTENZIONE: In czso ke isa perl sia Vikatan, sooo disponii servii Gi assisienz li sien9%9, Diba ak nici; Disa oe yl Ding Dizacd sand bw dalinkll Snot 68, 2 IG ib. 1-200-565-9149 TTY; 1-gon.g- 30208, lossary. You can view tle Glossary norte request a copy.