Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2019– 12/31/2019

Anthem Blue Cross and Blue Shield: Anthem Gold Pathway X HMO 1400 Coverage for: Individual + Family | Plan Type: HMO

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, [Link] 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 [Link]/sbc-glossary/
or call (855) 453-7031 to request a copy.
Important Questions Answers Why This Matters:
What is the overall $1,400/person or $2,800/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. Dental, Prescription Drugs, This plan covers some items and services even if you haven’t yet met the deductible amount.
covered before you Preventive care, Primary Care But a copayment or coinsurance may apply. For example, this plan covers certain preventive
meet your deductible? visit, and Vision for In-Network services without cost-sharing and before you meet your deductible. See a list of covered
Providers. preventive services at [Link]
Are there other No. You don't have to meet deductibles for specific services.
deductibles for
specific services?
What is the out-of- $7,900/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 $15,800/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. See You pay the least if you use a provider in Preferred Network. You pay more if you use a
you use a network [Link] or call (855) provider in In-Network. You will pay the most if you use an out-of-network provider, and you
provider? 453-7031 for a list of network might receive a bill from a provider for the difference between the provider’s charge and what
providers. 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.

CO/I/F/Anthem Gold Pathway X HMO 1400/36WX/NA/01-19

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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 Preferred In-Network Non-Network Limitations, Exceptions, &
Services You May Need Network Provider Provider Provider
Medical Event Other Important Information
(You will pay the (You will pay (You will pay the
least) more) most)
$30/visit
Primary care visit to treat an
Not Applicable deductible does not Not covered --------none--------
injury or illness
apply
$60/visit
If you visit a
Specialist visit Not Applicable deductible does not Not covered --------none--------
health care
apply
provider’s office
or clinic You may have to pay for services
that aren't preventive. Ask your
Preventive care/screening/
Not Applicable No charge Not covered provider if the services needed are
immunization
preventive. Then check what your
plan will pay for.
Diagnostic test (x-ray, blood
Not Applicable 30% coinsurance Not covered --------none--------
work)
If you have a test $250/procedure
Imaging (CT/PET scans, MRIs) Not Applicable then 30% Not covered --------none--------
coinsurance
$10/prescription
deductible does not
apply (retail) and $20/prescription Precertification may be required
Tier 1 - Typically Generic $25/prescription deductible does not Not covered for certain Prescription Drugs.
deductible does not apply (retail) Please note that certain Specialty
apply (home Drugs are only available from the
If you need
delivery) Specialty Pharmacy and you will
drugs to treat
not be able to get them at a Retail
your illness or $40/prescription Pharmacy or through the Home
condition deductible does not Delivery (Mail Order) Pharmacy.
Tier 2 - Typically Preferred apply (retail) and $50/prescription *See Prescription Drug Section of
Brand & Non-Preferred $120/prescription deductible does not Not covered your evidence of coverage,
Generics deductible does not apply (retail) available in the footnote below.
apply (home
delivery)

* For more information about limitations and exceptions, see plan or policy document at [Link]
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 What You Will Pay
Common Preferred In-Network Non-Network Limitations, Exceptions, &
Services You May Need Network Provider Provider Provider
Medical Event Other Important Information
(You will pay the (You will pay (You will pay the
least) more) most)
More information $80/prescription
about deductible does not
prescription apply (retail) and $90/prescription
Tier 3 - Typically Non-Preferred
drug coverage is $240/prescription deductible does not Not covered
Brand
available at deductible does not apply (retail)
[Link] apply (home
[Link]/pharmacyi delivery)
nformation/ $650/prescription
$660/prescription
Tier 4 - Typically Specialty deductible does not
Anthem Select deductible does not Not covered
(brand and generic) apply (retail and
Drug List apply (retail)
home delivery)
Facility fee (e.g., ambulatory
Not Applicable 30% coinsurance Not covered --------none--------
surgery center)
If you have
outpatient No coverage for Physician Out-
surgery of-Network Providers. No
Physician/surgeon fees Not Applicable 30% coinsurance Not covered
coverage for Anesthesia Out-of-
Network Providers.
Covered as In-
Emergency room care Not Applicable $500/visit Copay waived if admitted.
Network
If you need
Emergency medical Covered as In-
immediate Not Applicable 30% coinsurance --------none--------
transportation Network
medical
attention $100/visit
Covered as In-
Urgent care Not Applicable deductible does not --------none--------
Network
apply
2 months/benefit period for In-
Network Providers for Inpatient
Facility fee (e.g., hospital room) Not Applicable $1,000/admission Not covered physical medicine and
rehabilitation including day
If you have a rehabilitation programs.
hospital stay
No coverage for Physician Out-
of-Network Providers. No
Physician/surgeon fees Not Applicable 30% coinsurance Not covered
coverage for Anesthesia Out-of-
Network Providers.

* For more information about limitations and exceptions, see plan or policy document at [Link]
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 What You Will Pay
Common Preferred In-Network Non-Network Limitations, Exceptions, &
Services You May Need Network Provider Provider Provider
Medical Event Other Important Information
(You will pay the (You will pay (You will pay the
least) more) most)
If you need Office Visit Office Visit Office Visit
mental health, Not Applicable 30% coinsurance Not covered
Outpatient services --------none--------
behavioral Other Outpatient Other Outpatient Other Outpatient
health, or Not Applicable 30% coinsurance Not covered
substance abuse
services Inpatient services Not Applicable $1,000/admission Not covered --------none--------
Office visits Not Applicable 30% coinsurance Not covered
Childbirth/delivery professional Maternity care may include tests
If you are Not Applicable 30% coinsurance Not covered
services and services described elsewhere
pregnant
Childbirth/delivery facility in the SBC (i.e. ultrasound.)
Not Applicable $1,000/admission Not covered
services
28 hours/week for In-Network
Home health care Not Applicable 30% coinsurance Not covered
Providers.
20 visits each for Physical,
Speech, and Occupational
Rehabilitation services Not Applicable 30% coinsurance Not covered
therapy/benefit period. Applies to
If you need help In-Network Providers.
recovering or 20 visits each for Physical,
have other Speech, and Occupational
Habilitation services Not Applicable 30% coinsurance Not covered
special health therapy/benefit period. Applies to
needs In-Network Providers.
100 days/benefit period for In-
Skilled nursing care Not Applicable 30% coinsurance Not covered
Network Providers.
*See Durable Medical Equipment
Durable medical equipment Not Applicable 30% coinsurance Not covered
section
Hospice services Not Applicable 30% coinsurance Not covered --------none--------
Coverage is limited to 1 exam per
benefit period for In-Network
Providers.*See Vision Services
If your child Children’s eye exam Not Applicable No charge Not covered
Section of your evidence of
needs dental or coverage, available in the footnote
eye care below.
Coverage is limited to 1 unit per
Children’s glasses Not Applicable No charge Not covered
benefit period for In-Network

* For more information about limitations and exceptions, see plan or policy document at [Link]
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 What You Will Pay
Common Preferred In-Network Non-Network Limitations, Exceptions, &
Services You May Need Network Provider Provider Provider
Medical Event Other Important Information
(You will pay the (You will pay (You will pay the
least) more) most)
Providers.*See Vision Services
Section of your evidence of
coverage, available in the footnote
below.
Coverage is limited to 2 visits per
Children’s dental check-up Not Applicable 0% coinsurance Not covered 12 months for In-Network
Providers.

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.)
• Abortion (except in cases of rape, incest, or • Acupuncture • Cosmetic surgery
when the life of the mother is endangered)
• Dental care (Adult) • Hearing aids (Ages 18+) • Long-term care
• Non-emergency care when traveling outside • Routine eye care (Adult) • Routine foot care
the 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.)
• Bariatric surgery • Chiropractic care 20 visits/benefit period. • Infertility treatment
• Private-duty nursing

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: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), [Link]/ebsa/healthreform. Other coverage
options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit [Link] or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan
documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,
this notice, or assistance, contact:

* For more information about limitations and exceptions, see plan or policy document at [Link]
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ATTN: Grievances and Appeals, 700 Broadway, Mail Stop CO0104-0430, Denver, CO 80273
Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), [Link]/ebsa/healthreform

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption
from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? No

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see plan or policy document at [Link]
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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will
be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost
sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare
the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)

 The plan’s overall deductible $1,400  The plan’s overall deductible $1,400  The plan’s overall deductible $1,400
 Specialist copayment $60  Specialist copayment $60  Specialist copayment $60
 Hospital (facility) copayment $1,000  Hospital (facility) copayment $1,000  Hospital (facility) copayment $1,000
 Other coinsurance 30%  Other coinsurance 30%  Other coinsurance 30%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services
like: like: like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $1,400 Deductibles $90 Deductibles $1,100
Copayments $1,100 Copayments $2,600 Copayments $200
Coinsurance $1,000 Coinsurance $40 Coinsurance $578
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0
The total Peg would pay is $3,560 The total Joe would pay is $2,790 The total Mia would pay is $1,800

The plan would be responsible for the other costs of these EXAMPLE covered services.

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Language Access Services:

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Language Access Services:
It’s important we treat you fairly
That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the
basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t
English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services
number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age,
disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance
Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-
1019 (TDD: 1- 800-537-7697) or online at [Link] Complaint forms are available at
[Link]

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