Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2018 – 12/31/2018

Highmark Delaware: Shared Cost Blue EPO 3500 Coverage for: Individual/Family Plan Type: 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, please visit www.highmarkbcbsde.com or
call 1-888-601-2242. 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 1-888-601-2242 to request a copy.
Important Questions Answers Why this Matters:
What is the overall $3,500 individual/$7,000 family. Generally, you must pay all of the costs from providers up to the deductible amount
deductible? before 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 Network deductible does not apply to This plan covers some items and services even if you haven’t yet met the deductible
covered before you meet office visits, preventive care services, amount. But a copayment or coinsurance may apply. For example, this plan covers
your deductible? diagnostic medical services, emergency certain preventive services without cost-sharing and before you meet your deductible.
room services, urgent care, outpatient See a list of covered preventive services at
mental health, outpatient substance https://www.healthcare.gov/coverage/preventive-care-benefits/.
abuse, rehabilitation services, routine
eye exam, or pediatric dental check-up.

Copayments and coinsurance amounts

don’t count toward the network
deductible.
Are there other deductibles Yes. $250 individual for prescription You must pay all of the costs for these services up to the specific deductible amount
for specific services? drugs. before this plan begins to pay for these services.
There are no other specific deductibles.
What is the out-of-pocket limit $7,350 individual/$14,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you
for this plan? network. have other family members in this plan, they have to meet their own out-of-pocket
limits until the overall family out-of-pocket limit has been met.
What is not included in the Premiums, balance-billed charges, and Even though you pay these expenses, they don't count toward the out-of-pocket limit.
out–of–pocket limit? health care this plan doesn't cover.

An example of a benefit book can be found at https://shop.highmark.com/sales/#!/sbc-agreements. 1 of 10

Shared Cost Blue EPO 3500 ONX Base Jan
I_76168DE0410013-01_20180101_SBC
Will you pay less if you Yes. For a list of network providers, see This plan uses a provider network. You will pay less if you use a provider in the plan’s
use a network provider? www.highmarkbcbsde.com or call network. You will pay the most if you use an out-of-network provider, and you might
1-888-601-2242. receive a bill from a provider for the difference between the provider’s charge and
what 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.
Do I need a referral to see a No. You can see the specialist you choose without a referral.
specialist?

All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Limitations, Exceptions, and Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you visit a health Primary care visit to treat an injury or illness $40 copay/visit Not covered You may have to pay for services that
care provider’s Specialist visit $90 copay/visit Not covered aren’t preventive. Ask your provider if
office or clinic Preventive care/Screening/Immunization No charge No coverage the services needed are preventive.
for preventive care for preventive care Then check what your plan will pay for.
services services
Please refer to your preventive schedule
for additional information.

Primary care visits: No charge for first

two visits.

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 What You Will Pay
Common Medical Limitations, Exceptions, and Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you have a test Diagnostic test (x-ray, blood work) $20 copay/visit Not covered Precertification may be required.
for laboratory in a
non-hospital
$80 copay/visit
for laboratory in a
hospital
$90 copay/visit
for standard imaging
and machine tests
Imaging (CT/PET scans, MRIs) 30% coinsurance Not covered Precertification is required for advanced
radiology.
If you need drugs Tier 1 10% coinsurance Not covered Up to 34/90-day supply retail pharmacy.
to treat your illness (retail) Up to 90-day supply maintenance
or condition 10% coinsurance prescription drugs through mail order.
(mail order)
More information This plan has an HCR Progressive
Tier 2 15% coinsurance Not covered
about prescription Formulary.
(retail)
drug coverage is
15% coinsurance
available at
(mail order)
1-888-601-2242.
Tier 3 20% coinsurance Not covered
(retail)
20% coinsurance
(mail order)
Tier 4 30% coinsurance Not covered
(retail)
30% coinsurance
(mail order)
If you have Facility fee (e.g., ambulatory surgery center) 30% coinsurance Not covered Precertification may be required.
outpatient surgery Physician/surgeon fees 30% coinsurance Not covered Precertification may be required.

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 What You Will Pay
Common Medical Limitations, Exceptions, and Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you need Emergency room Care $500 copay/visit $500 copay/visit Copay waived if admitted as an
immediate medical inpatient.
attention Out-of-network: Not subject to
deductible.
Emergency medical transportation 30% coinsurance 30% coinsurance Out-of-network: Subject to network
deductible.
Urgent care $110 copay/visit Not covered −−−−−−−−−−−none−−−−−−−−−−−
If you have a Facility fee (e.g., hospital room) 30% coinsurance Not covered Precertification is required.
hospital stay Physician/surgeon fee 30% coinsurance Not covered Precertification may be required.
If you have mental Outpatient services $90 copay/visit Not covered Precertification is required for partial
health, behavioral hospital and intensive outpatient care.
health, or Inpatient services 30% coinsurance Not covered Precertification is required.
substance abuse
needs
If you are pregnant Office visits 30% coinsurance Not covered Precertification may be required for
Childbirth/delivery professional services 30% coinsurance Not covered some services.
Childbirth/delivery facility services 30% coinsurance Not covered Cost sharing does not apply for
preventive services.
Depending on the type of services, a
copayment, coinsurance, or deductible
may apply.
Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound.)

Network: The first visit to determine

pregnancy is covered at no charge.
Please refer to the Women’s Health
Preventive Schedule for additional
information.

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 What You Will Pay
Common Medical Limitations, Exceptions, and Other
Services You May Need Network Provider Out-of-Network
Event Important Information
(You will pay the Provider (You will
least) pay the most)
If you need help Home health care 30% coinsurance Not covered Precertification may be required.
recovering or have Network: 100 visits per benefit period.
other special health Rehabilitation services $90 copay/visit Not covered Network: 30 combined physical
needs medicine and occupational therapy visits
and 30 speech therapy visits per benefit
period. PT requires Precertification for
visits 9-30 per benefit period.
Habilitation services $90 copay/visit Not covered Network: 30 combined physical
medicine and occupational therapy visits
and 30 speech therapy visits per benefit
period. PT requires Precertification for
visits 9-30 per benefit period.
Skilled nursing care 30% coinsurance Not covered Precertification may be required.
Network: 120 days per confinement.
Benefits renew after 180 days without
care.
Durable medical equipment 30% coinsurance Not covered Precertification is required for some
equipment.
Hospice service 30% coinsurance Not covered Precertification may be required.
If your child needs Children’s Eye exam No charge Not covered **See below
dental or eye care Children’s Glasses No charge Not covered **See below
Children’s Dental check-up No charge Not covered **See below

*For more information about limitations and exceptions, see plan or policy document at www.highmarkbcbsde.com or call 1-888-601-2242.

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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.)
 Abortions, except where a pregnancy is the
result of rape or incest, or for a pregnancy  Acupuncture
 Routine eye care (Adult)
which, as certified by a physician, places the  Cosmetic surgery
life of the woman in danger unless an  Routine foot care
 Dental care (Adult)
abortion is performed.  Weight loss programs
 Long-term care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Non-emergency care when traveling outside
 Bariatric surgery
 Infertility treatment the U.S.
 Chiropractic care

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: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or at www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other options to continue coverage are available to you too, including buying individual insurance
coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit http://www.HealthCare.gov 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:
 Highmark Delaware at 1-888-601-2242.
 The Delaware Department of Insurance/Consumer Assistance Program: 841 Silver Lake Blvd, Dover, DE 19904, or 302-674-7300.
 Additionally, the Delaware Department of Insurance/Consumer Assistance Program can help you file your appeal.

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? Yes

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 page.––––––––––––––––––––––
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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 up
hospital delivery) controlled condition) care)

The plan’s overall deductible $3500 The plan’s overall deductible $3500 The plan’s overall deductible $3500
Specialist copayment $90 Specialist copayment $90 Specialist copayment $90
Hospital (facility) coinsurance 30% Hospital (facility) coinsurance 30% Hospital (facility) coinsurance 30%
Other coinsurance 30% Other coinsurance 30% Other coinsurance 30%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services 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 tests (blood work) Diagnostic test (x-ray) Durable medical equipment
Childbirth/Delivery Facility Services Diagnostic Prescription drugs Durable medical equipment (crutches) Rehabilitation services (physical
tests (ultrasounds and blood work) Specialist visit (glucose meter) therapy)
(anesthesia)

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 $3,500 Deductibles $2,400 Deductibles $800
Copayments $100 Copayments $1,000 Copayments $700
Coinsurance $2,400 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $6,000 The total Joe would pay is $3,400 The total Mia would pay is $1,500

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

Highmark Blue Cross Blue Shield Delaware is an independent corporation operating under licenses from the Blue Cross and Blue Shield Association.

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Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield Delaware which is an
independent licensee of the Blue Cross Blue Shield Association. Health care plans are subject to terms of the benefit
agreement.

To find more information about Highmark’s benefits and operating procedures, such as accessing the drug formulary or
using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call 1-855-873-
4109.