2022_anthem_gold_hra_sbc-1

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2022-12/31/2022 Anthem Blue Cross and Blue Shield: Gold HRA Coverage for: You, You+Spouse or Child(ren), You + Family | Plan Type: HRA 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, visit www.shbp.georgia.gov or call 1-855-641-4862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-855-641-4862 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible ? For network providers : $1,500 You | $2,250 You + Spouse or Child(ren) $3,000 You + Family. For out-of- network providers : $3,000 You | $4,500 You + Spouse or Child(ren) | $6,000 You + Family Generally, you must pay all of the costs from providers up to the deductible amount 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 covered before you meet your deductible ? Yes. Preventive care and primary care services are covered before you meet your deductible . This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan ? For network providers $4,000 You | $6,000 You + Spouse or Child(ren) $8,000 You + Family. For out-of- network providers : $8,000 You | $12,000 You + Spouse or Child(ren) | $16,000 You + Family The out-of-pocket limit is the most you could pay in a year for covered services. If you 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 out-of-pocket limit ? Copayments for certain services, premiums , balance-billing charges, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit . Will you pay less if you use a network provider ? Yes. See www.anthem.com/shbp This plan uses a provider network . You will pay less if you use a provider in the plan’s network . You will pay the most if you use an out-of-network provider , and you might receive a bill from a 1 of 7

* For more information about limitations and exceptions, see the plan or policy document at www.shbp.georgia.gov . 2 of 7 Important Questions Answers Why This Matters: or call 1-855-641-4862 for a list of network providers . 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 you need a referral to see a specialist ? No. You can see the specialist you choose without a referral . All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness 15% coinsurance After Deductible 40% coinsurance After Deductible There are childhood obesity visit limits. Specialist visit 15% coinsurance After Deductible 40% coinsurance After Deductible There are childhood obesity visit limits. Preventive care / screening / immunization No Charge Not Covered Covered services must be properly coded as preventive and provided by a network provider . No charge for hospital-based radiologist and anesthesiologist services provided by a non- network provider at a network facility and properly coded as preventive care for non- network providers . If you have a test Diagnostic test (x-ray, blood work) 15% coinsurance After Deductible 40% coinsurance After Deductible ---None--- Imaging (CT/PET scans, MRIs) 15% coinsurance After Deductible 40% coinsurance After Deductible Preauthorization may be required. If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://info.caremark.com /shbp Generic drugs and select preferred brand drugs (Tier 1) 15% coinsurance , with $20 min/$50 max (31-day supply) Same coinsurance and min/max as for network , but based on the allowed amount. You must pay out-of-pocket and submit a paper claim for reimbursement. For non-maintenance medication, there is a 31-day supply limit at retail pharmacies. Maintenance medications can be filled for up to a 90-day supply (retail or home delivery). For 32 – 62-day supply – monthly min/max is doubled. Preferred brand drugs (Tier 2) 25% coinsurance with $50 min/$80 max (31-day supply) Non-preferred brand drugs (Tier 3) 25% coinsurance with $80 min/$125 max (31-day supply)