PC Summary of Benefits & changes 1-1-19 › updated_summary_of_benefits.pdf• Dental implants, and nonsurgical treatment of temporomandibular joint syndrome (TMJ) • Hearing aids,

Personal ChoiceSummary of Benefits

LEHB

Independence +

Personal Choice. ,our popular Preferred Provider Organization (PPQ), gives you freedom of choice by allowing you to choose your owndoctors and hospitals. You can maximize your coverage by accessing your care through Personal Choices expansive network of hospitals,doctors and specialists, or by accessing care through preferred providers that participate in the BlueCard. PPO program. Of course, withPersonal Choice, you have the freedom to select providers who do not participate in the Personal Choice network or BlueCard. PPOprogram. However, if you receive services from out-of-network providers. you will have higher out-af-pocket costs and may have to submityour claim for reimbursement.With Personal Choice ...

• You do not need to enroll with a primary care physician• You never need a referral

Benefit In.Network Out-ot-Network

BENEFIT PERIODDEDUCTIBLE

IndividualFamily

AFTER DEDUCTIBLE, PLAN PAYS

OUT-OF-POCKET MAXIMUM'IndividualFamily

LIFETIME MAXIMUMDOCTOR'S OFFICE VISITS

Primary Care ServicesSpecialist Services

PREVENTIVE CARE FOR ADULTS AND CHILDRENPEDIATRIC IMMUNIZATIONSROUTINE GYNECOLOGICAL E.XAMIPAP1 per year for women of any age"

MAMMOGRAM

Calendar Year.

$0$0100%Unless otherwise noted

$1,500$3,000Unlimited

$15 Copayment$25 Copayment100%

100%

100%

100%

Calendar Year'

$500$1,00050%

$3,000$6,000Unlimited,50%, after deductible50%, after deductible50%, NO deductible

50%, NO deductible

50%, NO deductible

50%, NO deductible

Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), andthe actual charge of the provider. This amount may be Significant. Claims payments for Non.Preferred Professional Providers (physicians) are basedon the lesser of the Medicare ProfeSSional Allowable Payment or the actual charge of the provider. For covered services that are not recognized orreImbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (lBC) applicable proprietary fee schedule or the actualcharge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, payment is 50% of the actual charge ofthe provider. It IS important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge ofthe provider.

2 Combined [n/out-of.networkA calendar year benefit period begins on January 1 and ends on December 31. The deductible and out.of.pocket maximum amount start at $0 at thebeginning of each calendar year on January 1.

5 In-network out-of-pocket maximum includes deductible, copayments and coinsurance. Out-of-network out-of-pocket maximum includes coinsuranceonly.

The benefits may be changed by IBC to comply with applicable federal/state laws and regulations.

Benefits underwritten or administered by ace Insurance Company, a subsidiary of Independence Blue Cross-independent licensees of the Blue Cross and Blue Shield Association.

www.ibx.com

11118 - PA - 51 .•. PC Custom

Benefit In-Network Out-ol-Network

100% 100%, NO deductible

100% 50%, after deductible100% 50%, after deductible

100% 50%, after deductible

$10 Copayment 50%, after deductible

$10 Copayment 50%, after deductible

$10 Copayment 50%, after deductible

$10 Copayment 50%, after deductible

$10 Copayment 50%, after deductible

$25 Copayment 50%, after deductible

100% 50%, after deductible

100% 50%, after deductible

100% 50%, after deductible

100% 50%, after deductible

100% 50%, after deductible

NUTRITION COUNSELING FOR WEIGHT MANAGEMENT6 visits per benefit pef/od

ALLERGY INJECTIONS(Office visit copayment waived if no office VIsit is charged)

MATERNITYAll benefits for the newborn of a dependent daughter areexcluded from coverage after the mother (dependent daughter)has been discharged from the hospital. If the newborn remainsin the hospital after the mothers discharge the newborn will beassigned Its own claim. This becomes a different and separateadmission which would not be covered under the LEHB plan.

First DB visitHospital

INPATIENT HOSPITAL SERVICESFacilityPhysician/Surgeon

INPATIENT HOSPITAL DAYSOUTPATIENT SURGERY

FacilityPhysician/Surgeon

EMERGENCY ROOM

URGENT CARE CENTERAMBULANCE

EmergencyNon.emergency

OUTPATIENT LABORATORYOUTPATIENT RADIDLDGYTHERAPY SERVICES

Physical, Speech and OccupationalCardiac Rehabilitation36 VISits per year'

Pulmonary Repabilitation12 ..••islts per year

Respiratory TherapyOrthoptic/Pleoptic TherapylimIted to 8 sessions lifetime maximum'

RESTORATIVE SERVICES, INCLUDING CHIROPRACTICCARE20 VISitSper yeaf

CHEMOIRADIATIONIDIAL YSISOUTPATIENT PRIVATE DUTY NURSINGSKILLED NURSING FACILITYHDSPICE AND HDME HEALTH CAREDURABLE MEDICAL EQUIPMENT AND PROSTHETICS

100%

100%

$15 Copayment100%

100%100%365

100%100%$25 Copayment (Copaymentwaived if admitted)

$17 Copayment

50%, after deductible

50%, after deductible

50%, after deductible50%, after deductible'

50%, after deductible3

50%, after deductible70'

50%, after deductible50%, after deductible$25 Copayment, NOdeductible (Copaymentwaived if admitted)

50%, after deductible

Non.Preterred PrOViders may bill you the differences between the Ptan allowance, which IS the amount paid by Independence Blue Cross (IBC), andthe actual charge of the provider. This amount may be signifIcant. Claims payments for Non.Preferred Professional PrOViders (physicians) are basedon the lesser of the Medicare Professional Allowable Payment or the actual charge of the provider. For covered services that are not recognized orreimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actualcharge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, payment is 50% of the actual charge ofthe proVIder. It is Important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the actual charge ofthe provider.

2 Combined in/out-of-network3 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, serious mental illness and substance abuse

services.The benefits may be changed by IBC to comply with applicable federal/state laws and regulations.

Benefit In-Network Out-oj-NetworkOUTPATIENT DIABETIC EDUCATIONOUTPATIENT MENTAL HEALTH CAREINPATIENT MENTAL HEALTH CARESERIOUS MENTAL ILLNESS CARE

OutpatientInpatient

SUBSTANCE ABUSE TREATMENTOutpatient/Partial Facility VisitsRehabilitationDetoxification

100%

$25 Copayment

100%

$25 Copayment100%

$25 Copayment100%100%

Not covered

50%, after deductible

50%, after deductible

50%, after deductible50%, after deductible'

50%, after deductible50%, after deductible'50%, after deductible'

Non-Preferred Providers may bill you the differences between the Plan allowance, which is the amount paid by Independence Blue Cross (lBC), andthe actual charge of the provider. This amount may be significant. Claims rayments for Non-Preferred Professional Providers (physicians) are basedon the lesser of the Medicare Professional Allowable Payment or the actua charge of the provider. For covered services that are not recognized orreimbursed by Medicare, payment is based on the lesser of the Independence Blue Cross (IBC) applicable proprietary fee schedule or the actualcharge of the provider. For covered services not recognized or reimbursed by Medicare or IBC's fee schedule, payment is 50% of the actual charge ofthe provider, It is important to note that all percentages for out-af-network services are percentages of the Plan allowance. not the actual charge ofthe provider,

3 Inpatient hospital day limit combined for all out-of-network inpatient medical, maternity, mental health, senous mental illness and substance abuseservIces.

The benefits may be changed by IBC to comply with applicable federal/state laws and regulations,

What Is Not Covered?

• Services not medically necessary

• Services not billed and performed by a provider properlylicensed and qualified to render the medically necessarytreatment, service or supply

• Cosmetic services

• Routine foot care

• Supportive devices for the foot (orthotics), except forpodiatric appliances for the prevention of complicationsassociated with diabetes

• Dental care

• Vision care (except as specified in a group contract)

• Military or occupational injuries or illness

• Benefits payable by the government, Medicare or throughmotor vehicle insurance

• Cosmetic supplies

• Charges in excess of benefit maximums or allowablecharges as set forth in the group contract

• Services or supplies that are experimental or investigativeexcept routine costs associated with clinical trials

• Inpatient private duty nursing

• Dental implants, and nonsurgical treatment oftemporomandibular joint syndrome (TMJ)

• Hearing aids, hearing examinations/tests for theprescription/fitting of hearing aids, and cochlearelectromagnetic hearing dellices

• Maintenance of chronic conditions

• Self-injectable drugs

• Immunizations required for employment or travel.

• Gender reassignment surgery

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

Independence I~I LE H BCoverage Period: 01/01/2019 -12/31/2019

Coverage for: FAMILY I 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 sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only asummary. For more information about your coverage, or to get a copy of the complete terms of coverage, at www.ibx.com/LGBooklet or by calling 1-800-ASK-

BLUE (TTY:711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined termssee the Glossa . You can view the Glossary at www.healthcare.gov/sbc-glossa 1 or call1-800-ASK-BLUE TTY:711 to re uest a co .

Do you need a _re_fe_rra_1to see a Nspecialist? o.

Are there other deductibles forspecific services? No.

What is the overall deductible?

Are there services coveredbefore you meet yourdeductible?

What is the out.of.pocket limitfor this plan?

What is not included in the out-of-pocket limit? -

Will you pay less if you use anetwork provider?

For In-network Provider $0 person 1 $0 family; forOut-of-network Provider $500 person 1 $1,000family.

Yes.

For In-network Provider $1 ,500 person 1$3,000family; for Out-of-network Provider $3,000 person 1$6,000 family.Premiums, balance-billing charges, and health carethis plan doesn't cover.

Yes. See www.ibx.com/find_a_provideror call 1-800-ASK-BLUE (TTY:711) for a list of networkproviders.

IGenerally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily member must meet their own individual deductible until the total amount ofdeductible eXJlenses p_aiQJ)y~fqIJIlly_mefllb-,~rs meets the overall family deductible.This plan covers some items and services even if you haven't yet met the deductibleamount. But a copayment or coinsurance may apply. For example, this plan coverscertain preventive services without cost-sharing and before you meet your deductible.See a list of covered preventive services athtlps:llwww. healthcare.gov/coverage/preventive-care-benefits/.

You don't have to meet deductibles for specific services.

The out-of-pocket limit is the most you could pay in a year for covered services. If youhave other family members in this plan, they have to meet their own out-of-pocketlimits until the overall family out-of-pocket limit has been met.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

This plan uses a provider network. You will pay less if you use a provider in the plan'snetwork. You will pay the most if you use an out-of-network provider, and you mightreceive a bill from a provider for the difference between the provider's charge and whatyour 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 beforeyou get se~ces._

You can see the specialist you choose without a referral.

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

What You Will Pay ~ .. .Common Medical Event Services You May Need '-- .. ----- --.--~--'---Ot:Of N t LimitatIOns, Exceptions, & Other Important

an-ln.Network Provider I an up 'de Information. rovi er

2 of 5

50%

50%

Not Covered,

Not CoverediNot Covered

,50%, Deductible does notapply

150%

150%

$17 copay/visit

$25 copay/visitNo Charge

No Charge

No Charge

No Charge

Not Covered,INot CoveredNot Covered

'$15 Copayment (copayl/visit 150%

$25 copay/visit 50%

,None

iNoneAge and frequency schedules may apply. You mayhave to pay for services that aren't preventive. Askyour provider if the services needed are preventive.IThen check what your plan will pay for.INone -- ---,Pre-certification required for certain services. 'See:section General Information. 20% reduction in,benefits for failure to pre-cert out-of-network or

l'BlueCard services.None!None:None,This cost share amount is for specialty injectable or'infusion therapy drugs covered by the medical

Ibenefit. These drugs are typically administered by a,health care professional in an office or outpatient,facility. Self administered specially drugs follow the,applicable retail prescription cost-share under the'Prescription Drug Program. Prior-authorizationrequired. 'See section Outpatient Services.Pre-certification required. 'See section GeneralInformation. 20% reduction in benefits for failure topre-authorize out-of-network outpatient services ortreatments.Pre-certification required. 'See section GeneralInformation. 20% reduction in benefits for failure topre-authorize out-of-network outpatient services ortreatments.,

Covered at in-network level None,Covered at in-network level None

IYour costs for urgent care are based on careI received at a designated urgent care center or,facility, not your physician's office. Costs may vary'depending on where you receive care.

'For more information about limitations and exceptions, see plan or policy document at www.ibx.comlLGBoo~84

Urgent care

Ge~ric drugsPreferred brandNon-preferred dr!Jgs

Imaging (CT/PET scans, MRls)

Facility fee (e.g., ambulatoryIsurgery center) _

IPhysician/surgeon fees

I1Emergency room careIEmergency medical transportation

If you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available at Specially drugshtlp:/Iwww.lbx.com/preap ,proval

If you have a test

i If you have outpatientsurgery

Ilf you need immediatemedical attention

IPrimary care visit to treat an injuryor illness

If you visit a health care t Specialist visit,provider's office or I'clinic Preventive

,care/screening/immunization

!Diagnostic test (~-J?y, blood work)

. I ~ What You WiUPay - - _. l' . . .C Medical Event Services You May Need . I 0 t.Of N t k Limitations, Exceptions,. & Other Importantommon an In.Network Provider an u . e wor Information

Provider

Facility fee (e.g., hospital room) No ChargePre-certification required. $1,000 member penalty

50% for failure to pre-authorize inpatient services ore a hospital treatment for out-of-network care.

Pre-certification required. $1,000 member penaltyPhysician/surgeon fees No Charge 50% for failure to pre-authorize inpatient services or

treatment for_oL!J-of-network care.

d mental Outpatient services $25 copay/visit 50% Nonehavioral .-substanceices Inpatient services No Charge 50% None-

Office visit cost share applies to the first OS visitonly. Depending on the type of services, a

Office visits $15 copay/visit 50% copayment or coinsurance may apply. Maternitycare may include tests and services describedelsewhere in the SSC (i.e. ultrasound). Pre-notiflcation requested for maternity care.Office visit cost share applies to the first OS visitonly. Depending on the type of services, a

pregnant Childbirth/delivery professional No Charge 50% copayment or coinsurance may apply. Maternityservices care may include tests and services described

elsewhere in the SSC (i.e. ultrasound). Pre-notificationJeques ted for_maternity _care.Office visit cost share applies to the first OS visitonly. Depending on the type of services, a

Childbirth/delivery facility services No Charge 50% copayment or coinsurance may apply. Maternitycare may include tests and services describedelsewhere in the SSC (i.e. ultrasound). Pre-

- -- notification. requested for maternity_care.Pre-certification required. 20% reduction in benefits

Home health care No Charge 50% for failure to pre-authorize out-of-network outpatientservices or treatments. -Pre-certification required. 20% reduction in benefits

d help Rehabilitation services $10 copay/visit 50% for failure to pre-authorize out-of-network outpatientg or have - services or treatments.cial health Pre-certification required. 20% reduction in benefits

Habilitation services $10 copay/visit 50% for failure to pre-authorize out-of.network outpatient- services or treatments._.- -- ----- ._-

Pre-certfication required. $1,000 member penaltySkilled nursing care No Charge 50% for failure to pre.authorize inpatient services or

treatment for out-of.network care.

If you neerecoverinother speneeds

If you are

If you havstay

If you neehealth, behealth, orabuse serv

108484 3 of 5

I - __ ~_'(.Q.!LWI!IhY I .. .Common Medical Event, Services You May Need . I o~ Limitations, Exceptions,. & Other Important

I an In-Network Provider an ~rOVid:r or I Information

If your child needsdental or eye care

Durable medical equipment

Hospice services

Children's eye examChildren's glassesChildren's dental check-up

No Charge

No Charge

Not CoveredNot CoveredNot Covered

50%

50%

Not CoveredNot CoveredNot Covered

Pre-certification required. 20% reduction in benefitsfor failure to pre-authorize out-of-network outpatientservices or treatments,Pre-certification required. $1,000 member penaltyfor failure to pre-authorize inpatient services ortreatment for out-of-network care.NoneNoneNone

• Hearing aids

• Routine foot care

• Dental care (adult)

• Routine Eye care (adult)

to these services. This isn't a com lete list. Please see our plan document.

• Bariatric Surgery • Chiropractic Care

• Non-emergency care when traveling outside the U,S.. Private-duty nursingwww.bcbslobalcore.com

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. To contact the plan at 1-800-ASK-BLUE (TIV:711)or the contact information for lhose agencies is: For group health coverage subject to ERISA, contact the Department of Labor's Employee Benefits Security Administration at 1-866-444.EBSA (3272) or www.dol.gov/ebsa/healthreform; For non-federal governmental group health plans, contact the Department of Health and Human Services, Center forConsumer Information and Insurance Oversight, 1-877-267-2323 x61565 or www.cciio.cms.gov. Church plans are not covered by the Federal COBRA continuation coveragerules, If the coverage is insured, you should contact your State Insurance regulator regarding possible rights to continuation coverage under State law. Other coverage optionsmay be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visitwww,HealthCare,govorcaIl1-800-318-2596,

Excluded Services & Other Covered Services:Services Your Plan Generall Does NOT Cover Check our olic or Ian document for more information and a list of an other excluded services.

• Cosmetic Surgery

• Long-term care

• Weight loss programsOther Covered Services Limitations rna

• Acupuncture

• Infertility treatment

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~. 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 informationto submit a claim, ~, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Pennsylvania InsuranceDepartment - 1-877-881-6388 - hltp:/Iwww.insurance.pa.gov/Consumers.

Does this plan provide Minimum Essentiaf Coverage? Yes.If you don't have Minimum Essential Coverage for a month, you'li have to make a payment when you file your tax return unless you qualify for an exemption from therequirement that you have health coverage for that month,-----To see examples of howthisplanmightcovercosts fora sample medicalsituation.see the next section,-----

108484 4 of 5

. About th.ese Coverage.Exarnll_le_s_: _

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 dependingon the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments andcoinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Pleasenote these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospitaldelivery)

Managing Joe's type 2 Diabetes

(a year af routine In-netwark care af a well-cantralledcanditian)

Mia's Simple Fracture

(In-netwark emergency raam visit and follow up care)

• The plan's overall deductible

• Specialist copayment

• Hospital (facility) copayment

• Other coinsurance

$0

$25

$0

100%

• The plan's avera II deductible $0 • The plan's overall deductible $0

• Specialist copayment $25 • Specialist copayment $25

• Haspital (facility) copayment $0 • Hospital (facility) capayment $0

• Other coinsurance 100% • Other coinsurance 100%

This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)

$7,400

This EXAMPLE event includes services like:Emergency roam care (including medical supplies)Diagnastic test (x-ray)Durable medical equipment (crutches)Rehabilitatian services (physical therapy)

Total Example Cost $12,800

This EXAMPLE event includes services like:Primary care physician affice visits (including diseaseeducation)Diagnostic tests (blood work)Prescriptian drugsDurable medical equipment (g/ucose meter)

Total ExamRle Cost Total Examp'le Cost $1,900

In this example, Joe_would pay: _Cost Sharing

Inthis example, Peg wouldpay: _Cost Sharing

Deductibles . t=$~0~--_CopaYrnents_ __CjJlnsurarlce-~--~-~~-What isn't coveredLimits or exclusions-- ._--- ~--The total Peg would pay is

DeductiblesCapaymentsCainsurance

WhatisQ'Lcove[edLimits ar exclusians----------The tatal Joe wauld pay is

$0$100$0

$4,30Jl_$4,400

In this example, Mia wauld pay:Cost Sharing

DeductiblesCapayments.Cainsura'lce

What isn't coveredLimits or exclusians- -~- -------The tatalMia wauldpay is

$0__$80$0

$0$80

Note: These numbers assume the patient does not participate in the plan's well ness program. If yau participate in the plan's well ness pragram, yau may be able to.reduce yaurcasts. Far mare infarmatian abaut the wellness orooram 01ease cantact: 1-800-ASK-BLUE (TTY:71 t)

The plan wauld be respansible far the other casts of these EXAMPLE cavered services.

108484 5 of 5