Summary of Benefits and Coverage: What this Plan Covers ...

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

Coverage Period: Beginning on or after January 1, 2020

SoloCare Platinum Copay 40184-00

Coverage for:Individual or Individual + Family |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 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, call 1-800-811-4793 or visit . 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 or call 1-800-811-4793 to request a copy.

Important Questions

Answers

Why This Matters:

What is the overall deductible?

$0 person / $0 family. For out of network providers $20000 person / $40000 family Doesn't apply to preventive care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there services covered Yes. Preventive care services

before you meet your

are covered before you meet

deductible?

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 care without cost sharing and before you meet your deductible. See a list of covered preventive care at coverage/preventive-care-benefits.

Are there other deductibles for specific services?

No.

You don't have to meet a deductible for specific services, but see the chart starting on page 2 for other costs for services your plan covers.

What is the out-of-pocket limit for this plan?

Yes. For network providers $7000 person / $14000 family. For out of network providers $N/A person / $N/A family.

The out of pocket limit is the most you could pay during a coverage period (usually one year) for your share of the costs of covered services. This limit helps you plan for health care expenses.

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

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 or call 1-800-811-4793 for a list of preferred providers.

If you use a network provider or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network provider or hospital may use an out of network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do you need a referral to see a specialist?

No.

You can see your specialist of choice without permission from this plan.

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 2016

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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

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

Primary care visit to treat an injury or illness If you visit a health care provider's office or Specialist visit clinic Preventive care/screening/immunization

$5 copayment/visit $10 copayment/visit No Charge

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

$30 copayment/test type in an office or outpatient setting

$250 copayment/test type

40% coinsurance after deductible

40% coinsurance after deductible

If you need drugs to

treat your illness or Generic drugs (Tier 1)

$5 copayment/prescription

condition

Preferred brand drugs (Tier 2) $15 copayment/prescription

More information about

prescription drug

Non-preferred brand drugs

coverage is available (Tier 3)

$30 copayment/prescription

at

Specialty drugs (Tier 4)

$75 copayment/prescription



$5 copayment/prescription $15 copayment/prescription $30 copayment/prescription $75 copayment/prescription

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Physician/surgeon fees

$100 copayment $100 copayment

40% coinsurance after deductible

40% coinsurance after deductible

Emergency room care

$225 copayment/visit

$225 copayment/visit

If you need immediate medical attention

Emergency medical transportation

Urgent care

$225 copayment $10 copayment/visit

$225 copayment

40% coinsurance after deductible

If you have a hospital stay

Facility fee (e.g., hospital room)

Physician/surgeon fees

$150 copayment per day

0% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

Limitations, Exceptions, & Other Important Information

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details

Laboratory/Pathology No Charge

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details See your "Certificate of Coverage" for details See your "Certificate of Coverage" for details See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details See your "Certificate of Coverage" for details See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details Copay applies for a maximum of 5 days per hospital stay. See your "Certificate of Coverage" for details

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Common Medical Event If you need mental health, behavioral health, or substance abuse services

If you are pregnant

If you need help recovering or have other special health needs

Services You May Need

Outpatient services Inpatient services

Office visits

Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services

What You Will Pay

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

$5 copayment/office visit

40% coinsurance after deductible

$150 copayment per day

40% coinsurance after deductible

$5 copayment for 1st visit to 40% coinsurance after

Confirm Pregnancy

deductible

$300 copayment

$300 copayment 15% coinsurance after deductible $15 copayment/office visit

$15 copayment/office visit

$100 copayment/day 15% coinsurance after deductible 15% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

Limitations, Exceptions, & Other Important Information

See your "Certificate of Coverage" for details

Copay applies for a maximum of 5 days per hospital stay. Office Visits after confirmation of Pregnancy are subject to Coinsurance after Deductible. Cost Sharing does not apply for preventive services. Office Visits unrelated to pregnancy are subject to the PCP or Specialist Copay. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) and be subject to Coinsurance.

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details

Limited to 120 visits per year

Limited to 40 visits per year

Limited to 40 visits per year

Limited to 60 days per year

See your "Certificate of Coverage" for details

See your "Certificate of Coverage" for details

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Common Medical Event

If your child needs dental or eye care

Services You May Need Children's eye exam Children's glasses Children's dental check-up

What You Will Pay

Network Provider (You will pay the least)

15% coinsurance after deductible

Out-of-Network Provider (You will pay the most)

40% coinsurance after deductible

15% coinsurance after deductible

40% coinsurance after deductible

15% coinsurance after deductible

40% coinsurance after deductible

Limitations, Exceptions, & Other Important Information

Limited to one exam per year

Limited to 1 item per year Limited to 2 procedures per year

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.)

? Acupuncture

? Hearing Aids

? Private-Duty Nursing

? Bariatric Surgery

? Infertility Treatment

? Routine Eye Care (Adult)

? Chiropractic Care

? Long-Term Care

? Routine Foot Care

? Cosmetic Surgery

? Non-Emergency Care When Traveling Outside ? Weight Loss Programs the U.S.

? Dental Care (Adult)

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

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: Alliant Health Plans at 1-800-811-4793, the Georgia Department of Insurance, 1-800-656-2298 or oci., the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or iio... 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 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. The contact information for questions about your rights, this notice, or assistance: Alliant Health Plans at 1-800-811-4793, theGeorgia Department of Insurance, 1-800-656-2298 or oci., the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or iio... 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 or call 1-800-318-2596.

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.

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Does this plan meet Minimum Value Standards? Yes If your plan doesn't meet the minimum value standard, 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.???????????????????

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