Summary of Benefits and Coverage: Coverage Period: 01/01/2021 – 12/31 ...

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

UMR: HONDA HEALTH SAVINGS ACCOUNT (HSA) PLAN:

Coverage Period: 01/01/2021 ? 12/31/2021 Coverage for: Individual + Family | Plan Type: HDHP

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 or by calling 1-866-778-5885. 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 1-866-778-5885 to request a copy.

Important Questions

Answers

Why this Matters:

What is the overall deductible?

$1,500 person / $3,000 family In-network $3,000 person / $6,000 family Out-of-network

Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, the overall family deductible must be met before the plan begins to pay.

Are there services covered before you meet your deductible?

Yes. Preventive 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

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?

$3,000 person / $6,000 family In-network $6,000 person / $12,000 family Out-of-network

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, the overall family out-of-pocket limit must be met.

What is not included in the Penalties, premiums, balance billing charges, Even though you pay these expenses, they don't count toward the out-of-pocket

out?of?pocket limit?

and health care this plan doesn't cover.

limit.

Will you pay less if you use Yes. See or call 1-

a network provider?

866-778-5885 for a list of network providers.

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 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.

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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

In-network (You will pay the least)

Out-of-network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness

10% Coinsurance

30% Coinsurance

None

If you visit a health care provider's office or clinic

Specialist visit

10% Coinsurance

Preventive care/screening/ immunization

No charge; Deductible Waived

30% Coinsurance 30% Coinsurance

None

You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

Diagnostic test (x-ray, blood work)

If you have a test

Imaging (CT/PET scans, MRIs)

10% Coinsurance 10% Coinsurance

30% Coinsurance 30% Coinsurance

None

Precertification is required. If you don't get precertification, benefits could be reduced to a lower amount

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Common Medical Event

Services You May Need

What You Will Pay

In-network (You will pay the least)

Out-of-network (You will pay the most)

If you need drugs to treat your illness or condition.

Generic drugs (Tier 1) Preferred brand drugs (Tier 2)

$5 copay / retail; $10 copay / mail order

$30 copay / retail; $60 copay / mail order

More information about prescription drug coverage is available at myhonda .

Non-preferred brand drugs (Tier 3)

Specialty drugs (Tier 4)

$60 copay / retail; $120 copay / mail order

$125 copay / retail; $250 copay / mail order

Not Covered Not Covered Not Covered Not Covered

If you have outpatient surgery

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

10% Coinsurance

Physician/surgeon fees

10% Coinsurance

30% Coinsurance 30% Coinsurance

Limitations, Exceptions, & Other Important Information

Covers up to a 30-day supply (retail); 31-90 day supply (mail order).

Deductible waived for prescribed medication found on the Preventive Drug List.

When a generic is available but the pharmacy dispenses the brand, plan member will pay the difference between the brand discount and the generic discount.

Voluntary Maintenance Choice is a 90-day supply of maintenance drug at CVS retail pharmacy at mail order copay; If you refill a prescription at a retail pharmacy for the fourth time, you will have to pay $25 in addition to your regular copay or coinsurance. Members must use CVS Caremark's Specialty Pharmacy.

Precertification is required.

If you need immediate medical attention

Emergency room care

Emergency medical transportation

10% Coinsurance True ER;

10% Coinsurance True ER; In-network deductible applies to

50% Coinsurance Non-true ER 50% Coinsurance Non-true ER Out-of-network benefits

10% Coinsurance

10% Coinsurance

In-network deductible applies to Out-of-network benefits

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Common Medical Event

Services You May Need

What You Will Pay

In-network (You will pay the least)

Out-of-network (You will pay the most)

Urgent care

10% Coinsurance

30% Coinsurance

Limitations, Exceptions, & Other Important Information

None

If you have a hospital stay

Facility fee (e.g., hospital room)

Physician/surgeon fee

10% Coinsurance 10% Coinsurance

30% Coinsurance 30% Coinsurance

Precertification is required. If you don't get precertification, benefits could be reduced to a lower amount.

If you have mental health, behavioral health, or substance abuse needs

Outpatient services Inpatient services

If you are pregnant

Office visits

Childbirth/delivery professional services

10% Coinsurance

10% Coinsurance

No charge; Deductible Waived 10% Coinsurance

30% Coinsurance 30% Coinsurance 30% Coinsurance 30% Coinsurance

Precertification is required for Partial hospitalization.

Precertification is required. If you don't get precertification, benefits could be reduced to a lower amount.

Cost sharing does not apply to certain preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

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Common Medical Event

Services You May Need

What You Will Pay

In-network (You will pay the least)

Out-of-network (You will pay the most)

Childbirth/delivery facility services

10% Coinsurance

30% Coinsurance

Limitations, Exceptions, & Other Important Information

Home health care

10% Coinsurance

Rehabilitation services

10% Coinsurance

If you need help recovering or have other special health needs

Habilitation services Skilled nursing care

10% Coinsurance 10% Coinsurance

Durable medical equipment 10% Coinsurance

30% Coinsurance 30% Coinsurance 30% Coinsurance 30% Coinsurance 30% Coinsurance

120 Maximum visits per calendar year; Precertification is required.

60 Maximum visits per calendar year combined with Habilitation services; includes occupational, physical and speech therapy. 60 Maximum visits per calendar year combined with Rehabilitation services; includes occupational, physical and speech therapy.

120 Maximum days per calendar year; Precertification is required.

Precertification is required for DME in excess of $500 for rentals, $1,500 for purchases and $1,000 for prosthetics.

Hospice service

If your child needs dental or eye care

Children's eye exam

10% Coinsurance Not covered

30% Coinsurance Not covered

Precertification is required. None

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