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

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

UMR: ORLANDO HEALTH: 7670-00-413548: 001

Coverage Period: 01/01/2019 ? 12/31/2019 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, visit or by calling 1-800-826-9781. 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 1-844-614-8435 to request a copy.

Important Questions

Answers

Why this Matters:

What is the overall deductible?

$300 person / $600 family

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, 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 services are covered before you meet your deductible.

Are there other deductibles for specific No. services?

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

$3,250 person / $5,000 family

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

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 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?

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Penalties, premiums, balance billing charges, and health care this plan doesn't cover.

Yes. See or call 1-844-614-8435 for a list of network providers.

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'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 (a 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.

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 Providers (You will pay the least)

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

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness

$30 Copay per visit; Deductible Waived

Not covered

None

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

Specialist visit

$50 Copay per visit; Deductible Waived

Preventive care / screening No charge;

/ immunization

Deductible Waived

Not covered Not covered

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.

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

$10 Copay per visit x-rays; Deductible Waived $20 Copay lab tests; Deductible Waived (copay Not covered waived if use Orlando Health lab)

10% Coinsurance

Not covered

None None

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Common Medical Event

Services You May Need

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition.

Preferred brand drugs (Tier 2)

More information about prescription drug coverage is available at .

Non-preferred brand drugs (Tier 3)

What You Will Pay

In-Network Providers (You will pay the least)

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

10% Copay with a $5 minimum and up to a $10 maximum per prescription (In-house 30-day supply);

10% Copay with a $10 minimum and up to a $15 maximum per prescription (retail);

10% Copay with a $15 minimum and up to a $25 maximum per prescription (In-house 90-day supply)

20% Copay with a $25 minimum and up to a $55 maximum per prescription (In-house 30-day supply);

20% Copay with a $30 minimum and up to a $60 maximum per prescription (retail);

20% Copay with a $60 minimum and up to a $100 maximum per prescription (In-house 90day supply)

Not covered

20% Copay with a $45 minimum and up to a $95 maximum per prescription (In-house 30-day supply);

20% Copay with a $50 minimum and up to a $100 maximum per prescription (retail);

20% Copay with a $100 minimum and up to a $150 maximum per prescription (In-house 90day supply)

Limitations, Exceptions, & Other Important Information

Out-of-pocket limit applies Covers up to a 30-day supply (retail & specialty) No charge Diabetic supplies, must be filled at an In-house pharmacy You must pay the difference in cost between a Generic drug and a Brand-name drug, regardless of circumstances

Specialty drugs (Tier 4)

30% Copay with a $125 minimum and up to a $150 maximum per prescription (In-house only)

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Common Medical Event

Services You May Need

What You Will Pay

In-Network Providers (You will pay the least)

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

Limitations, Exceptions, & Other Important Information

If you have outpatient surgery

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

10% Coinsurance

Physician/surgeon fees

10% Coinsurance

Not covered

None

Not covered

None

If you need immediate medical attention

Emergency room care

Emergency medical transportation

Urgent care

If you have a hospital stay

Facility fee (e.g., hospital room)

Physician/surgeon fee

$150 Copay per visit; Deductible Waived

$150 Copay per visit; Deductible Waived True ER; Copay may be waived if admitted Not covered Non-true ER

$150 Copay per trip; Deductible Waived

$150 Copay per trip; Deductible Waived

$30 Copay per visit; Deductible Waived; Convenience Care Clinic $35 Copay per visit; Deductible Waived

Not covered

10% Coinsurance

Not covered

None

None

Preauthorization is required for some providers to be covered. Preauthorization is required. If you don't get preauthorization, benefits could be reduced by $500 of the total cost of the service.

10% Coinsurance

Not covered

None

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Common Medical Event

Services You May Need

What You Will Pay

In-Network Providers (You will pay the least)

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

Limitations, Exceptions, & Other Important Information

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

Outpatient services Inpatient services

$30 Copay per visit; Deductible Waived Office visits; 10% Coinsurance other outpatient services

Not covered

10% Coinsurance

Not covered

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 100% of the total cost of the service.

Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 100% of the total cost of the service.

Office visits

No charge; Deductible Waived

If you are pregnant

Childbirth/delivery professional services

$300 Copay per pregnancy; Deductible Waived

Childbirth/delivery facility services

10% Coinsurance

Not covered Not covered Not covered

Preauthorization is required for some providers to be covered. 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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