Bass pro group hdhp core plan

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Bass Pro Group HDHP Core Plan

Coverage Period: 01/01/2019-12/31/2019

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

Coverage for: Employee/Family| Plan Type: PS1

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 call UHC customer service at 844-554-5513 or the HR Support Center at 417-873-4357 Option 2. 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 and download the Glossary at .

Important Questions

What is the overall deductible?

Are there services covered before you meet your deductible?

Answers Network: $2,700 Individual / $5,400 Family Non-Network: $5,400 Individual / $10,800 Family per calendar year. Does not apply to services listed below as "No Charge".

Yes. Preventive Care is covered before you meet your deductible.

Why This Matters: 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. This plan covers some items and services even if you haven't yet met the

annual 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

services at coverage/preventive-care-benefits/

Are there other deductibles for specific services?

What is the out-ofpocket limit for this plan?

No, there are no other deductibles.

Medical- Network: $6,000 Individual / $12,000 Family Non-Network: Unlimited Individual / Unlimited Family per calendar year

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

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.

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

What is not included in Premiums, balance-billing charges, health care

the out-of-pocket

this plan doesn't cover, penalties for failure to

limit?

obtain pre-notification for services.

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Important Questions

Will you pay less if you use a network provider?

Do you need a referral to see a specialist?

Answers

Yes. See or call 844-554-5513 for a list of network providers.

No

Why This Matters: 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.

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

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

If you have a test

Services You May Need

Primary care visit to treat an injury or illness

Specialist visit

Preventive care/screening/ immunization Diagnostic test (x-ray, blood work)

What You Will Pay

Network Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

25% Coinsurance

50% Coinsurance

25% Coinsurance

50% Coinsurance

No Charge

50% Coinsurance

Limitations, Exceptions, & Other Important Information

Virtual visit - In network 25% coinsurance after deductible by a Designated Virtual Network Provider. If you receive services in addition to office visit, additional copays, deductibles, or coinsurance may apply. No virtual visit coverage for out-ofnetwork. Chiropractor services limited to 26 visits per year. Includes preventive health services specified in the health care reform law. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

25% Coinsurance

50% Coinsurance None

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Common Medical Event

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

Services You May Need

Imaging (CT/PET scans, MRIs) Generic Drugs (Tier 1) Preferred brand drugs (Tier 2) Non-preferred brand drugs (Tier 3)

Specialty drugs (Tier 4)

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees

What You Will Pay

Network Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

Limitations, Exceptions, & Other Important Information

25% Coinsurance

50% Coinsurance None

25% Coinsurance 25% Coinsurance

Not Covered Not Covered

Retail covers up to a 34-day supply. Mail Order covers up to a 90-day supply. See Formulary listing at or call 877-206-7431.

25% Coinsurance 25% Coinsurance

Not Covered Not Covered

Some drugs may require preauthorization. If the necessary preauthorization is not obtained, the drug may not be covered. For questions contact express- or 1877-206-7431.

Some drugs may require preauthorization. If the necessary preauthorization is not obtained, the drug may not be covered.

25% Coinsurance

50% Coinsurance None

25% Coinsurance 25% Coinsurance

25% Coinsurance 25% Coinsurance 25% Coinsurance 25% Coinsurance

50% Coinsurance 25% Coinsurance

25% Coinsurance 50% Coinsurance 50% Coinsurance 50% Coinsurance

None Non-emergency use of an Emergency Room is not covered. None None None

None

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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

If your child needs dental or eye care

Services You May Need Outpatient services

What You Will Pay

Network Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

Limitations, Exceptions, & Other Important Information

25% Coinsurance

50% Coinsurance None

Inpatient services

Office visits Childbirth/delivery professional services Childbirth/delivery facility services Home health care Rehabilitation services Habilitation services Skilled nursing care

25% Coinsurance

25% Coinsurance 25% Coinsurance

25% Coinsurance

25% Coinsurance 25% Coinsurance

Not Covered 25% Coinsurance

Durable medical equipment

25% Coinsurance

Hospice services

Children's eye exam Children's glasses Children's dental checkup

25% Coinsurance Not Covered Not Covered

Not Covered

50% Coinsurance 50% Coinsurance 50% Coinsurance 50% Coinsurance 50% Coinsurance 50% Coinsurance

Not Covered 50% Coinsurance

50% Coinsurance

50% Coinsurance Not Covered Not Covered Not Covered

None

Initial visit for Routine Pre-Natal Care subject to deductible and coinsurance, subsequent Routine Pre-Natal Care is covered at no cost.

Limited to 100 visits per year. None Not Covered Limited to 90 days per year. The plan limits coverage to one item of equipment, for the same or similar purpose and the accessories needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. None Not Covered Not Covered

Not Covered

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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.)

? Adult routine vision exam (i.e. refraction) ? Bariatric Surgery ? Child dental check-up ? Child routine vision exam (i.e. refraction)

? Child vision glasses ? Cosmetic Surgery ? Dental Care (Adult) ? Habilitation services

? Infertility treatment ? Long-term care ? Non-emergency care when traveling

outside the U.S. ? Weight loss programs

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

? Acupuncture (for anesthesia purposes only) ? Chiropractic care (26 visits per year)

? Hearing aids ($1000 per ear, every 3 years) ? Private-duty nursing (Home Health treatment ? Routine foot care

plan, up to 100 visits per year)

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: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or ebsa/healthreform. 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. For more information about your rights, this notice, or assistance, contact: Bass Pro Group LLC, 2500 East Kearney Street, Springfield, MO 65898 or the Employee Benefits Security Administration at 1-866-444-3272 or ebsa/healthreform. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at ebsa/healthreform and .

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.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Espa?ol): Para obtener asistencia en Espa?ol, llame al 844-554-5513. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 844-554-5513. Chinese (): 844-554-5513. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 844-554-5513.

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??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next section.?????????????????????? About these Coverage Examples:

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

Peg is Having a Baby

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

hospital delivery)

The plan's overall deductible

$2,700

Specialist coinsurance

25%

Hospital (facility)

25%

coinsurance

Other coinsurance

25%

Managing Joe's type 2 Diabetes

(a year of routine in-network care of a well-

controlled condition)

The plan's overall deductible

$2,700

Specialist coinsurance

25%

Hospital (facility)

25%

coinsurance

Other coinsurance

25%

Mia's Simple Fracture

(in-network emergency room visit and follow

up care)

The plan's overall deductible

$2,700

Specialist coinsurance

25%

Hospital (facility)

25%

coinsurance

Other coinsurance

25%

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

Total Example Cost

$12,800

In this example, Peg would pay:

Cost Sharing

Deductibles

$2,700

Copayments

$0

Coinsurance

$3,149

What isn't covered

Limits or exclusions

$96

The total Peg would pay is

$5,945

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost

$7,400

In this example, Joe would pay:

Cost Sharing

Deductibles

$2,700

Copayments

$0

Coinsurance

$1,175

What isn't covered

Limits or exclusions

$60

The total Joe would pay is

$3,875

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost In this example, Mia would pay:

Cost Sharing Deductibles Copayments Coinsurance

What isn't covered Limits or exclusions The total Mia would pay is

$1,900

$1,224 $0

$481

$0 $1,705

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