Summary of benefits and coverage what this plan covers

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

Coverage Period: 01/01/2020 - 12/31/2020

St. Joseph Health Texas HRA Medical Plan

Coverage for: Employee+Dependents | 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, ProvidenceHealth . 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 sbc-glossary or call 1-800-878-4445 to request a copy.

Important Questions

What is the overall deductible?

Answers

In-Network: $1,150/per person $2,300/per family (2 or more)

Are there services covered before you meet your deductible?

Yes. Office visits, most preventive care, emergency and urgent care services.

Are there other deductibles for specific services?

What is the out-ofpocket limit for this plan?

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

No.

In-Network: $3,300/per person $6,600/per family (2 or more)

Premiums, penalties, your costs for Supplemental Benefits, services not covered, fees above UCR.

Will you pay less if you use a network provider?

Yes. For a list of participating providers see Providence providerdirectory or call 1-800-878-4445.

Do you need a referral to see a specialist?

No.

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 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-ofpocket 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?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 bill). 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.

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SBC-ASO20-118415-446490

St. Joseph Health Texas HRA Plan

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

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

Primary care visit to treat an injury or illness Specialist visit

Preventive care/screening/ immunization

If you have a test

Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)

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

enceHealth

Preventive drugs: Generic and Formulary Brand-name

Generic drug

Formulary brand-name drug Non-formulary brandname drug

Specialty drug

What You Will Pay

ACO Network (You will pay the

least)

In-Network Provider

$20 copay/visit

$20 copay/visit

10% coinsurance 25% coinsurance

No charge

No charge

10% coinsurance 10% coinsurance

25% coinsurance 25% coinsurance

No charge

No charge

$10 copay retail $30 copay mail order

20% coinsurance retail and mail order

$10 copay retail $30 copay mail order

30% coinsurance retail and mail order

40% coinsurance retail and mail order

20% coinsurance up to $150/30-day supply retail

50% coinsurance retail and mail order

20% coinsurance up to $150/30-day supply retail

Out-of-Network Provider (You

will pay the most)

Not covered Not covered

Not covered

Not covered Not covered

Not covered

Not covered Not covered Not covered Not covered

Limitations, Exceptions, & Other Important Information

Deductible does not apply in-network. Some services such as lab and x-ray will include additional member costs. Express Care virtual covered in full in-network. Deductible does not apply. Some preventive services will include additional member costs. For more information see: . pdfs/members/document s/preventive-care-costs.pdf.

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Prior authorization required.

Deductible does not apply to Safe Harbor, Preventive or Generic drugs. ACA Preventive drugs are covered in full in-network. Covers up to a 90-day supply (retail and mail order prescription). Prior authorization may apply. Specialty drugs can only be purchased at a participating specialty pharmacy.

For more information about limitations and exceptions, see the plan or policy document at

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Common Medical Event

If you have outpatient surgery

Services You May Need

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

Physician/surgeon fees

What You Will Pay

ACO Network (You will pay the

least)

In-Network Provider

Out-of-Network Provider (You

will pay the most)

Limitations, Exceptions, & Other Important Information

10% coinsurance 25% coinsurance 10% coinsurance 25% coinsurance

Not covered Not covered

Prior authorization required.

If you need immediate medical attention

Emergency room care

Emergency medical transportation Urgent care

$250 copay 25% coinsurance 10% coinsurance

$250 copay 25% coinsurance 25% coinsurance

$250 copay 25% coinsurance

Deductible does not apply. For emergency medical conditions only. If admitted to hospital, copayment is not applied; all services subject to inpatient benefits.

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Not covered

Some services will include additional member costs.

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Facility fee (e.g., hospital room) Physician/surgeon fees

Outpatient services

Inpatient services

10% coinsurance 10% coinsurance No charge

10% coinsurance

25% coinsurance 25% coinsurance No charge

25% coinsurance

Not covered Not covered Not covered

Not covered

Prior authorization required.

All services except provider office visits must be prior authorized. Deductible does not apply to provider office visits. See your benefit summary for ABA services.

For more information about limitations and exceptions, see the plan or policy document at

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Common Medical Event

Services You May Need

If you are pregnant

Office visits

Childbirth/delivery professional services Childbirth/delivery facility services

Home health care

Rehabilitation services

If you need help recovering or have other special health needs

Habilitation services Skilled nursing care

Durable medical equipment

What You Will Pay

ACO Network (You will pay the

least)

In-Network Provider

Out-of-Network Provider (You

will pay the most)

Limitations, Exceptions, & Other Important Information

No charge

No charge

Not covered

Deductible does not apply in-network.

No charge 10% coinsurance

No charge 25% coinsurance

Not covered Not covered

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25% coinsurance 25% coinsurance Not covered

Inpatient Services: 10% coinsurance Outpatient Services: 10% coinsurance

Inpatient Services: 25% coinsurance Outpatient Services: 25% coinsurance

Not covered

Inpatient Services: 10% coinsurance Outpatient Services: 10% coinsurance

Inpatient Services: 25% coinsurance Outpatient Services: 25% coinsurance

Not covered

25% coinsurance 25% coinsurance Not covered

25% coinsurance 25% coinsurance Not covered

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Inpatient services: coverage limited to 30 days per calendar year. Outpatient services: coverage limited to 30 visits per calendar year. Limits do not apply to Mental Health Services. Inpatient services: coverage limited to 30 days per calendar year. Outpatient services: coverage limited to 30 visits per calendar year. Limits do not apply to Mental Health Services.

Prior authorization required. Coverage is limited to 60 days per calendar year.

Deductible does not apply to diabetes supplies from in-network providers.

Hospice services

No charge

No charge

No charge

Deductible does not apply.

For more information about limitations and exceptions, see the plan or policy document at

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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 checkup

What You Will Pay

ACO Network (You will pay the

least)

In-Network Provider

Out-of-Network Provider (You

will pay the most)

Limitations, Exceptions, & Other Important Information

Not covered

Not covered

Not covered

No coverage for eye exam.

Not covered

Not covered

Not covered

No coverage for glasses.

Not covered

Not covered

Not covered

No coverage for dental check-up.

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.)

? Cosmetic surgery (with certain exceptions) ? Dental care (Adult) ? Dental check-up (Child) ? Eye exam and glasses (Child)

? Infertility treatment ? Long-term care ? Private-duty nursing ? Non-emergency care when traveling outside the U.S.

? Routine eye care (Adult) ? Routine foot care (covered for diabetics) ? Weight loss programs

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

? Acupuncture ? Bariatric surgery

? Chiropractic care

? Hearing Aids (limits apply)

For more information about limitations and exceptions, see the plan or policy document at

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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: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or , or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or . 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: Providence Health Plan at 1-800-878-4445. Additionally, if your plan is governed by ERISA, you may also contact the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or .

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.

This Summary of Benefits and Coverage required by the Affordable Care Act summarizes the benefit options available to eligible employees as of January 1, 2020. The official plan document and summary plan description will provide more complete details regarding the terms of the Plan. If there is any conflict between the statements in this Summary and the official plan documents, the terms of the plan documents will govern all rights and obligations of participants, beneficiaries, plan fiduciaries and the Company. Covenant Health System reserves the right to amend or terminate these benefits or change the cost of coverage, for any reason, at any time.

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For more information about limitations and exceptions, see the plan or policy document at

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