Questions:

Call

1-800-499-1275

or visit us at

excellusbcbs.com

If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at

www.cciio.cms.gov

or call

1-800-499-1275

to request a copy.

Coverage Period: 07/01/2013-06/30/2014

Ind/Family

PPO

Coverage for:

Plan Type:

This is only a summary.

If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan

document at

excellusbcbs.com

or by calling

1-800-499-1275.

Summary of Benefits and Coverage:

What this Plan Covers & What it Costs

Excellus BCBS:Healthy Blue Copay

A nonprofit independent licensee of the Blue Cross Blue Shield Association

Important Questions

Answers

deductible?

$0

Individual /

$0

Family, In Network

$500

Individual /

$1500

Family, Out of network

Does not 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

.

deductibles for specific

services?

No.

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.

pocket limit on my

expenses?

Yes,

$1500

Individual

/ $4500

Family, Out of network

The

out-of-pocket limit

is the most you could pay during a coverage period (usually one

year) for your share of the cost of covered services. This limit helps you plan for health

care expenses.

What is not included in

limit?

Premiums, balance-billed

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

.

annual limit on what

the plan pays?

No.

The chart starting on page 2 describes any limits on what the plan will pay for

specific

covered services, such as office visits.

network of providers?

Yes. See

www.excellusbcbs.com or

call 1-800-499-1275

for a list of

participating providers.

If you use an in-network doctor or other health care

provider

, this plan will pay some or

all of the costs of covered services. Be aware, your in-network doctor 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

.

see a specialist?

No. You don ’ t need a referral to

see a specialist.

You can see the

specialist

you choose without permission from this plan.

plan doesn’t cover?

Yes.

Some of the services this plan doesn ’ t cover are listed on page [4 or 5]. See your policy or

plan document for additional information about

excluded services

.

---

·

Copayments

are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

·

Coinsurance

is

your

share of the costs of a covered service, calculated as a percent of the

allowed amount

for the service. For example, if the

plan ’ s

allowed

amount

for an overnight hospital stay is $1,000, your

coinsurance

payment of 20% would be $200. This may change if you

haven ’ t met your

deductible

.

·

The amount the plan pays for covered services is based on the

allowed amount

. If an out-of-network

provider

charges more than the

allowed

amount

, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the

allowed

amount

is $1,000, you may have to pay the $500 difference. (This is called

balance billing

.)

·

This plan may encourage you to use in-network

providers

by charging you lower

deductibles

,

copayments

and

coinsurance

amounts.

Common

In-network

Your Cost If

network

care provider’s office

or clinic

Primary care visit to treat an injury or illness

Adult $30 co-pay

Child No Charge

20% co-insurance Child up to age 19

Specialist visit

$50 co-pay

20% co-insurance ------none------

Other practitioner office visit

$50 co-pay

Acupuncture 20%

co-insurance

Chiropractic 20%

co-insurance

Acupuncture 10 Visit(s) per year

Preventive care/screening/immunization

No Charge

Adult Physical

20% co-insurance

Well Child No

Charge

Adult

Immunizations

20% co-insurance

Adult Physical 1 Visit(s) per year

If you have a test

Diagnostic test (x-ray, blood work)

X-Ray $50 co-pay

Lab Services No

Charge

20% co-insurance ------none------

Imaging (CT/PET scans, MRIs)

$50 co-pay

20% co-insurance ------none------

---

Common

In-network

Your Cost If

network

treat your illness or

More information

about prescription

drug coverage is

excellusbcbs.com

Generic drugs

Child copay No

Charge

Retail Prescription

$5 co-pay

Mail Order

Prescription $5 co-

pay

Not Covered

Child copay up to age 19

Preferred brand drugs

Retail Prescription

$35 co-pay

Mail Order

Prescription $35

co-pay

Not Covered

------none------

Non-preferred brand drugs

Retail Prescription

$70 co-pay

Mail Order

Prescription $70

co-pay

Not Covered

------none------

Specialty drugs

Retail Prescription

$70 co-pay

Mail Order

Prescription $70

co-pay

Not Covered

------none------

outpatient surgery

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

$250 co-pay

20% co-insurance ------none------

Physician/surgeon fees

No Charge

20% co-insurance ------none------

immediate medical

attention

Emergency room services

$250 co-pay

$250 co-pay

------none------

Emergency medical transportation

$250 co-pay

$250 co-pay

------none------

Urgent care

$50 co-pay

20% co-insurance

------none------

---

Common

In-network

Your Cost If

network

hospital stay

Facility fee (e.g., hospital room)

$500 co-pay

20% co-insurance ------none------

Physician/surgeon fee

No Charge

20% co-insurance ------none------

health, behavioral

health, or substance

abuse needs

Mental/Behavioral health outpatient services $50 co-pay

20% co-insurance ------none------

Mental/Behavioral health inpatient services

$500 co-pay

20% co-insurance ------none------

Substance use disorder outpatient services

$50 co-pay

20% co-insurance ------none------

Substance use disorder inpatient services

$500 co-pay

20% co-insurance ------none------

If you are pregnant

Prenatal and postnatal care

No Charge

20% co-insurance ------none------

Delivery and all inpatient services

No Charge

Physician 20%

co-insurance

Facility 20% co-

insurance

Anesthesia No

Charge

------none------

If you need help

recovering or have

other special health

needs

Home health care

No Charge

20% co-insurance 40 Visit(s) per year

Rehabilitation services

Outpatient $50 co-

pay

Inpatient $500 co-

pay

20% co-insurance

Outpatient 45 Visit(s) per year

Inpatient 60 Day(s) per year

Habilitation services

$50 co-pay

20% co-insurance 45 Visit(s) per year

Skilled nursing care

$500 co-pay

20% co-insurance 45 Day(s) per year

Durable medical equipment

20% co-insurance

20% co-insurance ------none------

Hospice service

No Charge

20% co-insurance ------none------

dental or eye care

Eye exam

$50 co-pay

20% co-insurance 1 Visit(s) per year

Glasses

$60 Allowance

$60 Allowance

Every 1 Year(s)

Dental check-up

Not Covered

Not Covered

------none------

---

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover

(This isn’t a complete list. Check your policy or plan document for other excluded services.)

·

Cosmetic surgery

·

Dental Care (Adult)

·

Long term care

·

Private-duty nursing

·

Routine foot care

·

Weight loss programs

Other Covered Services

services.)

·

Acupuncture

·

Bariatric Surgery

·

Chiropractic care

·

Hearing aids

·

Infertility treatment

·

Non-emergency care when traveling outside

the U.S.

·

Routine eye care (Adult)

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health

coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay

while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-800-499-1275. You may also contact your state insurance department, the

U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or

www.dol.gov/ebsa

,

or the U.S. Department of Health and

Human Services at 1-877-267-2323 x61565 or

www.cciio.cms.gov

.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to

appeal

or file a

grievance

. For

questions about your rights, this notice, or assistance, you can contact Customer Service at 1-800-499-1275.

·

For group health coverage subject to ERISA, you can contact your plan at 1-800-499-1275. You can also contact the Department of Labor ’ s

Employee Benefits Security Administration at 1-866-444-EBSA (3272) or

www.dol.gov/ebsa/healthreform

. If coverage is insured, you can contact

New York State Department of Financial Services at 1-800-342-3736

·

For non-federal governmental group health plans and church plans that are group health plans, call 1-800-499-1275. If coverage

is insured, you can contact New York State Department of Financial Services at 1-800-342-3736

·

Additionally, a consumer assistance program can help you file your appeal. Contact Community Health Advocates, the State ’ s consumer assistance

program, at 1-888-614-5400 or at

www.communityhealthadvocates.org.

---

Language Access Services:

Español: Para obtener asistencia en Español, llame al 1-800-499-1275.

Tagalog: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-499-1275.

中⽂

:

如果 ? 要中⽂的帮助，

请拨打这个号码

1-800-499-1275.

Dine: Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-499-1275.

––––––––––––

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

–––––––––––––

---

7 of 8

Excellus BCBS:Healthy Blue Copay

Coverage Period: 07/01/2013-06/30/2014

About these Coverage

Examples:

These examples show how this plan might cover

medical care in given situations. Use these

examples to see, in general, how much financial

protection a sample patient might get if they are

covered under different plans.

not a cost

estimator.

Don ’ t use these examples to

estimate your actual costs

under this plan. The actual

care you receive will be

different from these examples,

and the cost of that care will

also be different.

See the next page for

important information about

these examples.

Amount owed to providers:

$7,540

Plan pays:

$7,350

Patient pays:

$190

Sample care costs:

Hospital charges (mother)

Routine obstetric care

Hospital charges (baby)

Anesthesia

Laboratory tests

Prescriptions

Radiology

Vaccines, other preventive

Patient pays:

Deductibles

Copays

Coinsurance

Limits or exclusions

Total

$2,700

$2,100

$900

$900

$500

$200

$40

$7,540

$0

$40

$0

$150

$190

Amount owed to providers:

$5,400

Plan pays:

$3,290

Patient pays:

$2,110

Sample care costs:

Prescriptions

Medical Equipment and Supplies

Office Visits and Procedures

Education

Laboratory tests

Vaccines, other preventive

Total

$2,900

$1,300

$700

$300

$100

$100

$5,400

Patient pays:

Deductibles

Copays

Coinsurance

Limits or exclusions

Total

$0

$2,070

$0

$40

$2,110

Having a baby

(normal delivery)

Managing type 2 diabetes

(routine maintenance of

a well-controlled condition)

$200

Coverage Examples

Coverage for:

Plan Type:

Questions:

Call

1-800-499-1275

or visit us at

excellusbcbs.com

If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at

www.cciio.cms.gov

or call

1-800-499-1275

to request a copy.

---

Excellus BCBS:Healthy Blue Copay

Coverage Period: 07/01/2013-06/30/2014

Ind/Family

PPO

Coverage Examples

Coverage for:

assumptions behind the

Coverage Examples?

·

Costs don ’ t include

premiums

.

·

Sample care costs are based on national

averages supplied by the U.S. Department

of Health and Human Services, and aren ’ t

specific to a particular geographic area or

health plan.

·

The patient ’ s

condition was not an

excluded or preexisting condition.

·

All services and treatments started and

ended in the same coverage period.

·

There are no other medical expenses for

any member covered under this plan.

·

Out-of-pocket expenses are based only on

treating the condition in the example.

·

The patient received all care from in-

network

providers

. If the patient had

received care from out-of-network

providers

, costs would have been higher.

What does a Coverage Example

show?

For each treatment situation, the Coverage

Example helps you see how

deductibles

,

copayments

, and

coinsurance

can add up. It

also helps you see what expenses might be left

up to you to pay because the service or

treatment isn ’ t covered or payment is limited.

Can I use Coverage Examples to

compare plans?

ü

Yes.

When you look at the Summary of

Benefits and Coverage for other plans,

you ’ ll find the same Coverage Examples.

When you compare plans, check the “

Patient Pays ” box in each example. The

smaller that number, the more coverage the

plan

provides.

Does the Coverage Example

predict my own care needs?

û

No.

Treatments shown are just examples.

The care you would receive for this

condition could be different based on your

doctor ’ s advice, your age, how serious your

condition is, and many other factors.

Are there other costs I should

consider when comparing

plans?

ü

Yes.

An important cost is the

premium

you pay. Generally, the lower your

premium

, the more you ’ ll pay in out-of-

pocket costs, such as

copayments

,

deductibles

, and

coinsurance

. You

should also consider contributions to

accounts such as health savings accounts

(HSAs), flexible spending arrangements

(FSAs) or health reimbursement accounts

(HRAs) that help you pay out-of-pocket

expenses.

Does the Coverage Example

predict my future expenses?

û

No.

Coverage Examples are

not

cost

estimators. You can ’ t use the examples to

estimate costs for an actual condition. They

are for comparative purposes only. Your

own costs will be different depending on

the care you receive, the prices your

providers

charge, and the reimbursement

your health plan allows.

8 of 8

Questions:

Call

1-800-499-1275

or visit us at

excellusbcbs.com

If you aren ’ t clear about any of the underlined terms used in this form, see the Glossary. You can view the glossary at

www.cciio.cms.gov

or call

1-800-499-1275

to request a copy.