Professional Services Agreement - Gibson Insurance - Medical Service and Prescription Services for Employees through Anthem BCBS

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Your Summary of Benefits Behavioral Health Services Mental Illness and Substance Abuser: 40% o Inpatient Facility Services 20% o Inpatient Professional Services 20% o Physician Home and Office Visits (PCPISCP) $30$30 o Other Outpatient Services, Outpatient Facility 20% @ Hospital/Alternative Care Facility, Outpatient Professional Human Organ and Tissue Transplants3 NCS 50% o Acquisition and transplant procedures, harvest and storage Prescription Drug Options: Anthem National Drug list Network Tier structure equals 11213 (and 4, if applicable) Tier 1: 20% 50%, min $604 o Network Retail Pharmacies: Tier 2: 30% (30-day supply) Tier 3: 40% Includes diabetic test strip All Tiers: $250 maximum per prescription o Home Delivery Service: Tier 1: 20% Not covered (90-day supply) Tier 2: 30% Includes diabetic test strip Tier 3: 40% All Tiers: $750 maximum per prescription $2,6001$5,200 $5,2001$10,400 o Calendar Year Out of Pocket Maximum: Member may be responsible for additional cost when not selecting the available generic drug. Medicare Rx • Wrap Lifetime Maximum Medical Unlimited Unlimited Surgical Treatment of Morbid Obesity Not covered Not covered notes: o All medical and prescription drug deductibles, copsyments and coinsurance apply toward the out-of-pocket maximum (excluding Non -Network Human Organ and Tissue Transplant (HOTT) Services) o Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the deductible does not apply to Emergency Room Services where a copayment and coinsurance applies and may not apply to some Behavioral Health services where coinsurance applies. o Dependent Age: to end of the month which the child attains age 26 0 Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OBIGYNs and Geriatrics or any other Network Provider as allowed by the plan. o When allergy injections are rendered with a Physicians Home and Office Visit, only the Office Visit cost share applies. When the Office Visit cost share is a %coinsurance, deductible and coinsurance apply to allergy Injections.