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

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Your Summary of Benefits o NCS (No Cost Share) means no deductiblelcopaymenticoinsurance up to the maximum allowable amount. o PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other Network provider as allowed by the plan. o SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice. o Certain diabetic and asthmatic supplies have no deductiblelcopaymenUcoinsurance up to the maximum allowable amount at network pharmacies except diabetic test strips, a Benefit period = calendar year o Prosthetic limbs are unlimited and do not apply to the Plan Lifetime Maximum. o Mammograms (Diagnostic) are no copaymenUcoinsurance in Network office and outpatient facility settings. o Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. o Preventive Care Services that meet the requirements of federal and state law, Including certain screenings, immunizations and physician visits are covered. o Private Duty Nursing -- limited to 82 vlsilslCalendar Year and 164 visitsliifetime. o Elective abortions not covered unless otherwise noted in your Certificate of Coverage o Live Health Online (LHO) is covered at the PCP costshare f These covered services are not subject to the deductibielwpaymenl if you have a fiat dollar copayment and if rendered without an office visit. 2 We encourage you to review the Schedule of Benefits for limitations. 3 Kidney and Cornea are treated the same as any other illness and subject to the medical benefits. 4 Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips. Precertiftcation: Members are encouraged to always obtain prior approval when using non -network providers. Precertification will help the member know if the services are considered not medically necessary. Pre-existing Exclusion Period: none This summary of benefits has been updated to comply with federal and stale requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This benefit overview is for illustrative purposes and some content may be pendfng Indiana Department of Insurance approval. This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate, and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail. By signing this Summary of Benefits, I agree to the benefits for the product selected as of the effective date indicated. Authorized group signature (if applicable) v --YD ( Ur Date I ladsrktin4 signature (if applicable) Date