Agreement - Blue Cross Blue Shield - Self Fund Medical Insurance for CIty Employees for 2019

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Your Summary of Benefits Prescription Drugs: Anthem National Dr"77777 o Network Retail Pharmacies: (30-day supply) Includes diabetic test strip o Home Delivery Service: 20% Not covered (90-day supply) Includes diabetic test strip - Specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail service - Member may be responsible for additional cost when not selecting the available generic drug Medicare Rx • Wrap Notes: 0 All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non -Network Human Organ and Tissue Transplant (HOTT) Services. o Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%. o Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copaymenU coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional cost share applies. o Once the family deductible is satisfied by either one member or all members collectively, then the additional percentage coinsurance will be required before the family out-of-pocket is satisfied. Does not apply to embedded deductible plans. 0 Network and Non -network Deductible, copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other. o Dependent Age: to end of the month which the child attains age 26 0 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non -network provider, the member is responsible for any balance due after the plan payment. I No Cost Share (NCS): No deductible/copayment/coinsuran ce up to the maximum allowable amount. o Ambulance Non -network non -emergency use limited to $50,000 per benefit period. o Live Health Online (LHO) is covered at the PCP cost share. o Benefit period = calendar year o The maximum allowable HRA rollover contribution amount will be either three times your employer health account contribution or unlimited. 0 For employers that select calendar year benefits and have an effective date other than January 1, the Employees HRA Employer Contribution will be prorated based upon the number of months enrolled in the plan. 0 Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity. 0 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 visits/Calendar Year and 164 visits/lifetime 0 Wigs: limit 1 (one) maximum for wigs due to cancer diagnosis per benefit o Elective abortions not covered unless otherwise noted in your Certificate of Coverage. ' We encourage you to refer to the Schedule of Benefits for limitations. z Rx non -network diabeticlasthmatic supplies not covered except diabetic test strips. Meets Indiana state mandated effective 71112008. "Bridge is not an insurance loom and does not a,ppear in the Certificate. HRA hinds can be used for covered services under the benefit plan. Bridge amounts may be reduced if incentives are eamed and by Contribution Rol ever amounts in subsequent years. Employer must fund in order to be considered a Health Reimbursoment Account. Employer most continue to fund for the entire year at the HRA level indicated. Precertiflcatlon: 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 state 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.