Common use of Summary of Benefits and Coverage Clause in Contracts

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  In addition, some important terms used throughout this Agreement and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section. If you have any questions about your Health Benefit Plan, please call our Presbyterian Customer Service Center. We have Spanish and Navajo speaking representatives and we offer translation services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing mpaired users may call the TTY 711 or toll-free at 0000-000-0000. You may visit our ebsite for useful health information and services at xxx.xxx.xxx.

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care PhysicianPhysician (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  In additionPrior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, some important terms used throughout this Agreement your In- network Practitioner/Provider must call us and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section. If obtain Authorization before you have any questions about your Health Benefit Plan, please call our Presbyterian Customer Service Center. We have Spanish and Navajo speaking representatives and we offer translation services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing mpaired users may call the TTY 711 or toll-free at 0000-000-0000receive treatment. You may visit our ebsite for useful health information and must call us if you are seeking services at xxx.xxx.xxxOut-of- network (outside of the 5-county area). In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, In-network Cost Sharing amounts you pay will apply toward the amount you may have to pay In-network Annual Out- of-pocket Maximum after which In-network claims will be paid at 100%. Practitioners/Provider for obtaining Prior Authorization (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefitsif required). You should keep this Agreement, your Summary of Benefits must obtain Prior Authorization (if required) for services provided by a National PPO Provider and Coverage, and any follow all other attachments rules regarding Out-of-network Practitioners/Providers. For additional information regarding National PPO Providers or Endorsements to see if you may receive need a Prior Authorization for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  In addition, some important terms used throughout this Agreement and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section. If you have any questions about your Health Benefit PlanOut-of-network Services, please call our Presbyterian Customer Service Center. We have Spanish and Navajo speaking representatives and we offer translation Center prior to obtaining services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday Friday from 7:00 a.m. to 6:00 p.m. at (000505) 00023-0000 6980 or toll-free at 0-000-000-0000. Hearing mpaired impaired users may call the TTY 711 line at 11 or toll-free at 00000-000-000-0000. Many Health Care Services you receive from In-network and Out-of-network Practitioners and Providers require some payment from you. We refer to these payments as Cost Sharing. These are your Out-of-pocket costs and may be Copayments, Deductibles and/or Coinsurance amounts. Certain services are subject to an Annual Contract Year Deductible. The Annual Contract Deductible is the amount you and your Covered Dependents must pay for Covered Health Care Services each Contract Year before we begin to pay Covered Benefits for that Member. The Annual Contract Year Deductible may not apply to all Health Care Services. You may will pay a lower Annual Contract Year Deductible amount when you visit our ebsite In-network Practitioners/Providers. Refer to your Summary of Benefits and Coverage for useful health information the amount of your Annual Contract Year Deductible. Covered charges for In-network Practitioner and Provider services at xxx.xxx.xxx.only apply to the In- network Annual Contract Year Deductible limits and do not apply to the Out-of-network Annual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. Covered charges or Out-of-network Practitioner and Provider services only apply to the Out- of-network Annual Contract Year Deductible limits and do not apply to the In-network Annual Contract Year Deductible limits shown in the Summary of Benefits and Coverage. For Single coverage, the annual Contract Year Deductible requirement is fulfilled when one Member meets the individual Deductible listed in the Summary of Benefits and Coverage. For double or family coverage with two or more enrolled Members, the entire Family annual Contract Year Deductible must be met before benefits will be paid for the family. However, if one family Member reaches the Individual Deductible, the Plan will begin paying benefits for that Member who has met the Individual Deductible. The annual Contract Year Family and Individual Deductible amounts are list

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how the insured has the freedom to choose or change your Primary Care PhysicianProvider (PCP), what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some services that are excluded from the Covered Benefits and will not be paid. You should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services Out-of- network. In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible. Timeframe Requirement – This “Timeframe” symbol appears to remind you when you must take action within a certain timeframe to comply with your Plan. An example of a Timeframe Requirement is when you must enroll your newborn within 60 days of birth. Important Information – This “Important Information” symbol appears when there are special instructions or important information about your Covered Benefits or your Plan that requires special attention. An example of Important Information would be how Dependent Students may receive Covered Benefits. Call Presbyterian Customer Service Center – This “Call PCSC” symbol appears whenever we refer to our Presbyterian Customer Service Center or to remind you to call us for information. In addition, some important terms used throughout this Agreement and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Section. If you have any questions about your Health Benefit Plan, please call our Presbyterian Customer Service Center. We have Spanish and Navajo speaking representatives and we offer translation services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing mpaired users may call the TTY 711 or toll-free at 0000-000-0000. You may visit our ebsite for useful health information and services at xxx.xxx.xxx.

Summary of Benefits and Coverage. The A Summary of Benefits and Coverage (SBC) gives an overview of the benefit options of your insurance plan. All insurance companies are required to provide you with an SBC, which is in a format required by the government. You can find your SBC by going to My Health Toolkit. You may also contact a Customer Service Advocate and ask us to send you a copy of the SBC. We can send it to you electronically or mail a paper copy (free of charge). Please note: the format and content of an SBC is controlled by federal agencies. In the event of an inconsistency between the SBC and these Policy documents, these Policy documents are controlling. Preauthorization is also called prior authorization, prior approval or precertification. It is important to understand what Preauthorization means. It means the service has been determined to be medically appropriate for the patient’s condition. A Preauthorization does not guarantee that we will pay benefits. Preauthorization must be obtained for certain categories of benefits; a failure to get preauthorization may result in benefits being denied. We will make our final benefit determination when we process your claims. Even when a service is preauthorized, we review each claim to make sure: ● The patient is a chart that shows some specific Member under the Policy at the time service is provided; and ● The service is a Covered Benefits this Plan provides, the amount you Service (Policy limitations or exclusions may have to pay (Cost Sharing) apply); and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage● The service provided was Medically Necessary as defined by your Policy, including Benefitsappropriateness, Limitationshealth care setting, level of care, and Exclusionseffectiveness. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how to choose A Preauthorization may only be for a specific period of time or change your Primary Care Physician, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use number of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  In addition, some important terms used throughout this Agreement and the Summary of Benefits and Coverage will be capitalized. These terms are defined in the Glossary of Terms Sectionvisits/treatments. If you have any questions about your Health Benefit Planthis, please contact Marketplace Operations. If your request for Preauthorization of services is denied, you can request further review; see the Appeal Procedures Section of this Policy. Preauthorization denials are considered denied claims for purposes of appeals and grievances. Network Providers in South Carolina will be familiar with the requirement to obtain Preauthorization and will get the necessary approvals. If a Network Provider in South Carolina does not get Preauthorization, it cannot Balance-Bill you. If you use an Out-of-Network Provider, it is your responsibility to contact us before receiving services and/or supplies. An Out-of-Network Provider can Balance-Bill you for the difference unless prohibited by law. This is also true for Network Providers through the BlueCard® program. If you are outside the BlueExtend PPO service area and receive benefits through the BlueCard® program (see the Out- of-Area Services section of the Policy), you may need to request approval for any service you receive. A BlueCard Provider is not required to obtain approvals for you. It is your responsibility to make sure Preauthorization is obtained. In addition, a BlueCard Provider may charge you for any additional costs if the Preauthorization is not obtained. For some services to be covered, you will be required to use a Provider we designate, who may or may not be a Network Provider. These services may include mammography, Habilitation, Rehabilitation and vision care. If the Provider we designate is not an in-Network Provider, benefits will be provided at the in-Network Coinsurance amount. The Allowed Amount for these Providers will be the Medicare allowance and these Providers can bill you the difference between the Allowed Amount and the billed charges. For transplant services to be covered (in-Network or out-of-Network), you will be required to use the Provider we designate, and they perform the transplant at a Blue Distinction® Centers for Transplant Designation. To use the BlueCross Preauthorization process, call our Presbyterian Customer Service Centerthe numbers listed in the table below to reach the appropriate medical services personnel. We have Spanish Below is the list of services that must be Preauthorized. For Preauthorization requirements for Prescription drugs, please see the Prescription Drug section of this Policy. The following services or benefits require preauthorization. Your in-Network Provider should obtain any needed authorization; however, you remain responsible for any unauthorized charges or services. If a required preauthorization is not obtained, no benefits will be paid. Non-Emergency Hospital Services, (not required for maternity/newborns; see next page) Habilitation or Rehabilitation (including Inpatient Rehabilitation) Human Organ and/or Tissue Transplants Skilled Nursing Facility (SNF) Continuation of Inpatient or Skilled Nursing Facility admission (remaining as Inpatient longer than originally approved) Cardiac rehabilitation (Phase 1 and Navajo speaking representatives and we offer translation services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday from 7:00 a.m. to 6:00 p.m. at (2) Pulmonary rehabilitation In Columbia 000) -000-0000 In S.C. 000-000-0000 Outside S.C. 000-000-0000 Outpatient facility admissions for services Surgery (including pre-authorization for anesthesia) Dialysis (hemodialysis or tollperitoneal), including home dialysis (when required criteria are met) Home Health Care or Hospice Services Durable Medical Equipment when purchase price or rental is $500 or more; supplies used with the DME must be Preauthorized every 90 days. Treatment for hemophilia - care must be coordinated through a Center for Disease Control and Prevention (CDC) designated Hemophilia Treatment Center. You must see a Provider at the designated Hemophilia Treatment Center within 60 days of the beginning of your Benefit Period. Treatments for Varicose Veins and Venous Insufficiency Colonoscopies when not for screening/preventive purposes Virtual colonoscopies and capsule endoscopies Inter-free at Disciplinary Pain Management Program Ambulance Services for non-Emergency transport Inpatient admissions for Behavioral Health treatment Residential Treatment Center (RTC) Continuation of an Inpatient or RTC admission (remaining as Inpatient longer than originally approved) Outpatient/office diagnostic and therapeutic: Psychological testing, rTMS, ECT Outpatient facility admissions for services: Intensive outpatient and Partial Hospitalization Programs Applied Behavioral Analysis (ABA) Therapy related to Autism Spectrum Disorder Companion Benefit Alternatives, Inc. (CBA) – In Columbia 000-000-0000 Outside Columbia 800-868- 1032 Outpatient/office diagnostic MRI, MRA, PET scans and CT scans Radiation oncology Musculoskeletal/spine management (interventional pain management, lumbar and cervical spine surgery) services. Virtual colonoscopy or CT Colonography Evolent 000-000-0000 Genetic Counseling and Testing, including Prenatal Screening and Mutation Analysis Avalon Health Services, LLC 0-000-000-0000. Hearing mpaired users may call the TTY 711 0000 Prescription Drugs, Specialty Pharmacy medications, Injections/ Injectable drugs; medications that require special handling, Preauthorization, or toll-free at 0000exceed allowed quantities (See Prescription Drug section for details.) OptumRx Customer Service 000-000-00000000 Select Cardiac Procedures, Sleep Studies, Surgical Services (ortho, prostate, thyroid), Varicose Vein treatments. (See HealthHelp PA list for specific codes) HealthHelp 000-000-0000 Evolent is an independent company that preauthorizes certain radiological procedures on behalf of BlueCross. Companion Benefit Alternatives, Inc. is a separate company that preauthorizes Mental Health and Substance Use Disorder services on behalf of BlueCross. Avalon Health Services, LLC is an independent company that preauthorizes certain laboratory services and procedures on behalf of BlueCross. OptumRx is an independent company that provides pharmacy benefit management services on behalf of BlueCross. You may visit our ebsite have 60 days to add a newborn child to your coverage or to obtain other coverage for useful health information the child; see the Eligibility, Coverage and services at xxx.xxx.xxxWhen your Coverage Ends section. Coverage is not automatic and until the newborn is covered under this policy, we cannot process benefits or approve a Preauthorization if the child needs a continued stay in the Hospital. We recommend that you add the newborn to this coverage (or other coverage, if you prefer) as soon as possible after birth to ensure benefits for that child are processed timely.

Summary of Benefits and Coverage. The Summary of Benefits and Coverage is a chart that shows some specific Covered Benefits this Plan provides, the amount you may have to pay (Cost Sharing) and the Coverage Limitations and Exclusions. Please take time to read this Agreement and Summary of Benefits and Coverage, including Benefits, Limitations, and Exclusions. This Agreement describes your benefits and your rights and responsibilities as our Member. It also gives details on how the insured has the freedom to choose or change your Primary Care PhysicianPCP, what limits are placed on certain benefits, and what services are not Covered at all. Understanding how this Plan works can help you make the best use of your Covered Benefits. You should keep this Agreement, your Summary of Benefits and Coverage, and any other attachments or Endorsements you may receive for future reference. We use visual symbols throughout this Agreement to alert you to important requirements, restrictions and information. When one or more of the symbols is used, we will use bold print in the paragraph or section to point out the exact requirement, restriction, and information. These symbols are listed below: Refer To – This “Refer To” symbol will direct you to read related information in other sections of the Agreement or Summary of Benefits and Coverage when necessary. The Section being referenced will be bolded.  In addition, Exclusion – This “Exclusion” symbol will appear next to the description of certain Covered Benefits. The Exclusion symbol will alert you that there are some important terms used throughout this Agreement and services that are excluded from the Summary of Covered Benefits and Coverage will not be capitalized. These terms are defined in the Glossary of Terms Section. If you have any questions about your Health Benefit Plan, please call our Presbyterian Customer Service Center. We have Spanish and Navajo speaking representatives and we offer translation services for more than 140 languages. O F i w ur Presbyterian Customer Service Center representatives are available Monday through riday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing mpaired users may call the TTY 711 or toll-free at 0000-000-0000paid. You may visit should refer to the Exclusion Section when you see this symbol. Prior Authorization Required – This “Prior Authorization” symbol will appear next to those Covered Benefits that require our ebsite for useful health information Authorization (approval) in advance of those services. To receive full benefits, your In- network Practitioner/Provider must call us and obtain Authorization before you receive treatment. You must call us if you are seeking services at xxx.xxx.xxxOut-of- network (outside of the 5-county area). In the case of a Hospital in-patient admission following an Emergency Room visit, you or your physician should call as soon as possible.