Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

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 www.highmarkbcbsde.com or by calling 1-888-601-2242.

Important Questions Answers Why this Matters:

What is the overall $6,800 individual/$13,600 family.
deductible?
Network deductible does not apply
to preventive care services, routine
eye exam, pediatric dental check-up,
or any service with a copayment.
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.

Copayments, coinsurance amounts

Are there other deductibles
for specific services?
Is there an out-of-pocket
limit on my expenses?
What is not included in the
out-of-pocket limit?
Is there an overall annual
limit on what the plan
pays?
Does this plan use a
network of providers?
don't count toward the network
deductible.
No.
Yes, $7,150 individual/$14,300
family, network.
Premiums, balance-billed charges and
health care this plan doesn't cover.
No.
Yes. For a list of network providers,
see www.highmarkbcbsde.com or call
1-888-601-2242.
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.
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.
Even though you pay these expenses, they don't count toward the out-of-
pocket limit.
The chart starting on page 2 describes any limits on what the plan will pay for
specific covered services, such as office visits.
If you use a network doctor or other health care provider, this plan will pay
some or all of the costs of covered services. Be aware, your network doctor or
hospital may use an out-of-network provider for some services. Plans use the
term 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.

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy. A copy of your agreement can be found at
https://shop.highmark.com/sales/#!/sbc-agreements.
DE HMK Shared Cost Blue EPO 6800 ONX Base
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO
Do I need a referral to see a No. You can see the specialist you choose without permission from this plan.
specialist?
Are there services this plan Yes. Some of the services this plan doesn’t cover are listed in the Excluded Services
doesn’t cover? & Other Covered Services section. 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 network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Services You May Need Your Cost if You Your Cost if You Limitations & Exceptions
Medical Event Use a Network Use an Out-of-
Provider Network Provider
If you visit a Primary care visit to treat an injury or illness $25 copay/visit Not covered Preauthorization is required for some
health care services.
provider’s office Specialist visit 10% coinsurance Not covered Preauthorization is required for some
or clinic services.
Other practitioner office visit 10% coinsurance Not covered for Network limit: 30 visits per benefit
for chiropractor chiropractor period. Preauthorization is required
for certain services.
Preventive care No charge for No coverage for Please refer to your preventive
Screening preventive care preventive care schedule for additional information.
Immunization services services

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 2 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Limitations & Exceptions
Medical Event Use a Network Use an Out-of-
Provider Network Provider
If you have a test Diagnostic test (x-ray, blood work) Lab: $50 copay/ Not covered −−−−−−−−−none−−−−−−−−−−
visit; machine tests
and std. imaging:
10% coinsurance
Imaging (CT/PET scans, MRIs) 10% coinsurance Not covered Preauthorization is required for
advanced radiology.
If you need drugs Generic drugs 50% coinsurance Not covered Up to 34-day supply retail pharmacy.
to treat your (retail)
illness or 50% coinsurance Up to 90-day supply maintenance
condition (mail order) prescription drugs through mail order.

More information Certain participating retail pharmacy

Brand drugs 50% coinsurance Not covered
about prescription providers may have agreed to make
(retail)
drug coverage is Maintenance Prescription Drugs
50% coinsurance
available at available at the same cost-sharing and
(mail order)
www.highmarkbcbs quantity limits as the mail service
de.com. coverage.
Specialty drugs Depending on the Not covered Certain drugs may require prior
place of service, authorization. Coverage depends on
covered the same the specific drug, how and where it is
as PCP or specialist provided, and how it is billed.
office visit,
outpatient hospital
or suite infusion
center.
If you have Facility fee (e.g., ambulatory surgery center) 10% coinsurance Not covered Preauthorization is required for some
outpatient services.
surgery Physician/surgeon fees 10% coinsurance Not covered Preauthorization is required for some
services.
Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 3 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Limitations & Exceptions
Medical Event Use a Network Use an Out-of-
Provider Network Provider
If you need Emergency room services 10% coinsurance 10% coinsurance −−−−−−−−−none−−−−−−−−−−
immediate Emergency medical transportation 10% coinsurance 10% coinsurance −−−−−−−−−none−−−−−−−−−−
medical attention Urgent care 10% coinsurance Not covered −−−−−−−−−none−−−−−−−−−−
If you have a Facility fee (e.g., hospital room) 10% coinsurance Not covered Preauthorization is required.
hospital stay Physician/surgeon fee 10% coinsurance Not covered Preauthorization is required.
If you have Mental/Behavioral health outpatient services 10% coinsurance Not covered Preauthorization is required for partial
mental health, hospital and intensive outpatient care.
behavioral health, Mental/Behavioral health inpatient services 10% coinsurance Not covered Preauthorization is required.
or substance Substance use disorder outpatient services 10% coinsurance Not covered Preauthorization is required for partial
abuse needs hospital and intensive outpatient care.
Substance use disorder inpatient services 10% coinsurance Not covered Preauthorization is required.
If you are Prenatal and postnatal care 10% coinsurance Not covered Network: The first visit to determine
pregnant pregnancy is covered at no charge.
Please refer to the Women’s Health
Preventive Schedule for additional
information.
Delivery and all inpatient services 10% coinsurance Not covered −−−−−−−−−none−−−−−−−−−−

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 4 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Limitations & Exceptions
Medical Event Use a Network Use an Out-of-
Provider Network Provider
If you need help Home health care 10% coinsurance Not covered Network: 100 visits per benefit
recovering or period. Preauthorization is required.
have other special Rehabilitation services 10% coinsurance Not covered Network: 30 combined physical
health needs medicine and occupational therapy
visits and 30 speech therapy visits per
benefit period. PT requires
preauthorization for visits 9-30 per
benefit period.
Habilitation services 10% coinsurance Not covered Network: 30 combined physical
medicine and occupational therapy
visits and 30 speech therapy visits per
benefit period. PT requires
preauthorization for visits 9-30 per
benefit period.
Skilled nursing care 10% coinsurance Not covered Network: 120 days per benefit period.
Preauthorization is required.
Durable medical equipment 10% coinsurance Not covered Preauthorization is required for some
equipment.
Hospice service 10% coinsurance Not covered Preauthorization is required for
inpatient care.

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

Common Services You May Need Your Cost if You Your Cost if You Limitations & Exceptions
Medical Event Use a Network Use an Out-of-
Provider Network Provider
If your child Eye exam No charge Not covered One exam every 12 months for
needs dental or members under the age of 19
eye care Glasses No charge Not covered One pair of frames/lenses or contacts
every 12 months for members under
19 years of age. Davis provider -
Health Care Reform Vision Network.
Dental check-up No charge Not covered One exam every 6 months - United
Concordia Advantage Plus 2.0
Network.

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO

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.)

• Abortions, except where a pregnancy is • Custodial Care/Rest Homes • Routine foot care
the result of rape or incest, or for a
pregnancy which, as certified by a
physician, places the life of the woman in
danger unless an abortion is performed.
• Acupuncture • Dental care (Adult) • Weight loss programs
• Assisted Reproductive Technology • Experimental/Investigational Care • Worker's Compensation Claims
• Care by Family Members • Glasses (Adult)
• Cosmetic surgery • Long-term care

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)

• Bariatric surgery • Infertility treatment • Private-duty nursing

• Non-emergency care when traveling
• Chiropractic care • Routine eye care (Adult)
outside the U.S.
• Hearing aids

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2095436166_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type: EPO
Your Rights to Continue Coverage:
Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are
exceptions, however, such as if:
• You commit fraud
• The insurer stops offering services in the State
• You move outside the coverage area
For more information on your rights to continue coverage, contact the insurer at 1-888-601-2242. You may also contact your state insurance
department at The Delaware Department of Insurance /Consumer Assistance Program at 302.674.7300 (local) or 800.282.8611 (toll free).

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:
• Highmark Blue Cross Blue Shield Delaware: 1-888-601-2242, or www.highmarkbcbsde.com.
• The Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
• The Delaware Department of Insurance /Consumer Assistance Program: 841 Silver Lake Blvd, Dover, DE 19904, or 302.674.7300 (local),
800.282.8611 (toll free), or consumer@state.de.us.
• Additionally, the Delaware Department of Insurance/Consumer Assistance Program can help you file your appeal.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does
provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value)." This
health coverage does meet the minimum value standard for the benefits it provides.

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

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Coverage Examples Coverage for: Individual/Family | Plan Type: EPO

About these Coverage Examples: Managing type 2 diabetes

Having a baby
(normal delivery) (routine maintenance of
These examples show how this plan might
a well-controlled condition)
cover medical care in given situations. Use
these examples to see, in general, how much  Amount owed to providers: $7,540  Amount owed to providers: $5,400
financial protection a sample patient might get  Plan pays $740  Plan pays $3,600
if they are covered under different plans.  Patient pays $6,800  Patient pays $1,800

Sample care costs: Sample care costs:

This is Hospital charges (mother) $2,700 Prescriptions $2,900
not a cost Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
estimator. Hospital charges (baby) $900 Office Visits and Procedures $700
Anesthesia $900 Education $300
Laboratory tests $500 Laboratory tests $100
Don’t use these examples to
Prescriptions $200 Vaccines, other preventive $100
estimate your actual costs
under this plan. The actual Radiology $200 Total $5,400
care you receive will be Vaccines, other preventive $40
different from these Total $7,540 Patient pays:
examples, and the cost of Deductibles $1,600
that care will also be Patient pays: Copays $200
different. Deductibles $6,600 Coinsurance $0
Copays $200 Limits or exclusions $0
See the next page for
important information about Coinsurance $0 Total $1,800
these examples. Limits or exclusions $0
Total $6,800

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.

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 9 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
I_2110887674_20170101_SBC
Highmark Delaware: Shared Cost Blue EPO 6800 Coverage Period: 01/01/2017 - 12/31/2017
Coverage Examples Coverage for: Individual/Family | Plan Type: EPO

Questions and answers about the Coverage Examples:

What are some of the assumptions What does a Coverage Example show? Can I use Coverage Examples to
behind the Coverage Examples? For each treatment situation, the Coverage compare plans?
Example helps you see how deductibles,
• Costs don’t include premiums.
copayments, and coinsurance can add up. It Yes. When you look at the Summary of
• Sample care costs are based on national Benefits and Coverage for other plans, you’ll
averages supplied by the U.S. Department of also helps you see what expenses might be left up
to you to pay because the service or treatment find the same Coverage Examples. When you
Health and Human Services, and aren’t compare plans, check the “Patient Pays” box
specific to a particular geographic area or isn’t covered or payment is limited.
in each example. The smaller that number, the
health plan. more coverage the plan provides.
• The patient’s condition was not an excluded Does the Coverage Example predict
or preexisting condition. my own care needs? Are there other costs I should consider
• All services and treatments started and ended  No. Treatments shown are just examples. when comparing plans?
in the same coverage period. The care you would receive for this condition
• There are no other medical expenses for any could be different based on your doctor’s Yes. An important cost is the premium you
member covered under this plan. advice, your age, how serious your condition pay. Generally, the lower your premium, the
• Out-of-pocket expenses are based only on is, and many other factors. more you’ll pay in out-of-pocket costs, such as
treating the condition in the example. copayments, deductibles, and coinsurance.
You should also consider contributions to
• The patient received all care from network Does the Coverage Example predict accounts such as health savings accounts
providers. If the patient had received care my future expenses? (HSAs), flexible spending arrangements (FSAs)
from out-of-network providers, costs would
have been higher. No. Coverage Examples are not cost or health reimbursement accounts (HRAs) that
estimators. You can’t use the examples to help you pay out-of-pocket expenses.
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.

Questions: Call 1-888-601-2242 or visit us at www.highmarkbcbsde.com.

If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 10 of 9
at www.dol.gov/ebsa/healthreform and www.cciio.cms.gov or call 1-888-601-2242 to request a copy.
Highmark Blue Cross Blue Shield Delaware is an independent corporation operating under licenses from the Blue Cross and Blue Shield Association.

I_2110887674_20170101_SBC
Insurance or benefit administration may be provided by Highmark Blue Cross Blue Shield Delaware which is an
independent licensee of the Blue Cross Blue Shield Association. Health care plans are subject to terms of the
benefit agreement.

To find more information about Highmark’s benefits and operating procedures, such as accessing the drug
formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy,
call 1-855-873-4109.