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Reference ID: 1005205201012024Medical Benefit HighlightsPersonal Choice PPO Silver HSA-0 $4,400/100%Covered Services Your Costs (You pay)Benefits per Contract Year In-Network Out-of-Network Deductible (Aggregate)1Individual/Family $4,400/$8,800 $11,000/$22,000 Out-of-Pocket Maximum (Embedded)2Individual/Family $8,000/$16,000 $22,000/$44,000Coinsurance 0% 50% Preventive Services In-Network Out-of-NetworkPreventive Care No charge no deductible 50% no deductiblePreventive ColonoscopyPreventive Plus Providers No charge no deductible Not coveredHospital Based $750 no deductible 50% no deductible Physician Services In-Network Out-of-NetworkPrimary Care Physician (PCP)Office Visit No charge after deductible 50% after deductibleTelemedicine Visit No charge after deductible 50% after deductibleSpecialistOffice Visit No charge after deductible 50% after deductibleTelemedicine Visit No charge after deductible 50% after deductibleRetail Health Clinic Visit No charge after deductible 50% after deductibleUrgent Care Visit No charge after deductible 50% after deductible Virtual Care3In-Network Out-of-NetworkTelemedicine No charge after deductible Not coveredTeledermatology No charge after deductible Not coveredTelebehavioral Health No charge after deductible Not covered Therapy Services In-Network Out-of-NetworkPhysical Therapy (30 visits/year)4Freestanding No charge after deductible 50% after deductibleHospital Based No charge after deductible 50% after deductibleOccupational Therapy (30 visits/year)4Freestanding No charge after deductible 50% after deductibleHospital Based No charge after deductible 50% after deductibleSpeech Therapy (30 visits/year)5No charge after deductible 50% after deductible
Reference ID: 1005205201012024Emergency Services In-Network Out-of-NetworkEmergency Room No charge after deductible Covered at In-Network levelEmergency Ambulance No charge after deductible Covered at In-Network levelNon-Emergency Ambulance No charge after deductible 50% after deductible Hospital Services In-Network Out-of-NetworkInpatient Hospital Services (In-Network: 365 days/year; Out-of-Network: 70 days/year)6No charge after deductible 50% after deductibleMaternity Hospital Services6No charge after deductible 50% after deductibleInpatient Professional Services (includes Maternity)No charge after deductible 50% after deductible Outpatient Surgery In-Network Out-of-NetworkFreestanding No charge after deductible 50% after deductibleHospital Based No charge after deductible 50% after deductibleOutpatient Professional Services No charge after deductible 50% after deductible Outpatient Diagnostics In-Network Out-of-NetworkDiagnostic Medical (EKG) No charge after deductible 50% after deductibleRoutine Radiology (X-Ray)Freestanding No charge after deductible 50% after deductibleHospital BasedNo charge after deductible 50% after deductibleAdvanced Imaging (MRI/MRA,CT/CTA Scan, PET Scan)Freestanding No charge after deductible 50% after deductibleHospital Based No charge after deductible 50% after deductible Outpatient Lab and Pathology In-Network Out-of-NetworkFreestanding No charge after deductible 50% after deductibleHospital Based No charge after deductible 50% after deductible Other Medical Services In-Network Out-of-NetworkSpinal Manipulations (20 visits/year)5No charge after deductible 50% after deductibleAcupuncture (18 visits/year)5No charge after deductible 50% after deductibleStandard Injectables No charge after deductible 50% after deductibleAllergy Injections No charge after deductible 50% after deductibleBiotech/Specialty InjectablesHome/Office No charge after deductible 50% after deductibleOutpatient No charge after deductible 50% after deductibleChemotherapy No charge after deductible 50% after deductibleDialysis No charge after deductible 50% after deductibleSkilled Nursing Facility (120 days/year)5No charge after deductible 50% after deductible
Reference ID: 1005205201012024Home Health (60 visits/year)5No charge after deductible 50% after deductibleHospice No charge after deductible 50% after deductibleDurable Medical Equipment (DME) No charge after deductible 50% after deductibleMental Health – Outpatient (includes serious mental illness and substance abuse)Office Visit No charge after deductible 50% after deductibleAll Other Services No charge after deductible 50% after deductibleMental Health – Inpatient (includes serious mental illness and substance abuse)6No charge after deductible 50% after deductible 1Aggregate deductible: For family coverage, the entire family deductible must be met before copayments or coinsurance are applied for an individual member.2Embedded out-of-pocket maximum: Each covered family member only needs to satisfy his or her individual out-of-pocket maximum, not the entire family out-of-pocket maximum.3Telemedicine is provided by a designated telemedicine provider, please visit www.ibx.com/findcarenow.4Physical Therapy and Occupational Therapy combined visit limit in and out-of-network.5Combined in and out-of-network.6Inpatient hospital out-of-network day limit combined for all inpatient medical, maternity, mental health, serious mental illness, and substance abuse services. Personal Choice®, our popular Preferred Provider Organization (PPO), gives you freedom of choice by allowing you to choose your own doctors and hospitals. You can maximize your coverage by accessing your care through Personal Choice's network of hospitals, doctors, and specialists, or by accessing care through preferred providers that participate in the BlueCard® PPO program. Of course, with Personal Choice, you have the freedom to select providers who do not participate in the Personal Choice network or BlueCard PPO program. However, if you receive services from out-of-network providers, you will have higher out-of-pocket costs and may have to submit your claim for reimbursement.This summary represents only a partial listing of benefits and exclusions of the Medical Program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms, limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.ibx.com/SGBooklet or call 1-800-ASK-BLUE (TTY: 711).Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations.Certain services require preapproval/precertification by the health plan prior to being performed. To obtain a list of services that require authorization, please log on to http://www.ibx.com/preapproval or call the phone number that is listed on the back of your identification card.Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the Blue Cross and Blue Shield Association. www.ibx.com
Reference ID: 1005210801012024Drug Benefit HighlightsPersonal Choice PPO Silver HSA-0 $4,400/100%Covered Services Your Costs (You pay)Benefits per Contract Year In-Network Out-of-NetworkDeductible Medical deductible applies. Medical deductible applies.Out-of-Pocket Maximum Combined with Medical Combined with MedicalFormulary1ValueDispense as Written (DAW) Provision2Mandatory Generic Retail Pharmacy In-Network Out-of-NetworkTier 1 Low-Cost Generic Drugs $3 after deductible 50% Reimbursement after deductibleTier 2 Generic Drugs $20 after deductible 50% Reimbursement after deductibleTier 3 Preferred Brand Drugs $75 after deductible 50% Reimbursement after deductibleTier 4 Non-Preferred Drugs $150 after deductible 50% Reimbursement after deductibleTier 5 Self-Administered Specialty Drugs 50% up to $1,000 after deductibleNot coveredDispensing Limits3,430 day supply max 30 day supply max Mail Order PharmacyAvailable for maintenance drugsIn-Network Out-of-NetworkTier 1 Low-Cost Generic Drugs $6 after deductible Not coveredTier 2 Generic Drugs $40 after deductible Not coveredTier 3 Preferred Brand Drugs $150 after deductible Not coveredTier 4 Non-Preferred Drugs $300 after deductible Not coveredTier 5 Self-Administered Specialty Drugs Not covered Not coveredDispensing Limits 90 day supply max Not covered Drug Coverage In-Network Out-of-NetworkACA Preventive Drugs Covered CoveredCompound Medications Covered CoveredContraceptives Covered CoveredDiabetic Supplies (i.e., test strips) Covered CoveredGlucometers Covered CoveredInsulin Covered CoveredInsulin Needles and Syringes Covered CoveredLancets Covered CoveredPrescribed Tobacco Cessation Drugs (RX and OTC) Covered CoveredWeight Control Drugs Covered Covered
Reference ID: 1005210801012024Allergy Serum Not covered Not coveredBlood, Blood Plasma Not covered Not coveredDrugs used for Cosmetic Purposes Not covered Not coveredInjectable Fertility Drugs Not covered Not coveredInvestigational/Experimental Drugs Not covered Not coveredNon-Federal Legend Drugs Not covered Not coveredOver-The-Counter Drugs (Non-Prescription) Not covered Not covered 1Benefits will be provided for Covered Drugs and medicines appearing on the Drug Formulary. To check the formulary status of a drug or view a copy of the most recent formulary, log onto www.ibx.com.2When a prescription drug is not available in a generic form, benefits will be provided for the brand drug and you will be responsible for the member cost sharing for a brand drug. When a prescription drug is available in a generic form, benefits will be provided for that drug at the generic drug level only. If you purchase a brand drug, you will be responsible for paying the dispensing pharmacy the difference between the negotiated discount price for the generic drug and the brand drug plus the appropriate member cost sharing for a brand drug.3Maintenance medications may also be available for up to a 90-day supply at participating Act 207 Retail pharmacies for the same mail order member cost sharing as indicated above.4Mail order cost-sharing for 1-30 day supplies is equal to the in-network retail cost-sharing. Up to a 90-day supply of drugs to treat chronic conditions also available at Rite Aid. This summary represents only a partial listing of benefits and exclusions of the Prescription Drug Program described in this summary. If your employer purchases another program, the benefits and exclusions may differ. Also, benefits and exclusions may be further defined by pharmacy policy. As a result, this program may not cover all of your health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms, limitations, and exclusions of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.ibx.com/SGBooklet or call 1-800-ASK-BLUE (TTY: 711).Certain designated preventative medications will not be subject to any cost-sharing or deductibles, but will be subject to the terms and conditions of your benefits contract. Refer to your summary of benefits, member handbook, and/or benefit booklet to determine if your plan includes 100 percent coverage for in-network preventive services.Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician's original order are not covered. Devices or supplies except those specifically listed under covered drugs are not covered.The network required for this plan is the Preferred Pharmacy Network. The Preferred Pharmacy Network is a subset of the national retail pharmacy network, including most major chains and local pharmacies except Walgreens. Out-of-Network benefits apply to prescriptions filled at Non-Preferred pharmacies and you must pay the full retail price for your prescription then file a paper claim for reimbursement.Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the Blue Cross and Blue Shield Association. www.ibx.com
Reference ID: 1005236701012024Vision Benefit HighlightsPediatric/Adult Vision SML PPO HSA/HRA w/o Med DedPEDIATRIC BENEFITSCovered Services (Calendar Year) Your Costs (You pay)Exam In-Network Out-of-NetworkRoutine Eye Exam at Davis Participating Providers (1 exam/year)No charge Not coveredRetinal Imaging $39 Not covered Lenses (1 pair/year) In-Network Out-of-NetworkSingle Vision Lenses No charge Not coveredBifocal Lenses No charge Not coveredTrifocal Lenses No charge Not coveredLenticular Lenses No charge Not covered Lens Options In-Network Out-of-NetworkProgressive Lenses - Standard/Premium/Ultra/Ultimate$50/$90/$140/$175 Not coveredPolycarbonate Lenses - Single/Multifocal1No charge Not coveredDigital/Intermediate Lenses $30 Not coveredPhotochromic Lenses - Single/Multifocal No charge Not coveredPhotosensitive Lenses - Single/Multifocal $65 Not coveredHigh-Index 1.67 / High-Index 1.74 Lenses $55/$60 Not coveredBlue Light Lenses $15Not coveredPolarized Lenses $75Not coveredLens CoatingsTinted Plastic Lenses No chargeNot coveredUV-Coated Lenses No chargeNot coveredScratch-Resistant Lenses - Single/Multifocal No charge Not coveredScratch-Protection Plan - Single/Multifocal $20/$40 Not coveredAnti-Reflective Coating - Standard/Premium/Ultra/Ultimate$35/$48/$60/$85 Not covered Frames (1 pair/year) In-Network Out-of-NetworkCollection Fashion Frames No chargeNot coveredCollection Designer Frames No chargeNot coveredCollection Premier Frames No chargeNot coveredNon-Collection Frames Up to $150 Allowance Not coveredAdditional Visionworks Frames Option Up to $150 Allowance (plus a 20% discount on overage)2Not covered
Reference ID: 1005236701012024Contact Lenses (in lieu of glasses) (1 pair/year)In-Network Out-of-NetworkCollection Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredCollection Contact Lenses Disposable Boxes/Multipacks: 4 per yearPlanned Replacement Boxes/Multipacks: 2 per yearNot coveredNon-Collection Standard Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredNon-Collection Specialty & Disposable Contact Lenses Evaluation, Fitting & Follow-Up CareUp to $60 Allowance Not coveredNon-Collection Contact Lenses Up to $150 Allowance Not coveredMedically-Necessary Contact Lenses3No charge Not covered ADULT BENEFITSCovered Services (Calendar Year) Your Costs (You pay)Exam In-Network Out-of-NetworkRoutine Eye Exam at Davis Participating Providers (1 exam/year)No charge Not coveredRetinal Imaging $39 Not covered Lenses (1 pair/year) In-Network Out-of-NetworkSingle Vision Lenses No charge Not coveredBifocal Lenses No charge Not coveredTrifocal Lenses No charge Not coveredLenticular Lenses No charge Not covered Lens Options In-Network Out-of-NetworkProgressive Lenses - Standard/Premium/Ultra/Ultimate$65/$105/$140/$175 Not coveredPolycarbonate Lenses - Single/Multifocal1$35 Not coveredDigital/Intermediate Lenses $30 Not coveredPhotochromic Lenses - Single/Multifocal No charge Not coveredPhotosensitive Lenses - Single/Multifocal $70 Not coveredHigh-Index 1.67 / High-Index 1.74 Lenses $60/$120 Not coveredBlue Light Lenses $15 Not coveredPolarized Lenses $75 Not coveredLens CoatingsTinted Plastic Lenses $15 Not coveredUV-Coated Lenses No charge Not coveredScratch-Resistant Lenses - Single/Multifocal No charge Not coveredScratch-Protection Plan - Single/Multifocal $20/$40 Not covered
Reference ID: 1005236701012024Anti-Reflective Coating - Standard/Premium/Ultra/Ultimate$40/$55/$69/$85 Not covered Frames (1 pair/year) In-Network Out-of-NetworkCollection Fashion Frames No charge Not coveredCollection Designer Frames $15 Not coveredCollection Premier Frames $40 Not coveredNon-Collection Frames Up to $130 Allowance (plus a 20% discount on overage)2Not coveredAdditional Visionworks Frames Option Up to $180 Allowance (plus a 20% discount on overage)2Not covered Contact Lenses (in lieu of glasses) (1 pair/year)In-Network Out-of-NetworkCollection Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredCollection Contact Lenses Disposable Boxes/Multipacks: 4 per yearPlanned Replacement Boxes/Multipacks: 2 per yearNot coveredNon-Collection Standard Contact Lenses Evaluation, Fitting & Follow-Up CareNo charge Not coveredNon-Collection Specialty & Disposable Contact Lenses Evaluation, Fitting & Follow-Up CareUp to $60 Allowance Not coveredNon-Collection Contact Lenses Up to $130 Allowance2Not coveredMedically-Necessary Contact Lenses3No charge Not covered 1Polycarbonate lenses for dependent children, monocular patients, and patients with prescriptions greater than or equal to +/6.00 diopters are covered at no cost.2Member is responsible for balance. Additional discounts not applicable at Walmart, Costco, or Sam's Club locations.3Covered with prior approval. This summary represents only a partial listing of benefits of the Vision Care Program described in this summary. If your employer purchases another program, the benefits may differ. Also, benefits may be further defined by the vision policy. As a result, this vision plan may not cover all of your vision or health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms and limitations of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.ibx.com/SGBooklet or call 1-800-ASK-BLUE (TTY: 711).Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations.Administered by Davis Vision.Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the Blue Cross and Blue Shield Association. www.ibx.com
Reference ID: 1005235801012024Dental Benefit HighlightsPediatric Dental SML PPO Silver HSA 0 $4,400/100%PEDIATRIC BENEFITSCovered Services Your Costs (You pay)Benefits per Contract Year In-Network Out-of-NetworkAnnual Plan Maximum Unlimited Not coveredDeductible (per child) Medical deductible applies. Not coveredOut-of-Pocket Maximum (per child) Medical out-of-pocket maximum applies.Not coveredMedically Necessary Orthodontic Maximum (per child)Unlimited Not covered Coverage Type In-Network Out-of-NetworkDiagnostic & Preventive Services No charge no deductible Not coveredBasic Services No charge after deductible Not coveredMajor Services No charge after deductible Not coveredMedically Necessary Orthodontics No charge after deductible Not coveredCosmetic Orthodontic Services Not covered Not covered Key Covered Services In-Network Out-of-NetworkExams No charge no deductible Not coveredCleanings No charge no deductible Not coveredBitewing X-rays No charge after deductible Not coveredFluoride Treatments No charge after deductible Not coveredSealants No charge after deductible Not coveredBasic Restorative (Fillings) No charge after deductible Not coveredOral Surgery No charge after deductible Not coveredEndodontics No charge after deductible Not coveredPeriodontics No charge after deductible Not coveredCrowns No charge after deductible Not coveredBridges No charge after deductible Not coveredDentures No charge after deductible Not covered This summary represents only a partial listing of benefits of the Dental Plan described in this summary. If your employer purchases another program, the benefits may differ. Also, benefits may be further defined by dental policy. As a result, this dental plan may not cover all of your dental or health care expenses. Read your contract/member benefit booklet carefully for a complete listing of terms and limitations of the program. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.ibx.com/SGBooklet or call 1-800-ASK-BLUE (TTY: 711).Benefits may be changed by Independence Blue Cross to comply with applicable federal/state laws and regulations.Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross - Independent licensees of the Blue Cross and Blue Shield Association. www.ibx.com
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Taglines as of 12/31/2022 Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilitiesto communicate effectively with us, such as:qualified sign language interpreters, and writteninformation in other formats (large print, audio,accessible electronic formats, other formats). Free language services to people whoseprimary language is not English, such as:qualified interpreters and information written inother languages.If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA 19103, By phone: 1-888-377-3933 (TTY: 711) By fax: 215-761-0245, By email: civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms areavailable athttp://www.hhs.gov/ocr/office/file/index.html.