Can view the Glossary at https://www.healthcare.gov/sbc ...

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2019 - 12/31/2019

Syneos Health: Open Access Plus

Coverage for: Individual/Individual + Family | Plan Type: OAP

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share

the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is

only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go online at sp. For general

definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You

can view the Glossary at or call 1-855-281-1204 to request a copy.

Important Questions

Answers

Why This Matters:

Generally, you must pay all of the costs from providers up to the

deductible amount before this plan begins to pay. If you have

What is the overall

For in-network providers: $1,000/individual or $2,000/family

other family members on the plan, each family member must

deductible?

For out-of-network providers: $2,000/individual or $4,000/family meet their own individual deductible until the total amount of

deductible expenses paid by all family members meets the

overall family deductible.

This plan covers some items and services even if you haven't yet

Are there services covered before you meet your deductible?

Yes. In-network preventive care & immunizations, office visits, emergency room visits, urgent care facility visits.

met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at

.

Are there other deductibles for specific services?

No.

You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

For in-network providers $3,500/individual or $7,000/family For out-of-network providers $7,000/individual or $14,000/family

Combined medical/behavioral and pharmacy out-of-pocket limit

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Penalties for failure to obtain pre-authorization for services, premiums, balance-billing charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

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Important Questions

Answers

Will you pay less if you use a Yes. See or call 1-855-281-1204 for a list

network provider?

of network providers.

Do you need a referral to see a specialist?

No.

Why This Matters: This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

If you visit a health care provider's office or clinic

Services You May Need Primary care visit to treat an injury or illness

Specialist visit

Preventive care/ screening/ immunization

What You Will Pay

In-Network Provider

Out-of-Network Provider

(You will pay the least)

(You will pay the most)

CCN PCP: $35 copay/visit**

Non-CCN PCP: $35 copay/visit**

40% coinsurance

**Deductible does not apply

CCN Specialist: $35

copay/visit**

Non-CCN Specialist: $50

40% coinsurance

copay/visit**

**Deductible does not apply

No charge/visit**

40% coinsurance/visit

No charge/screening**

40% coinsurance/screening

No charge/immunizations**

40% coinsurance/ immunizations

**Deductible does not apply

Limitations, Exceptions, & Other Important Information

None

None

None None None You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

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Common Medical Event

If you have a test

If you need drugs to treat your illness or condition See expressscripts. com for information on drugs covered by your plan. Not all drugs are covered.

Services You May Need

Diagnostic test (x-ray, blood work)

What You Will Pay

In-Network Provider

Out-of-Network Provider

(You will pay the least)

(You will pay the most)

20% coinsurance

40% coinsurance

Imaging (CT/PET scans, MRIs)

20% coinsurance

40% coinsurance

Generic drugs (Tier 1)

Preferred brand drugs (Tier 2)

Retail: $10 copay Mail-Order: $25 copay

**Deductible does not apply Retail: 25% coinsurance, minimum $40 copay, maximum $75 copay Mail-Order: 25% coinsurance, minimum $100 copay, maximum $187.50 copay

Not covered Not covered

Non-preferred brand drugs (Tier 3)

**Deductible does not apply

Retail: 40% coinsurance, minimum $75 copay, maximum $150 copay Mail-Order: 40% coinsurance, minimum $187.50 copay, maximum $375 copay

Not covered

Specialty drugs (Tier 4)

**Deductible does not apply

Retail:25% coinsurance, maximum $200 copay Mail-Order: 25% coinsurance, maximum $200 copay

Not covered

**Deductible does not apply

Limitations, Exceptions, & Other Important Information

CCN Benefit level may apply. 50% penalty for no precertification. CCN Benefit level may apply. Mail-Order: Up to a 90 day supply

Mail-Order: Up to a 90 day supply

Mail-Order: Up to a 90 day supply

Mail-Order: Up to a 90 day supply

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Common Medical Event

Services You May Need

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Physician/surgeon fees

Emergency room care

If you need immediate medical attention

Emergency medical transportation

Urgent care

Facility fee (e.g., hospital If you have a hospital stay room)

Physician/surgeon fees

If you need mental health, behavioral health, or substance abuse services

Outpatient services

Inpatient services Office visits Childbirth/delivery professional services

What You Will Pay

In-Network Provider

Out-of-Network Provider

(You will pay the least)

(You will pay the most)

20% coinsurance

40% coinsurance

20% coinsurance

$250 copay/visit Deductible does not apply

40% coinsurance

$250 copay/visit Deductible does not apply

20% coinsurance

20% coinsurance

$50 copay/visit Deductible does not apply

$50 copay/visit Deductible does not apply

20% coinsurance

40% coinsurance

20% coinsurance

$50 copay/office visit** 20% coinsurance/all other services **Deductible does not apply

20% coinsurance

20% coinsurance

40% coinsurance

40% coinsurance/office visit 40% coinsurance/all other services

40% coinsurance 40% coinsurance

20% coinsurance

40% coinsurance

If you are pregnant

Childbirth/delivery facility services

20% coinsurance

40% coinsurance

Limitations, Exceptions, & Other Important Information

50% penalty for no precertification.

50% penalty for no precertification.

Per visit copay is waived if admitted

None

None

50% penalty for no precertification.

50% penalty for no precertification.

50% penalty if no precert of nonroutine services (i.e., partial hospitalization, IOP, etc.).

50% penalty for no precertification. Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

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Common Medical Event

Services You May Need

What You Will Pay

In-Network Provider

Out-of-Network Provider

(You will pay the least)

(You will pay the most)

Home health care

20% coinsurance

40% coinsurance

If you need help recovering or have other special health needs

Rehabilitation services

$35 copay/PCP visit**

$50 copay/Specialist visit** **Deductible does not apply

40% coinsurance

Habilitation services

$35 copay/PCP visit**

$50 copay/Specialist visit** **Deductible does not apply

Skilled nursing care

20% coinsurance

Durable medical equipment 20% coinsurance

40% coinsurance

40% coinsurance 40% coinsurance

Limitations, Exceptions, & Other Important Information

50% penalty for no precertification. Coverage is limited to 120 days annual max. 16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.) 50% penalty for failure to precertify speech therapy services. Coverage is limited to annual max of: 36 days for Pulmonary rehab; 60 days for Cognitive, Physical, Speech & Occupational therapies; 36 days for Cardiac rehab services; 20 days annual max for Chiropractic care services

Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.

CCN Benefit level may apply for Primary Care Physician services only.

Coverage for Habilitation services are limited to 60 days annual maximum

50% penalty for no precertification. Coverage is limited to 100 days annual max. 50% penalty for no precertification.

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