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1 Group Name Rochester Regional Health Plan Type 2018 PPO Copay

2 Excellus BlueCross BlueShield makes finding the information and support you need easier resources, savings, and tools are available online 24/7. Find a doctor or specialist online while you re home or far away. Research over 6,000 health topics. Get great member discounts and valuable information you can use all year long with Blue365 Welcome With Excellus BlueCross BlueShield, you get what you expect from Blue plus a whole lot more such as: More doctors, specialists, and hospitals to choose from Exclusive discounts on health-related products and services with Blue365 Answers to your health questions online Local customer service excellusbcbs.com In this booklet you will find: A chart that summarizes this plan s unique benefits and coverage* A glossary of terms to help you understand your coverage and options We have many valuable benefits and we provide a tremendous amount of choice. Whichever plan you pick, we're ready to meet your health care needs. Visit us at excellusbcbs.com *This benefit summary is not a contract or binding agreement; it is a summary of benefits and services. Privacy Policy Notice. We know how important your privacy is and we re committed to protecting it. Our policies and practices regarding the collection, use, and disclosure of personal health information are available at excellusbcbs.com and Member Services. EBCBS - 08/ M

3 Rochester Regional Health 2018 PPO Copay Plan Features Primary Care Physician (PCP) Not Required Referrals Not Required Out of network benefits Covered Student / Dependent Coverage Covered to age 26 Domestic Partner Covered Coverage Period 01/01/18-12/31/18 Questions? For assistance call (877) , Call our TTYphone at 1 (800) , or visit us at excellusbcbs.com/rrh 14019

4 Excellus BluePPO $10/$30/$50 Domestic, $25/$50/$90 Non Domestic Benefit Time Period: 01/01/ /31/2018 ROCHESTER REGIONAL HEALTH SYSTEM General Cost Sharing Expenses Deductible - Single $0 $0 $1,800 Deductible - Family $0 $0 $5,400 Each individual does not exceed the single deductible. Coinsurance 0% 0% 40% Annual Out of Pocket Maximum - Single $5,000 $5,000 $9,000 Annual Out of Pocket Maximum - Family $10,000 $10,000 $18,000 Out-of-pocket maximums accumulate the coinsurance amount and include the deductible, including carry over deductible if applicable, and copayment. Each individual does not exceed the single out of pocket maximum. Out-of-pocket maximums accumulate the coinsurance amount and include the deductible, including carry over deductible if applicable, and copayment. Once family OOP maximum has been met by any number of individuals, OOP maximum is met for all. One OOPM for both Domestic and In-Network combined. Office Visit Cost Shares Cost Share - Primary Care $30 $90 Cost Share - Specialist $50 $110 $30 Copay for In-Network $50 Copay for In-Network Plan Limits Plan/Calendar Year Diabetic Preauthorization and Step Therapy Calendar Year Benefits No Who is Covered Domestic Partner Coverage Yes 1 of /17/ :11:42

5 Inpatient Services Inpatient Facility Inpatient Hospital Services $500 $2,000 Mental Health Care $500 $2,000 Substance Use Detoxification $500 $2,000 Skilled Nursing Facility $500 $2,000 Physical Rehabilitation $2,000 Maternity Care $500 $2,000 $500 Copay for In-Network. $500 Copay for In-Network. $500 Copay for In-Network. 120 Days Per Plan Year 360 Days Lifetime Max. Pediatric (up to and including age 18): $500 Copay for In- Network. Limits are combined Domestic, INN and OON. 60 Days per year Covered in full for In-network. Limits are combined Domestic, INN and OON. $500 Copay for In-Network. Inpatient Professional Services Inpatient Hospital Surgery Anesthesia up to schedule of allowance Covered in full for In-network Includes anesthesia rendered for Inpatient, Outpatient, Office Visit, and Maternity services. Anesthesia does not require a preauth or referral. Pediatric (up to and including age 18): Covered in full for Innetwork Outpatient Facility Services Outpatient Facility Services SurgiCenters and Freestanding Ambulatory Centers Surgical Care $250 $2,000 Diagnostic X-ray $50 $90 Diagnostic Laboratory and Pathology $90 Radiation Therapy $90 Chemotherapy $90 Infusion Therapy Inclusive of Primary Service Inclusive of Primary Service Inclusive of Primary Service $250 Copay for In-Network. $50 Copay for In-Network. Advanced Imaging Services includes PET scans, MRI, nuclear medicine, and CAT scans. Covered in full for In-Network. for In-Network. for In-Network. Is inclusive in the Home Care benefit and not covered as a separate benefit. 2 of /17/ :11:42

6 Dialysis $90 Mental Health Care $30 $90 Substance Use Care $30 $90 for In-Network. $30 Copay for In-Network. Includes Partial Hospitalization $30 Copay for In-Network. Includes Partial Hospitalization Home and Hospice Care Home Care Home Care $90 40 Visits Per Plan Year Limits are combined INN and OON. Covered in full for In-network Hospice Care Hospice Care Inpatient Not Available Covered in full for In-network Outpatient and Office Professional Services Professional Services Office Surgery Diagnostic X-ray Diagnostic Laboratory and Pathology Radiation Therapy Chemotherapy Infusion Therapy Dialysis Mental Health Care Maternity Care PCP -$30 Specialist -$50 PCP -$30 Specialist -$50 PCP -$30 Specialist -$50 PCP -$30 Specialist -$50 PCP -$30 Specialist -$50 Inclusive of Primary Service PCP -$30 Specialist -$50 $30 PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 Inclusive of Primary Service PCP - $90 Specialist - $110 $90 Inclusive of Primary Service $30 PCP/$50 Specialist Copay for In-Network. $30 PCP/$50 Specialist Copay for In-Network. $30 PCP/$50 Specialist Copay for In-Network. $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit. $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit. Is inclusive in the Home Care benefit and not covered as a separate benefit. $30 PCP/$50 Specialist Copay for In-Network. 1 copay per visit. $30 PCP/Specialist Copay for In-Network. Covered in full for In-network 3 of /17/ :11:42

7 TeleMedicine Program Chiropractic Care Allergy Testing Allergy Treatment Including Serum Hearing Evaluations Routine Not Covered Not Available PCP -$30 Specialist -$50 Not Available Not Covered $30 PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 PCP - $30 Specialist - $50 Not Covered Not Covered 30 visits per year $30 PCP/$50 Specialist Copay for In-Network. Allergy Testing includes injections and scratch and prick tests. for In-Network. Includes desensitization treatments (injections & serums). 1 Exam every 2 years $30 PCP/$50 Specialist Copay for In-Network. Rehab and Habilitation Outpatient Facility Physical Rehabilitation $30 $90 Occupational Rehabilitation $30 $90 Speech Rehabilitation $30 $90 30 Visits Per Plan Year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 30 Visits per year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 30 Visits per year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 4 of /17/ :11:42

8 Outpatient Professional Services Physical Rehabilitation Occupational Rehabilitation Speech Rehabilitation $30 $30 $30 $90 $90 $90 30 Visits per year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 30 Visits per year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. 30 Visits per year $30 Copay for In-Network. Includes aggregate of visits for Domestic, INN and OON and professional and facility covered services for physical, speech, and occupational therapy. Preventive Services Preventive Professional Services Meeting Federal Guidelines* Adult Physical Examination Adult Immunizations Well Child Visits and Immunizations Routine GYN Visit Pre/Post-Natal Care Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional 1 Exam Per Plan Year for In-Network. for In-Network. for In-Network. for In-Network. for In-Network. for In-Network. for In-Network. for In-Network. Preventive Facility Services Meeting Federal Guidelines* Cervical Cytology Preventative Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility for In-Network. for In-Network for In-Network. for In-Network. 5 of /17/ :11:42

9 Preventive services in addition to those required under Federal Guidelines - Professional Prostate Cancer Screening Mammography Screening Professional Colonoscopy Screening Professional Bone Density Screening Professional for In-Network. for In-Network for In-Network. for In-Network. Not performed as part of office visit Preventive services in addition to those required under Federal Guidelines - Facility Mammography Screening Facility Colonoscopy Screening Facility Bone Density Screening Facility for In-Network for In-Network. for In-Network. Other Benefits Additional Benefits Treatment of Diabetes Insulin and Supplies Diabetic Equipment Durable Medical Equipment (DME) Medical Supplies Acupuncture Private Duty Nursing PCP -$30 Specialist -$50 PCP -$30 Specialist -$50 Not Available Not Available 50% Coinsurance Not Covered PCP - $90 Specialist - $110 PCP - $90 Specialist - $110 20% Coinsurance 20% Coinsurance 50% Coinsurance Not Covered 50% Coinsurance Not Covered $30 PCP/$50 Specialist Copay for In-Network. Limited to a 30 day supply for retail pharmacy or a 90 day supply for mail order pharmacy. $30 PCP/$50 Specialist Copay for In-Network. 10 Visits per year Limits combined Domestic, INN and OON. Not Covered Emergency Services ER Facility Facility Emergency Room Visit $195 $350 $350 $195 Copay for In-Network and Out-of- Network. Prior Authorization may not apply to any emergency care services. Emergency services are covered worldwide if provided by a hospital facility. 6 of /17/ :11:42

10 Transportation Prehospital Emergency and Transportation - Ground or Water Not Available $150 $150 Urgent Care Urgent Care Center Facility Visit $50 $125 Pediatric up to and including age 18: $50 Copay for In-Network Ancillary Benefits Vision Adult Eye Exams - Routine Adult Eyewear - Routine Covered Covered Pediatric Eye Exams - Routine Pediatric Eyewear - Routine Covered Covered 1 Exam Per 2 Plan Years Limits are combined INN and OON. One pair of corrective lenses after cataract surgery covered in full. $60 Allowance every 2 years Includes Frames/Lenses or Contact Lenses 1 Exam Per Plan Year Limits are combined INN and OON. for In-Network. One pair of corrective lenses after cataract surgery covered in full. $60 Allowance Per Plan Year Includes Frames/Lenses or Contact Lenses Rx Benefits Rx Plan Rx Plan $10/$30/$50 Domestic, $25/$50/$90 Non Domestic Rx Benefits Days Supply Per Retail Order Days Supply Per Mail Order Not Available 90 Copays Per Mail Order Supply Not Available 3 7 of /17/ :11:42

11 This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are combined limits for both in and out of network benefits. * For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are covered pursuant to the Patient Protection and Affordable Care Act requirements. 8 of /17/ :11:42

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19 Health plan terms To help you better understand our plans and your coverage, here are a few definitions* for frequently used health care terms. Primary Care Physician (PCP) A doctor who serves as your health care manager and coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP. Referral Instructions provided by a PCP for specialty care. Most plans do not require referrals. In-network coverage The coverage available when you receive services from a provider who participates in your health plan. Out-of-network coverage The coverage available when you receive services from a provider who does not participate in your health plan. Some plans may not include out-of-network coverage. Out-of-area Describes when you receive services while outside the geographic service area of your health plan. Your plan benefits may differ if you live or work beyond the geographic service area. Copay A dollar amount due at the time you receive certain services. A typical example would be an office visit copay due when visiting your physician s office for treatment. Allowed Amount The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full. Coinsurance A cost-sharing method that requires you pay a portion of the allowed amount for certain medical services. Deductible A set dollar amount you pay for covered services you receive before your insurer will make a payment. Out-of-pocket maximum The maximum amount of deductible and coinsurance payments that you will pay for health services each calendar year. * Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.

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