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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2023 - 12/31/2023
Highmark Blue Cross Blue Shield: Ranger Baseball LLC - Plan B Coverage for: Individual/Family Plan Type: HDHP

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, www.highmarkbcbs.com or call 1-800-701-
2324. 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 www.HealthCare.gov/sbc-glossary/ or call 1-800-701-2324 to request a copy.
Important Questions Answers Why This Matters:

What is the overall $4,500 individual/$9,000 family network. Generally, you must pay all of the costs from providers up to the deductible amount
deductible? $9,000 individual/$18,000 family out-of- before this plan begins to pay. If you have other family members on the plan, each
network. family member must meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the overall family
deductible.
Are there services covered Yes. Preventive care services are covered This plan covers some items and services even if you haven’t yet met the
before you meet your before you meet your network deductible. deductible amount. But a copayment or coinsurance may apply. For example, this
deductible? plan covers certain preventive services without cost-sharing and before you meet
Copayments and coinsurance amounts don't your deductible. See a list of covered preventive services at
count toward the network deductible. https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles No. You don’t have to meet deductibles for specific services.
for specific services?
What is the out-of-pocket $6,350 individual/$12,700 family network The out-of-pocket limit is the most you could pay in a year for covered services. If
limit for this plan? out-of-pocket limit, up to a total maximum you have other family members in this plan, they have to meet their own out-of-
out-of-pocket of $6,350 individual/$12,700 pocket limits until the overall family out-of-pocket limit has been met.
family.
$12,700 individual/$25,400 family out-of-
network.
What is not included in the Network: Premiums, balance-billed charges, Even though you pay these expenses, they don't count toward the out-of-pocket
out–of–pocket limit? and health care this plan doesn't cover do limit.
not apply to your total maximum out-of-
pocket.

Out-of-network: Copayments, premiums,
balance-billed charges, prescription drug
expenses, and health care this plan doesn't
cover.

An example of a benefit book can be found at https://shop.highmark.com/sales/#!/sbc-agreements. 1 of 10
16587-20, 21, 22, 90, 91, 92
GE_01658720_20230101_SBC