Page 12 - PWH.19 Employee Benefits

Summary of Benefits and Coverage: What this Plan Covers & What You P
Anthem Blue Cross and Blue Shield
Lumenos Health Savings Account Option E55 Rx9

The Summary of Benefits and Coverage (SBC) document will
plan would share the cost for covered health care services. NO
be provided separately. This is only a summary. For more infor
of coverage, https://eoc.anthem.com/eocdps/fi. For general definitions of co
copayment, deductible, provider, or other underlined terms see the Glossary. Y
333-5735 to request a copy.

Important Questions Answers Why This Matt

What is the overall $5,000/single or $10,000/family Generally, you m
deductible? for In-Network Providers. this plan begins
$10,000/single or must meet their
$20,000/family for Non- by all family mem
Network Providers.

Are there services Yes. Preventive care for In- This plan covers
covered before you Network Providers. But a copaymen
meet your deductible? services without
No. preventive servic
Are there other You don't have t
deductibles for $6,050/single or $12,100/family
specific services? for In-Network Providers. The out-of-pock
What is the out-of- $12,100/single or other family mem
pocket limit for this $24,200/family for Non- overall family ou
plan? Network Providers.
Non-Network Transplant Even though you
What is not included Services, Premiums, balance-
in the out-of-pocket billing charges, and health care This plan uses a
limit? this plan doesn't cover. network. You wi
Yes, Blue Access. See a bill from a pro
Will you pay less if www.anthem.com or call (855) pays (balance bil
you use a network 333-5735 for a list of network for some service
provider? providers.

Do you need a referral No. You can see the

OH/S/F/V06 LUM HSA Option E55 Rx9