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PPOPlan BenefitsVoluntary Employee BenefitAssociation TrustEffective January 1, 2021Visit our website atAlabamaBlue.comAn Independent Licensee of the Blue Cross and Blue Shield Association
East Alabama Medical CenterVoluntary Employee Benefit Association TrustEffective January 1, 2021BENEFITTier 1: DPN, EAMCHospital, UAB andChildren’s HospitalTier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-Network(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Benefit payments are based on the amount of the provider’s charge that Blue Cross and Blue Shield of Alabama recognizes forpayment of benefits. The allowed amount may vary depending upon the type provider and where services are rendered.Some services require a copay, coinsurance, calendar year deductible or deductible for each admission, visit or service.Calendar YearDeductiblen/aPharmacy DeductibleCalendar Year Out-ofPocket MaximumThe in-network and PPOCalendar Year Out-ofPocket cross apply.SUMMARY OF COST SHARING PROVISIONS(Includes Mental Health Disorders and Substance Abuse) 1,000 individual; 3,000 family 2,000 individual; 4,000 familyThere is nodeductible forout-of-networkservices. 150 per person; 300 perfamilyn/an/an/a 2,000 individual; 4,000family 4,000 individual; 8,000 family 6,000 individual; 12,000 familyAll deductibles, copays andcoinsurance apply to the Tier 1out-of-pocket maximumincluding out-of-networkemergency services for mentalhealth disorders and substanceabuse and prescription drugs.All deductibles, copays andcoinsurance apply to theTier 2 out-of-pocketmaximum including out-ofnetwork emergencyservices for mental healthdisorders and substanceabuse and prescriptiondrugs.There is no outof-pocketmaximum for outof-networkservices.After you reach your individualCalendar Year Out-of-PocketMaximum, applicable expensescovered at 100% for remainderof calendar yearAfter you reach yourindividual Calendar YearOut-of-Pocket Maximum,applicable expensescovered at 100% forremainder of calendar yearCalendar Year Out-of-Pocket MaximumAll deductibles, copaysand coinsurance apply tothe Tier 3 out-of-pocketmaximum including outof-network emergencyservices for mental healthdisorders and substanceabuse and prescriptiondrugs.After you reach yourindividual Calendar YearOut-of-Pocket Maximum,applicable expensescovered at 100% forremainder of calendaryearThe in-network and PPO Calendar Year Out-of-Pocket cross apply.INPATIENT HOSPITAL AND PHYSICIAN BENEFITS(Includes Mental Health Disorders and Substance Abuse)Inpatient Hospital(Including Maternity)and ResidentialTreatment Facilities100% of the allowedamount subject to a 300deductible per admission;no daily copayNote on Maternityadmissions: BabyYourself participant from1st trimester on- 300EAMC facility deductibleper admission; Non BYparticipant- 600 EAMCfacility deductible peradmission. Neonatal carecoverage allowable toAlabama providers.100% of the allowedamount, subject to a 500 copay per dayfor days 1-4 andsubject to calendaryear deductible70% for the allowedamount, subject tocalendar yeardeductibleNot covered
BenefitTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Tier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-NetworkInpatient PhysicianVisits andConsultations100% of the allowedamount; no copay ordeductible70% of the allowedamount, subject tocalendar yeardeductible50% for the allowedamount, subject tocalendar yeardeductibleNot coveredGastric BypassSurgery80% of the allowedamount, subject to a 1,000 deductible peradmissionNot coveredNot coveredNot coveredNot required at EAMC andEAMC DesignatedProviders. Required for allBlue Cross and Blue Shieldof Alabama ParticipatingFacilities in Alabama.Member is responsible forobtaining; if not obtained, a 500 penalty will beapplied. Call 1-800-2482342 for precertification.Required for alladmissions exceptmaternity andemergency hospitaladmissions. Memberis responsible forobtaining; if notobtained, a 500penalty will beapplied. Call 1-800248-2342 forprecertification.Required for alladmissions exceptmaternity andemergency hospitaladmissions. Memberis responsible forobtaining; if notobtained, a 500penalty will beapplied. Call 1-800248-2342 forprecertification.Not applicableNote: Coverage is limitedto the physicians andservices provided atPrinceton Baptist MedicalCenter and GrandviewMedical Center.Physician services forBariatric proceduresreceive Tier 1 level ofbenefits for each type ofservicePlease contact Blue Crossand Blue Shield customerservice for ificationIn Alabama, benefits for Non-Participating hospitals are available only in cases of accidental injury.OUTPATIENT HOSPITAL BENEFITS(Includes Mental Health Disorders and Substance Abuse)Precertification is required for some outpatient hospital benefits. Precertification is required for some provider-administered drugs;please see your benefit booklet.If precertification is not obtained, no benefits are available.Outpatient SurgeryFacility (IncludingAmbulatory SurgicalCenters)100% of the allowedamount subject to a 150annual copay100% of the allowedamount, subject to 300 facility copay70% of the allowedamount, subject tothe calendar yeardeductibleNot coveredEmergency Room(Medical Emergency)100% of allowed amountsubject to 100 facilitycopay100% of allowedamount subject to 100 facility copay100% of the allowedamount subject to a 100 facility copayEmergency Room(Accident)100% of allowed amountsubject to 100 facilitycopay100% of allowedamount subject to 100 facility copay100% of allowedamount subject to 100 facility copay100% of theallowed amountsubject to a 100facility copay100% of allowedamount subject to 100 facility copayEmergency Room(Non-Emergency)100% of allowed amountsubject to 500 facilitycopay70% of the allowedamount, subject tothe calendar yeardeductible50% of the allowedamount, subject tothe calendar yeardeductiblePain Center CoverageEAMC only.Not covered
BENEFITTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Tier 2: In-State/InNetwork BCBS ALPCP’s andFacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-NetworkFacility Charges forOutpatient DiagnosticLab, Pathology and Xray100% of the allowedamount subject to a 150annual copay100% of allowedamount subject to a 150 facility copay70% of the allowedamount, subject tothe calendar yeardeductibleNot coveredFacility Charges forOutpatientHemodialysis, IVTherapy,Chemotherapy andRadiation TherapyFacility Charges forInjections/Medications100% of the allowedamount subject to a 150annual copay100% of allowedamount subject to a 150 facility copay70% of the allowedamount, subject tothe calendar yeardeductibleNot covered100% of the allowedamount; no copay ordeductible70% of the allowedamount, subject tothe calendar yeardeductible50% of the allowedamount, subject tothe calendar yeardeductibleNot coveredIntensive OutpatientProgram (IOP) andPartial HospitalizationProgram (PHP)100% of the allowedamount after 40 dailyhospital copay100% of the allowedamount after 60daily hospital copay100% of the allowedamount after 100daily hospital copayNot covered(not related to ER visit,outpatient Xray/Lab/Pathology or IVChemo/Radiation Therapy)Precertification is requiredNote: In Alabama, benefits for non-participating hospitals available only in case of accidental injuryPHYSICIAN BENEFITS(Includes Mental Health Disorders and Substance Abuse)Precertification is required for some physician benefits. Precertification is required for some provider-administered drugs; pleasesee your benefit booklet.If precertification is not obtained, no benefits are available.Office Visits and InPerson ConsultationsCoverage for Tier 1 atEAMC DesignatedProvider Network onlySecond SurgicalOpinionsSurgery andAnesthesiaEmergency RoomPhysician100% of the allowedamount, subject to a 30copay for primary carephysicians; 40 forspecialists100% of the allowedamount, no deductible orcopay100% of the allowedamount, no deductible orcopay100% of the allowedamount, subject to a 40copay100% of the allowedamount, subject to a 40 copay for primarycare physicians; 60for specialists100% of the allowedamount, subject to a 60 copay70% of allowedamount, subject tocalendar yeardeductible100% of the allowedamount, subject to a 40 copay100% of the allowedamount, subject to a 60 copay for primarycare physicians; 100for specialists100% of the allowedamount, subject to a 100 copay50% of allowedamount, subject tocalendar yeardeductible.100% of the allowedamount, subject to a 40 copayNot coveredNot coveredNot covered100% of theallowed amount,subject to a 40copay
BENEFITTier 1: DPN, EAMCHospital, UAB andChildren’s HospitalTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-Network70% of the allowedamount, subject tothe calendar yeardeductible.70% of the allowedamount, subject tothe calendar yeardeductible50% of the allowedamount, subject tothe calendar yeardeductible50% of the allowedamount, subject tothe calendar yeardeductibleNot covered100% of the allowedamount, subject to a 150annual copay;Not coveredNot coveredNot coveredChemotherapy,Radiation and IVTherapy100% of the allowedamount, no deductible orcopay.100% of the allowedamount, no deductible orcopay.100% of the allowedamount, no deductible orcopay50% of the allowedamount, subject tothe calendar yeardeductibleNot coveredNot coveredAllergy Testing &Treatment70% of the allowedamount, subject tothe calendar yeardeductible.Not coveredNot coveredNot coveredNot covered(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Maternity Care(Prenatal, Delivery andPostnatal Care)100% of the allowedamount, no deductible orcopayDiagnostic X-rays andLab Exams (In thephysician’s office)100% of the allowedamount, no deductible orcopay.Coverage for Tier 1 atEAMC DesignatedProvider Network onlyMRI’s, CT Scans andEchocardiograms (Inthe Physician’s office)Tier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesNot coveredCoverage for Tier 1 atEAMC DesignatedProvider Network onlyTemporomandibularJoint Disorders(Phase I only)Not coveredPREVENTIVE BENEFITSRoutineImmunizations andPreventive Services e.com/SourceRxACAPreventiveDrugListfor a listing of thespecific drugs,immunizations andpreventive services orcall our CustomerService Department for aprinted copy Certain immunizationsmay also be obtainedthrough the PharmacyVaccine Network. SeeAlabamaBlue.com/VaccineNetworkDrugListfor more information100% of the allowedamount; no deductible orcopay100% of the allowedamount; nodeductible or copay100% of the allowedamount; no deductibleor copayNot covered
BenefitTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Additional RoutinePreventive ServicesNote: All colonoscopies(including the Cologuardstool test) will be paid at100% of the allowedamount, not subject todeductible, regardless ofdiagnosis for tiers 1, 2 and3Note: DEXA scans arelimited to once every 2years and a day and copayis waived when performedat EAMC.100% of the allowedamount; no deductible orcopay Urinalysis (whennecessary) CBC (whennecessary) TB skin testing (whennecessary) CA 125 (one percalendar year) Metabolic profile Thyroid profile Renal profile Liver profile Lipid profile Iron profile A1C Phosphorus Bilirubin TSH Thyroid screen Urine drug screen Hepatitis B panel Hepatitis panel acute Vitamin D B12 Glucose Screening Transferrin Test Colonoscopies(including Cologuardstool test) DEXA ScanTier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-Network100% of the allowedamount; no deductible orcopay Urinalysis (whennecessary) CBC (whennecessary) TB skin testing(when necessary) CA 125 (one percalendar year) Metabolic profile Thyroid profile Renal profile Liver profile Lipid profile Iron profile A1C Phosphorus Bilirubin TSH Thyroid screen Urine drug screen Hepatitis B panel Hepatitis panelacute Vitamin D B12 Glucose Screening Transferrin Test Colonoscopies(includingCologuard stooltest)100% of the allowedamount; no deductibleor copay Urinalysis (whennecessary) CBC (whennecessary) TB skin testing(when necessary) CA 125 (one percalendar year) Metabolic profile Thyroid profile Renal profile Liver profile Lipid profile Iron profile A1C Phosphorus Bilirubin TSH Thyroid screen Urine drugscreen Hepatitis B panel Hepatitis panelacute Vitamin D B12 GlucoseScreening Transferrin Test Colonoscopies(includingCologuard stooltestNot coveredNote: In some cases, office visit copays or facility copays may apply.
BENEFITTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 if theservice can’t be provided atEAMC.)Prescription DrugCard Prescription drugs (otherthan Specialty Drugs) 90 day supply may bepurchased but copayapplies for each 30 daysupply 30 day initial fill for allprescription medications Tiers 5 & 6 (Specialty)drugs - up to a 30 daysupply. Must bepurchased at EastAlabama Apothecary,EAMC ApothecarySpecialty Pharmacy orEAMC Cancer Center Generic drugsmandatory whenavailable The pharmacy networkfor the plan is EastAlabama Apothecary View SourceRx 1.0 andmaintenance drug lists atAlabamaBlue.com/SourceRx1DrugList6TChiropractic ServicesTier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesPRESCRIPTION DRUG BENEFITS(Includes Mental Health Disorders and Substance Abuse)Separate Pharmacy Deductible: 150 per person; 300 per familyOut-of-NetworkNot coveredAll Prescriptions Purchased at East Alabama Apothecary:Covered at 100% subject to drug deductible and the following copays:Tier 1: 4 (preferred generics)Tier 2: 15 (non-preferred generics)Tier 3: 45 (preferred brands)Tier 4: 45 (non-preferred brands)Tier 5: 100 (preferred specialty)Tier 6: 100 (non-preferred specialty)Not covered for Maintenance Drugs Purchased at a Blue Cross and BlueShield Participating Pharmacy:All maintenance drugs MUST be purchased at East Alabama Apothecary.(mail order options available)Tier 1 (Generic) Drugs: No benefits available. Maintenance drugs MUST bepurchased at East Alabama ApothecaryTier 2, 3 & 4 (Brand Name) Drugs: No benefit available. Maintenance drugsMUST be purchased at East Alabama Apothecary.Non- Maintenance Drug Prescriptions Purchased at a Blue Cross and BlueShield Participating Pharmacy:Prescription drugs are subject to the tier 3 deductible ( 2,000 individual/ 4,000family):Tier 1: 80% of the allowed amountTier 2: 60% of the allowed amountTier 3: 60% of the allowed amountTier 4: 60% of the allowed amountTier 5: 60% of the allowed amountTier 6: 60% of the allowed amountBENEFITS FOR OTHER COVERED SERVICES(Includes Mental Health Disorders and Substance Abuse)50% of the allowedamount; no deductible50% of the allowedamount; no deductibleNot coveredNot coveredOccupational Therapy90% of the allowedamount; no deductible70% of the allowedamount, subject to thecalendar yeardeductible50% of the allowedamount, subject to thecalendar yeardeductibleNot coveredPhysical Therapy90% of the allowedamount; no deductible70% of the allowedamount, subject to thecalendar yeardeductible50% of the allowedamount, subject to thecalendar yeardeductibleNot coveredSpeech Therapy90% of the allowedamount; no deductible70% of the allowedamount, subject to thecalendar yeardeductible50% of the allowedamount, subject to thecalendar yeardeductibleNot coveredLimited to a maximum of12 visits per member percalendar year
BENEFITDurable MedicalEquipment, (DME),Prosthetic Devices andSuppliesTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 ifthe service can’t be providedat EAMC.)HomeMed-EAMC DME(including TheOrthopedic Clinic): 90%of the allowed amount, nodeductibleTier 2: In-State/InNetwork BCBS ALPCP’s and FacilitiesTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-Network70% of the allowedamount, subject to thecalendar yeardeductible50% of the allowedamount, subject to thecalendar yeardeductibleNot covered100% of the allowedamount for physician’ssurgical services and100% of the allowedamount for inpatienthospital services subjectto inpatient deductible andcopayments70% of the allowedamount, subject to thecalendar yeardeductible, forphysician’s surgicalservices and inpatienthospital services50% of the allowedamount, subject to thecalendar yeardeductible, forphysician’s surgicalservices and inpatienthospital servicesNot covered90% of the allowedamount, no deductible70% of the allowedamount, subject to thecalendar yeardeductibleNot covered80% of the allowedamount, no deductible70% of the allowedamount, subject to thecalendar yeardeductible50% of the allowedamount, subject to thecalendar yeardeductibleAssisted ReproductiveTechnology, InfertilityTesting & Treatment100% of the allowedamount; no deductible100% of the allowedamount; no deductibleART and InfertilityTreatment are limited to 15,000 in a lifetime fortreatment-you must beemployed one yearbefore benefits areavailable.Members will receive Tier 1coverage at a Blue CrossBlue Shield PPO networkproviderPrecision Medical - thoseitems not carried byHomeMed-EAMC DMEThe Boutique at SpencerCancer Center is the onlyauthorized fitter andprovider for mastectomyprosthesis and othersupplies for breast cancerpatientsTransplants (Heart,liver, lungs, pancreas,kidney, bone marrow,heart-valve, skin,cornea and smallbowel)Pre-benefit counselingrequiredCardiac and PulmonaryRehabilitationPre-benefit counselingrequiredPrivate Duty NursingLimited to a 10,000lifetime maximumPre-benefit counselingrequiredPre-benefit counselingrequiredMedtronic aka Minimed is aTier 1 provider for insulinpumps50% of the allowedamount, subject to thecalendar yeardeductibleNot covered100% of the allowedamount; no deductibleNot covered
BENEFITSkilled Nursing FacilityCovered at EastAlabama Medical CenteronlyLong Term Care RehabOnly covered at EAMC –LanierPre-benefit counselingrequiredRoutine Hearing ExamHearing AidsLimited to 3,000 perear; 6,000 per lifetimePre-benefit counselingrequiredTier 1: DPN, EAMCHospital, UAB andChildren’s Hospital(Services rendered atUAB/Children’s Hospitals canonly be considered Tier 1 ifthe service can’t be providedat EAMC.)LHC and Compassusexclusive providersMedical NutritionTherapy ServicesFor adults and children,limited to 6 hours permember per calendar yearTier 3: All Out ofState/In-NetworkBCBS Providers andFacilitiesOut-of-Network80% of the allowedamount subject to a 300deductible per admission;limited to 120 days perperson each calendaryearNot coveredNot coveredNot covered100% of the allowedamount; no deductible orcopay when provided byan Audiologist. Includescoverage for routinehearing tests fornewborns.East Alabama ENT(Exclusive Provider):100% of the billedamount; no deductible orcopay70% of the allowedamount, no deductibleor copay when providedby an Audiologist.Includes coverage forroutine hearing tests fornewbornsNot coveredNot coveredNot coveredNot coveredNot coveredAmbulanceHome Health andHospice CareTier 2: In-State/InNetwork BCBS ALPCP’s and Facilities100% of the allowed amount; no deductible100% of the allowedamount; no deductible;through ParticipatingProvidersNon-participating providers inAlabama are not covered100% of the allowedamount, subject to a 30copayNot coveredNot coveredNot covered100% of the allowedamount, subject to a 30 copay100% of the allowedamount, subject to a 30 copayNot coveredHEALTH MANAGEMENT BENEFITS(Includes Mental Health Disorders and Substance Abuse)Individual CaseManagementChronic ConditionManagementCoordinates care in event of catastrophic or lengthy illness or injury.Baby Yourself A maternity program; For more information, please call 1-800-222-4379. You can also enroll agementCovers prescription contraceptives, which include: birth control pills, injectables, diaphragms, IUDsand other non-experimental FDA approved contraceptives; subject to applicable deductibles, copaysand coinsurance. IUDs limited to one every three years.Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease,congestive heart failure and chronic obstructive pulmonary disease and other specialized conditions.This is not a contract. Benefits are subject to the terms, limitations and conditions of the group contract.In Alabama, in-network services provided by mental health disorders and substance abuse professionals areavailable through the Blue Choice Behavioral Health Network. Sometimes an in-network provider may furnish aservice to you that is not covered under the contract between the provider and a Blue Cross and/or Blue ShieldPlan. When this happens, benefits may be denied or reduced. Please refer to your benefit booklet for the type ofprovider network that we determine to be an in-network provider for a particular service or supply.Groups 71967-7197009/16/2020 GMD
Notice of NondiscriminationBlue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association, complies with applicable Federalcivil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat themdifferently because of race, color, national origin, age, disability, or sex.Blue Cross and Blue Shield of Alabama: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpretersand written information in other formats (large print, audio, accessible electronic formats, other formats)Provides free language services to people whose primary language is not English, such as qualified interpreters and informationwritten in other languagesIf you need these services, contact our 1557 Compliance Coordinator. If you believe that we have failed to provide these services or discriminatedin another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax, or email at:Blue Cross and Blue Shield of Alabama, Compliance Office, 450 Riverchase Parkway East, Birmingham, Alabama 35244, Attn: 1557 ComplianceCoordinator, 1-855-216-3144, 711 (TTY), 1-205-220-2984 (fax), 1557Grievance@bcbsal.org (email). If you need help filing a grievance, our 1557Compliance 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 throughthe 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 ofHealth and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C.20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available reign Language AssistanceSpanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-216-3144 (TTY: 711)Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-216-3144 (TTY: 711)번으로 전화해 주십시오.Chinese: 3144（TTY: 711）。Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-216-3144 (TTY: 711).Arabic: ﻞﺼﺗا ـﺑ . ﺔﻔﻠﻜﺗ ﺔﺣﺎﺘﻣ ﻚﻟ ، ﺔﻐﻠﻟﺎﺑ نوﺪﺑ ، ﺔﯿﺑﺮﻌﻟا ﺪﺟﻮﺗ تﺎﻣﺪﺧ ةﺪﻋﺎﺴﻣ ﺎﻤﯿﻓ ﻖﻠﻌﺘﯾ ، اذإ ﺖﻨﻛ ثﺪﺤﺘﺗ : هﺎﺒﺘﻧا . (711 : )ﻒﺗﺎﮭﻟا ﻲﺼﻨﻟا 1-855-216-3144German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche leistungen zur Verfügung. Rufnummer: 1-855-216-3144(TTY: 711).French: ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposes gratuitement. Appelez le 1-855-216-3144 (ATS: 711).French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-216-3144 (TTY: 711).Gujarati: ધ્યાન આપો: જો તમ ે ગજરય ાતી બોલતયા હો ્, તો ભય ાષયા સહયાત્ યા સ ેવય ા, તમય ારયા મય ાટ ે નન ઃશલ ્ક ઉપલ ્ધ છ ે . 1-855-216-3144 પર ્કૉલ ્કર ો(TTY: 711).Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa1-855-216-3144 (TTY: 711).Hindi: ध्यान द े ं : अगर आपक भयाषया हि द ी ि ै , त ो आपक े लए भयाषया सि या्तया स ेवयाए ँ ननःश ुलक उपि ब ्ध ि ै ं।1-855-216-3144 (TTY: 711) पर कॉि कर े ं ।Laotian: ໂປດຊາບ: ຖ້ າວ່ າທ່ ານເວໍ ິລການຊ່ ວຍເຫ້ ານພາສາ, ໂດຍບໍ່ ເສ່ າ, ແມ່ ນມ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-855-216-3144 (TTY: 711).ື ຼ ອດີ ພົ ້ າພາສາ ລາວ, ການບັ ຽຄRussian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-216-3144(телетайп: 711).Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-216-3144 (TTY: 711).Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-216-3144 (TTY: 711).Turkish: DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz. 1-855-216-3144 (TTY: 711) irtibatnumaralarını arayın.Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-2163144 (TTY: 711).Japanese: ��1-855-216-3144（TTY: �。
(Includes Mental Health Disorders and Substance Abuse) Calendar Year Deductible n/a 1,000 individual; 3,000 family 2,000 individual; 4,000 family There is no deductible for out-of-network services. Pharmacy Deductible 150 per person; 300 per family n/a n/a n/a Calendar Year Out-of-Pocket Maximum The in-network and PPO
