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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2021 - 12/31/2021Culpeper Medical Center (CPMC): Anthem HealthKeepers 750/ 1,500DeductibleCoverage for: Individual Family Plan Type: POSThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and theplan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) willbe provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete termsof coverage, https://eoc.anthem.com/eocdps/aso. 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 (833)592-9956 to request a copy.Important QuestionsWhat is the overalldeductible?Are there servicescovered before youmeet your deductible?Are there otherdeductibles forspecific services?What is the out-ofpocket limit for thisplan?What is not includedin the out-of-pocketAnswers 750/person or 1,500/familyfor Preferred NetworkProviders and In-NetworkProviders combined. 750/person or 1,500/familyfor Non-Network Providers.Yes. Primary Care SpecialistVisit Preventive Care andVision Exam for PreferredNetwork and In-NetworkProviders. Tier 1 Tier 2 Tier 3Tier 4 Prescription Drugs forIn-Network and Non-NetworkProviders.No.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amount beforethis plan begins to pay. If you have other family members on the plan, each family membermust meet their own individual deductible until the total amount of deductible expenses paidby all family members meets the overall family deductible. 5,000/person or 10,000/family for PreferredNetwork Providers and InNetwork Providers combined. 5,000/person or 10,000/family for NonNetwork Providers.Premiums, balance-billingcharges, and health care thisThe out-of-pocket limit is the most you could pay in a year for covered services. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.This plan covers some items and services even if you haven’t yet met the deductible amount.But a copayment or coinsurance may apply. For example, this plan covers certain preventiveservices without cost-sharing and before you meet your deductible. See a list of coveredpreventive services at e-benefits/.You don't have to meet deductibles for specific services.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.VA/LG/Culpeper Medical Center (CPMC) Anthem HealthKeepers 750/ 1,500 Deductible/3ZM8/01-201 of 12
limit?Will you pay less ifyou use a networkprovider?plan doesn't cover.Yes, HealthKeepers. Seewww.anthem.com or call (833)592-9956 for a list of networkproviders.Do you need a referralto see a specialist?No.You pay the least if you use a provider in Preferred Network. You pay more if you use aprovider in In-Network. You will pay the most if you use an Non-Network Provider, and youmight receive a bill from a provider for the difference between the provider’s charge and whatyour plan pays (balance billing). Be aware your network provider might use an Non-NetworkProvider for some services (such as lab work). Check with your provider before you getservices.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.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessIf you visit ahealth careprovider’s officeor clinicSpecialist visitPreventive care/ screening/immunizationIf you have a testDiagnostic test (x-ray, bloodwork)Imaging (CT/PET scans, MRIs)If you need drugsto treat yourillness orconditionTier 1 - Typically GenericWhat You Will oviderProvider(You will pay(You will pay the(You will pay themore)most)least) 15/visit 20/visitdeductible does not deductible does not 30% coinsuranceapplyapply 30/visit 35/visitdeductible does not deductible does not 30% coinsuranceapplyapplyNo chargeLab – OfficeNo chargeX-Ray – Office0% coinsurance10% coinsuranceNot ApplicableNo charge30% coinsuranceLimitations, Exceptions, &Other Important ou may have to pay for servicesthat aren't preventive. Ask yourprovider if the services neededare preventive. Then check whatyour plan will pay for.Lab – OfficeLab – OfficeNo charge30% coinsuranceCosts may vary by site of service.X-Ray – OfficeX-Ray – Office20% coinsurance30% coinsurance20% coinsurance30% coinsurance Costs may vary by site of service. 15/prescription,30% coinsurance,deductible does not deductible does notapply (retail) andapply (retail) and*See Prescription Drug section 38/prescription, Not covered (homedeductible does notdelivery)* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso.2 of 12
What You Will PayCommonMedical EventServices You May NeedMore informationabout prescriptiondrug coverage isavailable athttp://www.anthe Tier 2 - Typically Preferredm.com/pharmacyi Brand & Non-Preferrednformation/Generic DrugsPreferredNetworkProvider(You will pay theleast)Not ApplicableEssential Drug ListTier 3 - Typically Non-PreferredBrand and Generic drugsIf you haveoutpatientsurgeryIf you needimmediatemedical attentionNot ApplicableTier 4 - Typically PreferredSpecialty (brand and generic)Not ApplicableFacility fee (e.g., ambulatorysurgery center)10% coinsurancePhysician/surgeon feesEmergency room careEmergency medicaltransportationIn-NetworkProvider(You will paymore)apply (homedelivery) 40/prescription,deductible does notapply (retail) and 100/prescription,deductible does notapply (homedelivery) 75/prescription,deductible does notapply (retail) and 188/prescription,deductible does notapply (homedelivery)20% coinsuranceup to 200/prescription,deductible does notapply (retail andhome delivery)20% coinsurance 30/visit 35/visitdeductible does not deductible does notapplyapply 300/visit 300/visitdeductible does not deductible does notapplyapply 100/trip 100/tripdeductible does not deductible does notapplyapplyNon-NetworkProvider(You will pay themost)Limitations, Exceptions, &Other Important Information30% coinsurance,deductible does notapply (retail) andNot covered (homedelivery)30% coinsurance,deductible does notapply (retail) andNot covered (homedelivery)30% coinsurance,deductible does notapply (retail) andNot covered (homedelivery)30% coinsurance--------none--------30% coinsurance--------none--------Covered as InNetworkCopay waived if admitted.Covered as InNetwork--------none--------* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso.3 of 12
CommonMedical EventServices You May NeedUrgent careIf you have ahospital stayFacility fee (e.g., hospital room)Physician/surgeon feesIf you needOutpatient servicesmental health,behavioral health,or substanceabuse servicesInpatient servicesIf you arepregnantOffice visitsChildbirth/delivery professionalservicesChildbirth/delivery facilityservicesHome health careRehabilitation servicesIf you need helprecovering orhave other specialhealth needsHabilitation servicesWhat You Will oviderProvider(You will pay(You will pay the(You will pay themore)most)least) 15/visit 20/visitdeductible does not deductible does not 30% coinsuranceapplyapply 300/visit 600/visitdeductible does not deductible does notapplyapply30% coinsurance0% coinsurance20% coinsuranceOffice VisitOffice VisitNo chargeNo chargeOther OutpatientOther OutpatientNo chargeNo charge 300/visit 300/visitdeductible does not deductible does notapplyapply0% coinsurance20% coinsurance0% coinsurance20% coinsurance 300/visit 600/visitdeductible does not deductible does notapplyapply20% coinsurance20% coinsurance 30/visit 30/visitdeductible does not deductible does notapplyapply 30/visit 30/visitdeductible does not deductible does notapplyapplyLimitations, Exceptions, &Other Important Information--------none--------30% coinsuranceOffice Visit30% coinsuranceOther Outpatient30% coinsurance150 days/admission for Inpatientrehabilitation and skilled nursingservices combined for InNetwork Providers and NonNetwork Providers.--------none-------Office Visit--------none-------Other Outpatient--------none--------30% coinsurance--------none--------30% coinsurance30% coinsurance30% coinsurance30% coinsuranceMaternity care may include testsand services described elsewherein the SBC (i.e. ultrasound).100 visits/benefit period for InNetwork Providers and NonNetwork Providers.30% coinsurance*See Therapy Services section.30% coinsurance150 days/admission for InpatientSkilled nursing care20% coinsurance20% coinsurance30% coinsurance rehabilitation and skilled nursingservices combined for In* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso.4 of 12
What You Will PayCommonMedical EventIf your childneeds dental oreye carePreferredNetworkProvider(You will pay theleast)Services You May NeedIn-NetworkProvider(You will paymore)Non-NetworkProvider(You will pay themost)Durable medical equipment20% coinsurance20% coinsurance30% coinsuranceHospice services20% coinsurance20% coinsuranceNot ApplicableNo chargeNot coveredNot coveredNot coveredNot covered30% coinsuranceReimbursed Up to 30Not coveredNot coveredChildren’s eye examChildren’s glassesChildren’s dental check-upLimitations, Exceptions, &Other Important InformationNetwork Providers and NonNetwork Providers.*See Durable MedicalEquipment Section--------none-------*See Vision Services section--------none--------Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any otherexcluded services.) Acupuncture Bariatric Surgery Cosmetic surgery Dental care (Adult) Dental care (Pediatric) Dental Check-up Glasses for a child Hearing aids Infertility treatment Long-term care Routine foot care unless medically Weight loss programsnecessaryOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care 30 visits/benefit period Routine eye care (Adult) 1 exam/benefitperiod. Most coverage provided outside theUnited States. Seewww.bcbsglobalcore.com Private-duty nursing* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso.5 of 12
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform, or contact Anthemat the number on the back of your ID card. Other coverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint iscalled a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plandocuments also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,this notice, or assistance, contact:ATTN: Grievances and Appeals, P.O. Box 27401, Richmond, VA 23279Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreformDoes this plan provide Minimum Essential Coverage? YesIf you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemptionfrom the requirement that you have health coverage for that month.Does this plan meet the Minimum Value Standards? YesIf your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the �–––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next ––––––––* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso.6 of 12
About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs willbe different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the costsharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to comparethe portion of costs you might pay under different health plans. Please note these coverage examples are based on self-onlycoverage.Peg is Having a Baby(9 months of in-network pre-natal care and ahospital delivery) The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other coinsurance 750 30 3000%This EXAMPLE event includes serviceslike:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)Total Example CostManaging Joe’s type 2 Diabetes(a year of routine in-network care of a wellcontrolled condition) The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other coinsuranceThis EXAMPLE event includes serviceslike:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter) 12,800In this example, Peg would pay:Total Example CostWhat isn’t coveredLimits or exclusionsThe total Peg would pay is 7,400 The plan’s overall deductible Specialist copayment Hospital (facility) copayment Other coinsuranceThis EXAMPLE event includes serviceslike:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example CostDeductiblesCopaymentsCoinsurance 60 760What isn’t coveredLimits or exclusionsThe total Joe would pay is 1,900Cost SharingCost Sharing 0 400 300 750 30 3000%In this example, Mia would pay:In this example, Joe would pay:Cost SharingDeductiblesCopaymentsCoinsurance 750 30 3000%Mia’s Simple Fracture(in-network emergency room visit and followup care) 0 2,500 0DeductiblesCopaymentsCoinsurance 60 500 100 60 2,560What isn’t coveredLimits or exclusionsThe total Mia would pay is 0 660The plan would be responsible for the other costs of these EXAMPLE covered services.7 of 12
Language Access Services:(TTY/TDD: 711)Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar menjë përkthyes, telefononi (833) 592-9956Amharic (አማርኛ): ስለዚህ ሰነድ ማንኛውም ጥያቄ ካለዎት በራስዎ ቋንቋ እርዳታ እና ይህን መረጃ በነጻ የማግኘት መብት አለዎት። አስተርጓሚ ለማናገር (833) 5929956 ይደውሉ።. (833) 592-9956Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն ևտեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ (833) 592-9956:(833) 592-9956.(833) 592-9956(833) 592-9956Chinese �訊。如需與譯員通話，請致電(833) 592-9956。(833) 592-9956.Dutch (Nederlands): Bij vragen over dit document hebt u recht op hulp en informatie in uw taal zonder bijkomende kosten. Als u een tolk wilt spreken,belt u (833) 592-9956.(833) 592-99568 of 12
Language Access Services:French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces informations et à une aide dans votrelangue. Pour parler à un interprète, appelez le (833) 592-9956.German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um miteinem Dolmetscher zu sprechen, bitte wählen Sie (833) 592-9956.Greek (Ελληνικά) Αν έχετε τυχόν απορίες σχετικά με το παρόν έγγραφο, έχετε το δικαίωμα να λάβετε βοήθεια και πληροφορίες στη γλώσσα σας δωρεάν. Για ναμιλήσετε με κάποιον διερμηνέα, τηλεφωνήστε στο (833) 592-9956.Gujarati (ગગગગગગગ): ગગ ગ ગગગગગગગગ ગગગગ ગગગગ ગગગગગ ગગગગગગગ ગગગ ગગ, ગગગગગ ગગગગ ગગગ ગગગગ ગગગગગગગ ગગગ ગગગ ગગગગગગગગગગગગગગ ગગગગ ગગગગગગ ગગ. ગગગગગગગગ ગગગગ ગગગ ગગગગ ગગગગ, ગગગ ગગગ (833) 592-9956.Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yonentèprèt, rele (833) 592-9956.(833) 592-9956Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yamtsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau (833) 592-9956.Igbo (Igbo): Ọ bụr ụ na ị nwere ajụjụ ọ bụla gbasara akwụkwọ a, ị nwere ikike ịnweta enyemaka na ozi n'asụsụ gị na akwụghị ụgwọ ọ bụla. Ka gị na ọkọwaokwu kwuo okwu, kpọọ (833) 592-9956.Ilokano (Ilokano): Nu addaan ka iti aniaman a saludsod panggep iti daytoy a dokumento, adda karbengam a makaala ti tulong ken impormasyon babaen tilenguahem nga awan ti bayad na. Tapno makatungtong ti maysa nga tagipatarus, awagan ti (833) 592-9956.Indonesian (Bahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasidalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi (833) 592-9956.Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costoaggiuntivo. Per parlare con un interprete, chiami il numero (833) 592-9956(833) 592-99569 of 12
Language Access Services:(833) 592-9956Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugisheumusemuzi, akura (833) 592-9956.Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가있습니다. 통역사와 이야기하려면(833) 592-9956 로 문의하십시오.(833) 592-9956.(833) 592-9956.(833) 592-9956Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuufmirgaa qabdaa. Turjumaana dubaachuuf, (833) 592-9956 bilbilla.Pennsylvania Dutch (Deitsch): Wann du Frooge iwwer selle Document hoscht, du hoscht die Recht um Helfe un Information zu griege in dei Schproochmitaus Koscht. Um mit en Iwwersetze zu schwetze, ruff (833) 592-9956 aa.Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji wswoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer (833) 592-9956.Portuguese (Português): Se tiver quaisquer dúvidas acerca deste documento, tem o direito de solicitar ajuda e informações no seu idioma, sem qualquercusto. Para falar com um intérprete, ligue para (833) 592-9956.(833) 592-995610 of 12
Language Access Services:(833) 592-9956.(833) 592-9956.Samoan (Samoa): Afai e iai ni ou fesili e uiga i lenei tusi, e iai lou ‘aia e maua se fesoasoani ma faamatalaga i lou lava gagana e aunoa ma se totogi. Ina iatalanoa i se tagata faaliliu, vili (833) 592-9956.Serbian (Srpski): Ukoliko imate bilo kakvih pitanja u vezi sa ovim dokumentom, imate pravo da dobijete pomoć i informacije na vašem jeziku bez ikakvihtroškova. Za razgovor sa prevodiocem, pozovite (833) 592-9956.Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con unintérprete, llame al (833) 592-9956.Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon saiyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (833) 592-9956.ิ ธิทThai (ไทย): � เกีย่ � ท่านมีสท์ จี่ ะได ้รับความชว่ ยเหลือและข �นโดยไม่มคี า่ ใชจ่้ าย โดยโทร(833) 592-9956 เพือ่ พูดคุยกับล่าม(833) 592-9956.(833) 592-9956Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàntoàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi (833) 592-9956. (833) 592-9956(833) 592-9956.11 of 12
Language Access Services:It’s important we treat you fairlyThat’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on thebasis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’tEnglish, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Servicesnumber on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age,disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to ComplianceCoordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health andHuman Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-3681019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html12 of 12
Urgent care 15/visit deductible does not apply 20/visit deductible does not apply 30% coinsurance -----none----- If you have a hospital stay Facility fee (e.g., hospital room) 300/visit deductible does not apply 600/visit deductible does not apply 30% coinsurance 150 days/admission for Inpatient rehabilitation and skilled nursing
