WIXLIB

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesBlue Cross and Blue Shield of North Carolina: Blue Advantage Bronze 8550Coverage Period: 01/01/2021 - 12/31/2021Coverage for: Individual Family Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe 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, visit www.bluecrossnc.com/booklets. Forgeneral definitions of common terms, such as allowed amount , balance billing, coinsurance , copayment , deductible , provider , or other underlined terms see theGlossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-888-206-4697 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible?In-Network: 8,550 Individual / 17,100 Family.Out-of-Network: 17,100Individual / 34,200 Family.Generally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the plan, each family member mustmeet their own individual deductible until the total amount of deductible expenses paid by allfamily members meets the overall family deductible .Are there services coveredbefore you meet yourdeductible?Yes. Preventive care .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/.Are there other deductiblesfor specific services?No.You don't have to meet deductibles for specific services.What is the out-ofpocket limit for this plan?In-Network: 8,550 Individual / 17,100 Family.Out-of-Network: 18,350Individual / 37,950 Family.The 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.What is not includedin the out-of-pocket limit?Premiums, balance-billingcharges, health care this plandoesn’t cover and penalties forfailure to obtain pre-authorizationfor services.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.B00070381 of 92020209U100025

Important QuestionsAnswersWhy This Matters:Will you pay less if you usea network provider?Yes. Seewww.bluecrossnc.com/FindADoctor or call 1-888-206-4697 for a listof network providers .This plan uses a provider network . You will pay less if you use a provider in the plan’s network .You will pay the most if you use an out-of-network provider , and you might receive a bill from aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). Be aware your network provider might use an out-of-network provider for some services(such as lab work). Check with your provider before you get services.Do you need a referral tosee a specialist ?No.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 EventIf you visit a healthcare provider's office orclinicServices You MayNeedLimitations, Exceptions, & OtherImportant InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Primary care visit to treat aninjury or illness0% after deductible30% after deductibleNoneSpecialist visit0% after deductible30% after deductibleNone.No Charge30% after deductibleYou may have to pay for services that aren’tpreventive . Ask your provider if the servicesneeded are preventive . Then check what yourplan will pay for. Limits may apply.0% after deductible30% after deductibleNone.0% after deductible30% after deductiblePrior authorization may be required or serviceswill not be covered.Preventivecare /screening /immunizationIf you have a testWhat You Will PayDiagnostic test (x-ray, bloodwork)Imaging (CT/PET scans,MRIs)*For more information about limitations and exceptions, see plan or policy document at www.bluecrossnc.com/booklets2 of 9

CommonMedical EventIf you need drugs to treatyour illness or conditionMore information aboutprescription drugcoverage is available atwww.bluecrossnc.com/rxinfoIf you have outpatientsurgeryIf you need immediatemedical attentionServices You MayNeedLimitations, Exceptions, & OtherImportant InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)Tier 1 Drugs0% after deductible0% after deductibleTier 2 Drugs0% after deductible0% after deductibleTier 3 Drugs0% after deductible0% after deductibleTier 4 Drugs0% after deductible0% after deductibleTier 5 Drugs0% after deductible0% after deductibleTier 6 Drugs0% after deductible0% after deductibleFacility fee (e.g., ambulatorysurgery center)0% after deductible30% after deductibleNone.Physician/surgeon fees0% after deductible30% after deductibleNone.Emergency room care0% after deductible0% after deductibleNone.0% after deductible0% after deductibleNone.0% after deductible0% after deductibleNone.Facility fee (e.g., hospitalroom)0% after deductible30% after deductiblePrior authorization may be required or serviceswill not be covered.Physician/surgeon fees0% after deductible30% after deductibleNone.0% after deductible30% after deductiblePrior authorization may be required or serviceswill not be covered.0% after deductible30% after deductiblePrior authorization may be required or serviceswill not be covered.Emergency medicaltransportationUrgent careIf you have a hospitalstayWhat You Will PayIf you need mentalOutpatient serviceshealth, behavioral health,or substance abuseInpatient servicesservicesPrior authorization may be required andcoverage limits may apply. *See PrescriptionDrug Section.*For more information about limitations and exceptions, see plan or policy document at www.bluecrossnc.com/booklets3 of 9

CommonMedical EventIf you are pregnantServices You MayNeedLimitations, Exceptions, & OtherImportant InformationNetwork Provider(You will pay the least)Out-of-Network Provider(You will pay the most)0% after deductible30% after deductible*See Family Planning section.0% after deductible30% after deductibleNone.0% after deductible30% after deductibleHome health care0% after deductible30% after deductibleRehabilitation services0% after deductible30% after deductibleOffice visitsChildbirth/deliveryprofessional servicesChildbirth/delivery facilityservicesIf you need helprecovering or have otherspecial health needsWhat You Will PayPrior authorization may be required or serviceswill not be covered.Prior authorization may be required or serviceswill not be covered.Combined 30 visits for physical / occupationaltherapy and chiropractic services. 30 visits forspeech therapy.Habilitation services0% after deductible30% after deductibleSkilled nursing care0% after deductible30% after deductibleDurable medical equipment0% after deductible30% after deductibleHospice services0% after deductible30% after deductibleNo Charge0% after deductible30% after deductible0% after deductibleCombined 30 visits for physical / occupationaltherapy and chiropractic services. 30 visits forspeech therapy.Coverage is limited to 60 days. Priorauthorization may be required or services willnot be covered .Prior authorization may be required or serviceswill not be covered . Limits may apply.Prior authorization may be required or servicesmay not be covered .Limited to one eye exam.Limited to one pair of glasses or contacts.No Charge30% after deductibleLimited to two dental cleanings.If your child needs dental Children's eye examor eye careChildren's glassesChildren's dental check-up*For more information about limitations and exceptions, see plan or policy document at www.bluecrossnc.com/booklets4 of 9

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 other excluded services .) Abortion (Except in cases of rape, incest, orwhen the life of the mother is endangered)Acupuncture Cosmetic surgeryDental care (Adult)Long-term care Routine eye care (Adult)Routine foot careWeight loss programsOther Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Bariatric surgeryChiropractic careHearing aids up to age 22 Infertility treatmentNon-emergency care when traveling outside the U.S. Private-duty nursingYour Rights to Continue Coverage:There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: North Carolina InsuranceConsumer Assistance Program at www.ncdoi.com/Smart or 1-855-408-1212 or contact Blue Cross NC at 1-888-206-4697 or BlueConnectNC.com. Other coverageoptions may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about theMarketplace , 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 is called a grievance or appeal . For more informationabout your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit aclaim, appeal , or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: N.C. Department of Insurance at1201 Mail Service Center, Raleigh, NC 27699-1201, or toll free 1-855-408-1212.Additionally, a consumer assistance program can help you file your appeal . Contact Health Insurance Smart NC, N.C. Department of Insurance, at 1201 Mail ServiceCenter, Raleigh, NC 27699-1201, 1-855-408-1212 (toll free).Does this plan provide Minimum Essential Coverage? Yes.Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit .*For more information about limitations and exceptions, see plan or policy document at www.bluecrossnc.com/booklets5 of 9

Does this plan meet the Minimum Value Standards? Not Applicable.If you 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 Marketplace .Language Access Services:To see examples of how this plan might cover costs for a sample medical situation, see the next section.*For more information about limitations and exceptions, see plan or policy document at www.bluecrossnc.com/booklets6 of 9