Summary of Benefits andCoverage: What this PlanCovers & What You Pay for CoveredServices Excellus BCBS: Excellus Blue PPO
A nonprofit independent licensee of the BlueCross Blue Shield Association

GAHP – Under65 PPO B with Rx coverage Coverage Period:01/01/2025- 06/30/2025 Coverage for: Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help youchoose a health plan. The SBC shows you howyou 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 geta copy of the complete terms of coverage, call 1-800-499-1275 or visit our website at
www.excellusbcbs.com. Forgeneral definitions of common terms, such asallowed amount, balance billing,coinsurance, copayment,deductible, provider, or other underlined terms, see the Glossary.You can view the Glossary atwww.cciio.cms.gov or https://www.healthcare.gov/sbc-glossary or call 1-800-499-1275 to requesta copy.

Important Questions
	Answers
	Why This Matters:

What is the overall deductible?
	
Out-of-network providers: $250 Individual/$500 Two Person/$750 Family
	Generally, you must pay allof the costs from providersup 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 totalamount ofdeductible expenses paid by all family membersmeets the overall family deductible.

Are there services covered before you meet your deductible?

Yes, Preventive Care
	This plan covers some items and services even if you haven’t yet met the deductible amount. Buta copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible.See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
	
Are there other deductibles for specific services?
	
No
	
You don’t have to meetdeductibles for specific services.

What is the out-of-pocket 
limit for this plan?
	
	In-Network: $3,000 Individual/ $6,000 2-person/ $9,000 Family; Out-of-Network: $3,300 Individual/
$6,600 2-person/ $9,900 Family 
	
The out-of-pocket limit is the most you could pay in a year for covered services. Ifyou have other family members in thisplan,theyhave to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?
	Costs for premiums, balance-billing charges, and health care this plan doesn’t cover.
	
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less ifyou use a network provider?
	
Yes. See www.excellusbcbs.com or call 1-800-499-1275 for a list 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 a out-of-network provider,and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays(balance billing).Be aware,your network provider might use an out-of-network provider for some services (such as lab work). Check with your providerbefore you get services.
	
Do you need a referral to see a specialist?
	
No.
	
You can see the specialist you choose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, ifa deductible applies.

Common Medical Event
	
Services You May Need
	What You Will Pay
	
Limitations, Exceptions,& Other Important Information
	
		In-Network Provider (You will pay the least)
	Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

If you have a test

If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.excellusbcbs.com/r xlist

If you have outpatient surgery

If you need immediate medical attention
	Primary care visit to treatan injury or illness
	
$25 copay/visit
	
20% coinsurance
	
None
	
	Specialist visit
	$30 copay/visit
	20% coinsurance
	None

Preventive care/screening/ immunization
	Adult physical: No charge
Adult Immunizations: No charge
Well Child visit: No charge
	Adult physical:20% coinsurance
Adult Immunizations: 20% coinsurance Well Child visit: No charge
	
You may have to pay for services thataren’tpreventive. Ask yourprovider if the services needed are preventive. Then check what your plan will pay for one (1)exam per calendar year.
	
	Diagnostic test (x-ray, blood work)
	X-ray: No charge Blood work: No charge
	X-ray: 20% coinsurance Blood work: No charge

Imaging:Prior authorization is required
	
	Imaging (CT/PET scans, MRIs)
	
No charge
	
20% coinsurance

Generic drugs (Tier 1)
	$5/prescription retail, $10/prescription mail order
	
Not covered

Covers up to a 30-day supply (retail prescription); 90 day supply (mail order prescription).

Prior authorization required for certain prescription drugs.

Specialty drugs must be filled bya designated pharmacy. Specialty drugsare noteligible for mail order.

Preferred brand drugs (Tier 2)
	$35/prescription retail, $70/prescription mail order
	
Not covered

Non-preferred brand drugs (Tier 3)
	$70/prescription retail, $140/prescription mail order
	
Not covered
		
	Facility fee (e.g., ambulatory surgery center)
	
No charge
	
20% coinsurance
	
None
	
	Physician/surgeon fees
	No charge
	20% coinsurance
	None

Emergency room care
	
$150 copay/visit
	$150 copay/visit Deductible does not apply

None

Emergency medical transportation
	
$50 copay/visit
	$50 copay/visit Deductible does not apply

* For more information about limitations and exceptions, see the plan or policy document atwww.excellusbcbs.com.                                                  Page 2 of 5

•	Long-term care
•	Private duty nursing

Common Medical Event
	
Services You May Need
	What You Will Pay
	
Limitations, Exceptions,& Other Important Information
	
		In-Network Provider (You will pay the least)
	Out-of-Network Provider (You will pay the most)

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

If you are pregnant

If you need help recovering or have other special health needs

If your child needs dental or eye care
	
Urgent care
	
$30 copay/visit
	20% coinsurance Deductible does not apply
		
	Facility fee (e.g.,hospital room)
	
No charge
	
20% coinsurance
	
None
	
	Physician/surgeon fees
	No charge
	20% coinsurance
	None

Outpatient services
	
$25 copay/visit
	
20% coinsurance

None

Inpatient services
	
$100 copay/visit
	
20% coinsurance
		
	Office visits
	No charge
	20% coinsurance

Cost sharing does not apply for preventive services.
	
	Childbirth/delivery professional services
	
No charge
	
20% coinsurance
		
	Childbirth/delivery facility services
	
No charge
	
20% coinsurance
		
	Home health care
	No charge
	20% coinsurance
	Deductible is limited to $50 Out-of-Network
	
	Rehabilitation services
	$30 copay/visit
	20% coinsurance
	
None
	
	Habilitation services
	$30 copay/visit
	20% coinsurance
		
	Skilled nursing care
	No charge
	20% coinsurance
	None
	
	Durable medical equipment
	No charge
	20% coinsurance
	None
	
	Hospice services
	No charge
	20% coinsurance
	Family bereavement counseling limited to 5 Visits per year
	
	Children’s eye exam
	Not covered
	Not covered
	None
	
	Children’s glasses
	Not covered
	Not covered
	None
	
	Children’s dental check-up
	Not covered
	Not covered
	None

Excluded Services &Other CoveredServices:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any otherexcluded services.)
	
•	Cosmetic surgery	•	Hearing aids	•	Routine eye care (Child) •	Dental care (Adult)                                                                                                                 •	Routine foot care
•	Dental care (Child)	•	Routine eye care (Adult)	•	Weight loss programs

* For more information about limitations and exceptions, see the plan or policy document atwww.excellusbcbs.com.                                                  Page 3 of 5

Other Covered Services (Limitations may apply to these services. This isn’t a complete list.Please see your plan document.)
	
•	Acupuncture
•	Bariatric surgery
	•	Chiropractic care •	Infertility treatment
	
•	Non-emergency care whentraveling outside the U.S.

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 those agencies is: Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov.ebsa/healthreform. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.govor call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaintagainst yourplan for a denial of a claim.This complaint is called a grievance or appeal. For more information about your rights, lookat the explanation ofbenefits you will receive for that medical claim. Your plan documentsalso provide complete information on how to submit a claim, appeal, or a grievance for any reason to yourplan. For more information about your rights,this notice, or assistance, contact: the phone numberon Your ID card orwww.excellusbcbs.com, the Department of Labor’s Employee BenefitSecurityAdministration at 1-866-444-EBSA (3272) or https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa. You mayalso contact the NewYork State Department of Financial Services Consumer Assistance Unit at 1-800-342-3736 or www.dfs.ny.gov.Additionally, a consumer assistance program can help you file your appeal. ContactCommunity Service Societyof New York, Community Health Advocates, 633 Third Avenue, 10th floor, New York, NY 10017, (888) 614-5400, http://www.communityhealthadvocates.org/ (website), cha@cssny.org (email). A list of states with Consumer Assistance Programs is available at: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/consumer-assistance-programs.docand http://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/.

Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includesplans, health insurance available through the Marketplace orother individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain typesof Minimum Essential Coverage,you may not be eligible forthe premium tax credit.

Does this plan meet the Minimum Value Standards?Yes.
If yourplan doesn’t meet the Minimum Value Standards, you may be eligible for apremium tax creditto help you pay for a plan through the Marketplace.

To see examples of how this plan might cover costs for a sample medicalsituation, see the next section.

* For more information about limitations and exceptions, see the plan or policy document atwww.excellusbcbs.com.                                                  Page 4 of 5

About these Coverage Examples:

This is not a costestimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focuson the cost-sharing amounts (deductibles, copaymentsand coinsurance) and excluded servicesunder the plan.Use this information to compare the portion of costs you might pay under differenthealth plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a

hospital delivery)

Managing Joe’s Type2 Diabetes (a year of routine in-network care of awell-
controlledcondition)

Mia’s Simple Fracture

(in-network emergency room visit and follow up

care)

The plan’s overall deductible Specialistcopayment Hospital (facility) copayment Other copayment

$0	The plan’s overall deductible $30	Specialistcopayment
$0	Hospital (facility) copayment $0	Other copayment

$0         The plan’s overall deductible                 $0 $30         Specialistcopayment                          $30 $0         Hospital (facility) copayment                  $0 $0         Other copayment                                  $0

This EXAMPLE event includes services like: Specialistoffice visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost
	$12,700

In this example, Peg would pay:
		
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$0
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$60
	
The total Peg would pay is
	$60

This EXAMPLE event includes services like: Primary care physician office visits (including disease education)
Diagnostic tests (blood work) Prescription drugs
Durable medical equipment(glucose meter)

Total Example Cost
	$5,600

In this example, Joe would pay:
		
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$130
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$20
	
The total Joe would pay is
	$150

This EXAMPLE event includes services like: Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment(crutches) Rehabilitation services (physical therapy)

Total Example Cost
	$2,800

In this example, Mia would pay:
		
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$250
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$0
	
The total Mia would pay is
	$250

The plan would be responsible for the other costsof these EXAMPLE covered services.

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