Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Excellus BCBS: Excellus BluePPO Signature Deduct 3
A nonprofit independent licensee of the BlueCross BlueShield Association

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you 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 get a copy of the complete terms of coverage, call 1-800-499-1275 or visit Our website at www.excellusbcbs.com. 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.cciio.cms.gov or www.healthcare.gov/sbc-glossary or call 1-800-499-1275to request a copy.

Important Questions | Answers | Why This Matters:
What is the overall deductible? | In-Network: $1,500 Individual/ $3,000 Family; Out-of-Network: $1,650 Individual/ $3,300 Family | Generally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.
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. But a 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 meet deductibles for specific services.

What is the out-of-pocket limit for this plan? | In-Network: $3,000 Individual/$6,000 Family; Out-of-Network: $3,300 Individual/ $6,600 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be 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 if you use a network provider? | Yes. See www.excellusbcbs.com or call 1-800-499-1275 for a list of network providers. | This plan uses a providernetwork. You will pay less if you use a provider in the plan'snetwork. You will pay the most if you use an 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 provider before you get services.

Do you need a referral to see a
specialist?

No

You can see the specialist you choose without a referral.

2019490-1 955484

GAHP

Coverage Period: 07/01/2023 - 06/30/2024 Coverage for: Family | Plan Type: PPO

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All copayment and coinsurance costs shown in this chart are after yourdeductible has been met, if a 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 | Primary care visit to treat an injury or illness | 20% Coinsurance | 40% Coinsurance | None
Specialist visit | 20% Coinsurance | 40% Coinsurance |

Preventive care/screening/ immunization

Adult Physical: No Charge Adult Immunizations: No Charge
Well Child Visit: No Charge Deductible does not apply

Adult Physical: 40% Coinsurance Adult Immunizations: 40% Coinsurance
Well Child Visit: No Charge

You may have to pay for services that aren't preventive. Ask your providerif the services needed are preventive. Then check what your planwill pay for1 Exam per calendar year

If you have a test | Diagnostic test (x-ray, blood work) | X-Ray: 20% Coinsurance Blood Work: 20% Coinsurance | X-Ray: 40% Coinsurance Blood Work: 40% Coinsurance | None
Imaging (CT/PET scans, MRIs) | 20% Coinsurance | 40% Coinsurance |

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

Tier 1 (Generic drugs)

$5/prescription retail, $10/ prescription mail order
No Charge Members to age 19 Deductibledoes apply

Not Covered

Covers up to a 30-day supply (retail); 90-day supply (mail order)/prescription
Prior authorization required for certain prescription drugs.
Specialty drugs must be filled by a designated pharmacy. Specialty drugs are not eligible for mail order

Tier 2 (Preferred brand drugs) | $35/prescription retail, $70/ prescription mail order Deductibledoes apply | Not Covered |
Tier 3 (Non-preferred brand drugs) | $70/prescription retail, $140/ prescription mail order Deductibledoes apply | Not Covered |
If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 20% Coinsurance | 40% Coinsurance | None
Physician/surgeon fees | 20% Coinsurance | 40% Coinsurance |
If you need immediate medical attention | Emergency room care | 20% Coinsurance | 20% Coinsurance | None
Emergency medical transportation | 20% Coinsurance | 20% Coinsurance | None
Urgent care | 20% Coinsurance | 40% Coinsurance | None
If you have a hospital stay | Facility fee (e.g., hospital room) | 20% Coinsurance | 40% Coinsurance | None
Physician/surgeon fees | 20% Coinsurance | 40% Coinsurance |
If you need mental health, | Outpatient services | 20% Coinsurance | 40% Coinsurance | None

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

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) |

behavioral health, or
substance abuse services

Inpatient services

20% Coinsurance

40% Coinsurance

If you are pregnant | Office visits | No Charge | 40% Coinsurance | Cost sharing does not apply for preventive services.
Childbirth/delivery professional services | 20% Coinsurance | 40% Coinsurance | Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.). Depending on the type of services, a copayment, coinsurance, or deductible may apply.
Childbirth/delivery facility services | 20% Coinsurance | 40% Coinsurance | None
If you need help recovering or have other special health needs | Home health care | 20% Coinsurance | 40% Coinsurance | None
Rehabilitation services | 20% Coinsurance | 40% Coinsurance | 45 Visits per calendar year limit
Habilitation services | 20% Coinsurance | 40% Coinsurance | 45 Visits per calendar year limit
Skilled nursing care | 20% Coinsurance | 40% Coinsurance | 45 Days per calendar year limit
Durable medical equipment | 20% Coinsurance | 40% Coinsurance | None
Hospice services | 20% Coinsurance | 40% Coinsurance | Family bereavement counseling limited to 5 Visits per calendar year
If your child needs dental or eye care | Children’s eye exam | 20% Coinsurance | 40% Coinsurance | 1 Exam per year
Children’s glasses | Not Covered | Not Covered | None
Children’s dental check-up | Not Covered | Not Covered |

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.)
• _Cosmetic _surgery	_• _Dental _care _(Adult)	• _Dental _care _(Child) • _Long-term _care	_• _Private-duty _nursing	• _Routine _foot _care • _Weight _loss _programs	^• ^Hearing ^aids

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
^• ^Routine ^eye ^care ^(Adult)	• ^Infertility ^treatment	• ^Non-emergency ^care ^when ^traveling ^outside ^the ^U.S.

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

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's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa.Other coverage options may be available to you too, including buying individual insurance coverage through the Health InsuranceMarketplace. 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 is called a grievanceor appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information 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 number on Your ID card orwww.excellusbcbs.com; Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa; New York State Department of Financial Services Consumer Assistance Unitat
1-800-342-3736 orwww.dfs.ny.gov. Additionally, a consumer assistance program can help you file your appeal. Contact the Consumer Assistance Program at 1-888-614-5400, or e-mail cha@cssny.org or www.communityhealthadvocates.org. 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.doc and www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants.

Does this plan provide Minimum Essential Coverage? Yes

Minimum Essential Coveragegenerally 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.

Does this plan meet the Minimum Value Standards? Yes

If yourplandoesn’t meet the Minimum Value Standards, you may be eligible for a premium tax creditto help you pay for a planthrough the Marketplace.

––––––––––––––––––––––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.excellusbcbs.com	4 of 5

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this planmight cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providerscharge, and many other factors. Focus on the cost sharingamounts (deductibles, copaymentsand coinsurance) and excluded servicesunder the plan. Use this information to compare the portion of costs you might pay under different health 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 type 2 Diabetes

(a year of routine in-network care of a well-controlled

condition)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

The plan's overall deductible Coinsurance

Hospital (facility)coinsurance

Othercoinsurance

$1,500	The plan's overall deductible 20%	_Coinsurance

20%	_Hospital _(facility)coinsurance

20%	_Othercoinsurance

$1,500            The plan's overall deductible                      $1,500 20%            _Coinsurance                                             20%

20%	_Hospital _(facility)coinsurance	20%

20%	_Othercoinsurance	20%

This EXAMPLE event includes services like: Specialist office 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 | $1,500
Copayments | $0
Coinsurance | $1,500
What isn’t covered
Limits or exclusions | $60
The total Peg would pay is | $3,060

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 | $1,500
Copayments | $60
Coinsurance | $770
What isn’t covered
Limits or exclusions | $20
The total Joe would pay is | $2,350

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 | $1,500
Copayments | $10
Coinsurance | $260
What isn’t covered
Limits or exclusions | $0
The total Mia would pay is | $1,770

The plan would be responsible for the other costs of these EXAMPLE covered services.	5 of 5