Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 01/01/2024 - 12/31/2024

Anthem® BlueCross and BlueShield Coverage for: Individual + Family | Plan Type: HMO
Anthem Bronze Pathway Essentials 9450 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)

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, https://eoc.anthem.com/eocdps/9C7WIND01012024. 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 (855) 886-6152 to request a copy.
Important Questions Answers Why This Matters:
What is the overall $9,450/person or $18,900/family Generally, you must pay all of the costs from providers up to the deductible amount before
deductible? for In-Network Providers. this plan begins to pay. If you have other family members on the plan, each family member
must meet their own individual deductible until the total amount of deductible expenses paid
by all family members meets the overall family deductible.

Are there services Yes. Preventive Care. Vision. For This plan covers some items and services even if you haven’t yet met the deductible amount.
covered before you more information see below. But a copayment or coinsurance may apply. For example, this plan covers certain preventive
meet your deductible? 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 No. You don't have to meet deductibles for specific services.
deductibles for
specific services?
What is the out-of- $9,450/person or $18,900/family The out-of-pocket limit is the most you could pay in a year for covered services. If you have
pocket limit for this for In-Network Providers. other family members in this plan, they have to meet their own out-of-pocket limits until the
plan? overall family out-of-pocket limit has been met.

What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
in the out-of-pocket charges, and health care this plan
limit? doesn't cover.
Will you pay less if Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s
you use a network www.anthem.com/find- network. You will pay the most if you use an out-of-network provider, and you might receive
provider? care/?alphaprefix=E7E a bill from a provider for the difference between the provider’s charge and what your plan
or call (855) 886-6152 for a list of
pays (balance billing). Be aware, your network provider might use an out-of-network provider
network providers. Costs may
vary by site of service and how for some services (such as lab work). Check with your provider before you get services.
the provider bills.

IN/IND/Anthem Bronze Pathway Essentials 9450 ($0 Virtual PCP + $0 Virtual Chat + $0 Select Drugs)/9C7W/01-24
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Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Level 1
In-Network Non-Network
Common Pharmacy- RX Limitations, Exceptions, &
Services You May Need Provider Provider
Medical Event Only Other Important Information
(You will pay (You will pay the
(You will pay the
more) most)
least)
Primary care visit to treat an Virtual visits (Telehealth)
Not Applicable 0% coinsurance Not covered
injury or illness benefits available.
Virtual visits (Telehealth)
If you visit a Specialist visit Not Applicable 0% coinsurance Not covered
benefits available.
health care
You may have to pay for services
provider’s office
that aren't preventive. Ask your
or clinic Preventive care/screening/
Not Applicable No charge Not covered provider if the services needed
immunization
are preventive. Then check what
your plan will pay for.
Diagnostic test (x-ray, blood
Not Applicable 0% coinsurance Not covered --------none--------
If you have a test work)
Imaging (CT/PET scans, MRIs) Not Applicable 0% coinsurance Not covered --------none--------
0% coinsurance
If you need drugs 0% coinsurance Not covered (retail
Generic drugs (Tier 1) (retail and home
to treat your (retail only) and home delivery)
delivery)
illness or
0% coinsurance
condition 0% coinsurance Not covered (retail For more information, refer to
Preferred brand drugs (Tier 2) (retail and home
More information (retail only) and home delivery) “Select Drug List” at
delivery)
about prescription http://www.anthem.com/pharm
0% coinsurance
drug coverage is Non-preferred brand drugs 0% coinsurance Not covered (retail acyinformation/
(retail and home
available at (Tier 3) (retail only) and home delivery) *See Prescription Drug section
delivery)
http://www.anthe
0% coinsurance
m.com/pharmacyi 0% coinsurance Not covered (retail
Specialty drugs (Tier 4) (retail and home
nformation/ (retail only) and home delivery)
delivery)
If you have Facility fee (e.g., ambulatory
Not Applicable 0% coinsurance Not covered --------none--------
outpatient surgery center)
surgery Physician/surgeon fees Not Applicable 0% coinsurance Not covered --------none--------
If you need Covered as In-
Emergency room care Not Applicable 0% coinsurance --------none--------
immediate Network

* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/9C7WIND01012024.
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 What You Will Pay
Level 1
In-Network Non-Network
Common Pharmacy- RX Limitations, Exceptions, &
Services You May Need Provider Provider
Medical Event Only Other Important Information
(You will pay (You will pay the
(You will pay the
more) most)
least)
medical attention Non-emergency Non-Network
Emergency medical Covered as In-
Not Applicable 0% coinsurance Ambulance Services are limited
transportation Network
to $50,000 per occurrence.
Covered as In-
Urgent care Not Applicable 0% coinsurance --------none--------
Network
60 days/year for Inpatient
If you have a Facility fee (e.g., hospital room) Not Applicable 0% coinsurance Not covered rehabilitation for In-Network
hospital stay Providers.
Physician/surgeon fees Not Applicable 0% coinsurance Not covered --------none--------
Office Visit
If you need Office Visit Office Visit
Virtual visits (Telehealth)
mental health, 0% coinsurance Not covered
Outpatient services Not Applicable benefits available.
behavioral health, Other Outpatient Other Outpatient
Other Outpatient
or substance 0% coinsurance Not covered
--------none--------
abuse services
Inpatient services Not Applicable 0% coinsurance Not covered --------none--------
Office visits Not Applicable 0% coinsurance Not covered
Childbirth/delivery professional Maternity care may include tests
If you are Not Applicable 0% coinsurance Not covered
services and services described elsewhere
pregnant
Childbirth/delivery facility in the SBC (i.e., ultrasound).
Not Applicable 0% coinsurance Not covered
services
100 visits/year In-Network
Home health care Not Applicable 0% coinsurance Not covered
Providers.
Rehabilitation services Not Applicable 0% coinsurance Not covered
If you need help *See Therapy Services section.
Habilitation services Not Applicable 0% coinsurance Not covered
recovering or
90 days/year for skilled nursing
have other
Skilled nursing care Not Applicable 0% coinsurance Not covered services for In-Network
special health
Providers.
needs
*See Durable Medical
Durable medical equipment Not Applicable 0% coinsurance Not covered
Equipment Section
Hospice services Not Applicable 0% coinsurance Not covered --------none--------
If your child Children’s eye exam Not Applicable No charge Not covered
*See Vision Services section
needs dental or Children’s glasses Not Applicable No charge Not covered
eye care Children’s dental check-up Not Applicable 0% coinsurance Not covered *See Dental Services section

* For more information about limitations and exceptions, see the plan or policy document at https://eoc.anthem.com/eocdps/9C7WIND01012024.
Page 3 of 11
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, or  Acupuncture  Bariatric surgery
when the life of the mother is endangered)  Dental care (Adult)  Hearing aids
 Cosmetic surgery  Long-term care  Non-emergency care when traveling outside
 Infertility treatment  Routine foot care unless medically necessary the U.S.
 Routine eye care (Adult)  Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Chiropractic care 12 visits/year  Private-duty nursing 82 visits/year in a
Home Setting only

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: State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395,
www.in.gov/idoi/3008.htm, or contact Anthem at the number on the back of your ID card. 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.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 information about 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 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 105568, Atlanta GA 30348-5568

State of Indiana Department of Insurance, 311 W. Washington Street, Suite 300, Indianapolis, Indiana 46204, (800) 622-4461, (317) 232-2395,
www.in.gov/idoi/3008.htm

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.

Does this plan meet the Minimum Value Standards? Not Applicable.
If 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 Marketplace.

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

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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 will
be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-
sharing amounts (deductibles, copayments and coinsurance) and excluded services under 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 Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)

 The plan’s overall deductible $9,450  The plan’s overall deductible $9,450  The plan’s overall deductible $9,450
 Specialist coinsurance 0%  Specialist coinsurance 0%  Specialist coinsurance 0%
 Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%  Hospital (facility) coinsurance 0%
 Other coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services
like: like: like:
Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $9,450 Deductibles $5,400 Deductibles $2,800
Copayments $0 Copayments $0 Copayments $0
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $9,510 The total Joe would pay is $5,420 The total Mia would pay is $2,800

The plan would be responsible for the other costs of these EXAMPLE covered services.
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Language Access Services:
It’s important we treat you fairly
That’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 the
basis 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’t
English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services
number 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 Compliance
Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-
1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

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