2-Attachment 8 - Presbyterian-SBC-EPO-Plan.pdf

What this Plan Covers and What You Pay for Covered Services Coverage Period: 07/01/2025-6/30/2026

Coverage for: Individual or Family | Plan Type: HMO

County of Bernalillo EPO Plan

What is the overall deductible?

$250 Individual / $750 Family

Generally, you must pay all of the costs from providers up to the deductible amount before 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 covered before you meet your deductible

Yes. Preventive care Behavioral Health services and any benefit where there is no charge, Covid- 19 testing, treatment and vaccines, and any service that have a copayment are covered before you meet your deductible.

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 care without cost sharing and before you meet your deductible. See a list of covered preventive services at 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?

$3,000 Individual / $6,000 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, they have to meet their own out-of-pocket limit until the overall family out-of-pocket limit has been met..

What is not included in the out-of-pocket limit?

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 https://www.phs.org/ or call 1-800-923-6980 for a list of participating 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 a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your provider network 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.

HWP20008_PHR10414

For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-923-6980 or visit www.phs.org. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-800-923-6980 to request a copy.

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What You Will Pay

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

Primary care visit to treat an injury or illness

Adult/Child: $30/$15 copayment/visit deductible does not apply

Not covered Video Visits with contracted providers through our national vendor are $0 copay and paid at 100% in network. Telehealth appointments with a contracted network provider, including Presbyterian Medical Group providers, require members to pay a normal copay or cost share in network.

Specialist visit Adult/Child: $60/$50 copayment/visit deductible does not apply

Not covered --------------None---------------

Preventive care/screening/immunization

No charge deductible does not apply

Not covered

You may have to pay for services that aren't preventive.

Ask your provider if the services needed are preventive.

Then check what your plan will pay for. There is zero cost-sharing for any telehealth service. Copayment does not include Medical Drugs which will have a separate charge. No cost sharing for COVID-19 testing, treatment and vaccines. Prior authorization is not required for gynecological or obstetrical ultrasounds.

If you have a test Diagnostic test (x-ray, blood work) No charge deductible does not apply Not covered

Prior authorization may be required or benefits may be denied.

Imaging (CT/PET scans, MRIs) Adult/Child: PET/MRI:

$150/$100 copayment/test; CT:

$125/$75 copayment/test deductible does not apply

Not covered

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

Preferred Generic Drugs (Tier 1)

$10 copay (retail) / $20 copay (mail order) deductible does not apply

Not covered

Tier 1, Tier 2, and Tier 3 cover up to a 30-day supply (retail prescription); 90-day supply (mail order prescription).

Tier 4 mail order is not covered.

Prior authorization for some drugs may be required.

Preferred brand drugs (Tier 2)

$40 copay (retail) / $80 copay (mail order) deductible does not apply

Not covered

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

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Non-preferred drugs (Tier 3) $75 copay (retail) / $200 copay (mail order) deductible does not apply

Self-Administered Specialty (Tier 4)

20% up to maximum of $400 per prescription (retail) deductible does not apply / Not available mail order

Not covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

$500/visit-Adult and $200/visit-Child deductible does not apply

Not covered Prior authorization may be required or benefits may be denied.

Physician/surgeon fees Included in facility fee Not covered Prior authorization may be required or benefits may be denied.

http://www.healthcare.gov/sbc-glossary/#deductible

If you need immediate medical attention

Emergency room care $250 copayment/visit deductible does not apply

$250 copayment/visit deductible does not apply

Waived if admitted into a hospital, then hospital copayment applies.

Emergency medical transportation

$50 copayment ground;

$100 copayment air; No charge inter-facility deductible does not apply

$50 copayment ground;

$100 copayment air; No charge inter-facility deductible does not apply

--------------None---------------

Urgent care Adult/Child: $50/$10 copayment /visit deductible does not apply

Adult/Child: $50/$10 copayment /visit deductible does not apply

--------------None---------------

If you have a hospital stay

Facility fee (e.g., hospital room) Adult/Child: $500/$350 copayment/admission

Not covered Prior Authorization may be required or benefits may be denied.

Physician/surgeon fees Included in facility fee Not covered Prior Authorization may be required or benefits may be denied.

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

Outpatient services No charge deductible does not apply

Not covered There is no cost-sharing for behavioral health services or drugs.

Inpatient services

No charge deductible does not apply

Prior authorization may be required or benefits may be denied. There is no cost-sharing for behavioral health services or drugs.

If you are pregnant

Office visits $30 copayment initial visit only; No charge all other visits. deductible does not apply

Not covered Depending on the type of services, a copayment, coinsurance, or deductible does apply.

Childbirth/delivery professional services No charge deductible does not apply Not covered --------------None---------------

Childbirth/delivery facility services $500 copayment/ admission deductible does not apply

Not covered Prior authorization may be required.

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If you need help recovering or have other special health needs

Home health care No Charge Not covered Prior authorization may be required or benefits may be

Rehabilitation services Adult/Child:$50/$40 copayment/visit deductible does not apply

Not covered Coverage is limited up to 24 visits not combined/ contract year. Prior authorization may be required or benefits may be denied.

Habilitation services Child:$40 copayment/visit deductible does not apply

Not covered --------------None---------------

Skilled nursing care Adult/Child: $500/$350 copayment/admission deductible does not apply

Not covered Coverage is limited up to 30 days/plan year. Prior authorization may be required or benefits may be denied.

Durable medical equipment 20% coinsurance Not covered Prior authorization may be required or benefits may be denied.

Hospice services Adult/Child:$500/$350 copayment/admission deductible does not apply

Not covered Prior authorization may be required or benefits may be

If your child needs dental or eye care

Children's eye exam Included in office visit copayment deductible does not apply

Not covered Coverage is limited to refraction eye exam associated with post cataract surgery or Keratoconus correction

Children's glasses

50% coinsurance

Coverage is limited to eyeglasses/contact lenses within 12 months following cataract surgery, correction of Keratoconus or when related to Genetic Inborn Errors of Metabolism. Prior authorization may be required or benefits may be denied.

Children's dental check-up Not covered Not covered --------------None---------------http://www.healthcare.gov/sbc-glossary/#home-health-care http://www.healthcare.gov/sbc-glossary/#rehabilitation-services http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#habilitation-services http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#skilled-nursing-care http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#durable-medical-equipment http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#hospice-services http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#coinsurance

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Cosmetic Surgery

• Dental Care (Adult)

• Dental check-up (Child)

• Long-Term Care

• Non-Emergency Care When Traveling Outside the U.S.

• Private-Duty Nursing

• Routine Eye Care (Adult)

• Routine Foot Care * Only covered when medically necessary for diabetes. See SPD for details.

• Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

• Acupuncture (20 visits per calendar year unless for rehabilitative or habilitative svc)

• Bariatric Surgery

• Chiropractic Care (20 visits per calendar year unless for rehabilitative or habilitative svc)

• Hearing Aids

• Infertility Treatment

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 http://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.gov or call 1-800-318-2596.

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: Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, you may contact the Office of the Superintendent of Insurance Managed Health Care Bureau at 1-855-427-5674 or by email at mhcb.grievance@state.nm.us.

If 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 exemption from the requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standard, you may be eligible for a premium tax credits to help you pay for a plan through the Marketplace.

Language Access Services:

Para obtener asistencia en Español, llame al 1-855-592-7737.

Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-592-7737.

如果需要中文的帮助，请拨打这个号码 1-855-592-7737.

Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-592-7737.

Learn more about Presbyterian's Notice of Nondiscrimination, go to www.phs.org/nondiscrimination.aspx.

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

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About these Coverage Examples:

The plans overall deductible $250 The plans overall deductible $250 The plans overall deductible $250 Specialist $60 Specialist $60 Specialist $60 Hospital (Facility) $500 Hospital (Facility) $500 Hospital (Facility) $500 Other No Charge Other No Charge Other No Charge

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:

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)

In this example, Joe would pay:

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:

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

Cost Sharing Deductibles $0 Copayments $500 Coinsurance $0

What isn't covered Limits or exclusions $60 The total Peg would pay is $560

Deductibles $250 Copayments $1000 Coinsurance $100

What isn't covered Limits or exclusions $20 The total Joe would pay is $1,370

Deductibles $200 Copayments $700 Coinsurance $0

What isn't covered Limits or exclusions $0 The total Mia would pay is $900

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 (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)

$5,600 Total Example Cost http://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#specialist http://www.healthcare.gov/sbc-glossary/#specialist http://www.healthcare.gov/sbc-glossary/#specialist http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#cost-sharing http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#excluded-services http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#plan