3-Attachment 9 - Presbyterian-SBC-PPO-Plan.pdf

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

What is the overall deductible?

In-Network: $1,000 Individual / $2,000 Family. Out-of-Network:

$1,500 Individual / $3,000 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?

In-Network: $5,000 Individual / $10,000 Family. Out-of- Network: $10,000 Individual / $20,000 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.

HWP20009_PHR10416

Individual or Family | PPO

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.

http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#plan 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/#plan http://www.healthcare.gov/sbc-glossary/#preventive-care http://www.healthcare.gov/sbc-glossary/#cost-sharing http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/coverage/preventive-care-benefits http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#balance-billing http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit http://www.healthcare.gov/sbc-glossary/#network-provider https://www.phs.org/ http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#network http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#network http://www.healthcare.gov/sbc-glossary/#out-of-network-provider http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#balance-billing http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#network http://www.healthcare.gov/sbc-glossary/#out-of-network-provider http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#referral http://www.healthcare.gov/sbc-glossary/#specialist http://www.healthcare.gov/sbc-glossary/#specialist http://www.phs.org/ http://www.healthcare.gov/sbc-glossary/#allowed-amount http://www.healthcare.gov/sbc-glossary/#balance-billing http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/

What You Will Pay

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

Primary care visit to treat an injury or illness

$30 copayment/visit deductible does not apply

50% coinsurance Telehealth /Video visits 50% coinsurance

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, or out of network provider require members to pay a normal copay or cost share in network or out of network.

Specialist visit $60 copayment/visit

50% coinsurance --------------None---------------

Preventive care/screening/immunization

No charge deductible does not apply

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 50% coinsurance

Prior authorization may be required or benefits may be denied.

Imaging (CT/PET scans, MRIs)

PET/MRI: $200

copayment/test; CT:

$125 copayment/test deductible does not apply

50% coinsurance

If you need drugs to treat your illness or condition More information about prescription drug coverage 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.

http://www.healthcare.gov/sbc-glossary/#provider http://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#specialist http://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preventive-care http://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#preventive-care http://www.healthcare.gov/sbc-glossary/#plan http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage http://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage

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

Not covered

Self-Administered Specialty (Tier 4)

20% up to a maximum of $400 per prescription

If you have outpatient surgery

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

20% coinsurance after deductible is met

50% coinsurance after deductible is met

Prior authorization may be required or benefits may be denied.

Physician/surgeon fees 20% coinsurance after deductible is met

50% coinsurance after deductible is met

Prior authorization may be required or benefits may be denied.

If you need immediate medical attention

Emergency room care $300 copayment/visit deductible does not apply

$300 copayment/visit 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 $75 copayment /visit deductible does not apply

$75 copayment /visit

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

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance Prior Authorization may be required or benefits may be denied.

Physician/surgeon fees 20% coinsurance 50% coinsurance 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

50% coinsurance 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/visit deductible does not apply

50% coinsurance Depending on the type of services, a copayment, coinsurance, or deductible does apply.

Childbirth/delivery professional services 20% coinsurance 50% coinsurance Deductible does apply.

Childbirth/delivery facility services 20% coinsurance 50% coinsurance Prior authorization may be required. Deductible does apply.

http://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-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/#copayment http://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation http://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation http://www.healthcare.gov/sbc-glossary/#copayment 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/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#urgent-care 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/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#deductible

If you need help recovering or have other special health needs

Home health care 20% coinsurance 50% coinsurance Prior authorization may be required or benefits may be

Rehabilitation services $75 copayment//visit deductible does not apply

50% coinsurance Coverage is limited up to 24 visits not combined/ contract year. Prior authorization may be required or benefits may be denied.

Habilitation services $30 copayment//visit deductible does not apply

50% coinsurance --------------None---------------

Skilled nursing care 20% coinsurance 50% coinsurance Coverage is limited up to 30 days/plan year. Prior authorization may be required or benefits may be denied.

Durable medical equipment 50% coinsurance 50% coinsurance Prior authorization may be required or benefits may be denied.

Hospice services 20% coinsurance 50% coinsurance 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

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/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance 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/#coinsurance 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/#coinsurance http://www.healthcare.gov/sbc-glossary/#skilled-nursing-care http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#durable-medical-equipment http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#hospice-services http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#coinsurance http://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible 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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(a year of routine in-network care of a well-controlled condition)

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.

Specialist office visits ( ) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ) Specialist visit ( )

Primary care physician office visits (

Diagnostic tests ( ) Prescription drugs Durable medical equipment ( )

Emergency room care (

Diagnostic test ( ) Durable medical equipment ( ) Rehabilitation services ( )

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

Total Example Cost

Total Example Cost

Deductibles $750 Copayments $100 Coinsurance $1,792

Limits or exclusions $60 $2,702

Deductibles $0 Copayments $1,060 Coinsurance $0

Limits or exclusions $55 $1,115

Deductibles $29 Copayments $630 Coinsurance $7

Limits or exclusions $0 $667

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

(in-network emergency room visit and follow up care) http://www.healthcare.gov/sbc-glossary/#plan