University of Minnesota Twin City Campus Coverage Period: 08/21/2017-08/19/18

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Student Only | Plan Type: PPO

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, visit www.bluecrossmn.com/uofm or call 1-866-870-0348. 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 1-866-866-0348 to request a copy.
Important Questions Answers Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount
before this plan begins to pay.
What is the overall
$0 This plan has an embedded deductible. If you have other family members on the plan,
deductible?
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.
This plan covers some items and services even if you haven’t yet met the deductible
Are there services Yes. Well-child care, prenatal care and Network amount. But a copayment or coinsurance may apply. For example, this plan covers
covered before you Preventive care services are covered before certain preventive services without cost-sharing and before you meet your deductible.
meet your deductible? 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 No. You don’t have to meet “other” deductibles for specific services.
services?

What is the out-of- The out-of-pocket limit is the most you could pay in a year for covered services. If you
$6,250/per person Network and Out-of-Network
pocket limit for this have other family members in this plan, they have to meet their own out-of-pocket limits
medical services and prescription drugs
plan? until the overall family out-of-pocket limit has been met.

What is not included in Premiums, balance-billing charges, and health

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
the out-of-pocket limit? care this plan doesn’t cover.
Will you pay less if you Yes. This plan uses a provider network. You will pay less if you use a provider in the plan’s

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use a network provider? See www.bluecrossmn.com/uofm or call 1-866- network. You will pay the most if you use an out-of-network provider, and you might
870-0348 for a list of network providers. 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
No. You can see the specialist you choose without a referral.
see a specialist?
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Services You May What You Will Pay Limitations, Exceptions, &
Network Provider
Medical Event Need Out-of-Network Provider Other Important Information
(You will pay the least)
Primary care visit to
20% coinsurance 20% coinsurance None
treat an injury or illness
Specialist visit 20% coinsurance 20% coinsurance None

If you visit a health care You may have to pay for

provider’s office or clinic services that aren’t preventive.
Preventive
Ask your provider if the services
care/screening/ No charge 20% coinsurance
you need are preventive. Then
immunization
check what your plan will pay
for.
Diagnostic test (x-ray,
20% coinsurance 20% coinsurance
blood work)
If you have a test None
Imaging (CT/PET
20% coinsurance 20% coinsurance
scans, MRIs)
If you need drugs to treat $15.00 copay retail drugs/ For additional information on
your illness or condition. Boynton Pharmacy only Not covered for retail drugs your prescription drug benefit,
Preferred generic drugs
A Retail Pharmacy is any Not covered for mail order or Not covered for mail order drugs please refer to your prescription
licensed pharmacy that you 90dayRx Retail drugs drug Pharmacy Benefit Manager
can physically enter to obtain at Boynton Health Services.
a prescription drug. A Mail Covers up to a 31-day supply
$25.00 copay retail drugs/
Service Pharmacy dispenses Not covered for retail drugs (retail prescription).
Boynton Pharmach only
prescription drugs through Preferred brand drugs Not covered for retail drugs No coverage for Out-of-Network
Not covered for mail order or
the U.S. Mail. providers.
90dayRx Retail drugs
More information about No coverage for mail order and
prescription drug coverage is 90dayRx Retail drugs.
available at Non-preferred drugs Not covered Not covered No coverage for these services.

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 Common Services You May What You Will Pay Limitations, Exceptions, &
Network Provider
Medical Event Need Out-of-Network Provider Other Important Information
(You will pay the least)
www.shb.umn.edu/twincities For additional information on
/students/shbp/pharmacybe your prescription drug benefits,
nefits.htm. Refer to applicable prescription Refer to applicable prescription please refer to your prescription
Specialty drugs
drug cost-sharing drug cost-sharing drug Pharmacy Benefit Manager
Boynton Health Service.
Covers up to a 31-day supply.
Facility fee (e.g.,
If you have outpatient ambulatory surgery 20% coinsurance 20% coinsurance None
surgery center)
Physician/surgeon fees 20% coinsurance 20% coinsurance None
Emergency room care 20% coinsurance 20% coinsurance
If you need immediate
Emergency medical
medical attention 20% coinsurance 20% coinsurance None
transportation
Urgent care 20% coinsurance 20% coinsurance
Facility fee (e.g.,
20% coinsurance 20% coinsurance None
hospital room)
If you have a hospital stay
Physician/surgeon fees 20% coinsurance 20% coinsurance None
If you need mental health, Outpatient services 20% coinsurance 20% coinsurance Services for marriage/couples
behavioral health, or
Inpatient services 20% coinsurance 20% coinsurance counseling are not covered.
substance abuse services
Prenatal Care: No charge Cost sharing does not apply to
Office visits Postnatal Care: 20% 20% coinsurance certain preventive services.
coinsurance Depending on the type of
Childbirth/delivery services, coinsurance may
If you are pregnant 20% coinsurance 20% coinsurance
professional services apply. Maternity care may
include tests and services
Childbirth/delivery
20% coinsurance 20% coinsurance described elsewhere in the SBC
facility services
(i.e. ultrasound).

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 Common Services You May What You Will Pay Limitations, Exceptions, &
Network Provider
Medical Event Need Out-of-Network Provider Other Important Information
(You will pay the least)
Home health care 20% coinsurance 20% coinsurance None
20% coinsurance for 20% coinsurance for occupational
Coverage is limited to a
occupational therapy therapy
maximum of per plan year of
20% coinsurance for physical 20% coinsurance for physical
Rehabilitation services $500 for physical, occupational
therapy therapy
and speech therapy services
20% coinsurance for speech 20% coinsurance for speech
from Out-of-Network providers.
therapy therapy
20% coinsurance for 20% coinsurance for occupational
If you need help recovering Coverage is limited to a
occupational therapy therapy
or have other special health maximum of per plan year of
20% coinsurance for physical 20% coinsurance for physical
needs Habilitation services $500 for physical, occupational
therapy therapy
and speech therapy services
20% coinsurance for speech 20% coinsurance for speech
from Out-of-Network providers.
therapy therapy
Skilled nursing care 20% coinsurance 20% coinsurance None
Durable medical
20% coinsurance 20% coinsurance None
equipment
Hospice services 20% coinsurance 20% coinsurance None
Children’s eye exam No charge 20% coinsurance None
Maximum of one (1) frame and
one (1) pair of lenses (or one (1)
pair of contact lenses) per
Children’s glasses No charge Not covered
person per calendar year.
If your child needs dental or
No coverage for services from
eye care
Out-of-Network providers
Services provided exclusively
Children’s dental check- through BHS Dental Clinic.
No charge Not covered
up No coverage for services from
Out-of-Network providers.

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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.)
 Acupuncture (except as specified in Plan
 Dental Care (except as specified in Plan benefits)  Non-preferred drugs
benefits)
 Infertility Treatment  Private Duty Nursing (as required by state law)
 Bariatric Surgery
 Long-Term Care  Routine Foot Care
 Cosmetic Surgery (except as specified in Plan
 Marital/couples counseling  Weight Loss Programs
benefits)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Chiropractic Care  Non-emergency care when traveling outside the
 Routine eye care (Adult)
 Hearing Aids (as required by state law) 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: www.mnsure, the U.S. Department of labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department
of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
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 to submit a claim, appeal, or a grievance for any reason to your plan. For questions about your rights, this notice, or assistance, you can
contact your Claims Administrator by calling toll-free 1-866-870-0348 or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or www.dol.gov/ebsa/healthreform. For more information about your rights, this notice, or assistance, contact: Minnesota Commissioner of Commerce by
calling (651) 539-1600 or toll-free 1-800-657-3602. If you are covered under a plan offered by the State Health Plan, a city, county, school district, or Service Coop,
you may contact the Department of Health and Human Services Health Insurance team at 888-393-2789.
Does this plan provide Minimum Essential Coverage? Yes.
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 Standards, you may be eligible for a premium tax credit to help you pay for a plan through MNsure.
Notice of Nondiscrimination Practices
Effective July 18, 2016
Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or gender. Blue Cross does not exclude people or treat them differently because of race, color, national origin, age, disability, or
gender.
Blue Cross provides resources to access information in alternative formats and languages:
 Auxiliary aids and services, such as qualified interpreters and written information available in other formats, are available free of charge to people with disabilities
to assist in communicating with us.

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 Language services, such as qualified interpreters and information written in other languages, are available free of charge to people whose primary language is not
English.
If you need these services, contact us at 1-800-382-2000 or by using the telephone number on the back of your member identification card. TTY users call 711.
If you believe that Blue Cross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or
gender, you can file a grievance with the Nondiscrimination Civil Rights Coordinator
 by email at: [email protected]
 by mail at: Nondiscrimination Civil Rights Coordinator
Blue Cross and Blue Shield of Minnesota and Blue Plus
M495
PO Box 64560
Eagan, MN 55164-0560
 or by telephone at: 1-800-509-5312
Grievance forms are available by contacting us at the contacts listed above, by calling 1-800-382-2000 or by using the telephone number on the back of your
member identification card. TTY users call 711. If you need help filing a grievance, assistance is available by contacting us at the numbers listed above.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
 electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
 by telephone at: 1-800-368-1019 or 1-800-537-7697 (TDD)
 or by mail at: U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, DC 20201
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Access Services:

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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 up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist copayment $0  Specialist copayment $0  Specialist copayment $0
 Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%
 Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%

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

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

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 $0 Deductibles $0 Deductibles $0
Copayments $60 Copayments $790 Copayments $0
Coinsurance $2,041 Coinsurance $585 Coinsurance $385
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0
The total Peg would pay is $2,161 The total Joe would pay is $1,430 The total Mia would pay is $385

The plan would be responsible for the other costs of these EXAMPLE covered services. 8 of 8