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

Coverage Period: Beginning on or after 01/01/2024

CJ Logistics America, LLC: HSA $5,000 Coverage for: Individual/Family | 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 bluecrossmn.com/cjlogistics or call 1-877-293-
7037. 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 1-877-293-7037 to request a copy.

Important Questions Answers Why this Matters:

$5,000 individual / $10,000 family Generally, you must pay all of the costs from providers up to the deductible amount before
medical and drug in-network this plan begins to pay. If you have other family members on the plan, each family member
What is the overall deductible? $5,000 individual / $10,000 family must meet their own individual deductible until the total amount of deductible expenses paid
medical and drug out-of-network by all family members meets the overall family deductible.
Yes. In-network well child care, This plan covers some items and services even if you haven’t yet met the deductible amount.
Are there services covered before prenatal care and preventive care But a copayment or coinsurance may apply. For example, this plan covers certain preventive
you meet your deductible? services are covered before you meet services without cost-sharing and before you meet your deductible. See a list of covered
your deductible. preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for
No You don’t have to meet deductibles for specific services.
specific services?
$5,000 individual / $10,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have
What is the out-of-pocket limit for medical and drug in-network other family members in this plan, they have to meet their own out-of-pocket limits until the
this plan? $10,000 individual / $20,000 family overall family out-of-pocket limit has been met.
medical and drug out-of-network
Premiums, balance-billing charges
What is not included in (unless balanced billing is prohibited),
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out-of-pocket limit? and health care this plan doesn't
cover.

GE10610309 – 10610316.
Effective 01/01/2024 - SBC_Version Effective 1/1/2024 SI Page 1 of 8
 Yes. If outside of Minnesota, your
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network is BlueCard PPO. If in
network. You will pay the most if you use an out-of-network provider, and you might receive a
Will you pay less if you use an in- Minnesota, your network is Aware.
bill from a provider for the difference between the provider’s charge and what your plan pays
network provider? See bluecrossmn.com/cjlogistics or
(balance billing). Be aware your in-network provider might use an out-of-network provider for
call 1-877-293-7037 for a list of in-
some services (such as lab work). Check with your provider before you get services.
network providers.
Do you need a referral to see a
No. You can see the specialist you choose without a referral.
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

Limitations, Exceptions, & Other
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an
0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍ None
injury or illness
Specialist visit 0% coinsurance‍‍‍‍ 40% coinsurance None
If you visit a health care You may have to pay for services
provider’s office or clinic that aren’t preventive. Ask your
Preventive care/screening/ Well child: 40% coinsurance‍‍‍‍
No charge provider if the services needed are
immunization Adult: 40% coinsurance preventive. Then check what your
plan will pay for.
Diagnostic test (x-ray, blood
0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
If you have a test work) May require prior authorization.
Imaging (CT/PET scans, MRIs) 0% coinsurance‍‍‍‍ 40% coinsurance‍‍
If you need drugs to treat 0% coinsurance‍‍‍‍‍/prescription Covers up to a 31-day supply‍‍(retail
your illness or condition. (retail) prescription); 90-day supply (mail
0% coinsurance‍‍‍‍/prescription service prescription and 90dayRx
Tier 1 (Preferred generic drugs) Not covered
More information about (mail service) retail prescription). May require prior
prescription drug coverage is 0% coinsurance‍‍‍‍/prescription authorization.
available at (90dayRx retail)
bluecrossmn.com/cjlogistics Tier 2 (Non-preferred generic 0% coinsurance‍‍‍‍‍/prescription Not covered
drugs) (retail)
0% coinsurance‍‍‍‍/prescription
(mail service)
0% coinsurance‍‍‍‍‍/prescription
(90dayRx retail)

For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 2 of 8
 What you Will Pay
Limitations, Exceptions, & Other
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)
0% coinsurance‍‍‍‍‍/prescription
(retail)
0% coinsurance‍‍‍‍/prescription
Tier 3 (Preferred brand drugs) Not covered
(mail service)
0% coinsurance‍‍‍‍‍/prescription
(90dayRx retail)
0% coinsurance‍‍‍‍/prescription
(retail)
Tier 4 (Non-preferred brand 0% coinsurance‍‍‍‍/prescription
Not covered
drugs) (mail service)
0% coinsurance‍‍‍‍‍/prescription
(90dayRx retail)
Covers up to a 31-day supply
(participating specialty drug network
Specialty drugs 0% coinsurance‍‍‍‍‍/prescription Not covered supplier prescription). May require
prior authorization.
0% coinsurance‍‍‍‍for outpatient
Facility fee (e.g., ambulatory
hospital facility & ambulatory 40% coinsurance‍‍‍‍
surgery center)
If you have outpatient surgery center
May require prior authorization.
surgery 0% coinsurance‍‍‍‍for outpatient
Physician/surgeon fees hospital facility & ambulatory 40% coinsurance‍‍‍‍
surgery center
Emergency room care 0% coinsurance‍‍‍‍ 0% coinsurance‍‍‍‍ Out-of-network services apply to the
If you need immediate Emergency medical in-network deductible and out-of-
0% coinsurance‍‍ 0% coinsurance‍‍ pocket limit.
medical attention transportation
Urgent care 0% coinsurance‍‍‍‍ 40% coinsurance‍‍ None
Facility fee (e.g., hospital room) 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍ None
If you have a hospital stay
Physician/surgeon fee 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍ None
Outpatient services 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
If you need mental health, Services for marriage/couples
behavioral health, or Inpatient services including counseling are not covered. May
residential adult mental health 0% coinsurance‍‍‍‍ 40% coinsurance require prior authorization.
substance use services
treatment
If you are pregnant Office visits Prenatal care: No charge Prenatal care: 40% coinsurance‍‍‍‍ Cost sharing does not apply for
Postnatal care: 0% coinsurance‍‍‍‍ Postnatal care: 40% coinsurance‍‍‍‍ preventive services. Depending on
For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 3 of 8
 What you Will Pay
Limitations, Exceptions, & Other
Common Medical Event Services You May Need In-Network Provider Out-of-Network Provider Important Information
(You will pay the least) (You will pay the most)
Childbirth/delivery professional the type of services, other cost
0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
services sharing may apply. Maternity care
may include tests and services
Childbirth/delivery facility described elsewhere in the SBC
0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
services (e.g., ultrasound).
Combined in-network and out-of-
network limit: 120 visits per benefit
Home health care 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
period. May require prior
authorization.
0% coinsurance‍‍‍‍for occupational 40% coinsurance‍‍‍‍for Limit of 15‍visits per benefit period
Rehabilitation services therapy, physical therapy, and occupational therapy, physical for occupational therapy, physical
speech therapy therapy, and speech therapy therapy, and speech therapy
0% coinsurance‍‍‍‍for occupational 40% coinsurance‍‍‍‍for services combined, when you use
If you need help recovering therapy, physical therapy, and occupational therapy, physical out-of-network providers. May
Habilitation services
or have other special health speech therapy therapy, and speech therapy require prior authorization.
needs
Combined 120 days limit per person
Skilled nursing care 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍ per benefit period. May require prior
authorization.
Limits may apply to certain services
and equipment (e.g., hearing aid,
Durable medical equipment 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍
wigs). May require prior
authorization.
Hospice service 0% coinsurance‍‍‍‍ 40% coinsurance‍‍‍‍ None
Age 0 through 5: 40%
coinsurance‍‍‍‍
Children’s eye exam No charge None
If your child needs dental or Age 6 through 18: 40%
eye care coinsurance‍‍‍‍
Children’s glasses Not covered Not covered No coverage for these services
Children’s dental check-up Not covered Not covered No coverage for these services
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.)
 Cosmetic surgery  Non-emergency care when traveling outside the U.S.  Routine foot care
 Dental care  Private duty nursing  Weight loss programs
 Long-term care  Routine eye care (Adult)
For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 4 of 8
 Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
 Acupuncture  Chiropractic care  Infertility treatment
 Bariatric surgery  Hearing aids
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
Minnesota Department of Commerce at 1-800-657-3602; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform; or, Department of Health and Human Services, Center for Consumer Information, and Insurance Oversight, at 1-877-267-2323 x 61565 or
www.cciio.cms.gov. For more information on your rights to continue coverage, contact Blue Cross at 1-877-293-7037. 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.mnsure.org or call 1-855-
366-7873.
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: Blue
Cross at 1-877-293-7037; Minnesota Department of Commerce at 1-800-657-3602; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or www.dol.gov/ebsa/healthreform. If you are covered under a plan offered by the State Health Plan, a city, county, school district, Service Cooperative, or church
plan, you may contact the Department of Health and Human Services Health Insurance team at 1-888-393-2789.
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 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 the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-855-903-2583.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-537-7720.
Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-855-315-4017.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-902-2583.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 5 of 8
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 prenatal 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 $5,000 The plan’s overall deductible $5,000 The plan’s overall deductible $5,000
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 like: This EXAMPLE event includes services like: Primary This EXAMPLE event includes services like:
Specialist office visits (prenatal care) care physician office visits (including disease Emergency room care (including medical supplies)
Childbirth/delivery professional services education) Diagnostic tests (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 $5,000 Deductibles $5,000 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 $5,060 The total Joe would pay is $5,020 The total Mia would pay is $2,800
The plan would be responsible for the other costs of these EXAMPLE covered services.

For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 6 of 8
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.
 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.

For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 7 of 8
Language Access Services:

For more information about limitations and exceptions, see the plan or policy document at bluecrossmn.com/cjlogistics Page 8 of 8