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2019 HEALTH INSURANCE

BE READY FOR ANYTHINGLearn What You Need to Know About Your 2019 Highmark Blue Cross Blue Shield Delaware Coverage Options

Benefit Period:January 1 to December 31, 2019

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CONNECTING CARE AND COVERAGE

We’re here for you if you have questions or need help along the way:• Call 1-855-822-6925 (TTY/TDD 711)

• Visit DiscoverHighmark.com

• Talk to your local insurance agent

You want to be ready for 2019 with the right health insurance coverage in place. At Highmark Blue Cross Blue Shield Delaware (Highmark Delaware), we’re here to help. That’s why we’ve been working on new solutions that offer high quality, easy-to-access care.

This guide contains the information you need to understand your health insurance options before you enroll in a 2019 plan. That helps avoid surprises when you see your doctor, receive care at a hospital, or fill a prescription. So you can feel confident that you are choosing the right plan to fit your real life—and your budget.

We understand that there is a lot to consider and that change can feel overwhelming at times. We hope you will use this guide to review details about our 2019 plans and contact us with any questions you have.

Whatever 2019 has in store for you and your family, or whatever your health demands, we want you to feel ready for anything. That’s why we’re offering you a range of plan options with easier access to care by:

• Teaming up with doctors and hospitals in your community so you don’t have to travel for care

• Providing access to thousands of participating physicians and hospitals across the country

• Bringing care to you on your terms with virtual medicine and direct access to a Blues on CallSM health coach who is a specially trained registered nurse

CHOOSE HIGHMARK DELAWARE FOR YOUR COVERAGE IN 2019 AND YOU’LL HAVE:

• Peace of mind knowing your health plan is from a name trusted by generations.

• A network that includes top-rated providers right in your own community.

• Benefits including $0 copays for preventive care, such as checkups, immunizations, and much more.

• Free tools and resources to help you better manage your health and get the most from your health coverage.

IMPORTANT DETAILS TO CONSIDER BEFORE CHOOSING A PLAN:

• The open enrollment period lasts just 6 weeks

• Prescription drug coverage — check to see if your drugs are covered

• Doctors and hospitals included in the Highmark Delaware network

We can also help you enroll through the Health Insurance Marketplace (“the Marketplace”). Or you can contact the Marketplace at:

• HealthCare.gov

• 1-800-318-2596 (TTY: 1-855-889-4325)

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BE READY FOR ANYTHING

BE ON TIME for Open Enrollment P. 5

BE WELL-INFORMED About Your Health Plan Options P. 6

BE PREPARED Before You Choose P. 10

BE KNOWLEDGEABLE with Base Plan Options & Monthly Rates

YOUR HEALTH INSURANCE GLOSSARY P. 28

Base Plans P. 12

Base Rates P. 25

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BE ON TIME for Open Enrollment

Open Enrollment is the time when you can enroll in health insurance coverage.

Enroll by December 15 or you won’t have coverage on January 1—unless you qualify for a Special Enrollment Period.

OPEN ENROLLMENT PERIOD: NOVEMBER 1 TO DECEMBER 15, 2018• Mark your calendar for this year’s Open Enrollment Period.

• Enroll by December 15, 2018 for coverage beginning January 1, 2019.

SPECIAL ENROLLMENT PERIOD

Most people will enroll during Open Enrollment. But you can also change or enroll in coverage through a Special Enrollment Period if you have a qualifying life event. Some examples are:

If you think a Special Enrollment Period may apply to you, you can learn more by visiting HealthCare.gov. You may be asked to submit documents to show that you’re eligible for a Special Enrollment Period.

A NEW BABY

LOSING MINIMAL ESSENTIAL COVERAGE, SUCH AS COVERAGE THROUGH AN EMPLOYER

GETTING MARRIED

MOVING TO A NEW, PERMANENT RESIDENCE WHERE YOU CAN’T HAVE ACCESS TO THE SAME HEALTH PLANS

15DE C

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HIGHMARK DELAWARE PLAN OPTIONS

BE WELL-INFORMED About Your Health Plan Options

This year’s plan options are designed with you in mind. Our 2019 plans focus on offering you high-quality care, right in your community. It’s easier than ever to prepare—Highmark Delaware has a variety of 2019 plan options.

To bring you top-quality care, we work with your local hospitals and providers. This helps to lower the rising costs of health care, and keeps your copays and other out-of-pocket costs lower.

Highmark Delaware has plans where you’ll have access to a network of community providers for low or no cost services—with one plan offering two free Primary Care Provider (PCP) office visits— plus national access to thousands of providers.

Along with providing access to care close to home, finding a provider isn’t complicated. Doctors, facilities, and other providers are either in-network, or out-of-network—it’s that simple.

A Highmark Delaware Exclusive Provider Organization (EPO) plan makes it easy to get the care you need with network providers. Highmark Delaware offers plan options with:

• $0 copay for your first two PCP office visits*

• $0 copay for your first two mental health office visits*

• $0 copay for your first two substance abuse disorder office visits*

• Services at NO COST when you choose in-network health care providers for:

> $0 preventive screens and routine wellness exams

> $0 immunizations and vaccinations

> $0 contraceptives

• Lower-cost Silver plan options for members who qualify for financial help from the Marketplace

• Nationwide access to care with BlueCard®

• No referrals for seeing specialists*The availability of $0 copay visits and the type of visits (PCP, mental health, and/or substance abuse) are dependent upon the plan selected.

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Do you need adult dental insurance? Visit HighmarkBlueEdgeDental.com to find out more.

HIGHMARK BLUE EDGE DENTAL

BE WELL-INFORMED About Your Health Plan Options

Major Events/Catastrophic CoverageIf you are under 30 or meet financial hardship requirements, the low-cost Major Events Blue EPO plan was designed to provide you with basic coverage at an affordable cost. You get the protection you need in case of an emergency, serious illness, or accident, and your first three visits to your primary care doctor—and certain preventive services—are covered at no cost.

Shared Cost Blue EPOPlans have copays with coverage for some services right from the start. For other services, you need to meet your deductible before we pay for your care. These plans are offered at three ACA metal levels—Bronze, Silver, and Gold—to give you a wide range of deductible levels from which to choose. See page 10 for a description of metal levels.

Health Savings Embedded Blue EPOPlans are qualified high deductible health plans and may be coupled with a Health Savings Account (HSA) that offers tax and savings advantages. Other than preventive care, you will pay most costs until your deductible is met. After that, Highmark Delaware pays most of the plan allowance for covered in-network care for the remainder of the benefit period.

Please note: Certain cost-sharing reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA. If you have questions, please check with your financial advisor.

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How to Find Out if Your Provider is In-Network: 3 Easy Ways Doctors, hospitals, and pharmacies in-networks often change. That’s why it is very important to make sure your provider and/or facility are in-network before choosing an insurance plan or going for services. That way, you’ll avoid surprises—and unexpected costs.

If you go to an out-of-network doctor, pharmacy, hospital, or other provider, you will have to pay 100% of the cost, except in the case of emergency care. Your services may not be covered by Highmark Delaware.

NATIONWIDE ACCESS TO CARE WITH BLUECARD®Wherever you go nationwide as a Highmark Delaware member, you have access to in-network providers.

Just show your Highmark Delaware ID card at the thousands of participating physicians and hospitals across the country and you’ll receive in-network access away from home.

BE WELL-INFORMED Choose a Network Primary Care Provider

Find a Doctor or RxIt’s quick and easy to find an in-network provider or facility. Search online by plan type to make sure your doctor, specialist, or hospital is in-network. See maps, office hours, quality ratings, member reviews, and more. Visit HighmarkBCBSDE.com and click Find a Doctor or Rx to get started.

It’s easy to check which prescribed drugs are covered under your 2019 insurance plan. View Highmark Delaware’s online Rx drug listing (or formulary) at HighmarkBCBSDE.com and click Find a Doctor or Rx.

GET MORE FROM YOUR HIGHMARK DELAWARE PLAN – CHOOSE AN IN-NETWORK PRIMARY CARE PROVIDER (PCP) Even when you’re healthy, having an in-network PCP feels great. A PCP is the doctor, medical professional, or practice that you visit for your primary and routine health care services, such as physicals and immunizations. The Journal of Health Affairs has found that people with PCPs enjoy lower overall health care costs and higher satisfaction with their care.

A PCP CAN HELP YOU:• Get the most value from your health

care dollar

• Achieve health goals

• Monitor chronic health conditions

• Make sure you receive preventive care, like annual exams

• Coordinate the care you receive from other providers, such as specialists, labs, and imaging centers, to prevent gaps or overlaps in service

• Improve your patient experience

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My Care NavigatorIs your doctor in-network? My Care Navigator health advocates make it easy for you to find or change to an in-network doctor or facility, schedule an appointment, and transfer your medical records. Call 1-888-BLUE-428 or visit MyCareNavigator.com.

Highmark Delaware Member ServiceAlready a Highmark Delaware member? You probably know the value of great customer service from our Member Service area. By calling the number on the back of your Highmark Delaware ID card, our dedicated team can also help find you an in-network doctor or facility.

IMPORTANT: 2019 Changes to the Prescription Drug ListPrescription drugs are an important part of your coverage. The list of the drugs that your plan covers is called a “formulary.”

As you choose a plan for 2019, be well-informed and avoid surprises. Be sure to check to see if your prescription drugs will be covered.

Highmark plans use the Essential Formulary which groups drugs into four levels or “tiers.” Each tier may include generic, brand-name and/or specialty drugs. If your doctor prescribes a drug that is not included in the Essential Formulary, you may have to pay 100% out of pocket, unless an exception is granted.

BE WELL-INFORMED Review Your Prescription Drug List

It’s easy to check how your prescription drugs are covered—visit HighmarkEssentialFormulary.com.

Tier 1 Tier 2 Tier 3 Tier 4

Low-Cost Generics Medium-Cost Generics &

Low-Cost Brands

High-Cost Generics & Medium/High-Cost

Brands

High-Cost Generics & High-Cost Brands

Essential Formulary - 4 Tiers of Drugs

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Ask yourself these important questions before choosing a plan!

• Is my doctor in-network?

• Is my hospital in-network?

• At what tier are my prescription drugs covered and how much will they cost?

• Can I get financial help through the Marketplace?

• Would I rather have lower monthly premiums or lower copays?

• Should I open a Health Savings Account (HSA) to manage out-of-pocket costs?

Highmark Delaware offers you the support you need to answer these questions and more. We want you to have the plan that works best for your needs—so you can be ready for anything.

Metal Levels and Essential Health BenefitsWhen you are shopping for one of Highmark Delaware’s Affordable Care Act (ACA) health insurance plans, it’s important to know about metal levels and essential health benefits.

Metal Levels Highmark Delaware’s Affordable Care Act health plans are grouped in metal categories: Bronze, Silver, and Gold. These levels are based on how you and your health plan split the costs of your health care. They are simply ways to categorize plan payment levels. They do not describe the quality of care you receive.

Essential Health BenefitsAll Highmark Delaware plans include these essential health benefits:

• Ambulatory services, such as primary care and specialist visits

• Maternity and newborn care

• Emergency services

• Prescription drugs, including retail and mail order

• Pediatric services, including dental and vision care

• Mental health and substance abuse services

• Rehabilitative and habilitative services and devices

• Hospitalization

• Laboratory services

• Preventive and wellness services, and chronic disease management

BE PREPARED Before You Choose

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BE PREPARED Before You Choose

You’ll need these documents for yourself and every family member you want to enroll: • Social Security numbers (or documents for legal immigrants)

• Birth dates

• Pay stubs, W-2 forms, or wage and tax statements—to determine your income

• Policy numbers for any current health insurance

• Information about any health insurance you or your family could get from your job

You May Qualify for Financial Help. It’s Easy to Check.Many people who buy insurance through the Marketplace are pleased to learn they can get help paying for insurance. Before you enroll, you should find out if you can get this help to lower the cost of your monthly premium. To start, check the 2019 Household Income Chart below.

You may qualify for one or both kinds of financial help:

• Advanced Premium Tax Credits (APTC), which may be applied—in advance—to lower what you pay each month for your premium on any Marketplace metal-level plan.

• Cost-Sharing Reductions (CSR)* will lower out-of-pocket costs that you may pay at the time of service for doctor visits, lab tests, drugs, and other covered services. You can only get these savings if you enroll in a Marketplace Silver metal-level plan.

Eligibility for financial help can only be determined through the Marketplace at HealthCare.gov.

This chart is only applicable for coverage in 2019 and in the 48 contiguous states and the District of Columbia. For families/households with more than 8 persons, add $4,180 for each additional person. HHS Poverty Guidelines for 2018 (January 31, 2018). Retrieved from https://aspe.hhs.gov/poverty-guidelines 10-25-18

*American Indians and Alaska Natives who are members of federally recognized tribes are eligible for cost-sharing reductions at alternative dollar thresholds.

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Cost-Sharing Reductions (CSR)

$12,140 - $30,350

$16,460 - $41,150

$20,780 - $51,950

$25,100 - $62,750

$29,420 - $73,550

$33,740 - $84,350

$38,060 - $95,150

$42,380 - $105,950

Advanced Premium Tax

Credits (APTC)

$12,140 - $48,560

$16,460 - $65,840

$20,780 - $83,120

$25,100 - $100,400

$29,420 - $117,680

$33,740 - $134,960

$38,060 - $152,240

$42,380 - $169,520

Medicaid Eligible Range

(100-138% or less FPL)

$12,140 - $16,753

$16,460 - $22,715

$20,780 - $28,676

$25,100 - $34,638

$29,420 - $40,600

$33,740 - $46,561

$38,060 - $52,523

$42,380 - $58,484

Persons In Family / Household2019 Household Income

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BE KNOWLEDGEABLE With Base Plan Options by County

2019 PLAN BENEFIT GRIDSThere's a lot to know and do when it comes to picking the right plan for you and your family.

If you are looking for more medical plan details, visit Highmark-SBC2019.com to find each plan’s Summary of Benefits and Coverage. If you do not have online access, you can get a paper copy of any Summary of Benefits free of charge by calling Highmark Delaware toll-free at 1-855-822-6925 (TTY/TDD 711).

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Formulary- Essential (Drug List) Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply) 0% after deductible 0% after deductible 0% after deductible 0% after deductible

Prescription Drug Coverage Mail (90 days supply) 0% after deductible 0% after deductible 0% after deductible 0% after deductible

Available in the following counties: Kent, New Castle, Sussex

CATASTROPHIC MAJOR EVENTS BLUE EPO 7900 On-Exchange Base Plan ID: 76168DE0400001-01 Off-Exchange Base Plan ID: 76168DE0400001-00

The chart below shows in-network and out-of-network costs for all categories as a member. Benefit In-Network Out-of-Network

Preventive Testing & Screenings Covered in full*

Preventive care includes services such as childhood immunizations, annual wellness exams, mammography screenings, and flu shots. Office visit copay may apply for some screenings.

No Coverage

Deductible and Out-of-Pocket Costs Deductible (Individual) $7,900

No Coverage Deductible-Aggregate (Family) $15,800 Out of Pocket Maximum (Individual) $7,900 Out of Pocket Maximum- Aggregate (Family) $15,800

Office/Clinic/Telemedicine Visits

Primary Care or Retail Clinic Office Visits 0% first 3 visits then 0% after deductible

No Coverage Specialist Office & Virtual Visits 0% after deductible Outpatient Mental Health Visits 0% after deductible Telemedicine Service 0% after deductible

Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient 0% after deductible

No Coverage Hospital Outpatient 0% after deductible Inpatient Hospital Maternity 0% after deductible Medical Care and Surgical Expenses 0% after deductible

Emergency Services Urgent Care Center Visits 0% after deductible No Coverage Emergency Room Services 0% after deductible 0% after deductible

Therapy, Rehabilitative and Habilitative Services Physical Therapy (Rehabilitative and Habilitative) 0% after deductibleSpeech & Occupational Therapy (Rehabilitative and Habilitative) 0% after deductible No Coverage Chiropractor Services 0% after deductible

Diagnostic Services Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing)

0% after deductible

Advanced Imaging (MRI, CAT, PET scan, etc.) 0% after deductible No Coverage Lab/Pathology 0% after deductible

Prescription Drugs

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BRONZE SHARED COST BLUE EPO BRONZE 7900 On-Exchange Base Plan ID: 76168DE0410018-01 Off-Exchange Base Plan ID: 76168DE0410018-00




No Coverage



Office/Clinic/Telemedicine Visits Primary Care or Retail Clinic Office Visits 0% after deductible

No Coverage

Specialist Office & Virtual Visits 0% after deductible

Outpatient Mental Health Visits 0% first 2 visits then

then 0% after deductible

Telemedicine Service 0% after deductible Hospital and Medical/Surgical Expenses (including maternity)

Hospital Inpatient 0% after deductible



Therapy, Rehabilitative and Habilitative Services Physical Therapy (Rehabilitative and Habilitative) 0% after deductible Speech & Occupational Therapy (Rehabilitative and Habilitative) 0% after deductible No Coverage Chiropractor Services 0% after deductible

Diagnostic Services Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 0% after deductible


Prescription Drugs

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Available in the following counties: Kent, New Castle, Sussex SHARED COST BLUE EPO BRONZE 4000 BRONZE On Exchange Base Plan ID: 76168DE0410010-01 Off Exchange Base Plan ID: 76168DE0410010-00




No Coverage



Office/Clinic/Telemedicine Visits Primary Care or Retail Clinic Office Visits $60 copay

No Coverage Specialist Office & Virtual Visits 30% after deductible

Outpatient Mental Health Visits 0% first 2 visits then 30% after deductible

Telemedicine Service $25 copay Hospital and Medical/Surgical Expenses (including maternity)






30% after deductible


Prescription Drugs

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SILVER HEALTH SAVINGS EMBEDDED BLUE EPO SILVER 4450 HSA On-Exchange Base Plan ID: 76168DE0420004-01 Off-Exchange Base Plan ID: 76168DE0420004-00




No Coverage


No Coverage Deductible-Embedded (Family) $8,900 Out of Pocket Maximum (Individual) $6,650 Out of Pocket Maximum- Embedded (Family) $13,300










Prescription Drugs

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Formulary- Essential (Drug List) Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply)

15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)

Prescription Drug Coverage Mail (90 days supply)

15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)


SILVER SHARED COST BLUE EPO SILVER 2400 - 2 FREE PCP VISITS On-Exchange Base Plan ID: 76168DE0410013-01 Off-Exchange Base Plan ID: 76168DE0410013-00




No Coverage




Primary Care or Retail Clinic Office Visits $0 first 2 visits then $40 copay

No Coverage Specialist Office & Virtual Visits $90 copay

Outpatient Mental Health Visits $0 first 2 visits then $90 copay




Emergency Services Urgent Care Center Visits $90 copay No Coverage

Emergency Room Services (Copay Waived if Admitted) $750 copay after deductible

$750 copay after deductible

Therapy, Rehabilitative and Habilitative Services Physical Therapy (Rehabilitative and Habilitative) $90 copay Speech & Occupational Therapy (Rehabilitative and Habilitative) $90 copay No Coverage Chiropractor Services 25% after deductible

Diagnostic Services Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) $90 copay


Prescription Drugs

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15% 25% 35% 50%


15% 25% 35% 50%


SILVER SHARED COST BLUE EPO SILVER 0 On-Exchange Base Plan ID: 76168DE0410020-01 Off-Exchange Base Plan ID: 76168DE0410020-00




No Coverage

Deductible and Out-of-Pocket Costs Deductible (Individual) $0

No Coverage Deductible-Aggregate (Family) $0 Out of Pocket Maximum (Individual) $7,800 Out of Pocket Maximum- Aggregate (Family) $15,600

Office/Clinic/Telemedicine Visits Primary Care or Retail Clinic Office Visits $40 copay




Hospital Inpatient $3,900 copay per day (Two Day Max)

No Coverage Hospital Outpatient 40%

Inpatient Hospital Maternity $3,900 copay per day (Two Day Max)

Medical Care and Surgical Expenses 40% Emergency Services

Urgent Care Center Visits $90 copay No Coverage Emergency Room Services (Copay Waived if Admitted) $1,400 copay $1,400 copay

Therapy, Rehabilitative and Habilitative Services Physical Therapy (Rehabilitative and Habilitative) $90 copay Speech & Occupational Therapy (Rehabilitative and Habilitative) $90 copay No Coverage Chiropractor Services 25%


Advanced Imaging (MRI, CAT, PET scan, etc.) 40% No Coverage Lab/Pathology 40%

Prescription Drugs

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15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)


15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)


SHARED COST BLUE EPO GOLD 1000 - 2 FREE PCP VISITS GOLD On Exchange Base Plan ID: 76168DE0410012-01 Off Exchange Base Plan ID: 76168DE0410012-00




No Coverage




Primary Care or Retail Clinic Office Visits $0 copay first 2 visits then $20 copay


Outpatient Mental Health Visits $0 copay first 2 visits then $45 copay





Emergency Room Services (Copay Waived if Admitted) $500 copay after deductible





Prescription Drugs

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15%(No deductible)

25%(No deductible)

35%(No deductible)

50% (No deductible)


15%(No deductible)

25%(No deductible)

35%(No deductible)

50% (No deductible)


PLATINUM SHARED COST BLUE EPO PLATINUM 200 - 2 FREE PCP VISITS On-Exchange Base Plan ID: 76168DE0410021-01 Off-Exchange Base Plan ID: 76168DE0410021-00




No Coverage

Deductible and Out-of-Pocket Costs Deductible (Individual) $200

No Coverage Deductible-Aggregate (Family) $400 Out of Pocket Maximum (Individual) $6,000 Out of Pocket Maximum- Aggregate (Family) $12,000


Primary Care or Retail Clinic Office Visits $0 first 2 visits Then $5 copay






Emergency Services Urgent Care Center Visits $10 copay No Coverage Emergency Room Services (Copay Waived if Admitted) $300 copay $300 copay




Prescription Drugs

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The following Highmark plan options are not available on the Marketplace and may be purchased directly through Highmark without financial help in Delaware:

• Shared Cost Blue EPO Silver 3500 - 2 Free PCP Visits

• Health Savings Embedded Blue EPO Silver 2750 HSA

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Formulary‐ Essential (Drug List) Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply)

15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)


15% (No deductible)

25% (No deductible)

35% (No deductible)

50% (No deductible)

Available in the following Counties: Kent, New Castle, Sussex

SHARED COST BLUE EPO SILVER 3500 ‐ 2 FREE PCP VISITS SILVER Off‐Exchange Base Plan ID: 76168DE0410019‐00

The chart below shows in‐network and out‐of‐network costs for all categories as a member. Benefit In‐Network Out‐of‐Network



No Coverage

Deductible and Out of Pocket Costs Deductible (Individual) $3,500

No Coverage Deductible‐Aggregate (Family) $7,000 Out of Pocket Maximum (Individual) $7,700 Out of Pocket Maximum (Family) $15,400


Primary Care or Retail Clinic Office Visits $0 first 2 visits then $50 copay







Emergency Room Services (Copay Waived if Admitted $700 copay after deductible


Therapy, Rehabilitative and Habilitative Services Physical & Occupational Therapy (Rehabilitative and Habilitative) $100 copay Speech Therapy (Rehabilitative and Habilitative) $100 copay No Coverage Chiropractor Services 25% after deductible



Prescription Drugs

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Formulary‐ Essential (Drug List) Tiers Tier 1 Tier 2 Tier 3 Tier 4 Prescription Drug Coverage Retail (31 days supply)











HEALTH SAVINGS EMBEDDED BLUE EPO SILVER 2750 HSA SILVER Off‐Exchange Base Plan ID: 76168DE0420005‐00

The chart below shows in‐network and out‐of‐network costs for all categories as a member. Benefit In‐Network Out‐of‐Network



No Coverage

Deductible and Out of Pocket Costs Deductible (Individual) $2,750

No Coverage Deductible‐Embedded (Family) $5,500 Out of Pocket Maximum (Individual) $6,650 Out of Pocket Maximum (Family) $13,300






Therapy, Rehabilitative and Habilitative Services Physical & Occupational Therapy (Rehabilitative and Habilitative) 20% after deductible Speech Therapy (Rehabilitative and Habilitative) 20% after deductible No Coverage Chiropractor Services 20% after deductible

Diagnostic Services Basic Diagnostic Services (standard imaging, diagnostic medical, allergy testing) 20% after deductible

Advanced Imaging (MRI, CAT, PET scan, etc.) 20% after deductible No Coverage Lab/Pathology

Prescription Drugs

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Understand How Your Monthly Premium Is Calculated At Highmark Delaware, we want you to trust in the value of your health care coverage. To help you understand how we calculate the price you pay, we have included a guide to rates on pages 25-27. The premium rate listed is the most a person* will pay for their premium each month.

Find Your Premium By:• The Highmark Delaware plan you wish

to purchase

• Your age—and the age of each dependent on your plan

• Your tobacco use—and the tobacco use of each dependent on your plan

BE KNOWLEDGEABLE with Monthly Premiums

If You Have More Than Three Children Under Age 21: Only include rates for you, your spouse/domestic partner, children between ages 21 and 26, and the three oldest children under age 21. Your policy will also cover your remaining children. Please include them as eligible dependents when you enroll.

*If you are also enrolling family members, you will need to get the base rate for each member of your family. Add these base rates together to get the rate that covers the family members on your plan.

25

Plan IDAge No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco0-14 233.25$ 233.25$ 268.91$ 268.91$ 286.45$ 286.45$ 395.02$ 395.02$ 15 253.98$ 253.98$ 292.82$ 292.82$ 311.91$ 311.91$ 430.13$ 430.13$ 16 261.91$ 261.91$ 301.96$ 301.96$ 321.64$ 321.64$ 443.55$ 443.55$ 17 269.84$ 269.84$ 311.10$ 311.10$ 331.38$ 331.38$ 456.98$ 456.98$ 18 278.37$ 278.37$ 320.94$ 320.94$ 341.86$ 341.86$ 471.44$ 471.44$ 19 286.91$ 286.91$ 330.78$ 330.78$ 352.35$ 352.35$ 485.89$ 485.89$ 20 295.75$ 295.75$ 340.97$ 340.97$ 363.21$ 363.21$ 500.87$ 500.87$ 21 304.90$ 312.52$ 351.52$ 360.31$ 374.44$ 383.80$ 516.36$ 529.27$ 22 304.90$ 312.52$ 351.52$ 360.31$ 374.44$ 383.80$ 516.36$ 529.27$ 23 304.90$ 312.52$ 351.52$ 360.31$ 374.44$ 383.80$ 516.36$ 529.27$ 24 304.90$ 312.52$ 351.52$ 360.31$ 374.44$ 383.80$ 516.36$ 529.27$ 25 306.12$ 313.77$ 352.93$ 361.75$ 375.94$ 385.34$ 518.43$ 531.39$ 26 312.22$ 320.03$ 359.96$ 368.96$ 383.43$ 393.02$ 528.75$ 541.97$ 27 319.54$ 327.53$ 368.39$ 377.60$ 392.41$ 402.22$ 541.15$ 554.68$ 28 331.43$ 339.72$ 382.10$ 391.65$ 407.02$ 417.20$ 561.28$ 575.31$ 29 341.18$ 349.71$ 393.35$ 403.18$ 419.00$ 429.48$ 577.81$ 592.26$ 30 346.06$ 354.71$ 398.98$ 408.95$ 424.99$ 435.61$ 586.07$ 600.72$ 31 353.38$ 362.21$ 407.41$ 417.60$ 433.98$ 444.83$ 598.46$ 613.42$ 32 360.70$ 369.72$ 415.85$ 426.25$ 442.96$ 454.03$ 610.85$ 626.12$ 33 365.27$ 374.40$ 421.12$ 431.65$ 448.58$ 459.79$ 618.60$ 634.07$ 34 370.15$ 379.40$ 426.75$ 437.42$ 454.57$ 465.93$ 626.86$ 642.53$ 35 372.59$ 381.90$ 429.56$ 440.30$ 457.57$ 469.01$ 630.99$ 646.76$ 36 375.03$ 384.41$ 432.37$ 443.18$ 460.56$ 472.07$ 635.12$ 651.00$ 37 377.47$ 386.91$ 435.18$ 446.06$ 463.56$ 475.15$ 639.25$ 655.23$ 38 379.91$ 389.41$ 437.99$ 448.94$ 466.55$ 478.21$ 643.38$ 659.46$ 39 384.78$ 394.40$ 443.62$ 454.71$ 472.54$ 484.35$ 651.65$ 667.94$ 40 389.66$ 428.63$ 449.24$ 494.16$ 478.53$ 526.38$ 659.91$ 725.90$ 41 396.98$ 438.66$ 457.68$ 505.74$ 487.52$ 538.71$ 672.30$ 742.89$ 42 403.99$ 449.24$ 465.76$ 517.93$ 496.13$ 551.70$ 684.18$ 760.81$ 43 413.75$ 463.81$ 477.01$ 534.73$ 508.12$ 569.60$ 700.70$ 785.48$ 44 425.95$ 482.18$ 491.07$ 555.89$ 523.09$ 592.14$ 721.35$ 816.57$ 45 440.28$ 504.12$ 507.59$ 581.19$ 540.69$ 619.09$ 745.62$ 853.73$ 46 457.35$ 530.53$ 527.28$ 611.64$ 561.66$ 651.53$ 774.54$ 898.47$ 47 476.56$ 560.91$ 549.43$ 646.68$ 585.25$ 688.84$ 807.07$ 949.92$ 48 498.51$ 596.22$ 574.74$ 687.39$ 612.21$ 732.20$ 844.25$ 1,009.72$ 49 520.16$ 633.03$ 599.69$ 729.82$ 638.79$ 777.41$ 880.91$ 1,072.07$ 50 544.55$ 667.07$ 627.81$ 769.07$ 668.75$ 819.22$ 922.22$ 1,129.72$ 51 568.64$ 696.58$ 655.58$ 803.09$ 698.33$ 855.45$ 963.01$ 1,179.69$ 52 595.16$ 729.07$ 686.17$ 840.56$ 730.91$ 895.36$ 1,007.93$ 1,234.71$ 53 622.00$ 761.95$ 717.10$ 878.45$ 763.86$ 935.73$ 1,053.37$ 1,290.38$ 54 650.96$ 797.43$ 750.50$ 919.36$ 799.43$ 979.30$ 1,102.43$ 1,350.48$ 55 679.93$ 832.91$ 783.89$ 960.27$ 835.00$ 1,022.88$ 1,151.48$ 1,410.56$ 56 711.33$ 871.38$ 820.10$ 1,004.62$ 873.57$ 1,070.12$ 1,204.67$ 1,475.72$ 57 743.04$ 910.22$ 856.65$ 1,049.40$ 912.51$ 1,117.82$ 1,258.37$ 1,541.50$ 58 776.89$ 951.69$ 895.67$ 1,097.20$ 954.07$ 1,168.74$ 1,315.69$ 1,611.72$ 59 793.65$ 972.22$ 915.01$ 1,120.89$ 974.67$ 1,193.97$ 1,344.09$ 1,646.51$ 60 827.50$ 1,013.69$ 954.03$ 1,168.69$ 1,016.23$ 1,244.88$ 1,401.40$ 1,716.72$ 61 856.77$ 1,049.54$ 987.77$ 1,210.02$ 1,052.18$ 1,288.92$ 1,450.97$ 1,777.44$ 62 875.98$ 1,073.08$ 1,009.92$ 1,237.15$ 1,075.77$ 1,317.82$ 1,483.50$ 1,817.29$ 63 900.06$ 1,102.57$ 1,037.69$ 1,271.17$ 1,105.35$ 1,354.05$ 1,524.29$ 1,867.26$ 64 914.70$ 1,120.51$ 1,054.56$ 1,291.84$ 1,123.32$ 1,376.07$ 1,549.08$ 1,897.62$

65+ 914.70$ 1,120.51$ 1,054.56$ 1,291.84$ 1,123.32$ 1,376.07$ 1,549.08$ 1,897.62$

76168DE0400001 76168DE041001076168DE0410018 76168DE0420004

Major Events Blue EPO 7900

Shared Cost Blue EPO Bronze 4000

Shared Cost Blue EPO Bronze 7900

Health Savings Embedded Blue EPO Silver 4450 HSA

Catastrophic Bronze Bronze Silver


PREMIUM RATE PLANS

(Use the Plan ID to find your plan on the Marketplace.)

26

Plan IDAge No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco No Tobacco Tobacco0-14 409.80$ 409.80$ 427.86$ 427.86$ 402.29$ 402.29$ 467.02$ 467.02$ 15 446.22$ 446.22$ 465.89$ 465.89$ 438.05$ 438.05$ 508.53$ 508.53$ 16 460.15$ 460.15$ 480.43$ 480.43$ 451.72$ 451.72$ 524.40$ 524.40$ 17 474.08$ 474.08$ 494.97$ 494.97$ 465.39$ 465.39$ 540.27$ 540.27$ 18 489.08$ 489.08$ 510.63$ 510.63$ 480.12$ 480.12$ 557.37$ 557.37$ 19 504.07$ 504.07$ 526.29$ 526.29$ 494.84$ 494.84$ 574.46$ 574.46$ 20 519.61$ 519.61$ 542.51$ 542.51$ 510.09$ 510.09$ 592.17$ 592.17$ 21 535.68$ 549.07$ 559.29$ 573.27$ 525.87$ 539.02$ 610.48$ 625.74$ 22 535.68$ 549.07$ 559.29$ 573.27$ 525.87$ 539.02$ 610.48$ 625.74$ 23 535.68$ 549.07$ 559.29$ 573.27$ 525.87$ 539.02$ 610.48$ 625.74$ 24 535.68$ 549.07$ 559.29$ 573.27$ 525.87$ 539.02$ 610.48$ 625.74$ 25 537.82$ 551.27$ 561.53$ 575.57$ 527.97$ 541.17$ 612.92$ 628.24$ 26 548.54$ 562.25$ 572.71$ 587.03$ 538.49$ 551.95$ 625.13$ 640.76$ 27 561.39$ 575.42$ 586.14$ 600.79$ 551.11$ 564.89$ 639.78$ 655.77$ 28 582.28$ 596.84$ 607.95$ 623.15$ 571.62$ 585.91$ 663.59$ 680.18$ 29 599.43$ 614.42$ 625.85$ 641.50$ 588.45$ 603.16$ 683.13$ 700.21$ 30 608.00$ 623.20$ 634.79$ 650.66$ 596.86$ 611.78$ 692.89$ 710.21$ 31 620.85$ 636.37$ 648.22$ 664.43$ 609.48$ 624.72$ 707.55$ 725.24$ 32 633.71$ 649.55$ 661.64$ 678.18$ 622.10$ 637.65$ 722.20$ 740.26$ 33 641.74$ 657.78$ 670.03$ 686.78$ 629.99$ 645.74$ 731.36$ 749.64$ 34 650.32$ 666.58$ 678.98$ 695.95$ 638.41$ 654.37$ 741.12$ 759.65$ 35 654.60$ 670.97$ 683.45$ 700.54$ 642.61$ 658.68$ 746.01$ 764.66$ 36 658.89$ 675.36$ 687.93$ 705.13$ 646.82$ 662.99$ 750.89$ 769.66$ 37 663.17$ 679.75$ 692.40$ 709.71$ 651.03$ 667.31$ 755.77$ 774.66$ 38 667.46$ 684.15$ 696.88$ 714.30$ 655.23$ 671.61$ 760.66$ 779.68$ 39 676.03$ 692.93$ 705.82$ 723.47$ 663.65$ 680.24$ 770.43$ 789.69$ 40 684.60$ 753.06$ 714.77$ 786.25$ 672.06$ 739.27$ 780.19$ 858.21$ 41 697.46$ 770.69$ 728.20$ 804.66$ 684.68$ 756.57$ 794.84$ 878.30$ 42 709.78$ 789.28$ 741.06$ 824.06$ 696.78$ 774.82$ 808.89$ 899.49$ 43 726.92$ 814.88$ 758.96$ 850.79$ 713.61$ 799.96$ 828.42$ 928.66$ 44 748.34$ 847.12$ 781.33$ 884.47$ 734.64$ 831.61$ 852.84$ 965.41$ 45 773.52$ 885.68$ 807.61$ 924.71$ 759.36$ 869.47$ 881.53$ 1,009.35$ 46 803.52$ 932.08$ 838.94$ 973.17$ 788.81$ 915.02$ 915.72$ 1,062.24$ 47 837.27$ 985.47$ 874.17$ 1,028.90$ 821.93$ 967.41$ 954.18$ 1,123.07$ 48 875.84$ 1,047.50$ 914.44$ 1,093.67$ 859.80$ 1,028.32$ 998.13$ 1,193.76$ 49 913.87$ 1,112.18$ 954.15$ 1,161.20$ 897.13$ 1,091.81$ 1,041.48$ 1,267.48$ 50 956.72$ 1,171.98$ 998.89$ 1,223.64$ 939.20$ 1,150.52$ 1,090.32$ 1,335.64$ 51 999.04$ 1,223.82$ 1,043.08$ 1,277.77$ 980.75$ 1,201.42$ 1,138.55$ 1,394.72$ 52 1,045.65$ 1,280.92$ 1,091.73$ 1,337.37$ 1,026.50$ 1,257.46$ 1,191.66$ 1,459.78$ 53 1,092.79$ 1,338.67$ 1,140.95$ 1,397.66$ 1,072.77$ 1,314.14$ 1,245.38$ 1,525.59$ 54 1,143.68$ 1,401.01$ 1,194.08$ 1,462.75$ 1,122.73$ 1,375.34$ 1,303.37$ 1,596.63$ 55 1,194.57$ 1,463.35$ 1,247.22$ 1,527.84$ 1,172.69$ 1,436.55$ 1,361.37$ 1,667.68$ 56 1,249.74$ 1,530.93$ 1,304.82$ 1,598.40$ 1,226.85$ 1,502.89$ 1,424.25$ 1,744.71$ 57 1,305.45$ 1,599.18$ 1,362.99$ 1,669.66$ 1,281.55$ 1,569.90$ 1,487.74$ 1,822.48$ 58 1,364.91$ 1,672.01$ 1,425.07$ 1,745.71$ 1,339.92$ 1,641.40$ 1,555.50$ 1,905.49$ 59 1,394.38$ 1,708.12$ 1,455.83$ 1,783.39$ 1,368.84$ 1,676.83$ 1,589.08$ 1,946.62$ 60 1,453.84$ 1,780.95$ 1,517.91$ 1,859.44$ 1,427.21$ 1,748.33$ 1,656.84$ 2,029.63$ 61 1,505.26$ 1,843.94$ 1,571.60$ 1,925.21$ 1,477.69$ 1,810.17$ 1,715.45$ 2,101.43$ 62 1,539.01$ 1,885.29$ 1,606.84$ 1,968.38$ 1,510.82$ 1,850.75$ 1,753.91$ 2,148.54$ 63 1,581.33$ 1,937.13$ 1,651.02$ 2,022.50$ 1,552.37$ 1,901.65$ 1,802.14$ 2,207.62$ 64 1,607.04$ 1,968.62$ 1,677.87$ 2,055.39$ 1,577.61$ 1,932.57$ 1,831.44$ 2,243.51$

65+ 1,607.04$ 1,968.62$ 1,677.87$ 2,055.39$ 1,577.61$ 1,932.57$ 1,831.44$ 2,243.51$

Shared Cost Blue EPO Platinum 200 - 2 Free PCP

Visits76168DE0410021

Shared Cost Blue EPO Gold 1000 - 2 Free PCP Visits

76168DE0410013 76168DE0410020 76168DE0410012

Shared Cost Blue EPO Silver 2400 - 2 Free PCP Visits

Shared Cost Blue EPO Silver 0

Silver Gold PlatinumSilver


PREMIUM RATE PLANS

(Use the Plan ID to find your plan on the Marketplace.)

27

Plan IDAge No Tobacco Tobacco No Tobacco Tobacco0-14 335.80$ 335.80$ 341.28$ 341.28$ 15 365.65$ 365.65$ 371.62$ 371.62$ 16 377.07$ 377.07$ 383.22$ 383.22$ 17 388.48$ 388.48$ 394.82$ 394.82$ 18 400.77$ 400.77$ 407.31$ 407.31$ 19 413.06$ 413.06$ 419.80$ 419.80$ 20 425.79$ 425.79$ 432.74$ 432.74$ 21 438.96$ 449.93$ 446.12$ 457.27$ 22 438.96$ 449.93$ 446.12$ 457.27$ 23 438.96$ 449.93$ 446.12$ 457.27$ 24 438.96$ 449.93$ 446.12$ 457.27$ 25 440.72$ 451.74$ 447.90$ 459.10$ 26 449.50$ 460.74$ 456.83$ 468.25$ 27 460.03$ 471.53$ 467.53$ 479.22$ 28 477.15$ 489.08$ 484.93$ 497.05$ 29 491.20$ 503.48$ 499.21$ 511.69$ 30 498.22$ 510.68$ 506.35$ 519.01$ 31 508.75$ 521.47$ 517.05$ 529.98$ 32 519.29$ 532.27$ 527.76$ 540.95$ 33 525.87$ 539.02$ 534.45$ 547.81$ 34 532.90$ 546.22$ 541.59$ 555.13$ 35 536.41$ 549.82$ 545.16$ 558.79$ 36 539.92$ 553.42$ 548.73$ 562.45$ 37 543.43$ 557.02$ 552.30$ 566.11$ 38 546.94$ 560.61$ 555.87$ 569.77$ 39 553.97$ 567.82$ 563.00$ 577.08$ 40 560.99$ 617.09$ 570.14$ 627.15$ 41 571.53$ 631.54$ 580.85$ 641.84$ 42 581.62$ 646.76$ 591.11$ 657.31$ 43 595.67$ 667.75$ 605.38$ 678.63$ 44 613.23$ 694.18$ 623.23$ 705.50$ 45 633.86$ 725.77$ 644.20$ 737.61$ 46 658.44$ 763.79$ 669.18$ 776.25$ 47 686.09$ 807.53$ 697.29$ 820.71$ 48 717.70$ 858.37$ 729.41$ 872.37$ 49 748.87$ 911.37$ 761.08$ 926.23$ 50 783.98$ 960.38$ 796.77$ 976.04$ 51 818.66$ 1,002.86$ 832.01$ 1,019.21$ 52 856.85$ 1,049.64$ 870.83$ 1,066.77$ 53 895.48$ 1,096.96$ 910.08$ 1,114.85$ 54 937.18$ 1,148.05$ 952.47$ 1,166.78$ 55 978.88$ 1,199.13$ 994.85$ 1,218.69$ 56 1,024.09$ 1,254.51$ 1,040.80$ 1,274.98$ 57 1,069.75$ 1,310.44$ 1,087.19$ 1,331.81$ 58 1,118.47$ 1,370.13$ 1,136.71$ 1,392.47$ 59 1,142.61$ 1,399.70$ 1,161.25$ 1,422.53$ 60 1,191.34$ 1,459.39$ 1,210.77$ 1,483.19$ 61 1,233.48$ 1,511.01$ 1,253.60$ 1,535.66$ 62 1,261.13$ 1,544.88$ 1,281.70$ 1,570.08$ 63 1,295.81$ 1,587.37$ 1,316.95$ 1,613.26$ 64 1,316.88$ 1,613.18$ 1,338.36$ 1,639.49$

65+ 1,316.88$ 1,613.18$ 1,338.36$ 1,639.49$

Silver

Shared Cost Blue EPO Silver 3500 - 2 Free PCP Visits

76168DE0410019

Silver

Health Savings Embedded Blue EPO silver 2750 HSA

76168DE0420005

PREMIUM RATES FOR YOUR COUNTY

These plans are only available directly through Highmark in Delaware. They are not available on the Marketplace.

28

BlueCard – A national program that enables Blue Plan members to obtain healthcare services while traveling or living in another Blue Plan’s service area. The program links participating healthcare providers with independent Blue Plans across the country and in more than 200 countries and territories worldwide. The level of BlueCard access is dependent upon your plan’s details. Refer to your plan documents for additional information.

Coinsurance – The costs of your care are shared between you and the insurance company. Coinsurance is the part of your medical bill that you pay after reaching your deductible. So if your medical bill for covered, in-network services is $100 and your coinsurance is 20%, you pay $20. The insurance company pays $80.

Copay or Copayment – A fixed dollar amount (like $25) that you pay each time you receive certain covered health care services.

Deductible – The amount of money you must pay for health care services before your health plan starts to pay.

• An embedded or aggregate deductible has two parts: an individual deductible and a family deductible. Each family member can meet but not exceed his/her own deductible before the family deductible is met. (Individual deductibles add up to meet the family deductible.)

Emergency Medical Condition – An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Room Care – Emergency services you receive in an emergency room.

Emergency Services – Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

EPO (Exclusive Provider Organization) – A health plan that provides benefits when care is received from network providers. Out-of-network care is not covered (except in an emergency).

Formulary – A list of prescription drugs covered by your health plan. In a tiered drug formulary, drugs are assigned a level or tier. Each tier has a different copay or coinsurance. You usually pay less when your doctor prescribes drugs in the lower tiers.

Habilitative Services- Health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

High Deductible Health Plan (HDHP) – These plans have higher deductibles than traditional health plans. Qualified HDHPs may be combined with a health savings account (HSA) that you can fund with tax-deductible contributions up to annual limits published by the IRS. You can use the HSA to pay for unreimbursed “qualified” medical expenses. Please note that not all HDHP plans are Qualified HDHPs. Certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA.

In-Network/Network Providers – A doctor, hospital, or other provider in the plan’s network. In-network providers have agreed to accept a certain rate for people with that plan. You pay less when you use an in-network provider instead of an out-of-network provider. (In certain circumstances, a plan may have a contract with an out-of-network provider.) Highmark Delaware EPO plans cover services performed by in-network providers.

Out-of-Network Provider – A doctor, hospital, or other provider who does not have a contract with your health insurer to provide services to you at a discount. You will generally pay more to see an out-of-network provider.

Out-of-Pocket Costs – The copayments, coinsurance, and deductible amounts you have to pay.

Out-of-Pocket Maximum – The most you have to pay out of your own pocket each benefit period (usually a year). After that, your health insurance company pays 100% of the cost for covered services.

Premium – The amount of money you pay each month for your health insurance. You must pay this amount every month, even if you don’t use services that month.

Preventive Care Services – Routine health care, like screenings, well visits, and checkups, to help prevent illnesses, disease, or other health problems.

Primary Care Provider (PCP) – The doctor or medical professional who provides most of your basic care, such as yearly preventive visits and screenings. In most cases your PCP will coordinate your care with specialists, health care facilities, and other providers.

Qualified Health Plan (QHP) – An insurance plan certified by the Marketplace. It must provide the 10 essential health benefits, follow established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meet other requirements.

Rehabilitative Services – Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Retail Clinic – Convenient walk-in centers for quick and less complex health needs that can be served outside the doctor’s office. Generally open in the evening and on weekends. Services include treatment of uncomplicated illness or preventative care.

Telemedicine/Virtual Medicine – Contacting and receiving health care guidance from a doctor in real time by using a smartphone, tablet, or computer.

Urgent Care Center – A walk-in center you can use when your doctor is unavailable, such as evenings or weekends, or when you have an illness or injury serious enough that you need care right away, but not serious enough for a trip to the emergency room. Urgent care visits are usually less costly than going to the emergency room, but more costly than a PCP visit.

Here are some commonly used health insurance plan terms to help you.

YOUR HEALTH INSURANCE GLOSSARY

29

HIGHMARK BLUE CROSS BLUE SHIELD DELAWARE DISCLOSURES

Important Benefit Details1. Embedded/Aggregate Family Deductible: For an agreement covering more than one (1) family member, as each member satisfies their individual

deductible, the plan will begin to pay benefits for covered services for that member for the remainder of the benefit period (January 1, 2019 – December 31, 2019), whether or not the entire family deductible has been satisfied. When the family deductible has been satisfied, the family deductible will be considered to have been satisfied for all remaining covered family members. No individual member may satisfy the entire family deductible.

2. You are responsible for out-of-pocket costs each benefit period (January 1, 2019 – December 31, 2019) up to the maximum amount shown. Thereafter, the plan pays 100% of the Provider’s Allowable Charge during the remainder of the benefit period. This amount does not include amounts in excess of the provider’s allowable charge.

3. Diagnostic Lab services include Laboratory, Pathology, and Allergy Testing. Diagnostic Lab services require one copay/coinsurance per date of service and type of service.

4. Basic Diagnostic Services include diagnostic X-ray and diagnostic medical. Basic diagnostic services require one copay/coinsurance per date of service and type of service.

5. Advanced Imaging services include, but are not limited to, CAT Scan, CTA, MRI, MRA, PET Scan, and PET/CT Scan. Advanced Imaging services require one copay/coinsurance per date of service and type of service.

6. Therapy and Rehab Services (Rehabilitative & Habilitative) - Therapy visit limits include in and out-of-network visits. Speech therapy is limited to 30-visits per contract year each for Rehabilitative and Habilitative service (60 visits total per contract year). This limit does not apply when Services for habilitative purposes are prescribed for the treatment of Mental Illness or Substance Abuse. Physical therapy and occupational therapy are a combined 30 visit limit per contract year each for Rehabilitative and Habilitative service (60 visits total per contract year). This limit does not apply when Services for habilitative purposes are prescribed for the treatment of Mental Illness or Substance Abuse.

7. Spinal Manipulations - Benefit Maximum: 30 visits per Benefit Period.

8. Skilled Nursing Facility Care - Benefit Maximum: 120 days per confinement; benefits renew after 180 days without care.

9. Pediatric Routine Vision Exam - Benefit Maximum: One pediatric exam every 12 months for members under the age of 19.

10. Pediatric Vision Services - Vision benefits utilize the Davis Vision-Health Care Reform Network. Pediatric Dental Benefits utilize Advantage Plus 2.0 Network.

11. All Highmark Delaware plans provide the HCR Progressive Formulary on the National Plus network.

All Highmark Delaware Health Savings base plans are Qualified High Deductible Health Plans and may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an HSA. If you have questions, please check with your financial advisor.

Highmark Blue Cross Blue Shield Delaware is a Qualified Health Plan issuer in the Health Insurance Marketplace.

Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association.

Please note that information regarding the Patient Protection and Affordable Care Act of 2010 (a.k.a. “PPACA”, “Affordable Care Act”, “ACA”, and/or “Health Care Reform”), as amended, and/or any other law, does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws. This information is intended to provide general information only and does not attempt to give you advice that relates to your specific circumstances. The information regarding any health plan will be subject to the terms of the applicable health plan benefit agreement. Any review of materials, request for information, or application does not obligate you to enroll for coverage. Please request the Outline of Coverage for details on benefits, conditions and exclusions. Providing your information is voluntary.

To find more information about Highmark’s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call (855) 329-0694 (TTY/TDD 711).

BlueCard® is a registered mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

Davis Vision is a separate company that administers the Plan’s vision benefits. United Concordia is a separate company that administers the Plan’s pediatric dental benefits.

You should confirm the network status of a provider prior to receiving services. You can call My Care Navigator at 1-888-BLUE-428 to confirm if a doctor or facility will be in-network in 2019. Blues on Call is a registered service mark of the Blue Cross and Blue Shield Association.

Blues on Call is a registered service mark of the Blue Cross and Blue Shield Association.

30

Discrimination is Against the Law

The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex assigned at birth, gender identity or recorded gender. Furthermore, the Claims Administrator/Insurer will not deny or limit coverage to any health service based on the fact that an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to which such health service is ordinarily available. The Claims Administrator/Insurer will not deny or limit coverage for a specific health service related to gender transition if such denial or limitation results in discriminating against a transgender individual. The Claims Administrator/Insurer:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, including sex stereotypes and gender identity, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 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, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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There’s a lot to know and do when it comes to picking the right plan for you and your family. We are here to help!

Complete the checklist below to make sure you’ve answered the most important questions before choosing a plan.

❏❏ I have reviewed the hospitals that will be in-network and out-of-network for my plan.

❏❏ I’ve checked to see if my doctor is in-network by calling 1-888-BLUE-428 or visiting MyCareNavigator.com OR Find a Doctor or Rx at HighmarkBCBSDE.com.

❏❏ I understand that if I go to an out-of-network doctor, pharmacy, hospital, or other provider, I will have to pay 100% of the cost, except in the case of emergency care.

❏❏ I have checked how my prescriptions are covered at Find a Doctor or Rx at HighmarkBCBSDE.com.

BE CONFIDENT in your choice of health plan

• Call us at 1-855-822-6925 (TTY/TDD 711)

• Visit DiscoverHighmark.com

• Talk to your local insurance agent

You can also visit the Health Insurance Marketplace (“the Marketplace”) at HealthCare.gov, or call the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

DE-27615 10/18 CS211488

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