2025 Summary HCCSC Anthem HealthSync PPO 1

Your summary of benefits Anthem® Blue Cross and Blue Shield Your Plan: Huntington County Community School Corporation Employee Benefit Trust: Anthem POS 3 Tier Your Network: HealthSync Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge Mental Health & Substance Use Disorder Services No charge Specialist care $30 copay per visit deductible does not apply Cost if you use a Cost if you use an In- Cost if you use an Covered Medical Benefits Preferred Network Network Provider Out-of-Network Provider Provider Overall Deductible $2,000 person / $5,000 person / $15,000 person / $4,000 family $10,000 family $30,000 family Overall Out-of-Pocket Limit $7,000 person / $7,000 person / $21,000 person / $14,000 family $14,000 family $42,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Out-of-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. The deductibles for Preferred Network and In-Network cross apply. Satisfying one helps satisfy the other. The out-of-pocket limits for Preferred Network and In-Network cross apply as well. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and $15 copay per visit $40 copay per visit 50% coinsurance after Substance Use Disorder Services virtual and deductible does not deductible does not deductible is met office apply apply Specialist Care virtual and office $30 copay per visit $80 copay per visit 50% coinsurance after deductible does not deductible does not deductible is met apply apply Page 1 of 10