Anthem SBC Option 1

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 - 12/31/2025 Coverage for: Individual + Family | Plan Type: POS + Elkhart Community Schools: Anthem HealthSync POS HSA 3 Tier HSA 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, https://eoc.anthem.com/eocdps/aso. 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 www.healthcare.gov/sbc-glossary/ or call (833) 578-4441 to request a copy. Important Questions Answers Why This Matters: What is the overall $3,000/person or $6,000/family Generally, you must pay all of the costs from providers up to the deductible amount before deductible? for Preferred Network Providers. this plan begins to pay. If you have other family members on the policy, the overall family $5,000/person or $10,000/family deductible must be met before the plan begins to pay. for In-Network Providers. $15,000/person or $30,000/family for Out-of- Network Providers. Are there services Yes. Preventive Care. For more This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you information see below. But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of- $7,000/person or $14,000/family The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this for Preferred Network Providers other family members in this plan, they have to meet their own out-of-pocket limits until the plan? and In-Network Providers overall family out-of-pocket limit has been met. combined. $21,000/person or $42,000/family for Out-of- Network Providers. What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this plan limit? doesn't cover. Will you pay less if Yes. See You pay the least if you use a provider in Preferred Network. You pay more if you use a you use a network www.anthem.com/find- provider in In-Network. You will pay the most if you use an Out-of-Network Provider, and provider? care/?alphaprefix=K6Z you might receive a bill from a provider for the difference between the provider’s charge and IN/LG/Anthem HealthSync POS HSA 3 Tier/BYAM/01-25 Page 1 of 11