09 NATA $5000 $8000 8060 $30 $60 Plan 9 SBC

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/2024 – 09/30/2025 SM Regence BlueCross BlueShield of Oregon: Regence Classic Coverage for: Individual and Eligible 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, go to https://regence.com or call 1 (888) 367-2116. 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 healthcare.gov/sbc-glossary or call 1 (888) 367-2116 to request a copy. Important Questions Answers Why This Matters: In-network provider: $5,000 individual / Generally, you must pay all of the costs from providers up to the deductible amount What is the overall $10,000 family per calendar year. before this plan begins to pay. If you have other family members on the plan, each deductible? Out-of-network provider: $10,000 individual / family member must meet their own individual deductible until the total amount of $20,000 family per calendar year. 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 Are there services covered Yes. Certain preventive care, prescription drug deductible amount. But a copayment or coinsurance may apply. For example, before you meet your coverage and those services listed below as this plan covers certain preventive services without cost sharing and before you deductible? "deductible does not apply." meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? In-network provider: $8,000 individual / The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket $16,000 family per calendar year. have other family members in this plan, they have to meet their own out-of-pocket limits limit for this plan? Out-of-network provider: $16,000 individual / until the overall family out-of-pocket limit has been met. $32,000 family per calendar year. What is not included in the Premiums, balance-billing charges, and health Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? care this plan doesn't cover. This plan uses a provider network. You will pay less if you use a provider in the plan's Yes. See https://regence.com/go/OR/Preferred network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use or call 1 (888) 367-2116 for a list of network receive a bill from a provider for the difference between the provider's charge and what a network provider? providers. 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? Page 1 of 7 Northwest Automotive Trades Association OO0124SCLAX