Group Name Plan Type

2018 PPO Copay Rochester Regional Health

Welcome

With Excellus BlueCross BlueShield, you get what you expect from Blue plus a whole lot more such as:

• More doctors, specialists, and hospitals tochoose from

• Exclusive discounts on health-related productsand services with Blue365®

• Answers to your health questions online

• Local customer service

In this booklet you will find:

• A chart that summarizes this plan’s unique benefitsand coverage*

• A glossary of terms to help you understand yourcoverage and options

We have many valuable benefits and we provide a tremendous amount of choice. Whichever plan you pick, we're ready to meet your health care needs.

Visit us at excellusbcbs.com

*This benefit summary is not a contract or binding agreement;it is a summary of benefits and services.

Privacy Policy Notice. We know how important your privacy is and we’re committed to protecting it. Our policies and practices regarding the collection, use, and disclosure of personal health information are available at excellusbcbs.com and Member Services.

EBCBS - 08/104747-10M

excellusbcbs.com

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• Find a doctor or specialist online while you’re homeor far away.

• Research over 6,000 health topics.

• Get great member discounts and valuableinformation you can use all year long withBlue365®

Questions? For assistance call (877) 408-4960,

Call our TTYphone at 1 (800) 421-1220,

2018 PPO Copay

Rochester Regional Health

or visit us at excellusbcbs.com/rrh

Plan Features

Primary Care Physician (PCP) Not Required

Referrals Not Required

Out of network benefits Covered

Student / Dependent Coverage Covered to age 26

Domestic Partner Covered

Coverage Period 01/01/18-12/31/18

14019

Excellus BluePPO$10/$30/$50 Domestic, $25/$50/$90 Non Domestic

Benefit Time Period: 01/01/2018 - 12/31/2018

ROCHESTER REGIONAL HEALTH SYSTEM

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General Information

Cost Sharing Expenses

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Deductible - Single $0 $0 $1,800

Deductible - Family $0 $0 $5,400Each individual does not exceed the single

deductible.

Coinsurance 0% 0% 40%

Annual Out of Pocket Maximum - Single $5,000 $5,000 $9,000

Out-of-pocket maximums accumulate the

coinsurance amount and include the

deductible, including carry over deductible

if applicable, and copayment.

Annual Out of Pocket Maximum - Family $10,000 $10,000 $18,000

Each individual does not exceed the single

out of pocket maximum. Out-of-pocket

maximums accumulate the coinsurance

amount and include the deductible,

including carry over deductible if

applicable, and copayment. Once family

OOP maximum has been met by any

number of individuals, OOP maximum is

met for all. One OOPM for both Domestic

and In-Network combined.

Office Visit Cost Shares

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Cost Share - Primary Care $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

Copay for In-Network

Cost Share - Specialist $50 Copayment $110 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $50

Copay for In-Network

Plan Limits

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Plan/Calendar Year Calendar Year Benefits

Diabetic Preauthorization and Step

TherapyNo

Who is Covered

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Domestic Partner Coverage Yes

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Inpatient Facility

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Inpatient Hospital Services $500 Copayment $2,000 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

$500 Copay for In-Network.

Mental Health Care $500 Copayment $2,000 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

$500 Copay for In-Network.

Substance Use Detoxification $500 Copayment $2,000 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

$500 Copay for In-Network.

Skilled Nursing Facility $500 Copayment $2,000 Copayment40% Coinsurance

Subject to Deductible

120 Days Per Plan Year

360 Days Lifetime Max. Pediatric (up to

and including age 18): $500 Copay for In-

Network. Limits are combined Domestic,

INN and OON.

Physical Rehabilitation Covered in Full $2,000 Copayment40% Coinsurance

Subject to Deductible

60 Days per year

Pediatric (up to and including age 18):

Covered in full for In-network. Limits are

combined Domestic, INN and OON.

Maternity Care $500 Copayment $2,000 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

$500 Copay for In-Network.

Inpatient Professional Services

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Inpatient Hospital SurgeryPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in full for In-network

AnesthesiaPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

Covered in Full up to

schedule of allowance

Includes anesthesia rendered for Inpatient,

Outpatient, Office Visit, and Maternity

services. Anesthesia does not require a

preauth or referral. Pediatric (up to and

including age 18): Covered in full for In-

network

Outpatient Facility Services

Outpatient Facility Services

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

SurgiCenters and Freestanding

Ambulatory Centers Surgical Care$250 Copayment $2,000 Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

$250 Copay for In-Network.

Diagnostic X-ray $50 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $50

Copay for In-Network. Advanced Imaging

Services includes PET scans, MRI,

nuclear medicine, and CAT scans.

Diagnostic Laboratory and Pathology Covered in Full $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in full for In-Network.

Radiation Therapy Covered in Full $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Chemotherapy Covered in Full $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Infusion TherapyInclusive of Primary

Service

Inclusive of Primary

Service

Inclusive of Primary

Service

Is inclusive in the Home Care benefit and

not covered as a separate benefit.

Inpatient Services

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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Dialysis Covered in Full $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Mental Health Care $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes Partial

Hospitalization

Substance Use Care $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes Partial

Hospitalization

Home and Hospice Care

Home Care

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Home Care Covered in Full $90 Copayment40% Coinsurance

Subject to Deductible

Pediatric (up to and including age

18): Covered in full for In-network

Hospice Care

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Hospice Care Inpatient Not Available Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in full for In-network

Outpatient and Office Professional Services

Professional Services

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Office Surgery

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Diagnostic X-ray

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Diagnostic Laboratory and Pathology

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Radiation Therapy

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

1 copay per visit.

Chemotherapy

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

1 copay per visit.

Infusion Therapy

PCP/Specialist -

Inclusive of Primary

Service

PCP/Specialist -

Inclusive of Primary

Service

Inclusive of Primary

Service

Is inclusive in the Home Care benefit and

not covered as a separate benefit.

Dialysis

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

1 copay per visit.

Mental Health CarePCP/Specialist - $30

Copayment

PCP/Specialist - $90

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/Specialist Copay for In-Network.

Maternity CarePCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in full for In-network

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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

TeleMedicine ProgramPCP/Specialist - Not

Covered

PCP/Specialist - Not

CoveredNot Covered Not Covered

Chiropractic CarePCP/Specialist - Not

Available

PCP/Specialist - $30

Copayment

40% Coinsurance

Subject to Deductible30 visits per year

Allergy Testing

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Allergy Testing includes injections and

scratch and prick tests.

Allergy Treatment Including SerumPCP/Specialist -

Covered in Full

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network. Includes

desensitization treatments (injections &

serums).

Hearing Evaluations RoutinePCP/Specialist - Not

Available

PCP - $30 Copayment

Specialist - $50

Copayment

40% Coinsurance

Subject to Deductible

1 Exam every 2 years

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Rehab and Habilitation

Outpatient Facility

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Physical Rehabilitation $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

30 Visits Per Plan Year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

Occupational Rehabilitation $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

30 Visits per year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

Speech Rehabilitation $30 Copayment $90 Copayment40% Coinsurance

Subject to Deductible

30 Visits per year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Physical RehabilitationPCP/Specialist - $30

Copayment

PCP/Specialist - $90

Copayment

40% Coinsurance

Subject to Deductible

30 Visits per year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

Occupational RehabilitationPCP/Specialist - $30

Copayment

PCP/Specialist - $90

Copayment

40% Coinsurance

Subject to Deductible

30 Visits per year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

Speech RehabilitationPCP/Specialist - $30

Copayment

PCP/Specialist - $90

Copayment

40% Coinsurance

Subject to Deductible

30 Visits per year

Pediatric (up to and including age 18): $30

Copay for In-Network. Includes aggregate

of visits for Domestic, INN and OON and

professional and facility covered services

for physical, speech, and occupational

therapy.

Preventive Services

Preventive Professional Services Meeting Federal Guidelines*

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Adult Physical ExaminationPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

1 Exam Per Plan Year

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Adult ImmunizationsPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Well Child Visits and ImmunizationsPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Routine GYN VisitPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Pre/Post-Natal CarePCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Mammography Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Colonoscopy Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Bone Density Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Preventive Facility Services Meeting Federal Guidelines*

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Cervical Cytology Preventative Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Mammography Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network

Colonoscopy Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Bone Density Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Outpatient Professional Services

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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Prostate Cancer ScreeningPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Mammography Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network

Colonoscopy Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Bone Density Screening ProfessionalPCP/Specialist -

Covered in Full

PCP/Specialist -

Covered in Full

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network. Not

performed as part of office visit

Preventive services in addition to those required under Federal Guidelines - Facility

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Mammography Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network

Colonoscopy Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Bone Density Screening Facility Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18):

Covered in Full for In-Network.

Other Benefits

Additional Benefits

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Treatment of Diabetes Insulin and

Supplies

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Limited to a 30 day supply for retail

pharmacy or a 90 day supply for mail order

pharmacy.

Diabetic Equipment

PCP -$30 Copayment

Specialist -$50

Copayment

PCP - $90 Copayment

Specialist - $110

Copayment

40% Coinsurance

Subject to Deductible

Pediatric (up to and including age 18): $30

PCP/$50 Specialist Copay for In-Network.

Durable Medical Equipment (DME)PCP/Specialist - Not

Available

PCP/Specialist - 20%

Coinsurance

40% Coinsurance

Subject to Deductible

Medical SuppliesPCP/Specialist - Not

Available

PCP/Specialist - 20%

Coinsurance

40% Coinsurance

Subject to Deductible

AcupuncturePCP/Specialist - 50%

Coinsurance

PCP/Specialist - 50%

Coinsurance

50% Coinsurance

Subject to Deductible

10 Visits per year

Limits combined Domestic, INN and OON.

Private Duty NursingPCP/Specialist - Not

Covered

PCP/Specialist - Not

CoveredNot Covered Not Covered

Emergency Services

ER Facility

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Facility Emergency Room Visit $195 Copayment $350 Copayment $350 Copayment

Pediatric (up to and including age 18):

$195 Copay for In-Network and Out-of-

Network. Prior Authorization may not apply

to any emergency care services.

Emergency services are covered

worldwide if provided by a hospital facility.

Preventive services in addition to those required under Federal Guidelines - Professional

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Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Prehospital Emergency and

Transportation - Ground or WaterNot Available $150 Copayment $150 Copayment

Urgent Care

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Urgent Care Center Facility Visit $50 Copayment $125 Copayment40% Coinsurance

Subject to Deductible

Pediatric up to and including age 18: $50

Copay for In-Network

Ancillary Benefits

Vision

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Adult Eye Exams - Routine Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

1 Exam Per 2 Plan Years

Limits are combined INN and OON. One

pair of corrective lenses after cataract

surgery covered in full.

Adult Eyewear - Routine Covered Covered40% Coinsurance

Subject to Deductible

$60 Allowance every 2 years

Includes Frames/Lenses or Contact

Lenses

Pediatric Eye Exams - Routine Covered in Full Covered in Full40% Coinsurance

Subject to Deductible

1 Exam Per Plan Year

Limits are combined INN and OON.

Pediatric (up to and including age 18):

Covered in Full for In-Network. One pair of

corrective lenses after cataract surgery

covered in full.

Pediatric Eyewear - Routine Covered Covered40% Coinsurance

Subject to Deductible

$60 Allowance Per Plan Year

Includes Frames/Lenses or Contact

Lenses

Rx Benefits

Rx Plan

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Rx Plan$10/$30/$50 Domestic, $25/$50/$90 Non

Domestic

Rx Benefits

Benefit Name RRH Network Excellus Network Out of NetworkLimits and Additional Information

Days Supply Per Retail Order 90 90

Days Supply Per Mail Order Not Available 90

Copays Per Mail Order Supply Not Available 3

Transportation

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This document is not a contract. It is only intended to highlight the coverage of this program. Benefits are determined by

the terms of the contract. Any inconsistencies between this document and the contract shall be resolved in favor of the

contract in effect at the time services are rendered. All benefits are subject to medical necessity. All day and visit limits are

combined limits for both in and out of network benefits.

* For non-grandfathered groups, Preventive Services coverage required by the Patient Protection and Affordable Care Act are not

quoted herein. Please refer to the United States Preventive Services Task Force list of items and services rated "A" or "B" that are

covered pursuant to the Patient Protection and Affordable Care Act requirements.

Primary Care Physician (PCP)—A doctor who serves as your health care manager and coordinates virtually all of the health care services you routinely receive. Some plans do not require you to choose a PCP.

Referral—Instructions provided by a PCP for specialty care. Most plans do not require referrals.

In-network coverage—The coverage available when you receive services from a provider who participates in your health plan.

Out-of-network coverage—The coverage available when you receive services from a provider who does not participate in your health plan. Some plans may not include out-of-network coverage.

Out-of-area—Describes when you receive services while outside the geographic service area of your health plan. Your plan benefits may differ if you live or work beyond the geographic service area.

Copay—A dollar amount due at the time you receive certain services. A typical example would be an office visit copay due when visiting your physician’s office for treatment.

Allowed Amount—The maximum amount your health plan will pay for a specific service. In-network providers agree to accept the allowed amount as payment in full.

Coinsurance—A cost-sharing method that requires you pay a portion of the allowed amount for certain medical services.

Deductible—A set dollar amount you pay for covered services you receive before your insurer will make a payment.

Out-of-pocket maximum—The maximum amount of deductible and coinsurance payments that you will pay for health services each calendar year.

To help you better understand our plans and your coverage, here are a few definitions* for frequently used health care terms.

Some definitions may vary slightly by plan. In case of a conflict between your legal plan documents and this information, the plan documents will govern.

Health plan terms

*