Summary of Benefits and Coverage: Carilion Choice POS II

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Washington and Lee University: Carilion Choice POS II

Coverage Period: 07/01/2024-06/30/2025

Coverage for: Individual + Family 
Plan Type: POS

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, www.HealthReformPlanSBC.com or by calling 1-888-982-3862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.

Important Questions	Answers	Why This Matters:
What is the overall deductible?	For each Plan Year, Tier 1 In-Network: Individual (IND) $750 / Family (FAM) $1,500. Tier 2: IND $750/ FAM $1,500. Out-of-Network: IND $1,000 / FAM $2,000.	Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?	Yes. Emergency care; plus in-network office visits, inpatient hospital services & preventive care are covered before you meet your deductible.	This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive 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 deductibles for specific services?	No.	You don't have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Tier 1 In-Network: IND $3,000/ FAM $6,000. Tier 2: IND $3,000/ FAM $6,000. Out-of- Network: IND $3,250/ FAM $6,500	The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance-billing charges, health care this plan doesn't cover & penalties for failure to obtain pre-authorization for services.	Even though you pay these expenses, they don't count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See www.aetna.com/docfind or call 1-888-982-3862 for a list of In-Network providers.	This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work).Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event	Services You May Need	What You Will Pay: Tier 1 In-Network Provider (You will pay the least)	What You Will Pay: Tier 2 In-Network Provider (You will pay more)	What You Will Pay: Out-of-Network Provider (You will pay the most)	Limitations, Exceptions, & Other Important Information
If you visit a health care provider's office or clinic	Primary care visit to treat an injury or illness	$5 copay/visit, deductible doesn't apply	$30 copay/visit, deductible doesn't apply	20% coinsurance	None
If you visit a health care provider's office or clinic	Specialist visit	$50 copay/visit, deductible doesn't apply	$50 copay/visit, deductible doesn't apply	20% coinsurance	None
If you visit a health care provider's office or clinic	Preventive care /screening /immunization	No charge	No charge	20% coinsurance	You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test	Diagnostic test (x-ray, blood work)	10% coinsurance for laboratory; $20 copay/visit for x-ray, deductible doesn't apply	10% coinsurance for laboratory; $20 copay/visit for x-ray, deductible doesn't apply	20% coinsurance	None
If you have a test	Imaging (CT/PET scans, MRIs)	$100 copay/visit, deductible doesn't apply	$100 copay/visit, deductible doesn't apply	20% coinsurance	None
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aetna.com/pha rmacyinsurance/individual s-families	Generic drugs	Not covered	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aetna.com/pha rmacyinsurance/individual s-families	Preferred brand drugs	Not covered	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aetna.com/pha rmacyinsurance/individual s-families	Non-preferred brand drugs	Not covered	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.aetna.com/pha rmacyinsurance/individual s-families	Specialty drugs	Not covered	Not covered	Not covered	Not covered
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$300 copay/visit, deductible doesn't apply	$300 copay/visit, deductible doesn't apply	20% coinsurance	None
If you have outpatient surgery	Physician/surgeon fees	No charge	No charge	20% coinsurance	None
If you need immediate medical attention	Emergency room care	$300 copay/visit, deductible doesn't apply	$300 copay/visit, deductible doesn't apply	$300 copay/visit, deductible doesn't apply	Out-of-network emergency use paid the same as in-network. No coverage for non-emergency use.
If you need immediate medical attention	Emergency medical transportation	$300 copay/trip, deductible doesn't apply	$300 copay/trip, deductible doesn't apply	$300 copay/trip, deductible doesn't apply	Out-of-network emergency use paid the same as in-network. Non-emergency transport: not covered, except if pre-authorized.
If you need immediate medical attention	Urgent care	$50 copay/visit, deductible doesn't apply	$50 copay/visit, deductible doesn't apply	20% coinsurance	No coverage for non-urgent use
If you have a hospital stay	Facility fee (e.g., hospital room)	$500 copay/stay, deductible doesn't apply	$500 copay/stay, deductible doesn't apply	20% coinsurance	Penalty of $400 for failure to obtain preauthorization for out-of-network care.
If you have a hospital stay	Physician/surgeon fees	10% coinsurance	10% coinsurance	20% coinsurance	None
If you need mental health, behavioral health, or substance abuse services	Outpatient services	Office: $25 copay/visit, deductible doesn't apply; other outpatient services: no charge	Office: $25 copay/visit, deductible doesn't apply; other outpatient services: no charge	Office & other outpatient services: 20% coinsurance	None
If you need mental health, behavioral health, or substance abuse services	Inpatient services	$500 copay/stay, deductible doesn't apply	$500 copay/stay, deductible doesn't apply	20% coinsurance	Penalty of $400 for failure to obtain preauthorization for out-of-network care.
If you are pregnant	Office visits	No charge	No charge	20% coinsurance	Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain pre-authorization for out-of-network care may apply.
If you are pregnant	Childbirth/delivery professional services	10% coinsurance	10% coinsurance	20% coinsurance	Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain pre-authorization for out-of-network care may apply.
If you are pregnant	Childbirth/delivery facility services	$500 copay/stay, deductible doesn't apply	$500 copay/stay, deductible doesn't apply	20% coinsurance	Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain pre-authorization for out-of-network care may apply.
If you need help recovering or have other special health needs	Home health care	10% coinsurance	10% coinsurance	20% coinsurance	100 visits/plan year. Penalty of $400 for failure to obtain pre-authorization for out-of-network care.
If you need help recovering or have other special health needs	Rehabilitation services	$50 copay/visit, deductible doesn't apply	$50 copay/visit, deductible doesn't apply	20% coinsurance	None
If you need help recovering or have other special health needs	Habilitation services	No charge	No charge	20% coinsurance	None
If you need help recovering or have other special health needs	Skilled nursing care	10% coinsurance	10% coinsurance	20% coinsurance	100 days/plan year. Penalty of $400 for failure to obtain pre-authorization for out-of-network care.
If you need help recovering or have other special health needs	Durable medical equipment	10% coinsurance	10% coinsurance	20% coinsurance	Limited to 1 durable medical equipment for same/similar purpose. Excludes repairs for misuse/abuse.
If you need help recovering or have other special health needs	Hospice services	0% coinsurance	0% coinsurance	20% coinsurance	Penalty of $400 for failure to obtain preauthorization for out-of-network care.
If your child needs dental or eye care	Children's eye exam	No charge	No charge	20% coinsurance	1 routine eye exam/12 months.
If your child needs dental or eye care	Children's glasses	No charge	No charge	No charge	$150 maximum/12 months.
If your child needs dental or eye care	Children's dental check-up	Not covered	Not covered	Not covered	Not covered

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Cosmetic surgery
• Dental care (adult & child)
• Long-term care
• Non-emergency care when traveling outside the U.S.
• Prescription Drugs
• Routine foot care
• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

• Acupuncture - 10 visits/plan year for disease, injury & chronic pain.
• Bariatric surgery - Limited to in-network providers.
• Chiropractic care - 30 visits/plan year.
• Hearing aids - $3,000 maximum/lifetime.
• Infertility treatment - For more information & exceptions, see policy document provided by your employer or call the number on your ID card.
• Private-duty nursing - 20- 8 hour shifts/plan year.
• Routine eye care (adult) - 1 routine eye exam/12 months.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:

• For more information on your rights to continue coverage, contact the plan at 1-888-982-3862.
• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law.

Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

• If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number at 1-888-982-3862. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• Additionally, a consumer assistance program can help you file your appeal. Contact information is at: https://www.aetna.com/individuals-families.html.

Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet Minimum Value Standards? No.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.