Summary of Benefits andCoverage: What this PlanCovers & What You Pay For Covered Services Clovis Unified School District
Employee Health Plan (Retirees with Medicare)

Coverage Period:09/01/2023 – 08/31/2024

Coverage for: Individual & Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you howyou 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 ofthe complete terms ofcoverage, visit www.myhnas.com or call
1-855-323-1124. For general definitionsof common terms, such asallowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can viewthe Glossary at www.myhnas.com or call 1-855-323-1124 to request a copyor it can be accessed at www.dol.gov/ebsa/healthreform.

Important Questions
	
Answers
	
Why This Matters:
	
What is the overall deductible?
	
$0
	
See the Common Medical Events chart below for your costs for services thisplan covers.
	
Are there services covered before you meet your deductible?
	
Not applicable.
	
Not applicable.
	
Are there other deductibles forspecific services?
	
No.
	
You don’t have to meetdeductibles for specific services.
	
What is the out-of-pocket limit for this plan?
	
Not applicable.
	
This plan does not have an out-of-pocket limit on your expenses.
	
What is not included in the out-of-pocket limit?
	
Not applicable.
	
This plan does not have an out-of-pocket limit on your expenses.

Will you pay less ifyou use a network provider?
	Yes. In CA:See www.blueshieldca.com/networkTa ndemPPO or call 1-800-810-2583 for a list of network providers. Outside of CA: See www.blueshieldca.comor call
1-800-810-2583 for a list of 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 receivea bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware that yournetwork provider mightuse 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 see a specialist?
	
No.
	
You can see the specialist you choose without a referral.

1 of 6

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
	
Limitations, Exceptions,& Other Important Information
	
		In-Network Provider (You will pay the least)
	Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic

If you have a test

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

If you are pregnant
	
Primary care visit to treatan injury or illness

No charge

50% coinsurance
	Includes chiropractic care.Chiropractic care from a non-participating provider is not covered.Chiropractic care is managed by Physmetrics: 1-877-519-8839.
	
	Specialist visit
	No charge
	50% coinsurance
	None
	
	Preventive care/screening/ immunization
	
No charge
	
50% coinsurance
	
None
	
	Diagnostic test (x-ray, blood work)
	
No charge
	
50% coinsurance
	
None

Imaging (CT/PET scans, MRIs)
	
No charge
	
50% coinsurance
	Precertification required for MRIs & CAT scans.**
	
	Facility fee (e.g.,ambulatory surgery center)
	
No charge
	
50% coinsurance
	
Precertification required.**
	
	Physician/surgeon fees
	No charge
	50% coinsurance
	Precertification required.**
	
	Emergency room care
	No charge
	No charge
	None
	
	Emergency medical transportation
	
No charge
	
No charge
	
None
	
	Urgent care
	No charge
	50% coinsurance
	None
	
	Facility fee (e.g.,hospital room)
	No charge
	50% coinsurance
	Precertification required.**

Physician/surgeon fees
	
No charge
	
50% coinsurance
	
None

Outpatient services
	
No charge
	
50% coinsurance
	
Precertification required.** Managed by Halcyon: 1-888-425-4800.

Cost-sharing does not apply for in-network routine prenatal services that are considered preventive care.

Inpatient services
	
No charge
	
50% coinsurance

Office visits
	
No charge
	
50% coinsurance
		
	Childbirth/delivery professional services
	
No charge
	
50% coinsurance
	
None
	
	Childbirth/delivery facility services
	
No charge
	
50% coinsurance
	
None

For more information aboutlimitations and exceptions,see the plan or policy document atwww.myhnas.com.	2 of 6

Common Medical Event
	
Services You May Need
	What You Will Pay
	
Limitations, Exceptions,& Other Important Information
	
		In-Network Provider (You will pay the least)
	Out-of-Network Provider (You will pay the most)

If you need help recovering or have other special health needs

If your child needs dental or eye care
	
Home health care
	
No charge
	
50% coinsurance
	Limited to 60 visits per year– must be within 7 days of a hospital confinement.Precertification required.**

Rehabilitation services
	
No charge
	
50% coinsurance
	Includes physical, speech,occupational, and other rehabilitative therapies. PT/OT/ST is managed by Physmetrics: 1-877-519-8839.

Habilitation services
	
No charge
	
50% coinsurance
	Precertification required forskilled nursing facility confinement.**
	
	Skilled nursing care
	No charge
	50% coinsurance
	Precertification required.**
	
	Durable medical equipment
	No charge
	50% coinsurance
	Precertification required.**

Hospice services
	
No charge
	
No charge
	Case management must be involved. Precertification required.**
	
	Children’s eye exam
	No charge
	50% coinsurance
	None
	
	Children’s glasses
	Not covered
	Not covered
	None
	
	Children’s dental check-up
	Not covered
	Not covered
	None

** Precertification is required before certain medical services. Emergencyadmissionsmust be certified within 48 hours following the admission. To precertify services, call the phone number indicated on your ID card. Failure to precertify out-of-network services may result in a denial of your claim.

For more information aboutlimitations and exceptions,see the plan or policy document atwww.myhnas.com.	3 of 6

Common Medical Event
	
Services You May Need
	What You Will Pay
	
Limitations, Exceptions,& Other Important Information
	
		Retail Pharmacy
(30 day supply)
	Mail Order Pharmacy
(90 day supply)

If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.caremark.com

Generic drugs

$9/prescription

$18/prescription
	
Certain medications considered preventive care underACA are payable atno cost-share to the member.

All refills for maintenance drugs after two fills at a retail pharmacy are required to be filled through the mail order pharmacy.

Prescription drugs obtained from a non-participating provider are not covered.

Preferred brand drugs

$30/prescription

$60/prescription

Non-preferred brand drugs

$40/prescription

$80/prescription

For more information aboutlimitations and exceptions,see the plan or policy document atwww.myhnas.com.	4 of 6

benefit	benefit
Excluded Services &Other CoveredServices:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any otherexcluded services.)

•	Acupuncture	•	Hearing aids	•	Private duty nursing
•	Cochlear implants	•	Long-term care	•	Refractive eye surgery
•	Cosmetic surgery	•	Non-emergency care whentraveling outside the	•	Routine eye care (adult) •	Dental care (adult)                                                  U.S.	•	Weight loss programs

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

•	Bariatric surgery, limited to $5,000 maximum	•	Infertility treatment, limited to $5,000 maximum	•	Treatment of TMJ
•	Chiropractic care	•	Medically necessary treatmentof sleep disorders •	Some routine foot care

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: HealthNow Administrative Services,1-855-323-1124, www.myhnas.com; Department of Labor/Employee BenefitsSecurityAdministration, 1-866-444-EBSA (3272), www.dol.gov/ebsa/healthreform. 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.govor call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaintagainst yourplan 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 documentsalso provide complete information 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: Department ofLabor/Employee Benefits Security Administration at 1-866-444-EBSA (3272) or visit www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file yourtax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes
If yourplan doesn’t meet the Minimum Value Standards, you may be eligible for apremium tax creditto help you pay for a plan through the Marketplace.

Language Access Services:
Spanish (Español):Para obtenerasistencia en Español, llame al 1-855-323-1124.
Tagalog (Tagalog):Kung kailangan ninyo ang tulong saTagalog tumawag sa 1-855-323-1124.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-855-323-1124.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-323-1124.
––––––––––––––––––––––To see examplesofhow this plan might cover costsfora sample medical situation, see the next section.––––––––––––––––––––––

For more information aboutlimitations and exceptions,see the plan or policy document atwww.myhnas.com.	5 of 6

About these Coverage Examples:

This is not a costestimator. Treatments shown are j
	
ust
	
examples of how t
	
his plan might cover medical care. Your actual costs will be charge, and many other factors.Focus on the cost sharing under the plan. Use this information to compare the portion of
e examples are based on self-only coverage.
	
	different d amounts ( costs you
	epend deduc
	ing o tibles
	n the actual care you receive, the pri , copayments and coinsurance) and
nder different health plans. Please n
	c e
	es your providers xcluded services

		might pay u
		ote these coverag

Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-
controlled condition)

Mia’s Simple Fracture
(in-network emergency room visit and follow up care)

The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance

$0	The plan’s overall deductible $0	Specialist copayment
0%	Hospital (facility) coinsurance 0%	Other coinsurance

$0        The plan’s overall deductible                 $0 $0        Specialist copayment                           $0 0%        Hospital (facility) coinsurance               0% 0%        Other coinsurance                               0%

This EXAMPLE event includes services like: Specialistoffice visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost
	$12,700

In this example, Peg would pay:
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$10
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$60
	
The total Peg would pay is
	$70

This EXAMPLE event includes services like: Primary care physician office visits (including disease education)
Diagnostic tests (blood work) Prescription drugs
Durable medical equipment(glucose meter)

Total Example Cost
	$5,600

In this example, Joe would pay:
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$470
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$20
	
The total Joe would pay is
	$490

This EXAMPLE event includes services like: Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment(crutches) Rehabilitation services (physical therapy)

Total Example Cost
	$2,800

In this example, Mia would pay:
Cost Sharing
	
Deductibles
	$0
	
Copayments
	$10
	
Coinsurance
	$0
	
What isn’t covered
	
Limits or exclusions
	$0
	
The total Mia would pay is
	$10

The plan would be responsible for the other costsof these EXAMPLE covered services.	6 of 6