There's a plan in here with all over it - For Benefit Period: January 1 to December 31, 2021 - Highmark Insurance ...

 
There’s a plan
in here with
                 your name

all over it.

Your guide to finding just the right
Individual or Family plan for you.

For Benefit Period:
January 1 to December 31, 2021
Go ahead.
Get picky about
your plan.
With lots of great coverage options from Highmark,
this book will help you find the plan, the product,
and the network access that matters most to you.

Looking for something in particular? You can easily
navigate through the guide by clicking on the headings
 in the Table of Contents.

Why choose Highmark?������������������������������������������������������������������������������������ 1
Affordable Care Act basics������������������������������������������������������������������������������6
Financial help info����������������������������������������������������������������������������������������������8
Enrollment dates���������������������������������������������������������������������������������������������� 10
Enrollment checklist����������������������������������������������������������������������������������������� 11
Product and network highlights���������������������������������������������������������������������12
Plan details by county ������������������������������������������������������������������������������������ 24
Helpful health insurance definitions������������������������������������������������������������ 37
Legal info ���������������������������������������������������������������������������������������������������������� 38
Why choose a
Highmark health plan?
Woah. So many reasons. Here are three big ones right off the top of our heads.

                                                Expert care, close to home.
                                                With Highmark, you’re covered here, there, just about everywhere
                                                with a network that gives you access to in-network facilities
                                                throughout Pennsylvania, as well as select facilities in Maryland,
                                                New Jersey, New York, Ohio, and West Virginia.

                                                Coast-to-coast coverage
                                                with BlueCard®.
                                                All of our plans come with BlueCard coverage, accepted by 96%
                                                of hospitals and 95% of doctors in the U.S.* BlueCard gives you
                                                access to routine, urgent, and emergency care, no matter where
                                                you are. Traveling abroad? You’re also covered in 190 countries.

                                                No red tape.
                                                Lose the timewasting of going to an appointment just to get
                                                another appointment. See whichever in-network doctors you
                                                want to see — no referral. Or call 1-888-Blue-428, and we’ll find a
                                                specialist for you. No hoops, no hoopla.

                                          And that’s just for starters.
                               Turn the page for even more reasons to choose Highmark.

* According to the Blue Cross and Blue Shield Association.

                                                                                                                      1
How easy do we
    make it to find care
    and get care?
    Almost too easy.

2
DENTAL AND VISION COVERAGE

All your care, all in one plan.
Healthy eyes and teeth are important parts of your overall health and
regular check-ups can help you stay ahead of potential problems down
the road. That’s why many of our plans come with adult dental and
vision benefits included. No need to purchase separate plans.

TELEMEDICINE

Face to face with
a doctor, 24/7.
Need to see a doctor but don’t want to leave your couch? Get a
diagnosis, treatment plan, or prescription any time, right from your
phone or computer. Best of all — telemedicine services provided by
American Well are free with many of our plans. Just call the number on
the back of your ID card for details. That’s laid-back-in-a-recliner easy.

BLUE DISTINCTION**

See specialists who
get proven results.
Only doctors who consistently deliver safe, effective treatments
make our Blue Distinction list. When you use our Find a Doctor
tool, a special logo will be by their name, so you can cherry-pick
a top-performing specialist for any care you need

JOHNS HOPKINS MEDICINE COLLABORATION

Expert teamwork
for advanced care.
We collaborate with some of the best minds, like Johns Hopkins
Medicine, for cancer research. That lets us bring the latest innovative
medical breakthroughs right to your neighborhood.

                                                                             3
How simple is it
    for you to get
    answers and
    reach your goals?
    Super simple.

4
THE HIGHMARK APP AND MEMBER WEBSITE

Your entire plan at your fingertips.
No more searching for old files or waiting on snail mail. Your digital
ID card, Find a Doctor tool, deductible progress, and claims status
are all available via the Highmark Plan app (available on Google Play
or in the Apple App Store) or online at highmarkblueshield.com.

MY CARE NAVIGATOR

Your appointments, booked for you.
It’s as simple as calling 1-888-Blue-428. We’ll help you find the in-
network doctor you need and reserve some space on their calendar
for a checkup. Which means less on-hold music for you.

BLUES ON CALLSM

Answers from a health pro, 24/7.
Medical concerns during off hours? Just call 1-888-Blue-428
to get support from a registered nurse or a health coach any time
and put your worries to bed.

WELLNESS

Personalized support
for health goals.
Looking to lose weight? Quit smoking? Be more active? Get guidance
based on your lifestyle, trackers to measure your progress, resources
like Sharecare, and access to experienced wellness coaches to make
healthy choices and keep you motivated. Once you’re enrolled,
visit mycare.sharecare.com.

BLUE365®

Discounts to help you
stay healthy and active.
From workout gear to gym memberships to healthy meal services,
we’ll take a little off the top while you’re taking a little off your
middle. Member-only deals are at blue365deals.com.

                                                                         5
Before we get
    much further,
    let’s cover some
    Affordable Care Act
    (ACA) essentials.

6
ACA basics
Metal levels
ACA plans are broken into four categories based on how
you and your plan share the costs of your health care.

Just so you know, metal levels reflect cost-sharing differences
only — which means you get the same quality of care at any level.

                      CATASTROPHIC                          BRONZE                           SILVER                           GOLD

      Premium                   $                               $$                             $$$                            $$$$
Out-of-Pocket
        Costs
                              $$$$                             $$$                              $$                                 $

                      Never use health care                                                                         Use health care services
                       services unless it’s            Don’t use a lot of             Are eligible for CSR           somewhat frequently
 Makes sense              an emergency.               health care services             or want to balance               and/or want low
      if you:            Only available               and/or want to keep               premiums with                 out-of-pocket costs
                       if you’re under 30           premium payments low.             out-of-pocket costs.            for most commonly
                      or have a hardship.                                                                                used services.

                  ACA also includes Platinum level plans; however, Highmark does not offer these types of plans in Pennsylvania.

Ways to save
Good news: There are two ways to                                           Even better news: More than 80% of
save available for Affordable Care                                         our ACA members qualify.* Take a look
Act (ACA) enrollees.                                                       to see if you do.

    Advanced Premium Tax Credits (APTC), which may be applied — in advance — to lower what
    you pay each month for your premium on any level Marketplace plan except Catastrophic.

    Cost-Sharing Reductions (CSR) will lower out-of-pocket costs that you may pay at the time of
    service for doctor visits, lab tests, drugs, and other covered services. CSR plans also offer lower
    deductibles. You can only get these savings if you enroll in an Extra Savings Silver plan.

*Based on on-exchange Highmark enrollment during 2020 OEP.

                                                                                                                                               7
See if you qualify
    To see if you’re eligible for financial help, locate your qualifying income and household size on the chart
    below. Then refer to the Standard or Extra Savings plans for your county to find the plans that will reduce
    how much you pay for care.

    If you don’t qualify for Cost-Sharing Reductions, you may be eligible for Advanced Premium Tax Credits.
    Please refer to the Standard plan options for your county.

                              What is the income for those covered under this health plan?

                              Eligible for             Eligible for                                                             Eligible for
     Who Needs                Medicaid                 CSRs and APTCs                                                           APTCs
     Coverage?
                                                       Silver Extra Savings plans                                               Standard
                              Medicaid
                              Eligible Range
                              (100-138% or less FPL)   138-149%                150-199%                 200-249%
                                                                                                                                250%-400%
                                                       CSR plans               CSR plans                CSR plans

     Single                   Less than $17,607        $17,608 - $19,139       $19,140 - $25,519        $25,520 - $31,899       $31,900 - $51,039

     Family of 2              Less than $23,790        $23,791 - $25,859       $25,860 - $34,479        $34,480 - $43,099       $43,100 - $68,959

     Family of 3              Less than $29,792        $29,973 - $32,579       $32,580 - $43,439        $43,440 - $54,299       $54,300 - $86,879

     Family of 4              Less than $36,155        $36,156 - $39,299       $39,300 - $52,399        $52,400 - $65,499       $65,500 - $104,799

     Family of 5              Less than $42,337        $42,338 - $46,019       $46,020 - $61,359        $61,360 - $76,699       $76,700 - $122,719

     Family of 6              Less than $48,519        $48,520 - $52,739       $52,740 - $70,319        $70,320 - $87,899       $87,900 - $140,639

     Family of 7              Less than $54,702        $54,703 - $59,459       $59,460 - $79,279        $79280 - $99,099.       $99,100 - $158,559

     Family of 8              Less than $60,884        $60,885 - $66,179       $66,180 - $88,239        $88,240 - $110,299      $110,300 - $176,479

    *Income between 100% and 400% FPL: If your income is in this range, in all states you qualify for premium tax credits that lower your monthly
    premium for a Pennsylvania Insurance Exchange health insurance plan.
    *Income below 138% FPL: If your income is below 138% FPL and your state has expanded Medicaid coverage, you qualify for Medicaid based
    only on your income.
    *American Indians and Alaska Natives who are members of federally recognized tribes are eligible for cost-sharing reductions at alternative dollar
    thresholds.
    This chart is only applicable for coverage in 2021 and in the 48 contiguous states and the District of Columbia. For families/households with more
    than 8 persons, add $4,480 for each additional person. HHS Poverty Guidelines for 2020 (January 31, 2020). Retrieved from
    https://aspe.hhs.gov/poverty-guidelines.

                       Check to see if you qualify for one or both types of help.
                                          Call 855-400-9159.

8
ACA plans vs. short-term plans
In addition to the availability of APTC and CSR, all ACA plans provide coverage for preexisting
conditions and the ten essential health benefits (see page 13). Short-term plans — which are
plans that come with a fixed, limited term — do not. Short-term plans can seem like a cheaper
alternative to ACA coverage but often come with hidden costs and exclusions that can make
them more expensive in the long run.

Other types of hidden costs in short-term plans:

                                           SHORT-TERM PLANS                     ACA PLANS

      Capped out-of-pocket spending                X                               ✓
            10 Essential Health Benefits           X                               ✓
      No limits on covered doctor visits           X                               ✓
    No dollar limits on covered benefits           X                               ✓
No limits on prescription drug coverage            X                               ✓

                                                                                                  9
Next, enrollment dates.
     There are two different ways you can be eligible to enroll in or change
     your ACA coverage. One is a fixed period that happens every year.
     The other is for special cases that can happen any time.

     EXTENDED OPEN ENROLLMENT PERIOD
     November 1, 2020 – January 15, 2021
     If you sign up by December 15, 2020,
     your plan takes effect on January 1, 2021.
     If you sign up between December 16, 2020
     and January 15, 2021, your plan takes effect
     on February 1, 2021.

     SPECIAL ENROLLMENT PERIODS
     Can happen any time throughout the year
     Outside the Open Enrollment Period, you can only get or
     change coverage if you have a qualifying life event. Examples
     include losing your existing coverage, a new addition to the
     family, getting married, or moving to a new area where you
     can’t keep your current plan. A Special Enrollment Period
     only lasts 60 days from the qualifying life event.

        If you think you’re eligible for a Special Enrollment Period, you may be asked to submit
           documents to prove it. You can go to discoverhighmark.com for more information.

10
Finally, your ACA
Enrollment Checklist.
Here’s the info you’ll need for each person
who will be covered on your plan.

       Date of birth

       Social Security number
       (or legal immigrant documents)

       Income documentation for all household members,
       even if they won’t be covered by the plan
       (pay stubs, W-2 forms, or wage and tax statements)

       Current health insurance policy numbers (if applicable)

       Info on any health insurance you or your family
       could get from your job

All set? Great. Let’s dig into the details for 2021 —
and find you the plan with the benefits and features
that matter most to you.

                                                                 11
2021 Highmark
     product and
     network highlights
     Now that we’ve gotten the preliminaries out of the way,
     let’s take a look at the products and networks available
     in your area in 2021.

12
Cue the highlight reel.
With Highmark, you get all the essentials — and so much more.

First, you get access to                                                  But Highmark goes
the ten essential health                                                  above and beyond.
benefits — plus coverage                                                  Here are just some of the awesome
for preexisting conditions.                                               benefits you’ll find for the 2021 plan year.*
                                                                          Go ahead. Start circling the ones you want.
They include:
                                                                          •   Low office visit copay
•   Outpatient care
                                                                          •   Free telemedicine through American Well
•   Emergency services
                                                                          •   $0 prescription copays for Tier 1 drugs
•   Hospitalization (like surgery
    and overnight stays)                                                  •   Free preventive vaccines,** tests,
                                                                              and screenings***
•   Pregnancy, maternity,
    and newborn care                                                      •   Adult dental and vision coverage

•   Mental health and substance                                           •   Predictable copays that start day 1,
    use disorder services                                                     no deductible to meet

•   Prescription drugs                                                    •   Prescription drug coverage that
                                                                              starts day 1, no deductible to meet
•   Rehabilitative and habilitative
    services and devices                                                  •   Enhanced resources for managing
                                                                              chronic conditions
•   Laboratory services
                                                                          •   2 free mental health visits
•   Preventive and wellness services
    and chronic disease management                                        •   2 free substance abuse disorder visits

•   Pediatric services, including dental                                  •   Potential tax-free savings with
    and vision care                                                           a Health Savings Account****
                                                                              –   Money can go in tax-free and lower
                                                                                  your taxable income
                                                                              –   Money comes out tax-free when used
                                                                                  for qualified medical expenses
                                                                              –   Interest and earnings on any unused money
                                                                                  grows tax-free
                                                                              –   Unused money rolls over from year to year

* Not all plans include these benefits. The availability of benefits depends on your selected plan.
** As listed on the Highmark Preventive Schedule when given at a participating pharmacy.
*** As presented on the Highmark Preventive Schedule. To check the preventive schedule for covered care,
visit https://www.highmarkblueshield.com/pdffiles/Highmark_Preventive_Schedule_2020.pdf.
**** Please note: Qualified High Deductible Health Plans may be coupled with a Health Savings Account (HSA). However, certain Cost-Sharing
Reductions (CSR) or plan variations of this plan that are offered through the Health Insurance Marketplace are not intended to be used with an
HSA. If you have questions, please check with your financial advisor.

                                                                                                                                                 13
my Direct Blue EPO
     Enjoy in-network access to top-quality care throughout central
     Pennsylvania and the Lehigh Valley, plus full BlueCard access
     coast to coast.
     With my Direct Blue EPO plans, it’s very simple: providers are either in network or out
     of network. You can even see most specialists with no need for referrals. Even better,
     the BlueCard program gives you access to the majority of hospitals and doctors
     nationwide — so you’ll be covered for routine, urgent, and emergency care wherever
     you go.

14
To see if your provider is in network,
visit highmarkblueshield.com and click Find a Doctor or Pharmacy.

my Direct Blue EPO plans are available for
residents of the counties highlighted below.

                                                      COLUMBIA
                                                 MONTOUR
                                      UNION
               CENTRE                                                             NORTHAMPTON
                                              NORTHUMBERLAND
                                   SNYDER
                        MIFFLIN   JUNIATA                  SCHUYLKILL           LEHIGH

                                               DAUPHIN
                                                                        BERKS
                                  PERRY
                                                         LEBANON

                              CUMBERLAND
                                                            LANCASTER

      FULTON     FRANKLIN                         YORK
                                  ADAMS

                                                                                                15
my Direct Blue EPO In-Network Hospitals

     ALLEGHENY                         BLAIR                              • Penn Medicine – Chester
     • AHN Allegheny General           • Conemaugh Nason Medical            County Hospital
       Hospital                          Center
                                                                          CLARION
     • AHN Allegheny Valley Hospital   • Tyrone Hospital
                                                                          • BHS Clarion Hospital
     • AHN Brentwood                   • UPMC Altoona
       Neighborhood Hospital                                              CLINTON
     • AHN Forbes Hospital             BRADFORD
                                                                          • Bucktail Medical Center
     • AHN Jefferson Hospital          • Guthrie Robert Packer Hospital
                                                                          • UPMC Susquehanna
     • AHN McCandless                  • Guthrie Towanda Memorial
                                                                            Lock Haven
       Neighborhood Hospital             Hospital
     • AHN West Penn Hospital          • Guthrie Troy Community           COLUMBIA
                                         Hospital                         • CHS Berwick Hospital Center
     • Heritage Valley Kennedy
     • Heritage Valley Sewickley       BUCKS                              CRAWFORD
     • St. Clair Hospital              • Doylestown Hospital              • Meadville Medical Center
     • The Children’s Home             • Jefferson Health –               • Titusville Area Hospital
       of Pittsburgh                     Bucks Hospital
     • The Children’s Institute                                           CUMBERLAND
       of Pittsburgh                   BUTLER
                                                                          • Geisinger Holy Spirit Hospital
     • UPMC Children’s Hospital of     • BHS Butler Memorial Hospital
                                                                          • UPMC Carlisle
       Pittsburgh
                                       CAMBRIA
     • UPMC Western                                                       DAUPHIN
       Psychiatric Hospital            • Conemaugh Memorial
                                                                          • Penn State Health
                                         Medical Center
                                                                            Children’s Hospital
     ARMSTRONG                         • Conemaugh Miners
                                                                          • Penn State Health Milton
     • Armstrong County Memorial         Medical Center
                                                                            S. Hershey Medical Center
       Hospital                        • Select Specialty Hospital –
                                         Johnstown                        DELAWARE
     BEAVER
                                                                          • Crozer-Chester Medical Center
     • Heritage Valley Beaver          CARBON
                                                                          • Delaware County
                                       • St. Luke’s Hospital –
     BEDFORD                                                                Memorial Hospital
                                         Lehighton Campus
     • UPMC Bedford                                                       • Main Line Health –
                                       CENTRE                               Riddle Hospital
     BERKS                             • Mount Nittany Medical Center
                                                                          ERIE
     • Penn State Health St. Joseph
       Medical Center                  CHESTER                            • AHN Saint Vincent Hospital
     • Surgical Institute of Reading   • Main Line Health – Bryn Mawr     • Corry Memorial Hospital
                                         Rehab Hospital                   • Millcreek Community Hospital
                                       • Main Line Health –               • Select Specialty Hospital - Erie
                                         Paoli Hospital

16
FAYETTE                          LUZERNE                           • Main Line Health –
• Highlands Hospital             • CHS Wilkes-Barre                  Lankenau Medical Center
• Uniontown Hospital               General Hospital
                                                                   NORTHAMPTON
                                 • Geisinger Wyoming Valley
FRANKLIN                           Medical Center                  • Lehigh Valley Hospital –
                                                                     Coordinated Health Bethlehem
• WellSpan Chambersburg          • Lehigh Valley Hospital –
  Hospital                         Hazleton                        PHILADELPHIA
• WellSpan Waynesboro Hospital
                                 LYCOMING                          • Children’s Hospital
                                                                     of Philadelphia
GREENE                           • Geisinger Jersey Shore
                                                                   • Einstein Medical
• Washington Health System       • UPMC Susquehanna Muncy
                                                                     Center Philadelphia
  Greene                         • UPMC Susquehanna
                                                                   • Jefferson Health –
                                   Williamsport
LACKAWANNA                                                           Frankford Hospital
                                 • UPMC Susquehanna
• CHS Moses Taylor Hospital                                        • Jefferson Health –
                                   Williamsport DP Campus
• CHS Regional Hospital                                              Methodist Hospital
  of Scranton                    MCKEAN                            • Jefferson Health – Thomas
• Geisinger Community                                                Jefferson University Hospital
                                 • Bradford Regional Medical
  Medical Center                   Center                          • Jefferson Health –
                                                                     Torresdale Hospital
                                 • UPMC Kane
LANCASTER                                                          • Jefferson Health – WillsEye
• Lancaster General Hospital     MERCER                              Hospital
• Lancaster General Hospital     • AHN Grove City Hospital         • Penn Medicine – Hospital of
  Women & Babies                 • Edgewood Surgical Hospital        the University of Pennsylvania
• Lancaster Surgery Center       • Sharon Regional Health System   • Penn Medicine – Penn
                                                                     Presbyterian Medical Center
LAWRENCE                         • UPMC Horizon – Greenville
                                                                   • Penn Medicine –
• Lawrence County Surgery        • UPMC Horizon – Shenango
                                                                     Pennsylvania Hospital
  Center of Edgewood Surgical      Valley
                                                                   • Temple Health – Fox Chase
  Hospital                                                           Cancer Center
                                 MONROE
• UPMC Jameson                                                     • Temple Health – Temple
                                 • Lehigh Valley Hospital –
                                   Pocono                            University Hospital
LEBANON
                                 • St. Luke’s Hospital –
• WellSpan Good Samaritan                                          POTTER
  Hospital                         Monroe Campus
                                                                   • UPMC Cole
LEHIGH                           MONTGOMERY
                                                                   SCHUYLKILL
• Lehigh Valley Hospital –       • Einstein Medical Center
                                   Elkins Park                     • Lehigh Valley Hospital –
  17th Street                                                        Schuylkill E. Norwegian Street
• Lehigh Valley Hospital –       • Einstein Medical Center
                                   Montgomery                      • Lehigh Valley Hospital –
  Cedar Crest                                                        Schuylkill S. Jackson Street
• Lehigh Valley Hospital –       • Holy Redeemer Hospital
  Coordinated Health Allentown     and Medical Center              SOMERSET
• Lehigh Valley Hospital –       • Jefferson Health –              • Conemaugh Meyersdale
  Muhlenberg                       Abington Hospital                 Medical Center
• Lehigh Valley Reilly           • Jefferson Health –              • UPMC Somerset
  Children’s Hospital              Abington-Landsdale Hospital
                                 • Main Line Health – Bryn
                                   Mawr Hospital

                                                                                                      17
SUSQUEHANNA
     • Barnes-Kasson Hospital           IN-NETWORK ACCESS TO THESE
     • Endless Mountains Health         OUT-OF-STATE HOSPITALS
       Systems                          THROUGH BLUECARD*
                                        MARYLAND
     TIOGA
                                        • Meritus Medical Center
     • UPMC Susquehanna Wellsboro
                                        • The Johns Hopkins Hospital
     UNION                              • University of Maryland
     • Evangelical Community              Medical Center
       Hospital                         • UPMC Western Maryland
                                        • WVU Medicine – Garrett
     VENANGO                              Regional Medical Center
     • UPMC Northwest
                                        NEW YORK
     WARREN                             • AHN Westfield
                                          Memorial Hospital
     • Warren General Hospital
                                        • Guthrie Corning Hospital
     WASHINGTON                         • Olean General Hospital
     • Advanced Surgical Hospital       • UR Medicine – Jones
     • AHN Canonsburg Hospital            Memorial Hospital
     • Monongahela Valley Hospital      • UR Medicine – Strong
     • Washington Hospital                Memorial Hospital
                                        OHIO
     WAYNE
                                        • Cleveland Clinic
     • Wayne Memorial Hospital
                                        WEST VIRGINIA
     WESTMORELAND                       • Weirton Medical Center
     • AHN Hempfield                    • WVU Medicine –
       Neighborhood Hospital              Children’s Hospital
     • Excela Health Frick Hospital     • WVU Medicine – J.W. Ruby
     • Excela Health Latrobe Hospital     Memorial Hospital
     • Excela Health Westmoreland
       Hospital
     • Select Specialty Hospital –
       Laural Highlands

     WYOMING
     • CHS Tyler Memorial Hospital

     *In addition, my Direct Blue EPO plans provide in-network access to out-of-state providers
     that participate with local Blue Plans through the BlueCard program. Please refer to the
     provider directory for additional out-of-state hospitals. You can find the provider directory
     at highmarkblueshield.com under the Find a Doctor or Pharmacy tab.

18
my Blue Access EPO
Your choice for comprehensive in-network access throughout
central Pennsylvania and the Lehigh Valley.
With my Blue Access EPO plans, you have in-network access to high-quality, cost-effective care
from more than 9,800 physicians and 50 community hospitals in western and central Pennsylvania.
You can even see in-network specialists with no need for referrals. Even better, the BlueCard
program gives you access to 96% of hospitals and 95% of doctors nationwide* — so you’ll be
covered for routine, urgent, and emergency care wherever you go.

To see if your provider is in network,
visit highmarkblueshield.com and click Find a Doctor or Pharmacy.*
According to the Blue Cross Blue Shield Association
*

my Blue Access EPO plans are available for
residents of the counties highlighted below.

                                                                     COLUMBIA
                                                      UNION     MONTOUR
                      CENTRE                                                                    NORTHAMPTON
                                                          NORTHUMBERLAND
                                               SNYDER
                                                                          SCHUYLKILL           LEHIGH
                                           JUNIATA
                         MIFFLIN
                                                              DAUPHIN
                                                                                       BERKS
                                             PERRY
                                                                        LEBANON

                                     CUMBERLAND
                                                                           LANCASTER

       FULTON         FRANKLIN                                   YORK
                                            ADAMS

                                                                                                              19
my Blue Access EPO In-Network Hospitals

     ADAMS                             • UPMC St. Margaret                BUTLER
     • WellSpan Gettysburg Hospital    • UPMC Western Psychiatric         • BHS Butler Memorial Hospital
                                         Hospital                         • UPMC Passavant – Cranberry
     ALLEGHENY
     • AHN Allegheny General           ARMSTRONG                          CAMBRIA
       Hospital                        • Armstrong County Memorial        • Conemaugh Memorial Medical
     • AHN Allegheny Valley Hospital     Hospital                           Center
     • AHN Brentwood                   BEAVER                             • Conemaugh Miners Medical
       Neighborhood Hospital           • Curahealth Hospital                Center
     • AHN Forbes Hospital               Heritage Valley                  • Select Specialty Hospital –
     • AHN Jefferson Hospital          • Heritage Valley Beaver             Johnstown
     • AHN McCandless
                                       BEDFORD                            CARBON
       Neighborhood Hospital                                              • St. Luke’s – Lehighton Campus
                                       • UPMC Bedford
     • AHN West Penn Hospital
                                       BERKS                              CENTRE
     • Curahealth Pittsburgh
                                       • Penn State Health St. Joseph     • Mount Nittany Medical Center
     • Heritage Valley Kennedy
     • Heritage Valley Sewickley         Medical Center                   CHESTER
     • LifeCare Behavioral Health      • Surgical Institute of Reading    • Main Line Health – Bryn
       Hospital of Pittsburgh          • Tower Health –                     Mawr Rehab Hospital
     • Select Specialty Hospital –       Reading Hospital                 • Main Line Health – Paoli
       McKeesport                      BLAIR                                Hospital
     • Select Specialty Hospital –     • Conemaugh Nason                  • Penn Medicine – Chester
       Pittsburgh UPMC                   Medical Center                     County Hospital
     • St. Clair Hospital              • Tyrone Hospital                  • Tower Health – Brandywine
     • The Children’s Home                                                  Hospital
                                       • UPMC Altoona
       of Pittsburgh                                                      • Tower Health – Jennersville
                                       BRADFORD                             Hospital
     • The Children’s Institute
       of Pittsburgh                   • Guthrie Robert Packer Hospital   • Tower Health – Phoenixville
     • UPMC Children’s Hospital        • Guthrie Towanda Memorial           Hospital
                                         Hospital
       of Pittsburgh                                                      CLARION
     • UPMC East                       • Guthrie Troy Community
                                                                          • BHS Clarion Hospital
                                         Hospital
     • UPMC Magee-Womens
                                                                          CLEARFIELD
       Hospital                        BUCKS
                                                                          • Penn Highlands Clearfield
     • UPMC McKeesport                 • Doylestown Hospital
                                                                          • Penn Highlands DuBois
     • UPMC Mercy                      • Jefferson Health –
     • UPMC Montefiore                   Bucks Hospital                   CLINTON
     • UPMC Passavant –                • St. Luke’s Hospital –            • Bucktail Medical Center
       McCandless                        Quakertown Campus                • UPMC Susquehanna Lock
     • UPMC Presbyterian               • St. Luke’s Hospital –              Haven
     • UPMC Shadyside                    Upper Bucks Campus

20
COLUMBIA                             GREENE                           • St. Luke’s Hospital –
• CHS Berwick Hospital Center        • Washington Health System         Allentown Campus
• Geisinger Bloomsburg Hospital        Greene                         • St. Luke’s Hospital –
                                                                        Sacred Heart Campus
CRAWFORD                             HUNTINGDON
                                                                      • St. Luke’s University Hospital –
• Meadville Medical Center           • Penn Highlands Huntingdon        Bethlehem
• Titusville Area Hospital           INDIANA                          LUZERNE
CUMBERLAND                           • Indiana Regional Medical       • CHS Wilkes-Barre
• Geisinger Holy Spirit Hospital       Center                           General Hospital
• Select Specialty Hospital –        JEFFERSON                        • Geisinger Wyoming Valley
  Camp Hill                          • Penn Highlands Brookville        Medical Center
• UPMC Carlisle                      • Punxsutawney Area Hospital     • Lehigh Valley Hospital –
• UPMC Pinnacle West Shore                                              Hazleton
                                     LACKAWANNA
DAUPHIN                              • CHS Moses Taylor Hospital      LYCOMING
• Penn State Health Children’s       • CHS Regional Hospital          • Geisinger Jersey Shore Hospital
  Hospital                             of Scranton                    • UPMC Susquehanna Muncy
• Penn State Health Milton S.        • Geisinger Community            • UPMC Susquehanna
  Hershey Medical Center               Medical Center                   Williamsport
• UPMC Pinnacle Community                                             • UPMC Susquehanna
                                     LANCASTER
  Osteopathic                                                           Williamsport Divine
                                     • Lancaster General Hospital       Providence Campus
• UPMC Pinnacle Harrisburg
                                     • Lancaster General Hospital
DELAWARE                               Women & Babies                 MCKEAN
• Crozer-Chester Medical Center      • Lancaster Surgery Center       • Bradford Regional Medical
                                                                        Center
• Delaware County Memorial           • UPMC Lititz
  Hospital                                                            • UPMC Kane
                                     • WellSpan Ephrata Community
• Main Line Health –                   Hospital                       MERCER
  Riddle Hospital                                                     • AHN Grove City Hospital
                                     LAWRENCE
ELK                                  • Lawrence County Surgery        • Edgewood Surgical Hospital
• Penn Highlands Elk                   Center of Edgewood Surgical    • Sharon Regional Health System
ERIE                                   Hospital                       • UPMC Horizon – Greenville
• AHN Saint Vincent Hospital         • UPMC Jameson                   • UPMC Horizon – Shenango
                                                                        Valley
• Corry Memorial Hospital            LEBANON
• Millcreek Community Hospital       • WellSpan Good Samaritan        MIFFLIN
• Select Specialty Hospital – Erie     Hospital                       • Geisinger Lewistown Hospital
• UPMC Hamot                         LEHIGH                           MONROE
FAYETTE                              • Lehigh Valley Hospital –       • Lehigh Valley Hospital – Pocono
                                       17h Street                     • St. Luke’s Hospital – Monroe
• Highlands Hospital
                                     • Lehigh Valley Hospital –         Campus
• Uniontown Hospital
                                       Cedar Crest
                                                                      MONTGOMERY
FRANKLIN                             • Lehigh Valley Hospital –
                                       Coordinated Health Allentown   • Einstein Medical Center
• WellSpan Chambersburg
                                                                        Elkins Park
  Hospital                           • Lehigh Valley Hospital –
                                       Muhlenberg                     • Einstein Medical Center
• WellSpan Waynesboro Hospital
                                                                        Montgomery
FULTON                               • Lehigh Valley Reilly
                                       Children’s Hospital            • Holy Redeemer Hospital
• Fulton County Medical Center                                          and Medical Center

                                                                                                           21
• Jefferson Health –               PHILADELPHIA                       POTTER
       Abington Hospital                • Children’s Hospital              • UPMC Cole
     • Jefferson Health –                 of Philadelphia
                                                                           SCHUYLKILL
       Abington-Landsdale Hospital      • Einstein Medical
                                                                           • Geisinger St. Luke’s Hospital
     • Main Line Health – Bryn Mawr       Center Philadelphia
       Hospital                                                            • Lehigh Valley Hospital -
                                        • Jefferson Health – Frankford
                                                                             Schuylkill E. Norwegian Street
     • Main Line Health – Lankenau        Hospital
       Medical Center                                                      • Lehigh Valley Hospital -
                                        • Jefferson Health – Methodist
                                                                             Schuylkill S. Jackson Street
     • Tower Health – Pottstown           Hospital
       Hospital                                                            • St. Luke’s Hospital – Miners
                                        • Jefferson Health – Thomas
                                                                             Campus
     MONTOUR                              Jefferson University Hospital
                                        • Jefferson Health – Torresdale    SOMERSET
     • Geisinger Jane Weis
       Children’s Hospital                Hospital                         • Chan Soon-Shiong Medical
                                        • Jefferson Health – WillsEye        Center at Windber
     • Geisinger Medical Center
                                          Hospital                         • Conemaugh Meyersdale
     NORTHAMPTON                        • Penn Medicine – Hospital of        Medical Center
     • Leigh Valley Hospital –            the University of Pennsylvania   • UPMC Somerset
       Coordinated Health Bethlehem     • Penn Medicine – Penn
                                                                           SUSQUEHANNA
     • St. Luke’s Hospital – Anderson     Presbyterian Medical Center
       Campus                                                              • Barnes-Kasson Hospital
                                        • Penn Medicine – Pennsylvania
     • St. Luke’s Hospital –              Hospital                         • Endless Mountains Health
       Easton Campus                                                         Systems
                                        • Temple Health – Fox Chase
     NORTHUMBERLAND                       Cancer Center                    TIOGA
     • Geisinger Shamokin Area          • Temple Health – Temple           • UPMC Susquehanna
       Community Hospital                 University Hospital                Wellsboro
                                        • Tower Health – Chestnut          UNION
                                          Hill Hospital
                                                                           • Evangelical Community
                                                                             Hospital

                                                   H

22
VENANGO
• UPMC Northwest                 IN-NETWORK ACCESS TO THESE
                                 OUT-OF-STATE HOSPITALS
WARREN                           THROUGH BLUECARD*
• Warren General Hospital
                                 MARYLAND
WASHINGTON                       • Meritus Medical Center
• Advanced Surgical Hospital     • The Johns Hopkins Hospital
• AHN Canonsburg Hospital        • University of Maryland
• Monongahela Valley Hospital      Medical Center
• Washington Hospital            • UPMC Western Maryland
WAYNE                            • WVU Medicine – Garrett
                                   Regional Medical Center
• Wayne Memorial Hospital
                                 NEW YORK
WESTMORELAND
                                 • AHN Westfield Memorial
• AHN Hempfield                    Hospital
  Neighborhood Hospital
                                 • Guthrie Corning Hospital
• Excela Health Frick Hospital
                                 • Olean General Hospital
• Excela Health Latrobe
                                 • UR Medicine – Jones Memorial
  Hospital
                                   Hospital
• Excela Health Westmoreland
                                 • UR Medicine – Strong
  Hospital
                                   Memorial Hospital
• Select Specialty Hospital –
  Laurel Highlands               OHIO
                                 • Cleveland Clinic
WYOMING
• CHS Tyler Memorial Hospital    WEST VIRGINIA
                                 • Weirton Medical Center
YORK
                                 • WVU Medicine –
• OSS Orthopaedic Hospital         Children’s Hospital
• UPMC Hanover                   • WVU Medicine – J.W. Ruby
• UPMC Memorial                    Memorial Hospital
• WellSpan York Hospital

*
 In addition, my Blue Access EPO plans provide in-network access to out-of-state
providers that participate with local Blue Plans through the BlueCard program. You
can find the provider directory at highmarkblueshield.com under the Find a Doctor or
Pharmacy tab.

                                                                                       23
Now, let’s dig
     into plan details.

24
To make it easier, we’ve sorted them
by what’s available where you live.
Just find your county and jump to that section.

Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon,
Lehigh, Northampton, Perry, and Schuylkill Counties
Standard plan options ��������������������������������������������������������������������������������������������������26
Extra Savings plan options ������������������������������������������������������������������������������������������28

Adams, Centre*, Columbia, Fulton, Juniata, Mifflin, Montour,
Northumberland, Snyder, Union, and York Counties
Standard plan options ��������������������������������������������������������������������������������������������������30
Extra Savings plan options ������������������������������������������������������������������������������������������ 32

Adult Vision and Dental Benefits ��������������������������������������������������������������������������34

* If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans:
16801, 16802, 16803, 16804, 16805, 16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852,
16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875, 16877, or 16882

           You’ll see plan summaries here. If you want any plan’s
            full benefit list, visit Highmark-SBC2021.com or get a
           paper copy by calling 1-833-258-0188 (TTY/TDD 711).

                                                                                                                              25
Plan summaries – Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties

                                                                                                                                                         Coverage Level
                                                                                                                                                         Catastrophic                Bronze                Bronze                      Silver
                                                                                                                                                         8550                        HSA 6900              3800                        HSA 3450

                                                                                                                                                         my Direct Blue EPO1         my Direct Blue EPO1   my Direct Blue EPO1         my Direct Blue EPO1
                                                                                                                                 Plan Availability
                                                                                                                                                         my Blue Access EPO          my Blue Access EPO    my Blue Access EPO          my Blue Access EPO

                                                                                                                                                         Individual: $8,550          Individual: $6,900    Individual: $3,800          Individual: $3,450
                                                                                                                                 In-Network Deductible
                                                                                                                                                         Family: $17,100             Family: $13,800       Family: $7,600              Family: $6,900

                                                                                                                                 In-Network, Out-of-     Individual: $8,550          Individual: $6,900    Individual: $8,500          Individual: $6,900
                                                                                                                                 Pocket Maximum          Family: $17,100             Family: $13,800       Family: $17,000             Family: $13,800

                                                                                                                                                         First 3 visits free, then                                                     $70 copay after
                                                                                                                                 Primary Care Visit                                  $0 after deductible   $60 copay
                                                                                                                                                         $0 after deductible                                                           deductible

                                                                                                                                                                                                                                       $70 copay after
                                                                                                                                 Specialist Visit        $0 after deductible         $0 after deductible   50% after deductible
                                                                                                                                                                                                                                       deductible

                                                                                                                                 Outpatient Mental
                                                                                                                                                                                                           First 2 visits free, then   $70 copay after
                                                                                                                                 Health and Substance    $0 after deductible         $0 after deductible
                                                                                                                                                                                                           50% after deductible        deductible
                                                                                                                                 Abuse Visits

                                                                                                                                 Physical &
                                                                                                                                                                                                                                       $70 copay after
                                                                                                                                 Occupational            $0 after deductible         $0 after deductible   50% after deductible
                                                                                                                                                                                                                                       deductible
                                                                                                                                 Therapy/Chiropractic3

                                                                                                                                 Lab Services                                                                                          $90 copay after
                                                                                                                                                         $0 after deductible         $0 after deductible   50% after deductible
                                                                                                                                 (Diagnostic / X-ray)                                                                                  deductible

                                                                                                                                                                                                                                       $140 copay after
                                                                                                                                 Urgent Care             $0 after deductible         $0 after deductible   $100 copay
                                                                                                                                                                                                                                       deductible

                                                                                                                                 Emergency                                                                                             $750 copay after
                                                                                                                                                         $0 after deductible         $0 after deductible   50% after deductible
                                                                                                                                 Services                                                                                              deductible

                                                                                                                                 Hospital Inpatient
                                                                                                                                 (including              $0 after deductible         $0 after deductible   50% after deductible        10% after deductible
                                                                                                                                 Maternity)

                                                                                                                                 Pharmacy                $0/$0/$0/$0                 $0/$0/$0/$0           50%/50%/50%/50%             $0/$30/$150/50%
                                                                                                                                 Summary4                after deductible            after deductible      after deductible            after deductible

                                                                                                                                 Includes Adult Dental
                                                                                                                                                         No                          No                    Yes                         No
                                                                                                                                 and Vision Option5

              26
Coverage Level
                                     Silver                         Silver                    Silver                 Gold 800               Gold 0
                                     2900                           2600                      HSA 1850

                                     my Direct Blue EPO1            my Direct EPO1*           my Direct Blue EPO1*   my Direct Blue EPO1    my Direct Blue EPO1
     Plan Availability
                                     my Blue Access EPO             my Blue Access EPO*       my Blue Access EPO*    my Blue Access EPO     my Blue Access EPO

                                                                                              Individual: $1,850
     In-Network                      Individual: $2,900             Individual: $2,600                               Individual: $800       Individual: $0
                                                                                              Family: $3,700
     Deductible                      Family: $5,800                 Family: $5,200                                   Family: $1,600         Family: $0
                                                                                              [Non-embedded]2

     In-Network,
                                     Individual: $7,800             Individual: $8,500        Individual: $6,900     Individual: $6,000     Individual: $7,500
     Out-of-Pocket
                                     Family: $15,600                Family: $17,000           Family: $13,800        Family: $12,000        Family: $15,000
     Maximum

     Primary Care Visit              $50 copay                      $40 copay                 30% after deductible   $15 copay              $20 copay

     Specialist Visit                $50 copay                      $40 copay                 30% after deductible   $15 copay              $20 copay

     Outpatient
     Mental Health and               $50 copay                      $40 copay                 30% after deductible   $15 copay              $20 copay
     Substance Abuse Visits

     Physical &
     Occupational                    $75 copay                      $40 copay                 30% after deductible   $40 copay              $45 copay
     Therapy/Chiropractic3

     Lab Services
                                     $75 copay                      $65 copay                 30% after deductible   $30 copay              $35 copay
     (Diagnostic / X-ray)

     Urgent Care                     $100 copay                     $80 copay                 30% after deductible   $30 copay              $40 copay

     Emergency                       $750 copay after
                                                                    30% after deductible      30% after deductible   $250 copay             $300 copay
     Services                        deductible

     Hospital Inpatient
                                     30% after deductible           30% after deductible      30% after deductible   20% after deductible   40% after deductible
     (including Maternity)

     Pharmacy                                                                                 30%/30%/30%/30%
                                     $0/$30/$150/50%                $0/$30/$150/50%                                  $0/$25/$75/50%         $0/$30/$150/50%
     Summary4                                                                                 after deductible

     Includes Adult Dental
                                     Yes                            Yes                       No                     Yes                    No
     and Vision Option5

* These plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced
  Premium Tax Credits or Cost-Sharing Reductions.
1
    Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO
2
    This plan has a Non-Embedded deductible. See Disclosures page for more info.
3
    Limit of 30 combined physical and occupational therapy visits per benefit period.
4
    Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
5
    See page 34 for Adult Dental and Vision benefit details.

                                                                                                                                                                   27
Plan summaries – Berks, Cumberland, Dauphin, Franklin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and Schuylkill Counties Extra Savings Plans

                                                                                                                                                                               Income Level
                                                                                                                                                                               138%-149% FPL                                  150-199% FPL

                                                                                                                                                                               Coverage Level
                                                                                                                                                                               Silver 100              Silver 0               Silver 700
                                                                                                                                                                               my Direct Blue EPO1     my Direct Blue EPO1    my Direct Blue EPO1
                                                                                                                                                     Plan Availability
                                                                                                                                                                               my Blue Access EPO      my Blue Access EPO     my Blue Access EPO

                                                                                                                                                                               Individual: $100        Individual: $0         Individual: $700
                                                                                                                                                     In-Network Deductible
                                                                                                                                                                               Family: $200            Family: $0             Family: $1,400

                                                                                                                                                     In-Network, Out-of-       Individual: $1,400      Individual: $1,200     Individual: $2,850
                                                                                                                                                     Pocket Maximum            Family: $2,800          Family: $2,400         Family: $5,700

                                                                                                                                                     Primary Care Visit        $5 copay                $1 copay               $25 copay

                                                                                                                                                     Specialist Visit          $5 copay                $1 copay               $25 copay

                                                                                                                                                     Outpatient Mental
                                                                                                                                                     Health and Substance      $5 copay                $1 copay               $25 copay
                                                                                                                                                     Abuse Visits

                                                                                                                                                     Physical & Occupational
                                                                                                                                                                               $5 copay                $5 copay               $25 copay
                                                                                                                                                     Therapy/Chiropractic2

                                                                                                                                                     Lab Services
                                                                                                                                                                               $15 copay               $5 copay               $45 copay
                                                                                                                                                     (Diagnostic / X-ray)

                                                                                                                                                     Urgent Care               $10 copay               $5 copay               $50 copay

                                                                                                                                                     Emergency Services        $150 after deductible   $75 copay              $300 after deductible

                                                                                                                                                     Hospital Inpatient
                                                                                                                                                                               10% after deductible    10% after deductible   10% after deductible
                                                                                                                                                     (including Maternity)

                                                                                                                                                     Pharmacy Summary3         $0/$5/$15/50%           $0/$5/$15/50%          $0/$10/$50/50%

                                                                                                                                                     Includes Adult Dental
                                                                                                                                                                               Yes                     No                     Yes
                                                                                                                                                     and Vision Option4

                28
Income Level
                                      150-199% FPL                          200-249% FPL

                                      Coverage Level
                                      Silver 0                              Silver 2100                        Silver 1050
                                      my Direct Blue EPO1                   my Direct Blue EPO1                my Direct Blue EPO1
     Plan Availability
                                      my Blue Access EPO                    my Blue Access EPO                 my Blue Access EPO

                                      Individual: $0                        Individual: $2,100                 Individual: $1,050
     In-Network Deductible
                                      Family: $0                            Family: $4,200                     Family: $2,100

     In-Network, Out-of-              Individual: $2,800                    Individual: $6,800                 Individual: $5,800
     Pocket Maximum                   Family: $5,600                        Family: $13,600                    Family: $11,600

     Primary Care Visit               $15 copay                             $50 copay                          $60 after deductible

     Specialist Visit                 $15 copay                             $50 copay                          $60 after deductible

     Outpatient Mental
     Health and Substance             $15 copay                             $50 copay                          $60 after deductible
     Abuse Visits

     Physical & Occupational
                                      $30 copay                             $75 copay                          $60 after deductible
     Therapy/Chiropractic2

     Lab Services
                                      $25 copay                             $75 copay                          $75 after deductible
     (Diagnostic / X-ray)

     Urgent Care                      $30 copay                             $100 copay                         $120 after deductible

     Emergency Services               $275 copay                            $750 after deductible              $750 after deductible

     Hospital Inpatient
                                      10% after deductible                  30% after deductible               10% after deductible
     (including Maternity)

     Pharmacy Summary3                $0/$10/$50/50%                        $0/$30/$150/50%                    $0/$30/$150/50% after deductible

     Includes Adult Dental
                                      No                                    Yes                                No
     and Vision Option4

1
    Includes my Direct Blue EPO and my Direct Blue Lehigh Valley EPO
2
    Limit of 30 combined physical and occupational therapy visits per benefit period.
3
    Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
4
    See page 34 for Adult Dental and Vision benefit details.

                                                                                                                                                  29
Plan summaries – Adams, Centre**, Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties

                                                                                                                                                          Coverage Level
                                                                                                                                                          Catastrophic               Bronze                Bronze                      Silver
                                                                                                                                                          8550                       HSA 6900              3800                        HSA 3450

                                                                                                                                  Plan Availability       my Blue Access EPO         my Blue Access EPO    my Blue Access EPO          my Blue Access EPO

                                                                                                                                                          Individual: $8,550         Individual: $6,900    Individual: $3,800          Individual: $3,450
                                                                                                                                  In-Network Deductible
                                                                                                                                                          Family: $17,100            Family: $13,800       Family: $7,600              Family: $6,900

                                                                                                                                  In-Network, Out-of-     Individual: $8,550         Individual: $6,900    Individual: $8,500          Individual: $6,900
                                                                                                                                  Pocket Maximum          Family: $17,100            Family: $13,800       Family: $17,000             Family: $13,800

                                                                                                                                                          First 3 visits free,
                                                                                                                                  Primary Care Visit                                 $0 after deductible   $60 copay                   $70 after deductible
                                                                                                                                                          then $0 after deductible

                                                                                                                                  Specialist Visit        $0 after deductible        $0 after deductible   50% after deductible        $70 after deductible

                                                                                                                                  Outpatient Mental
                                                                                                                                                                                                           First 2 visits free, then
                                                                                                                                  Health and Substance    $0 after deductible        $0 after deductible                               $70 after deductible
                                                                                                                                                                                                           50% after deductible
                                                                                                                                  Abuse Visits

                                                                                                                                  Physical &
                                                                                                                                  Occupational            $0 after deductible        $0 after deductible   50% after deductible        $70 after deductible
                                                                                                                                  Therapy/Chiropractic2

                                                                                                                                  Lab Services
                                                                                                                                                          $0 after deductible        $0 after deductible   50% after deductible        $90 after deductible
                                                                                                                                  (Diagnostic / X-ray)

                                                                                                                                  Urgent Care             $0 after deductible        $0 after deductible   $100 copay                  $140 after deductible

                                                                                                                                  Emergency
                                                                                                                                                          $0 after deductible        $0 after deductible   50% after deductible        $750 after deductible
                                                                                                                                  Services

                                                                                                                                  Hospital Inpatient
                                                                                                                                  (including              $0 after deductible        $0 after deductible   50% after deductible        10% after deductible
                                                                                                                                  Maternity)

                                                                                                                                  Pharmacy                $0/$0/$0/$0                $0/$0/$0/$0           50%/50%/50%/50%             $0/$30/$150/50%
                                                                                                                                  Summary3                after deductible           after deductible      after deductible            after deductible

                                                                                                                                  Includes Adult Dental
                                                                                                                                                          No                         No                    Yes                         No
                                                                                                                                  and Vision Option4

              30
Coverage Level
                              Silver 2900               Silver                   Silver                   Gold 800                  Gold 0
                                                        2600                     HSA 1850

  Plan Availability           my Blue Access EPO        my Blue Access EPO*      my Blue Access EPO*      my Blue Access EPO        my Blue Access EPO

                                                                                 Individual: $1,850
                              Individual: $2,900        Individual: $2,600                                Individual: $800          Individual: $0
  In-Network Deductible                                                          Family: $3,700
                              Family: $5,800            Family: $5,200                                    Family: $1,600            Family: $0
                                                                                 [Non-embedded] 1

  In-Network, Out-of-         Individual: $7,800        Individual: $8,500       Individual: $6,900       Individual: $6,000        Individual: $7,500
  Pocket Maximum              Family: $15,600           Family: $17,000          Family: $13,800          Family: $12,000           Family: $15,000

  Primary Care Visit          $50 copay                 $40 copay                30% after deductible     $15 copay                 $20 copay

  Specialist Visit            $50 copay                 $40 copay                30% after deductible     $15 copay                 $20 copay

  Outpatient Mental
  Health and Substance        $50 copay                 $40 copay                30% after deductible     $15 copay                 $20 copay
  Abuse Visits

  Physical &
  Occupational                $75 copay                 $40 copay                30% after deductible     $40 copay                 $45 copay
  Therapy/Chiropractic2

  Lab Services
                              $75 copay                 $65 copay                30% after deductible     $30 copay                 $35 copay
  (Diagnostic / X-ray)

  Urgent Care                 $100 copay                $80 copay                30% after deductible     $30 copay                 $40 copay

  Emergency
                              $750 after deductible     30% after deductible     30% after deductible     $250 copay                $300 copay
  Services

  Hospital Inpatient
  (including                  30% after deductible      30% after deductible     30% after deductible     20% after deductible      40% copay
  Maternity)

  Pharmacy                                                                       30%/30%/30%/30%
                              $0/$30/$150/50%           $0/$30/$150/50%                                   $0/$25/$75/50%            $0/$30/$150/50%
  Summary3                                                                       after deductible

  Includes Adult Dental
                              Yes                       Yes                      No                       Yes                       No
  and Vision Option4

* Plans are available directly from Highmark and are not available on the Pennsylvania Insurance Exchange. They do not qualify for Advanced
  Premium Tax Credits or Cost-Sharing Reductions.
**If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805,
  16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875,
  16877, or 16882
1 This plan has a Non-Embedded deductible. See Disclosures page for more info.
2 Limit of 30 combined physical and occupational therapy visits per benefit period.
3 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
4 See page 34 for Adult Dental and Vision benefit details.

                                                                                                                                                            31
Plan summaries – Adams, Centre**, Columbia, Fulton, Juniata, Mifflin, Montour, Northumberland, Snyder, Union, and York Counties Extra Savings Plans

                                                                                                                                                                                Income Level
                                                                                                                                                                                138%-149% FPL                                150-199% FPL

                                                                                                                                                                                Coverage Level
                                                                                                                                                                                Silver 100              Silver 0             Silver 700

                                                                                                                                                      Plan Availability         my Blue Access EPO      my Blue Access EPO   my Blue Access EPO

                                                                                                                                                                                Individual: $100        Individual: $0       Individual: $700
                                                                                                                                                      In-Network Deductible
                                                                                                                                                                                Family: $200            Family: $0           Family: $1,400

                                                                                                                                                      In-Network, Out-of-       Individual: $1,400      Individual: $1,200   Individual: $2,850
                                                                                                                                                      Pocket Maximum            Family: $2,800          Family: $2,400       Family: $5,700

                                                                                                                                                      Primary Care Visit        $5 copay                $1 copay             $25 copay

                                                                                                                                                      Specialist Visit          $5 copay                $1 copay             $25 copay

                                                                                                                                                      Outpatient Mental
                                                                                                                                                      Health and Substance      $5 copay                $1 copay             $25 copay
                                                                                                                                                      Abuse Visits
                                                                                                                                                      Physical & Occupational
                                                                                                                                                                                $5 copay                $5 copay             $25 copay
                                                                                                                                                      Therapy/Chiropractic1
                                                                                                                                                      Lab Services
                                                                                                                                                                                $15 copay               $5 copay             $45 copay
                                                                                                                                                      (Diagnostic / X-ray)

                                                                                                                                                      Urgent Care               $10 copay               $5 copay             $50 copay

                                                                                                                                                      Emergency Services        $150 after deductible   $75 copay            $300 after deductible

                                                                                                                                                      Hospital Inpatient
                                                                                                                                                                                10% after deductible    10%                  10% after deductible
                                                                                                                                                      (including Maternity)

                                                                                                                                                      Pharmacy Summary2         $0/$5/$15/50%           $0/$5/$15/50%        $0/$10/$50/50%

                                                                                                                                                      Includes Adult Dental
                                                                                                                                                                                Yes                     No                   Yes
                                                                                                                                                      and Vision Option3

         32
Income Level
                                   150-199% FPL                           200-249% FPL

                                   Coverage Level
                                   Silver 0                               Silver 2100                             Silver 1050

  Plan Availability                my Blue Access EPO                     my Blue Access EPO                      my Blue Access EPO

                                   Individual: $0                         Individual: $2,100                      Individual: $1,050
  In-Network Deductible
                                   Family: $0                             Family: $4,200                          Family: $2,100

  In-Network, Out-of-              Individual: $2,800                     Individual: $6,800                      Individual: $5,800
  Pocket Maximum                   Family: $5,600                         Family: $13,600                         Family: $11,600

  Primary Care Visit               $15 copay                              $50 copay                               $60 after deductible

  Specialist Visit                 $15 copay                              $50 copay                               $60 after deductible

  Outpatient Mental
  Health and Substance             $15 copay                              $50 copay                               $60 after deductible
  Abuse Visits
  Physical & Occupational
                                   $30 copay                              $75 copay                               $60 after deductible
  Therapy/Chiropractic1
  Lab Services
                                   $25 copay                              $75 copay                               $75 after deductible
  (Diagnostic / X-ray)

  Urgent Care                      $30 copay                              $100 copay                              $120 after deductible

  Emergency Services               $275 copay                             $750 after deductible                   $750 after deductible

  Hospital Inpatient
                                   10%                                    30% after deductible                    10% after deductible
  (including Maternity)

  Pharmacy Summary2                $0/$10/$50/50%                         $0/$30/$150/50%                         $0/$30/$150/50% after deductible

  Includes Adult Dental
                                   No                                     Yes                                     No
  and Vision Option3

**If you’re a Centre county resident, you must live in one of the following ZIP codes to enroll in one of these plans: 16801, 16802, 16803, 16804, 16805,
  16820, 16823, 16826, 16827, 16828, 16832, 16835, 16841, 16844, 16851, 16852, 16853, 16854, 16856, 16864, 16865, 16868, 16870, 16872, 16875,
  16877, or 16882
1 Limit of 30 combined physical and occupational therapy visits per benefit period.
2 Visit highmarkacaformulary.com to view our Formulary and see if your drug is covered, and at which tier.
3 See page 34 for Adult Dental and Vision benefit details.

                                                                                                                                                            33
Adult Vision Benefits

                        For all plans with Adult Dental and Vision —
                        these are your vision benefits.
                        In-network
                        Vision Benefits                                                                                                 Frequency - Once Every:
                        Eye Examination (including dilation when professionally indicated)                                              12 months

                        Spectacle Lenses                                                                                                12 months

                        Frame                                                                                                           12 months

                        Contact Lenses (in lieu of eyeglass lenses)                                                                     12 months

                        Copayments
                        Eye Examination                                                                                                 $0

                        Spectacle Lenses                                                                                                $0

                        Contact Lens Evaluation, Fitting, and Follow-Up Care                                                            n/a

                        Eyeglass Benefit - Frame                                                             Average Retail Value
                        Non-Collection Frame Allowance (Retail):                                             Up to $130                         Up to $60

                                                                 Fashion level                               Up to $125                         Included

                        Davis Vision Frame Collection    1
                                                                 Designer level                              Up to $175                         $20 copayment
                        (in lieu of Allowance):
                                                                 Premier level                               Up to $225                         $40 copayment

                        Eyeglass Benefit - Spectacle Lenses                                                      Average Retail Value               Member Charges
                        Clear plastic single-vision, lined bifocal, trifocal or lenticular lenses (any Rx)       $60-$120                           Included

                        Oversize Lenses                                                                          $20                                Included

                        Tinting of Plastic Lenses                                                                $20                                $11

                        Scratch-Resistant Coating                                                                $25-$40                            Included

                        Scratch Protection Plan Single Vision                                                    $60-$120                           $20

                        Scratch Protection Plan Multifocal                                                       $60-$120                           $40

                        Polycarbonate Lenses2                                                                    $60-$75                            $0 or $30

                        Ultraviolet Coating                                                                      $25-$30                            $12

                        Standard Anti-Reflective (AR) Coating                                                    $50-$70                            $35

                        Premium AR Coating                                                                       $65-$90                            $48

                        Ultra AR Coating                                                                         $100-$125                          $60

                        Standard Progressive Lenses                                                              $150-$195                          $50

                        Premium Progressives (Varilux®, etc.)                                                    $195-$225                          $90

                        Ultra Progressive Lenses                                                                 $225-$300                          $140

                        Intermediate-Vision Lenses                                                               $150-$175                          $30

                        High-Index Lenses                                                                        $90-$150                           $55

                        Polarized Lenses                                                                         $95-$110                           $75

                        Plastic Photosensitive Lenses                                                            $95-$150                           $65

   34
Contact Lens Benefit (in lieu of eyeglasses)
Non-Collection Contact Lenses: Materials Allowance                                                    Up to $85

                                   Disposable                                                         Covered In Full
Collection Contact Lenses1
                                   Planned Replacement                                                Covered In Full
in lieu of Allowance): Materials
                                   Evaluation, Fitting, and Follow-up Care                            Included

Medically Necessary Contact
                                   Materials, Evaluation, Fitting, and Follow-Up Care                 Included
Lenses (with prior approval)

Collection is available at most participating independent provider offices. Collection is subject to change.
1

Collection is inclusive of select torics and multifocals.
2
  Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with
prescriptions +/- 6.00 diopters or greater.

One-year eyeglass breakage warranty included.
Adult Vision benefits utilize the Davis Vision Network. There is no out-of-network coverage. Davis Vision
is a separate company that administers Highmark vision benefits.

To find a provider in the Davis Vision Network, visit highmarkblueshield.com and select the Find a Doctor or
Pharmacy tab.

                                                                                                                        35
Adult Dental Benefits

                        For all plans with Adult Dental and Vision —
                        these are your dental benefits.
                        Dental Benefits
                        Annual Deductible Per Insured Person                             $50 Per Calendar Year

                        Annual Deductible Per Insured Family                             $150 Per Calendar Year

                        Annual Maximum Per Insured Person                                $1,250

                                                                           Policy Pays
                        Covered Services:                                                                         Elimination Period
                                                                           In Network    Out of Network

                        Oral Evaluations (Exams)                           100%          0%                       None

                        Radiographs (All X-Rays)                           100%          0%                       None

                        Prophylaxis (Cleanings)                            100%          0%                       None

                        Palliative Treatment (Emergency)                   100%          0%                       None

                        Sealants                                           100%          0%                       None

                        Space Maintainers                                  100%          0%                       None

                        Repairs of Crowns, Inlays, Onlays, Fixed Partial
                                                                           80%           0%                       6 Months
                        Dentures, and Dentures

                        Basic Restorative (Fillings, etc.)                 80%           0%                       None

                        Simple Extractions                                 80%           0%                       6 Months

                        Surgical Extractions                               50%           0%                       6 Months

                        Complex Oral Surgery                               50%           0%                       6 Months

                        Endodontics (Root canals, etc.)                    50%           0%                       6 Months

                        General Anesthesia and/or Nitrous Oxide and/or
                                                                           80%           0%                       6 Months
                        IV Sedation

                        Nonsurgical Periodontics                           50%           0%                       6 Months

                        Periodontal Maintenance                            50%           0%                       None

                        Surgical Periodontics                              50%           0%                       6 Months

                        Crowns, Inlays, Onlays                             50%           0%                       6 Months

                        Prosthetics (Fixed Partial Dentures, Dentures)     50%           0%                       6 Months

                        Adjustments and Repairs of Prosthetics             80%           0%                       None

                        Implant Services                                   0%            0%                       None

                        Consultations                                      100%          0%                       None

                        Orthodontics                                       0%            0%                       None

                        The percentage in the Policy Pays column is the percentage of the plan allowance that the Policy will
                        pay for Covered Services provided by a Participating Dentist. Participating Dentists accept the Maximum Allowable Charge
                        as payment in full.
                        Adult Dental benefits utilize the United Concordia Advantage Network. Members must use a United Concordia provider.
                        There is no Out-of-Network coverage for this benefit. United Concordia Companies, Inc., is a separate company that
                        administers pediatric dental benefits for Highmark members.
                        To find a dental provider in the Advantage Network, visit highmarkblueshield.com and select the Find a Doctor or Pharmacy tab.

   36
Health care lingo, translated.
When you’re choosing plans, you’re bound to see certain terms over and over.
Here’s a cheat sheet for a few of the most important ones.

BlueCARD®                                     HIGH-DEDUCTIBLE HEALTH                      PREMIUM
A program that connects independent           PLAN (HDHP)                                 The monthly amount paid for coverage.
Blue Plans across the country. It             A plan that usually comes with
                                                                                          PREVENTIVE CARE SERVICES
gives Blue Plan members access to             a lower premium because you pay more
                                                                                          Routine care like screenings and
in-network coverage while outside             for health care services up
                                                                                          checkups that help you healthy. Refer to
their plan area. The level of coverage        front before the insurance company
                                                                                          the Highmark Preventive Schedule for
depends on your chosen plan.                  starts to pay. These plans are often
                                                                                          the list of preventive care services.
                                              combined with a health
COINSURANCE
                                              savings account.                            PRIMARY CARE PROVIDER (PCP)
The percentage of total cost of
                                                                                          The medical professional you see for
care you may owe for certain                  IN-NETWORK PROVIDER
                                                                                          most of your basic care, like yearly
covered services after reaching your          A doctor or hospital that has
                                                                                          preventive visits and screenings.
deductible. For example, if your plan         an agreement with the plan and
pays 80%, you pay 20%.                        will accept plan allowance plus             QUALIFIED HEALTH PLAN (QHP)
                                              member copay or coinsurance                 A plan that has been certified by the
COPAY
                                              as payment in full.                         Health Insurance Marketplace and
The set amount you pay for certain
                                                                                          meets all ACA requirements. That
covered services, could be $20 for a          OUT-OF-NETWORK PROVIDER
                                                                                          includes providing the 10 essential
doctor visit or $30 for a specialist visit.   A doctor or hospital that does not
                                                                                          health benefits and staying inside the
If you owe a copay, you must pay it           have an agreement with the plan
                                                                                          limits for deductibles, copays, and
when you check in for your visit.             and does not have to accept plan
                                                                                          out-of-pocket maximums.
                                              allowance as payment in full.
DEDUCTIBLE
                                                                                          REHABILITATIVE SERVICES
The set amount you pay for covered            OUT-OF-POCKET MAXIMUM
                                                                                          Care that helps you keep, get back,
health services or drug costs before          The most you’d pay for covered
                                                                                          or improve skills and functioning
your plan starts paying.                      care in a benefit period or year.
                                                                                          after you were sick, hurt, or disabled.
                                              If you reach this amount, your
EMERGENCY SERVICES
                                              plan pays 100% after that.                  RETAIL CLINIC
Care for a condition needing
                                                                                          Walk-in centers for less complex health
immediate attention to avoid                  PLAN ALLOWANCE
                                                                                          needs, generally open in the evenings
severe harm.                                  The set amount an in-network
                                                                                          and on weekends.
                                              provider has agreed to accept for a
FORMULARY
                                              covered health care service. Member         TELEMEDICINE
A list of drugs selected by the plan
                                              responsibility for the service can          Telemedicine is health care that you get
based on certain clinical factors.
                                              be found in the Outline of Coverage.        from a doctor in real time via a smart
The list of medicines is sorted
                                              The plan pays the difference between        device, computer, or telephone.
by tier. Lower tiers usually mean
                                              the plan allowance and the member
lower copays.
                                              responsibility. If an out-of-network        URGENT CARE CENTER
                                                                                          A walk-in center for when you have a
HABILITATIVE SERVICES                         provider bills for more than the
                                              plan allowance, you may have to             condition that’s serious enough to need
Health care services that help you
                                              pay the difference. If your plan does not   care right away, but not serious enough
keep, acquire, or improve skills and
                                              include out-of-network coverage and         for a trip to the emergency room.
functioning for daily living following
disease, illness, or injury.                  you receive care, other than emergency      VIRTUAL VISIT
                                              or urgent care, you may be responsible      A type of telemedicine that you receive
HEALTH SAVINGS ACCOUNT (HSA)                  for the entire cost..                       from a PCP or specialist via email or
An account to set aside pre-tax money
                                                                                          online videoconferencing.
to pay for qualified medical expenses.
You can only have an HSA if you
have a Qualified High-Deductible
Health Plan.

                                                                                                                                     37
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