Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 11/01/2023 – 10/31/2024

Gig Harbor Firefighters Union Health & Welfare Trust: Active Plan Coverage for: Individual, Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is
only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see www.lucenthealth.com/cypress or call 1-
877-236-0844. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-877-236-0844 to request a copy.
Important Questions Answers Why This Matters:
Generally, you must pay all the costs from up providers up to the deductible
amount before this plan begins to pay. If you have other family members on the
What is the overall
$500 individual / $1,000 family plan, each family member must meet their own individual deductible until the total
deductible?
amount of deductible expenses paid be all family members meets the overall family
deductible.
This plan covers some items and services even if you haven’t yet met the
Yes. Preventive care, Primary Care,
Are there services covered deductible amount. But a copayment or coinsurance may apply. For example, this
Specialist visits, and services listed with a
before you meet your plan covers certain preventive services without cost-sharing and before you meet
copayment are covered before you meet
deductible? your deductible. See a list of covered preventive services at
your deductible.
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
No You don’t have to meet deductibles for specific services.
for specific services?
Generally, you must pay all the costs from up providers up to the deductible
amount before this plan begins to pay. If you have other family members on the
What is the out-of-pocket limit
$3,000 individual / $6,000 family plan, each family member must meet their own individual deductible until the total
for this plan?
amount of deductible expenses paid be all family members meets the overall family
deductible.
What is not included in the Premiums, balance-billing charges, penalties Even though you pay these expenses, they don’t count toward the out–of–pocket
out-of-pocket limit? and health care this plan doesn’t cover. limit.
This plan uses a large list of providers through 6 Degrees (Medivi-Propon).
Providers are identified as friendly or non-friendly to the plan’s payments. Members
Yes. See https://medivi.6degreeshealth.com can use any provider they choose. Members can request 6 Degrees contact
Will you pay less if you use a
or call 1-877-350-2899 for a list of network providers not on their list to create care arrangement. You might receive a bill from
network provider?
providers. a provider for the difference between the provider’s charge and what your plan
pays (balance billing). Contact Lucent if you receive a balance bill. Check with your
provider or the Propon list before you receive services.
Do you need a referral to see
No You can see the specialist you choose without a referral.
a specialist?

Page 1 of 6
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
Primary care visit to treat
an injury or illness
If you visit a health care Specialist visit
provider’s office or
clinic
Preventive care/screening/
immunization
Diagnostic test (x-ray,
blood work)
If you have a test
Imaging (CT/PET scans,
MRIs)
Generic drugs (Tier 1)
If you need drugs to
treat your illness or Preferred brand drugs
condition (Tier 2)
More information about
prescription drug
coverage is available at
www.magellanrx.com or Non-preferred brand drugs
call 1-800-424-5876.
(Tier 3)
Specialty drugs (Tier 4)
* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress.
What You Will Pay
Limitations, Exceptions, & Other Important
Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
$20 copay/visit; $20 copay/visit;
None
deductible does not apply deductible does not apply
$20 copay/visit; $20 copay/visit; Chiropractic care is limited to 20 visits per
deductible does not apply deductible does not apply calendar year.
You may have to pay for services that aren’t
No charge; No charge; preventive. Ask your provider if the services
deductible does not apply deductible does not apply you need are preventive. Then check what
your plan will pay for.
Physician’s Office: Physician’s Office:
$20 copay/visit; $20 copay/visit;
deductible does not apply deductible does not apply None
All other settings: All other settings:
20% coinsurance 20% coinsurance
20% coinsurance 20% coinsurance Preauthorization is required.
Retail:
$10 copay/prescription
Mail Order: Not Covered
Deductible does not apply to any drug tier.
$20 copay/prescription
Retail: Covers up to a 34-day supply (retail
$35 copay/prescription prescription); 90-day supply (mail order
Not Covered prescription).
Mail Order:
$70 copay/prescription
Retail: Prescription Drugs recommended by the
50% of the cost up to HRSA or USPSTF will be covered at 100% as
$100 copay/prescription required by ACA.
Mail Order: Not Covered
50% of the cost up to Specialty drugs are limited to a 30-day
$200 copay/prescription supply.
Retail and Mail Order:
Not Covered
50% of the cost up to
Page 2 of 6

Common Medical Event Services You May Need
Facility fee (e.g.,
If you have outpatient ambulatory surgery
surgery center)
Physician/surgeon fees
Emergency room care
If you need immediate Emergency medical
medical attention transportation
Urgent care
Facility fee (e.g., hospital
If you have a hospital
room)
stay
Physician/surgeon fees
If you need mental Outpatient services
health, behavioral
health, or substance
abuse services
Inpatient services
Office visits
Childbirth/delivery
If you are pregnant
professional services
Childbirth/delivery facility
services
* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress.
What You Will Pay
Limitations, Exceptions, & Other Important
Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
$500 copay/prescription
Preauthorization is required. If you do not
20% coinsurance 20% coinsurance receive preauthorization, benefits will be
reduced by $250.
20% coinsurance 20% coinsurance None
$200 copay then $200 copay then Copay waived if admitted. Network deductible
20% coinsurance 20% coinsurance applies to Out-of-Network benefits.
Network deductible applies to Out-of-Network
20% coinsurance 20% coinsurance
benefits.
$20 copay/visit; $20 copay/visit;
None
deductible does not apply deductible does not apply
Preauthorization is required. If you do not
20% coinsurance 20% coinsurance receive preauthorization, benefits will be
reduced by $250.
20% coinsurance 20% coinsurance None
Office: Office:
$20 copay/visit; $20 copay/visit;
deductible does not apply deductible does not apply None
All other outpatient: All other outpatient:
20% coinsurance 20% coinsurance
Preauthorization is required. If you do not
20% coinsurance 20% coinsurance receive preauthorization, benefits will be
reduced by $250.
Cost Sharing does not apply to preventative
$20 copay/visit; $20 copay/visit;
services. Depending on the type of service, a
deductible does not apply deductible does not apply copayment, coinsurance, or deductible may
apply. Maternity care may include tests and
services described elsewhere in the SBC (i.e.
20% coinsurance 20% coinsurance
ultrasound). Preauthorization is required for
vaginal deliveries requiring more than a 48
hour stay and cesarean section deliveries
20% coinsurance 20% coinsurance requiring more than a 96 hour stay to avoid
penalty.
Page 3 of 6
 What You Will Pay
Limitations, Exceptions, & Other Important
Common Medical Event Services You May Need Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Preauthorization is required. If you don't
No charge; deductible No charge; deductible
Home health care receive preauthorization, benefits could be
does not apply does not apply
reduced by $250.
Physician’s Office: Physician’s Office: Preauthorization is required. If you don't
Rehabilitation services $20 copay/visit; $20 copay/visit; receive preauthorization, benefits could be
deductible does not apply deductible does not apply reduced by $250. Physical, occupational and

Habilitation services
If you need help
recovering or have
other special health
needs Skilled nursing care
Durable medical
equipment
No charge; deductible
Hospice services
Children’s eye exam
If your child needs $50 maximum benefit per
Children’s glasses
dental or eye care
Children’s dental check-up
All other settings: All other settings: speech therapy is limited to 60 combined
visits per calendar year.
20% coinsurance 20% coinsurance
Preauthorization is required. If you don't
20% coinsurance 20% coinsurance receive preauthorization, benefits could be
reduced by $250.
Preauthorization is required. If you don't
20% coinsurance 20% coinsurance receive preauthorization, benefits could be
reduced by $250.
Preauthorization is required. If you don't
No charge; deductible
receive preauthorization, benefits could be
does not apply does not apply
reduced by $250.
Routine screenings covered as defined
under the Patient Protection and Affordable
Not Covered Not Covered Care Act of 2010. For more information,
please refer to separate vision plan through
VSP.
Reimbursement requires documentation of
primary insurance payment.
$50 maximum benefit per
For more information on Vision Benefits,
Calendar Year Calendar Year
please refer to your separate vision plan
through VSP.
Routine screenings covered as defined under
the Patient Protection and Affordable Care
Not Covered Not Covered Act of 2010. For more information, please
refer to separate dental plan through Delta
Dental.

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress. Page 4 of 6
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric Surgery • Infertility Treatment • Routine eye care (Adult) (See VSP Vision
• Cosmetic Surgery • Long Term Care Plan)
• Dental Care (adult) (see Delta Dental Plan) • Non-emergency care when traveling outside the U.S. • Routine Foot Care
• Hearing Aids • Private Duty Nursing • Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (limited to 8 visits per diagnosis) • Dental Care (the Trust offers separate dental benefits through Delta Dental)
• Chiropractic Care (limited to 20 visits per calendar year) • VSP Vision Plan for Adult Eye Exam (the Trust offers separate vision benefits through VSP)
• Naturopathy up to 6 visits per diagnosis annually
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Department of Health
and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be
available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact: the plan at Gig Harbor Firefighters Union Health & Welfare Trust Health Plan c/o Lucent Health Solutions, LLC at or call PO Box 7020 Appleton,
WI 54912-7020 or call 1-877-236-0844. You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272)
or www.dol.gov/ebsa/healthreform, Additionally, a consumer assistance program can help you file your appeal. A list of states with Consumer Assistance Programs
is available at: www.dol.gov/ebsa/healthreform and http://www.cms.gov/CCIO/Resources/Consumer-Assistance-Grants.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-877-236-0844
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-236-0844
Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-877-236-0844
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-236-0844

To see examples of how this plan might cover costs for a sample medical situation, see the next section.
* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress. Page 5 of 6
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $500  The plan’s overall deductible $500  The plan’s overall deductible $500
 Specialist copayment $20  Specialist copayment $20  Specialist copayment $20
 Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%
 Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $500 Deductibles $500 Deductibles $500
Copayments $300 Copayments $900 Copayments $200
Coinsurance $2,300 Coinsurance $60 Coinsurance $300
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $3,060 The total Joe would pay is $1,480 The total Mia would pay is $1,000

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

Page 6 of 6