Benefit Summary - A, G, C, E, Y, J and M

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1 Benefit Summary - A, G, C, E, Y, J and M Benefit Year: Calendar Year Payment for Services Deductible Individual $600 $1,200 Family (Embedded*) $1,200 $2,400 Coinsurance (the percentage amount the Covered Person pays) Covered Person Pays 20% 40% Out-of-pocket Limit Individual $2,600 $4,400 Family (Embedded*) $5,200 $8,800 Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the Calendar Year. and Deductible and Out-of-pocket Limits are separate and do not cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between and, unless noted differently. *Embedded Deductible and/or Coinsurance Embedded Deductible means that family members may combine their covered expenses to satisfy the required calendar year deductible. However, no one family member contributes more than the individual deductible amount. Embedded Family Coinsurance means family members may combine their covered expense to satisfy the family Coinsurance Limit. No one family member contributes more than the individual Coinsurance Limit to satisfy the family s Coinsurance Limit.

2 Physician Services Primary Care Physician Office Visit $20 Copay Specialist Physician Office Visit $20 Copay Other Covered Physician Office Services and supplies (with or without an office visit billed) Allergy Injections and Serum (only one copay applies per day per provider) Applicable Office Visit Copay Applicable Office Visit Copay Other Injections Covered Services included as part of the Physician Office Visit or Physician Office Services Copayment benefits are stated in the Physician Office Services section of the Summary Plan Description (SPD). Convenient Care/Retail Clinics (Quick Care) Same as a Primary Care Physician Hospital or Facility Services Emergency Room Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) - Facility $150 Copay then Deductible and Coinsurance level of benefits - Professional Services level of benefits Inpatient Hospital and Long Term Acute Care Inpatient Physical Rehabilitation Outpatient Cardiac Rehabilitation (limited to 18 sessions per calendar year) Outpatient Hospital and Facility Services Outpatient Pulmonary Rehabilitation (Chronic lung disease is limited to 18 sessions per Calendar Year.) Skilled Nursing Facility (limited to 60 days per Calendar Year) Urgent Care Facility Services (a single copay applies to each urgent care visit) $40 Copay

3 Mental Illness, Substance Dependence and Abuse Inpatient Services Outpatient Services - Office Services $20 Copay - All Other Outpatient Items & Services Emergency Room Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) - Facility $150 Copay then level of benefits - Professional Services level of benefits Preventive Services ACA required preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency) ACA required covered preventive services (outside of limits) Other covered preventive services not required by ACA Immunizations - Pediatric (up to age 7) Coinsurance - Age 7 and older Independent Laboratory (preventive) Same as Preventive Services Innetwork level of benefits Same as Preventive Services Innetwork level of benefits Vision exam, including refraction (limited to one every 24 months) $20 Copay Covered Services Acupuncture Advanced Diagnostic Imaging (CT, MRI, MRA, MRS, PET & SPECT scans and other Nuclear Medicine) Ambulance (to the nearest facility for appropriate care) Ground Ambulance level of benefits Air Ambulance (In-Network level of benefits if due to emergency) Autism Spectrum Disorder (limited to Covered Persons up to age 21) Biofeedback

4 Cochlear implants Diabetic Services Self-management training and education Services include podiatric appliances and equipment Hearing Aids Home Health Aide, Skilled Nursing and Respiratory Care Home Health Aide and Skilled Nursing Care (limited to 60 days per Calendar Year combined) Respiratory Care (limited to 60 days per calendar year) Hospice Services Independent Laboratory (diagnostic) level of benefits Infertility Services to diagnose Same as any other illness Same as any other illness Treatment to promote fertility Nicotine Addiction Medical services and therapy Same as Substance Dependence and Abuse Same as Substance Dependence and Abuse Nicotine addiction classes & alternative therapy, such as acupuncture Oral Surgery and Dentistry Organ and Tissue Transplantation Ostomy Supplies Pregnancy, Maternity and Newborn Care Pregnancy and Maternity Newborn care Dependent child maternity is covered Radiation Therapy and Chemotherapy Radiology (x-ray) Services and other Diagnostic Test Renal Dialysis

5 Sexual Dysfunction Sleep Studies (attended sleep study) Temporomandibular and Craniomandibular Joint Disorder Therapy & Manipulations Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy and chiropractic or osteopathic manipulative treatments or adjustments (combined limit to 75 sessions per Calendar Year) $20 Copay Therapy evaluation/re-evaluation (not included in session limit) Vision Exams (diagnostic) See Physician Office Services See Physician Office Services (unless necessary to safeguard the life of the woman, or that the Voluntary Abortions unborn child's viability was threatened by continuation of the Pregnancy)

6 Prescription Drugs Prescription Drug Copayment Limit (the maximum Copayment amount the Covered Person pays each Calendar Year for Covered Prescription Drugs) Individual $3,000 Family (Embedded) $6,000 Retail per 30-day supply Generic drugs (including non-formulary contraceptives) Formulary Brand Name Drugs Non-formulary Brand Name Drugs Mail order per 90-day supply ($5 Minimum, $25 Maximum) ($25 Minimum, $50 Maximum) 50% ($50 Minimum, $75 Maximum) ($5 Minimum, $25 Maximum) + Penalty ($25 Minimum, $50 Maximum) + Penalty 50% ($50 Minimum, $75 Maximum) + Penalty Generic drugs (including non-formulary contraceptives) ($10 Minimum, $50 Maximum) Formulary Brand Name Drugs ($50 Minimum, $100 Maximum) Non-formulary Brand Name Drugs 50% ($100 Minimum, $150 Maximum) Contraceptives Formulary - Generic Penalty - Brand Name Penalty Non-formulary - Generic Same as any other non-formulary generic - Brand Name Same as any other non-formulary brand name Diabetic Supplies and Medications, including 10% of allowable charge 10% of allowable charge Insulin + penalty Specialty Drugs (specialty drugs must be purchased through a designated specialty pharmacy after two fills Infertility FDA approved prescription drugs to promote fertility Nicotine Addiction FDA approved prescription drugs and over-thecounter nicotine addiction drugs and deterrents ($75 Minimum, $100 Maximum) Penalty Obesity FDA approved prescription drugs This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is

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