UTAH VALLEY UNIVERSITY OREM, UT

Transcription

1 UTAH VALLEY UNIVERSITY OREM, UT Health Benefit Summary Plan Description BENEFITS ADMINISTERED BY

2 Table of Contents INTRODUCTION... 1 PLAN INFORMATION... 2 BENEFIT CLASS DESCRIPTION... 4 LOCATION DESCRIPTION... 5 MEDICAL SCHEDULE OF BENEFITS... 6 MEDICAL SCHEDULE OF BENEFITS MEDICAL SCHEDULE OF BENEFITS TRANSPLANT SCHEDULE OF BENEFITS TRANSPLANT SCHEDULE OF BENEFITS OUT-OF-POCKET EXPENSES AND MAXIMUMS OUT-OF-POCKET EXPENSES AND MAXIMUMS ELIGIBILITY AND ENROLLMENT SPECIAL ENROLLMENT PROVISION TERMINATION COBRA CONTINUATION OF COVERAGE WAIVER OF PREMIUM UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF PROVIDER NETWORK COVERED MEDICAL BENEFITS TELADOC SERVICES HOME HEALTH CARE BENEFITS TRANSPLANT BENEFITS PRESCRIPTION DRUG BENEFITS PHARMACY COORDINATION OF BENEFITS WITH OTHER GROUP PLANS PHARMACY MEMBER SELF-PAY REIMBURSEMENT CLAIMS PROCEDURE PRESCRIPTION DRUG AND MAIL ORDER PHARMACY PROGRAM EXCLUSIONS PRESCRIPTION CLAIMS AND APPEALS PROCEDURES... 78

3 HEARING AID BENEFITS OPTUMHEALTH EAP MENTAL HEALTH BENEFITS SUBSTANCE ABUSE AND CHEMICAL DEPENDENCY BENEFITS CARE MANAGEMENT COORDINATION OF BENEFITS RIGHT OF SUBROGATION, REIMBURSEMENT AND OFFSET GENERAL EXCLUSIONS CLAIMS AND APPEAL PROCEDURES FRAUD OTHER FEDERAL PROVISIONS HIPAA ADMINISTRATIVE SIMPLIFICATION MEDICAL PRIVACY AND SECURITY PROVISION PLAN AMENDMENT AND TERMINATION INFORMATION GLOSSARY OF TERMS

4 UTAH VALLEY UNIVERSITY GROUP HEALTH BENEFIT PLAN SUMMARY PLAN DESCRIPTION INTRODUCTION The purpose of this document is to provide you and your covered Dependents, if any, with summary information in English on benefits available under this Plan as well as with information on a Covered Person's rights and obligations under the UTAH VALLEY UNIVERSITY Health Benefit Plan (the "Plan"). You are a valued Employee of UTAH VALLEY UNIVERSITY, and your employer is pleased to sponsor this Plan to provide benefits that can help meet your health care needs. Please read this document carefully and contact your Human Resources or Personnel office if you have questions or if you have difficulty translating this document. UTAH VALLEY UNIVERSITY is named the Plan Administrator for this Plan. The Plan Administrator has retained the services of independent Third Party Administrators to process claims and handle other duties for this self-funded Plan. The Third Party Administrators for this Plan are UMR, Inc. (hereinafter "UMR") for medical claims, and EnvisionRxOptions for pharmacy claims. The Third Party Administrators do not assume liability for benefits payable under this Plan, since they are solely claims paying agents for the Plan Administrator. The employer assumes the sole responsibility for funding the Plan benefits out of general assets; however, Employees help cover some of the costs of covered benefits through contributions, Deductibles, out-of-pocket amounts, and Plan Participation amounts as described in the Schedule of Benefits. All claim payments and reimbursements are paid first by the Employees contributions and then paid out of the general assets of the employer and there is no separate fund that is used to pay promised benefits. Some of the terms used in this document begin with a capital letter, even though such terms normally would not be capitalized. These terms have special meaning under the Plan. Most capitalized terms are listed in the Glossary of Terms, but some are defined within the provisions in which they are used. Becoming familiar with the terms defined in the Glossary of Terms will help you to better understand the provisions of this Plan. Each individual covered under this Plan will be receiving an identification card that he or she may present to providers whenever he or she receives services. On the back of this card are phone numbers to call in case of questions or problems. This document summarizes the benefits and limitations of the Plan and will serve as the SPD and Plan document. Therefore it will be referred to as both the Summary Plan Description ( SPD ) and Plan document. This document becomes effective on July 1,

5 PLAN INFORMATION Plan Name Name And Address Of Employer Name, Address And Phone Number Of Plan Administrator Named Fiduciary Employer Identification Number Assigned By The IRS Type Of Benefit Plan Provided Type Of Administration Name And Address Of Agent For Service Of Legal Process UTAH VALLEY UNIVERSITY GROUP HEALTH BENEFIT PLAN UTAH VALLEY UNIVERSITY 800 W UNIVERSITY PKWY OREM UT UTAH VALLEY UNIVERSITY 800 W UNIVERSITY PKWY OREM UT UTAH VALLEY UNIVERSITY Self-funded Health & Welfare Plan providing group health benefits. The administration of the Plan is under the supervision of the Plan Administrator. The Plan is not financed by an insurance company and benefits are not guaranteed by a contract of insurance. UMR provides administrative services such as claim payments for medical claims. UTAH VALLEY UNIVERSITY MAILSTOP W UNIVERSITY PKWY OREM UT Services of legal process may also be made upon the Plan Administrator. Funding Of The Plan Employer and Employee Contributions Benefits are provided by a benefit Plan maintained on a self-insured basis by your employer. Benefit Plan Year Benefits begin on July 1 and end on the following June 30. For new Employees and Dependents, a Benefit Plan Year begins on the individual's Effective Date and runs through June 30 of the same Benefit Plan Year. Plan s Fiscal Year July 1 through June 30 Compliance It is intended that this Plan comply with all applicable laws. In the event of any conflict between this Plan and the applicable law, the provisions of the applicable law will be deemed controlling, and any conflicting part of this Plan will be deemed superseded to the extent of the conflict

6 Discretionary Authority The Plan Administrator will perform its duties as the Plan Administrator and in its sole discretion, will determine appropriate courses of action in light of the reason and purpose for which this Plan is established and maintained. In particular, the Plan Administrator will have full and sole discretionary authority to interpret all Plan documents, including this SPD, and make all interpretive and factual determinations as to whether any individual is entitled to receive any benefit under the terms of this Plan. Any construction of the terms of any Plan document and any determination of fact adopted by the Plan Administrator will be final and legally binding on all parties, except that the Plan Administrator has delegated certain responsibilities to the Third Party Administrators for this Plan. Any interpretation, determination or other action of the Plan Administrator or the Third Party Administrators will be subject to review only if a court of proper jurisdiction determines its action is arbitrary or capricious or otherwise a clear abuse of discretion. Any review of a final decision or action of the Plan Administrator or the Third Party Administrators will be based only on such evidence presented to or considered by the Plan Administrator or the Third Party Administrators at the time they made the decision that is the subject of review. Accepting any benefits or making any claim for benefits under this Plan constitutes agreement with and consent to any decisions that the Plan Administrator or the Third Party Administrators make, in their sole discretion, and further, means that the Covered Person consents to the limited standard and scope of review afforded under law

7 BENEFIT CLASS DESCRIPTION The Covered Person's benefit class is determined by the designations shown below: Class Class Description Benefit Plan Network** A01 A02 ALL ACTIVE EMPLOYEES WITH GREEN $500 DEDUCTIBLE PLAN ALL ACTIVE EMPLOYEES WITH WHITE $1000 DEDUCTIBLE PLAN 001 0L-XZ 002 0L-XZ A03 ALL ACTIVE EMPLOYEES WITH HDHP SINGLE 003 0L-XZ A04 ALL ACTIVE EMPLOYEES WITH HDHP 2P/FAMILY 004 0L-XZ A05 A06 ALL ACTIVE EMPLOYEES WITH GREEN $500 DEDUCTIBLE PLAN ALL ACTIVE EMPLOYEES WITH WHITE $1000 DEDUCTIBLE PLAN XZ XZ A07 ALL ACTIVE EMPLOYEES WITH HDHP SINGLE XZ A08 ALL ACTIVE EMPLOYEES WITH HDHP 2P/FAMILY XZ C01 C02 ALL COBRA PARTICIPANTS WITH GREEN $500 DEDUCTIBLE PLAN ALL COBRA PARTICIPANTS WITH WHITE $1000 DEDUCTIBLE PLAN 001 0L-XZ 002 0L-XZ C03 ALL COBRA PARTICIPANTS WITH HDHP SINGLE 003 0L-XZ C04 ALL COBRA PARTICIPANTS WITH HDHP 2P/FAMILY 004 0L-XZ C05 C06 ALL COBRA PARTICIPANTS WITH GREEN $500 DEDUCTIBLE PLAN ALL COBRA PARTICIPANTS WITH WHITE $1000 DEDUCTIBLE PLAN XZ XZ C07 ALL COBRA PARTICIPANTS WITH HDHP SINGLE XZ C08 ALL COBRA PARTICIPANTS WITH HDHP 2P/FAMILY XZ **Note: See the Provider Network section of this SPD for network description

8 LOCATION DESCRIPTION Location Description Billing Division Reporting Sub 001 UTAH VALLEY UNIVERSITY 800 W UNIVERSITY PKWY OREM UT COBRA 800 W UNIVERSITY PKWY OREM UT PRE-65 RETIREES 800 W UNIVERSITY PKWY OREM UT VARIABLE HOURED EMPLOYEES 800 W UNIVERSITY PKWY OREM UT

9 MEDICAL SCHEDULE OF BENEFITS Benefit Plan(s) 001 (Green Plan) All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses section of this SPD for more details. Benefits are subject to all provisions of this Plan including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the Care Management section of this SPD for a description of these services and prior authorization procedures. Note: Refer to the Provider Network section for clarifications and possible exceptions to the In-Network or Out-of-Network classifications. If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, that means that it is a combined Maximum Benefit for services that the Covered Person receives from all In-Network and Outof-Network providers and facilities. The applicable Deductible must be satisfied before member Co-pays or Plan Participation Rates will apply, unless otherwise indicated as Deductible Waived. IN-NETWORK OUT-OF-NETWORK Annual Deductible Per Plan Year: Per Person $500 $1,000 Per Family $1,000 $2,000 Plan Participation Rate, Unless Otherwise Stated Below: Paid By Plan After Satisfaction Of Deductible 80% 60% Annual Out-Of-Pocket Maximum: Per Person $4,500 $6,500 Per Family $9,000 $12,000 Ambulance Transportation: Paid By Plan After In-Network Deductible 80% 80% Breast Pumps: Paid By Plan 100% No Benefit Cardiac Pulmonary Rehabilitation: Maximum Visits Per Plan Year 50 Visits Included In Occupational / Physical / Speech Outpatient Hospital And Office Therapy Maximum Co-pay Per Visit $40 Not Applicable Paid By Plan 100% 60% Cardiac Rehabilitation Phase 1 & 2: Maximum Visits Per Plan Year 50 Visits Included In Occupational / Physical / Speech Outpatient Hospital And Office Therapy Maximum Co-pay Per Visit $40 Not Applicable Paid By Plan 100% 60%

10 Contraceptive Methods And Counseling Approved By The FDA: IN-NETWORK OUT-OF-NETWORK For Men: Paid By Plan 80% 60% For Women: Paid By Plan 100% 60% Durable Medical Equipment: Paid By Plan After Deductible 80% 60% Emergency Services / Treatment: Urgent Care: Co-pay Per Visit $40 Not Applicable Paid By Plan 100% 60% Emergency Room / Emergency Physicians: Co-pay Per Visit $250 $250 (Waived If Admitted As Inpatient Within 24 Hours) Paid By Plan 100% 100% Note: Network Benefits Will Be Paid For An Emergency Admission To A Non-Network Hospital As Long As The Claims Administrator Is Notified Within 48 Hours Of The Admission Or On The Same Day Of Admission If Reasonably Possible After Member Is Admitted To A Non-Network Hospital. If Member Continues Stay In A Non-Network Hospital After The Date Their Physician Determines That It Is Medically Appropriate To Transfer To A Network Hospital, Non-Network Benefits Will Apply. Extended Care Facility Benefits, Such As Skilled Nursing, Convalescent, Or Subacute Facility: Maximum Days Per Plan Year 60 Days Paid By Plan 80% 60% Note: Admission Must Occur Within 5 Days Of Inpatient Discharge. Home Health Care Benefits: Paid By Plan 80% 60% Note: A Home Health Care Visit Will Be Considered A Periodic Visit By Either A Nurse Or Qualified Therapist, As The Case May Be, Or Up To Four (4) Hours Of Home Health Care Services. Hospice Care Benefits: Paid By Plan After Deductible 80% 60%

11 Hospital Services: IN-NETWORK OUT-OF-NETWORK Pre-Admission Testing: Paid By Plan 80% 60% Inpatient Services / Inpatient Physician Charges; Room And Board Subject To The Payment Of Semi-private Room Rate Or Negotiated Room Rate: Paid By Plan 80% 60% Outpatient Services / Outpatient Physician Charges: Paid By Plan 80% 60% Outpatient Imaging Charges: Paid By Plan 80% 60% Outpatient Lab And X-ray Charges: Paid By Plan 80% 60% Outpatient Surgery / Surgeon Charges: Paid By Plan 80% 60% Indemnity Benefit For Adoption: Maximum Benefit Per Child $4,000 Paid By Plan 100% 100% Infertility Treatment (Diagnostic, Evaluation, Testing and Treatment): Paid By Plan Note: Does Not Include Assisted Reproduction. Services Do Not Apply To Annual Out-Of-Pocket Maximum. 50% No Benefit Manipulations: Co-pay Per Visit $40 Not Applicable Maximum Visits Per Plan Year 20 Visits Paid By Plan 100% Maternity: Routine Prenatal, Delivery and Postnatal Services: Co-pay For Initial Visit Only $40 Not Applicable Paid By Plan 100% 60% Note: The Initial Visit Co-Pay Applies To Charges Incurred To Confirm Pregnancy, Not Actual Services Related To Preventive/Prenatal Care. Non-Routine Maternity Services, Tests and Care: Paid By Plan 80% 60% 50%

12 Mental Health, Substance Abuse And Chemical Dependency Benefits: IN-NETWORK OUT-OF-NETWORK Inpatient Services / Physician Charges: Paid By Plan 80% 60% Outpatient Or Partial Hospitalization Services And Physician Charges: Paid By Plan 80% 60% Office Visit: Co-pay Per Visit $30 Not Applicable Paid By Plan 100% 60% Nutritional Supplements, Vitamins And Electrolytes: Paid By Plan 80% 60% Oral Surgery: Impacted Wisdom Teeth: Paid By Plan 80% 60% Excision Of Tumors: Paid By Plan 80% 60% Surgical Procedures Required To Correct Accidental Injuries Of The Jaws, Cheeks, Lips, Tongue, Roof And Floor Of The Mouth: Paid By Plan After In-Network Deductible 80% 80% Reduction Of Fractures And Dislocations Of The Jaw: Paid By Plan 80% 60% External Incision And Drainage Of Cellulitus: Paid By Plan 80% 60% Incision Of Accessory Sinuses, Salivary Glands Or Ducts: Paid By Plan 80% 60% Excision Of Exostosis Of Jaws And Hard Palate: Paid By Plan 80% 60% Orthognathic, Prognathic And Maxillofacial Surgery: Maximum Benefit Per Surgery $2,500 Paid By Plan 50% No Benefit Orthotic Appliances, Devices And Casts: Paid By Plan 80% No Benefit

13 Physician Office Visit: IN-NETWORK OUT-OF-NETWORK Primary Care Physician Visit: Co-pay Per Visit $30 Not Applicable Paid By Plan 100% 60% Specialist Visit: Co-pay Per Visit $40 Not Applicable Paid By Plan 100% 60% Note: A Specialist Co-pay Will Be Applied To After Hour Care. Physician Office Services: Paid By Plan 80% Allergy Injections And Allergy Serum: Benefit Deductible Per Plan Year $80 Paid By Plan 100% After Allergy Deductible, Medical Deductible Waived 60% 60% Office Imaging: Paid By Plan 80% 60% Preventive / Routine Care Benefits. See Glossary Of Terms For Definition. Benefits Include: Preventive / Routine Physical Exams At Appropriate Ages: Paid By Plan 100% Immunizations: Paid By Plan 100% No Benefit No Benefit Note: Foreign Travel Immunizations Will Not Be Covered. Vitamin B 12 Injections: Maximum Benefit Per Plan Year 3 Injections Paid By Plan 100% No Benefit Note: After The 3 rd Injection, Vitamin B12 Is Only Covered Under The Prescription Card. The Only Exception Is For Treatment Of Pernicious Anemia Or Pregnancy, In Which Case, The Medical Plan Will Continue To Cover As Indicated Above. If Administered At A Physician s Office, The Office Co-pay May Apply. Preventive / Routine Diagnostic Tests, Lab, And X-rays At Appropriate Ages: Paid By Plan 100% No Benefit

14 IN-NETWORK Preventive / Routine Mammograms And Breast Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Pelvic Exams And Pap Tests: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine PSA Test And Prostate Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Screenings / Services At Appropriate Ages And Gender: Paid By Plan 100% Preventive / Routine Colonoscopies, Sigmoidoscopies, And Similar Routine Surgical Procedures Performed For Preventive Reasons: Paid By Plan 100% Preventive / Routine Hearing Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Eye Exams And Glaucoma Testing: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Eye Refractions: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Counseling For Alcohol Or Substance Abuse, Tobacco Use, Obesity, Diet, And Nutrition: Paid By Plan 100% Preventive / Routine Oral Fluoride Supplements Prescribed For Children Ages 6 Months To 5 Years Whose Primary Water Source Is Deficient In Fluoride: Paid By Plan 100% OUT-OF-NETWORK No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit

15 IN-NETWORK In Addition, The Following Preventive / Routine Services Are Covered For Women: Gestational Diabetes Papillomavirus DNA Testing Counseling For Sexually Transmitted Infections (Provided Annually)* Counseling For Human Immune-Deficiency Virus (Provided Annually)* Breastfeeding Support, Supplies, And Counseling Counseling For Interpersonal And Domestic Violence For Women (Provided Annually)* Paid By Plan 100% OUT-OF-NETWORK No Benefit *These Services May Also Apply To Men. Sterilizations: For Men: Paid By Plan 80% 60% For Women: Paid By Plan 100% Teladoc Services: Co-pay Per Visit $20 $20 Paid By Plan 100% Temporomandibular Non-Surgical Joint Disorder Benefits: Paid By Plan 50% No Benefit Therapy Services: 60% 100% Occupational / Physical / Speech Outpatient Hospital And Office Therapy: Co-pay Per Visit $40 Not Applicable Maximum Visits Per Plan Year Including Cardiac 50 Visits Pulmonary Rehabilitation And Cardiac Rehabilitation Phase 1 & 2 Paid By Plan 100% 60% All Other Covered Expenses: Paid By Plan 80% 60%

16 MEDICAL SCHEDULE OF BENEFITS Benefit Plan(s) 002 (White Plan) All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses section of this SPD for more details. Benefits are subject to all provisions of this Plan including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the Care Management section of this SPD for a description of these services and prior authorization procedures. Note: Refer to the Provider Network section for clarifications and possible exceptions to the In-Network or Out-of-Network classifications. If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, that means that it is a combined Maximum Benefit for services that the Covered Person receives from all In-Network and Outof-Network providers and facilities. The applicable Deductible must be satisfied before member Co-pays or Plan Participation Rates will apply, unless otherwise indicated as Deductible Waived. IN-NETWORK OUT-OF-NETWORK Annual Deductible Per Plan Year: Per Person $1,000 $2,150 Per Family $2,000 $4,300 Plan Participation Rate, Unless Otherwise Stated Below: Paid By Plan After Satisfaction Of Deductible 80% 60% Annual Out-Of-Pocket Maximum: Per Person $5,000 $7,650 Per Family $10,000 $14,300 Ambulance Transportation: Paid By Plan After In-Network Deductible 80% 80% Breast Pumps: Paid By Plan 100% No Benefit Cardiac Pulmonary Rehabilitation: Maximum Visits Per Plan Year 50 Visits Included In Occupational / Physical / Speech Outpatient Hospital And Office Therapy Maximum Co-pay Per Visit $45 Not Applicable Paid By Plan 100% 60% Cardiac Rehabilitation Phase 1 & 2: Maximum Visits Per Plan Year 50 Visits Included In Occupational / Physical / Speech Outpatient Hospital And Office Therapy Maximum Co-pay Per Visit $45 Not Applicable Paid By Plan 100% 60%

17 Contraceptive Methods And Counseling Approved By The FDA: IN-NETWORK OUT-OF-NETWORK For Men: Paid By Plan 80% 60% For Women: Paid By Plan 100% 60% Durable Medical Equipment: Paid By Plan 80% 60% Emergency Services / Treatment: Urgent Care: Co-pay Per Visit $45 Not Applicable Paid By Plan 100% 60% Emergency Room / Emergency Physicians: Co-pay Per Visit $250 $250 (Waived If Admitted As Inpatient Within 24 Hours) Paid By Plan 100% 100% Note: Network Benefits Will Be Paid For An Emergency Admission To A Non-Network Hospital As Long As The Claims Administrator Is Notified Within 48 Hours Of The Admission Or On The Same Day Of Admission If Reasonably Possible After Member Is Admitted To A Non-Network Hospital. If Member Continues Stay In A Non-Network Hospital After The Date Their Physician Determines That It Is Medically Appropriate To Transfer To A Network Hospital, Non-Network Benefits Will Apply. Extended Care Facility Benefits, Such As Skilled Nursing, Convalescent, Or Subacute Facility: Maximum Days Per Plan Year 60 Days Paid By Plan 80% 60% Note: Admission Must Occur Within 5 Days Of Inpatient Discharge. Home Health Care Benefits: Paid By Plan 80% 60% Note: A Home Health Care Visit Will Be Considered A Periodic Visit By Either A Nurse Or Qualified Therapist, As The Case May Be, Or Up To Four (4) Hours Of Home Health Care Services. Hospice Care Benefits: Paid By Plan 80% 60%

18 Hospital Services: IN-NETWORK OUT-OF-NETWORK Pre-Admission Testing: Paid By Plan 80% 60% Inpatient Services / Inpatient Physician Charges; Room And Board Subject To The Payment Of Semi-private Room Rate Or Negotiated Room Rate: Paid By Plan 80% 60% Outpatient Services / Outpatient Physician Charges: Paid By Plan 80% 60% Outpatient Imaging Charges: Paid By Plan 80% 60% Outpatient Lab And X-ray Charges: Paid By Plan 80% 60% Outpatient Surgery / Surgeon Charges: Paid By Plan 80% 60% Indemnity Benefit For Adoption: Maximum Benefit Per Child $4,000 Paid By Plan 100% 100% Infertility Treatment (Diagnosis, Evaluation, Testing and Treatment): Paid By Plan Note: Does Not Include Assisted Reproduction. Services Do Not Apply To Annual Out-Of-Pocket Maximum. 50% No Benefit Manipulations: Co-pay Per Visit $45 Not Applicable Maximum Visits Per Plan Year 20 Visits Paid By Plan 100% Maternity: Routine Prenatal, Delivery and Postnatal Services: Co-pay For Initial Visit Only $45 Not Applicable Paid By Plan 100% 60% Note: The Initial Visit Co-Pay Applies To Charges Incurred To Confirm Pregnancy, Not Actual Services Related To Preventive/Prenatal Care. Non-Routine Maternity Services, Tests and Care: Paid By Plan 80% 60% 50%

19 Mental Health, Substance Abuse And Chemical Dependency Benefits: IN-NETWORK OUT-OF-NETWORK Inpatient Services / Physician Charges: Paid By Plan 80% 60% Outpatient Or Partial Hospitalization Services And Physician Charges: Paid By Plan 80% 60% Office Visit: Co-pay Per Visit $35 Not Applicable Paid By Plan 100% 60% Nutritional Supplements, Vitamins And Electrolytes: Paid By Plan 80% 60% Oral Surgery: Impacted Wisdom Teeth: Paid By Plan 80% 60% Excision Of Tumors: Paid By Plan 80% 60% Surgical Procedures Required To Correct Accidental Injuries Of The Jaws, Cheeks, Lips, Tongue, Roof And Floor Of The Mouth: Paid By Plan After In-Network Deductible 80% 80% Reduction Of Fractures And Dislocations Of The Jaw: Paid By Plan 80% 60% External Incision And Drainage Of Cellulitus: Paid By Plan 80% 60% Incision Of Accessory Sinuses, Salivary Glands Or Ducts: Paid By Plan 80% 60% Excision Of Exostosis Of Jaws And Hard Palate: Paid By Plan 80% 60% Orthognathic, Prognathic And Maxillofacial Surgery: Maximum Benefit Per Occurrence $2,500 Paid By Plan 50% No Benefit Orthotic Appliances, Devices And Casts: Paid By Plan 80% No Benefit

20 Physician Office Visit: IN-NETWORK OUT-OF-NETWORK Primary Care Physician Visit: Co-pay Per Visit $35 Not Applicable Paid By Plan 100% 60% Specialist Visit: Co-pay Per Visit $45 Not Applicable Paid By Plan 100% 60% Note: A Specialist Co-pay Will Be Applied To After Hour Care. Physician Office Services: Paid By Plan 80% 60% Allergy Injections And Allergy Serum: Benefit Deductible Per Plan Year $80 Paid By Plan 100% After Allergy 60% Deductible, Medical Deductible Waived Office Imaging: Paid By Plan 80% 60% Preventive / Routine Care Benefits. See Glossary Of Terms For Definition. Benefits Include: Preventive / Routine Physical Exams At Appropriate Ages: Paid By Plan 100% Immunizations: Paid By Plan 100% No Benefit No Benefit Note: Foreign Travel Immunizations Will Not Be Covered. Vitamin B 12 Injections: Maximum Benefit Per Plan Year 3 Injections Paid By Plan 100% No Benefit Note: After The 3 rd Injection, Vitamin B12 Is Only Covered Under The Prescription Card. The Only Exception Is For Treatment Of Pernicious Anemia Or Pregnancy, In Which Case, The Medical Plan Will Continue To Cover As Indicated Above. If Administered At A Physician Office, The Office Copay May Apply. Preventive / Routine Diagnostic Tests, Lab, And X-rays At Appropriate Ages: Paid By Plan 100% No Benefit

21 IN-NETWORK Preventive / Routine Mammograms And Breast Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Pelvic Exams And Pap Tests: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine PSA Test And Prostate Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Screenings / Services At Appropriate Ages And Gender: Paid By Plan 100% Preventive / Routine Colonoscopies, Sigmoidoscopies, And Similar Routine Surgical Procedures Performed For Preventive Reasons: Paid By Plan 100% Preventive / Routine Hearing Exams: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Eye Exams And Glaucoma Testing: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Eye Refractions: Maximum Exams Per Plan Year 1 Exam Paid By Plan 100% Preventive / Routine Counseling For Alcohol Or Substance Abuse, Tobacco Use, Obesity, Diet, And Nutrition: Paid By Plan 100% Preventive / Routine Oral Fluoride Supplements Prescribed For Children Ages 6 Months To 5 Years Whose Primary Water Source Is Deficient In Fluoride: Paid By Plan 100% OUT-OF-NETWORK No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit

22 IN-NETWORK In Addition, The Following Preventive / Routine Services Are Covered For Women: Gestational Diabetes Papillomavirus DNA Testing Counseling For Sexually Transmitted Infections (Provided Annually)* Counseling For Human Immune-Deficiency Virus (Provided Annually)* Breastfeeding Support, Supplies, And Counseling Counseling For Interpersonal And Domestic Violence For Women (Provided Annually)* Paid By Plan 100% OUT-OF-NETWORK No Benefit *These Services May Also Apply To Men. Sterilizations: For Men: Paid By Plan 80% 60% For Women: Paid By Plan 100% 60% Teladoc Services: Co-pay Per Visit $25 $25 Paid By Plan 100% 100% Temporomandibular Non-Surgical Joint Disorder Benefits: Paid By Plan 50% No Benefit Therapy Services: Occupational / Physical / Speech Outpatient Hospital And Office Therapy: Co-pay Per Visit $45 Not Applicable Maximum Visits Per Plan Year Including Cardiac 50 Visits Pulmonary Rehabilitation And Cardiac Rehabilitation Phase 1 & 2 Paid By Plan 100% 60% All Other Covered Expenses: Paid By Plan 80% 60%

23 MEDICAL SCHEDULE OF BENEFITS Benefit Plan(s) 003 (Single HDHP), 004 (Family HDHP) All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses section of this SPD for more details. Benefits are subject to all provisions of this Plan including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the Care Management section of this SPD for a description of these services and prior authorization procedures. Note: Refer to the Provider Network section for clarifications and possible exceptions to the In-Network or Out-of-Network classifications. If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, that means that it is a combined Maximum Benefit for services that the Covered Person receives from all In-Network and Outof-Network providers and facilities. The applicable Deductible must be satisfied before member Co-pays or Plan Participation Rates will apply, unless otherwise indicated as Deductible Waived. IN-NETWORK OUT-OF-NETWORK Annual Deductible Per Plan Year: Note: Medical And Pharmacy Expenses Are Subject To The Same Deductible Single Coverage $2,000 $4,000 Family Coverage $4,000 $8,000 Plan Participation Rate, Unless Otherwise Stated Below: Paid By Plan After Satisfaction Of Deductible 80% 60% Annual Out-Of-Pocket Maximum: Note: Medical And Pharmacy Expense Are Subject To The Same Out-Of-Pocket Maximum Single Coverage $3,000 $6,000 Family Coverage $6,000 $12,000 Ambulance Transportation: Paid By Plan After In-Network Deductible 80% 80% Breast Pumps: Paid By Plan 100% No Benefit Cardiac Pulmonary Rehabilitation: Maximum Visits Per Plan Year 50 Visits Included In Occupational / Physical / Speech Outpatient Hospital And Office Therapy Maximum Co-pay Per Visit After Deductible $35 Not Applicable Paid By Plan After Co-pay 100% 60%