meet the deductible. Yes. For a list of in-network providers, see PrincetonUniversity.

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: For each Calendar Year In-network: Individual $200 / Family $400 You must pay all the costs up to the amount before this plan begins to What is the overall Out-of-network: Individual $750 / Family pay for covered services you use. The starts over every January 1st. See? $1,500 Does not apply to office visits, the chart starting on page 2 for how much you pay for covered services after you preventive care, and emergency care innetwork. meet the. Are there other s for specific services? Is there an out-of-pocket limit on my expenses? Premiums, balance-billed charges, penalties What is not included in for failure to obtain pre-authorization for the out-of-pocket limit? services and health care this plan doesn t cover. Is there an overall annual limit on what No. the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? No. Yes, the out-of-pocket limit for the Princeton Health Plan is salary based. See for details. For the Prescription Plan the In-Network limit is Individual $3,500/Family $7,000. Yes. For a list of in-network providers, see PrincetonUniversity. No. Yes. You don t have to meet s for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. If you aren t clear about any of the terms used in this form, see the Glossary at Page 1 of 8

2 Copayments are fixed dollar amounts (for example, $20) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 10% would be $100. This may change if you haven t met your. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower s, copayments, and coinsurance amounts. Common Medical Event Services You May Need Primary care visit to treat an injury or illness In-Network Provider $20 copay Out-Of-Network Provider Limitations & Exceptions Applies to Internal Medicine, Pediatrics, Family Practice, and General Medicine. If you visit a health care provider s office or clinic Specialist visit Other practitioner office visit Preventive care/ screening/ immunization Diagnostic test (x-ray, blood work) $30 copay $30 copay Chiropractic visits limited to 20 per year, Nutrition visits limited to 12 per year. Age and frequency schedules may apply. If you have a test Imaging (CT/PET scans, MRIs), BRCA testing Precertification required, or services will not be covered. In-Network provider will obtain necessary precertification. You are responsible for obtaining precertification for Out-of-Network services. If you aren t clear about any of the terms used in this form, see the Glossary at Page 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition (Prescription coverage is provided by Express Scripts.) More information about prescription drug coverage is available at Scripts.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Single-Source Brand drugs Multi-Source drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee In-Network Provider Per Prescription $5 copay (retail) $10 copay (mail order) Per Prescription $25 copay (retail) $50 copay (mail order) Member pays the Generic copay plus the difference between the Plan's cost of the brand drug and the Plan's cost of the generic drug. Costs are the same as the categories above $60 copay $30 copay Out-Of-Network Provider Per Prescription $5 copay (retail) $10 copay (mail order) Per Prescription $25 copay (retail) $50 copay (mail order) Member pays the Generic copay plus the difference between the Plan's cost of the brand drug and the Plan's cost of the generic drug. Costs are the same as the categories above $60 copay Limitations & Exceptions Covers up to a 30-day supply (retail); day supply (mail order). If a maintenance medication is purchased at a retail pharmacy for more than 3 months, subsequent refills will cost twice the retail copayment rate. Some prescriptions may require Prior Authorization, Step Therapy and Quantity Duration Programs. Most Specialty drugs must be purchased through Express Scripts Specialty Pharmacy, Accredo. Precertification required, or services will not be covered. In-Network provider will obtain necessary precertification. You must obtain precertification for Out-of-Network services. Non-emergency use not covered. Non-emergency use requires precertification. Precertification required, or services will not be covered. In-Network provider will obtain necessary precertification. You must obtain precertification for Out-of-Network services. If you aren t clear about any of the terms used in this form, see the Glossary at Page 3 of 8

4 Common Medical Services You May Out-Of-Network Event Need In-Network Provider Provider Limitations & Exceptions Mental/Behavioral $30 copay 30% coinsurance; health outpatient services waived Mental/Behavioral Precertification required the same as health inpatient services described for outpatient surgery on page 3. If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal One $30 copay care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service $30 copay 30% coinsurance; waived Not Covered Precertification required the same as described for outpatient surgery on page 3. Precertification required for extended inpatient stays. Coverage limited to 60 visits per calendar year. Precertification same as described for outpatient surgery on page 3. Limited to 50 visits per calendar year each for Speech, Physical and Occupational Therapy, pulmonary and cardiac rehab. Age and visit limits may apply. Coverage limited to 60 visits per calendar year. Coverage is limited to 180 days maximum per calendar year inpatient. Precertification for inpatient hospice same as described for outpatient surgery on page 3. If you aren t clear about any of the terms used in this form, see the Glossary at Page 4 of 8

5 Common Medical Event Services You May Need Eye exam In-Network Provider Out-Of-Network Provider Limitations & Exceptions under Princeton Health Plan; covered under VSP if elected. If you need dental or eye care Glasses Dental check-up under Princeton Health Plan; covered under VSP if elected. under Princeton Health Plan; covered under Aetna or MetLife Dental Plans if elected. Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture (except in lieu of anesthesia) Glasses Routine eye care Cosmetic surgery Long-term care Routine foot care Weight Loss Programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Nutritionist (12 visit limit per year) Hearing aids - up to $1,500 every 3 years Non-emergency care when traveling outside of the US (covered at out-of-network level) Chiropractic care (20 visit limit per year) Infertility Coverage Does not require Gender Reassignment services, including diagnosis of underlying medical condition, but Psychotherapy, Hormone Replacement if one exists, treatment is covered with no Therapy and Gender Reassignment Surgery lifetime maximum. Other infertility treatment limited to $20,000 lifetime maximum. Specific treatments may have lifetime attempt limits. If you aren t clear about any of the terms used in this form, see the Glossary at Page 5 of 8

6 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at (Aetna) or (877) (United Healthcare). You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna at or United Healthcare at (877) , the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Additionally, a consumer assistance program can help you file an appeal. Contact information for Aetna is and for United Healthcare is Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 Para obtener asistencia en Español, llame al Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (acturial value). This health coverage does meet the minimum value standard for the benefits it provides. To see examples of how this plan might cover costs for a sample medical situation, see the next page. If you aren t clear about any of the terms used in this form, see the Glossary at Page 6 of 8

7 Coverage Examples About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $ 7,540 Amount owed to providers: Plan pays: $ 6,830 Plan pays: $ 4,620 Patient pays: $ 710 Patient pays: $ 780 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) Anesthesia Laboratory tests Prescriptions Radiology Vaccines, other preventive Total Patient pays: Deductibles Copays * Coinsurance Limits or exclusions Total Having a baby (normal delivery) $ 5,400 Sample care costs: $ 2,700 Prescriptions $ 2,900 $ 2,100 Medical Equipment and Supplies $ 1,300 $ 900 Office Visits and Procedures $ 700 $ 900 Education $ 300 $ 500 Laboratory tests $ 100 $ 200 Vaccines, other preventive $ 100 $ 200 Total $ 5,400 $ 40 $ 7,540 Patient pays: Deductibles $ 200 Copays** $ 450 $ 200 Coinsurance $ 130 $ 60 Limits or exclusions $ - $ 450 Total $ 780 $ 710 Managing type 2 diabetes (routine maintenance of a well-controlled condition) *Assumes a $30 copay for maternity care and 3 Mail Order copays for generic prescriptions **Assumes 4 Physician Specialist copays, 3 Nutritionist copays, and copays for 4 Mail Order generic prescriptions and 4 Mail Order Single-Source Brand prescriptions If you aren t clear about any of the terms used in this form, see the Glossary at Page 7 of 8

8 Coverage Examples Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-ofnetwork providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how s, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, s, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. If you aren t clear about any of the terms used in this form, see the Glossary at Page 8 of 8