Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020-12/31/2020 Writers’ Guild-Industry Health Fund: PPO 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, please contact the Fund Office at 1-818- 846-1015 or 1-800-227-7863 or through our website, www.pwga.org. 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 1-800- 227-7863 to request a copy.

Important Answers Why This Matters: Questions Generally, you must pay all of the costs from providers up to the deductible amount What is the overall before this plan begins to pay. If you have other family members on the plan, each $400 person / $1,200 family deductible? family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Yes. Preventive Care, LiveHealth online visit, In- This plan covers some items and services even if you haven’t met the deductible Are there services network prescription drugs and primary care amount. But a copayment or coinsurance may apply. For example, this plan covers covered before services through “The Industry Health Network” certain preventive services without cost-sharing and before you meet your deductible. you meet your (TIHN, Southern California only) are covered before See a list of covered preventive services at deductible? you meet your deductible. https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for No You don’t have to meet deductibles for specific services. specific services? Network Providers: $1,000/individual (coinsurance only) The out-of-pocket limit is the most you could pay in a year for covered services. What is the out-of- Non-Network Providers: $20,000/individual pocket limit for (coinsurance only) In addition to having a Plan out-of-pocket limit for coinsurance, the Fund complies with this plan? ACA Network Providers: $8,150/individual; the Affordable Care Act (ACA) annual out-of-pocket limit on in-network cost sharing for $16,300/family (includes deductibles, coinsurance, Plan Participants. copayments) What is not Premium, balance-billed charges, provider included in the discounts and health care expenses this Plan does Even though you pay these expenses, they don’t count toward the out-of-pocket limit. out-of-pocket not cover. limit?

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Important Answers Why This Matters: Questions This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might Will you pay less Yes. For The Industry Health Network (TIHN, receive a bill from a provider for the difference between the provider’s charge and what if you use a Southern California only), call 1-800- 876-8320. For your plan pays (balance billing). Be aware your network provider might use an out-of- network provider? the Blue Cross/Blue Card network at 1-800-810- network provider for some services (such as lab work). Check with your provider before BLUE (2583). you get services. Do you need a Yes. If you obtain services through TIHN (in This plan will pay some or all of the costs to see a specialist for covered services but referral to see a Southern California only), you need a referral when only if you have a referral before you see the specialist. specialist? seeing a specialist.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Services You Non-Network Limitations, Exceptions, & Other Important Network Provider Out-of-Area Medical Event May Need (You will pay Information (You will pay the least) Provider the most) 15% coinsurance ($10 copay/visit through TIHN, Copay for LiveHealth online visit will be waived if the Primary care visit deductible does not apply). 20% 40% online doctor refers the patient to the emergency to treat an injury coinsurance coinsurance room. or illness LiveHealth online: $20 If you visit a copay/visit, deductible does health care not apply. provider’s office 15% coinsurance ($10 or clinic 20% 40% Specialist visit copay/visit through TIHN, None coinsurance coinsurance deductible does not apply) Preventive You may have to pay for services that aren’t 20% 40% care/screening/ No charge preventive. Ask your provider if the services needed coinsurance coinsurance immunization are preventive, then check what your plan will pay. Diagnostic test (x- 15% coinsurance (No charge 20% 40% If you have a ray, blood work) through TIHN) coinsurance coinsurance None test Imaging (CT/PET 15% coinsurance (No charge 20% 40% scans, MRIs) through TIHN) coinsurance coinsurance

* For more information about limitations and exceptions, see the plan or policy document at www.pwga.org. 2 of 7 What You Will Pay Common Services You Non-Network Limitations, Exceptions, & Other Important Network Provider Out-of-Area Medical Event May Need (You will pay Information (You will pay the least) Provider the most) Retail $10 copay/Rx;  Retail covers up to a 30-day supply Generic drugs Mail order $20 copay/Rx  Mail order covers up to a 90-day supply Preferred brand Retail $25 copay/Rx;  Deductible does not apply If you need drugs Mail order $50 copay/Rx  * See SPD for list of over-the-counter generic drugs drugs to treat Non-preferred Retail $50 copay/Rx; available at no cost at an In-Network pharmacy with your illness or You pay the pharmacy the full brand drugs Mail order $100 copay/Rx a prescription condition amount of your prescription and More information must submit a claim to Express  Drugs on the ESI’s drug exclusion list will not be about Scripts. You'll receive a covered by the Plan without an advanced exception prescription reimbursement of the highest dollar  Retail Hepatitis C drugs and Compound drugs require preauthorization to avoid non-payment drug coverage is Same copays as generic, amount according to the plan available at Specialty drugs preferred brand or non- formula.  No charge for FDA-approved generic contraceptives www.express- preferred brand drugs. (or brand name contraceptives if a generic is scripts.com medically inappropriate)  Mail order service is mandatory for maintenance medications through ESI or Smart90 program (Walgreens, Duane Reade, Happy Harry’s)  *Out-of-Network and Out-of-Area ambulatory Facility fee (e.g., surgery centers are limited to maximum payment of 15% 20% 40% ambulatory $1500 If you have coinsurance coinsurance coinsurance surgery center)  Some surgery services may require outpatient preauthorization review surgery 15% coinsurance (No charge Physician/surgeon 20% 40% Some surgery services may require preauthorization after $100 copay through fees coinsurance coinsurance review. TIHN) If services are rendered at a network facility by a 20% 40% network physician, you pay 15% coinsurance plus Emergency room 15% coinsurance after $50 coinsurance coinsurance balance billing for Non-Network or Out-of-Area If you need care ER copay after $50 ER after $50 ER anesthesiologist, radiologist, pathologist as defined in immediate copay copay the SPD. Professional/physician charges may be medical billed separately. attention Emergency 20% 20% 20% medical None coinsurance coinsurance coinsurance transportation

* For more information about limitations and exceptions, see the plan or policy document at www.pwga.org. 3 of 7 What You Will Pay Common Services You Non-Network Limitations, Exceptions, & Other Important Network Provider Out-of-Area Medical Event May Need (You will pay Information (You will pay the least) Provider the most) Air or Sea ambulance is subject to medical necessity Air or Sea 15% 20% 40% review and covered if the transport is to the nearest ambulance coinsurance coinsurance coinsurance equipped facility. 15% 20% 40% Urgent care None coinsurance coinsurance coinsurance 15% coinsurance after $100 20% 40% Requires preauthorization review. Private room Facility fee (e.g., copay/admission (No charge coinsurance coinsurance payable only if medically necessary or the hospital hospital room) after $100 copay/admission after $100 after $100 only has private rooms (payable at semi-private room If you have a through TIHN) copay/admission copay/admission rate). hospital stay 15% coinsurance (No charge Physician/surgeon 20% 40% after $100 copay through $100 copay applies to surgeon fees through TIHN. fees coinsurance coinsurance TIHN) Office visits and other outpatient services: 15% coinsurance Office visits and Office visits and Facility requires preauthorization review (includes Outpatient other outpatient other outpatient If you need Intensive Outpatient Programs and Partial services LiveHealth online: $10 services: 20% services: 40% mental health, Hospitalization). behavioral copay/visit, deductible does coinsurance coinsurance health, or not apply. substance abuse services 20% 40% Requires preauthorization review. Private room 15% coinsurance after $100 coinsurance coinsurance payable only if medically necessary or the hospital Inpatient services copay/admission after $100 after $100 only has private rooms (payable at semi-private room copay/admission copay/admission rate).

Prenatal care: No charge  Prenatal care (other than ACA-required preventive 20% 40% screenings) is not covered for dependent children Office visits coinsurance coinsurance  Maternity care may include tests and services Office visits: 15% If you are described elsewhere in the SBC (i.e., ultrasound) coinsurance pregnant

15% coinsurance (No charge Childbirth/delivery 20% 40% after $100 copay through  Delivery expenses are not covered for dependent professional coinsurance coinsurance children TIHN) services

* For more information about limitations and exceptions, see the plan or policy document at www.pwga.org. 4 of 7 What You Will Pay Common Services You Non-Network Limitations, Exceptions, & Other Important Network Provider Out-of-Area Medical Event May Need (You will pay Information (You will pay the least) Provider the most)  Preauthorization is required if hospital stay is longer 15% coinsurance after $100 20% 40% than 48 hours for vaginal delivery or 96 hours for C- Childbirth/delivery copay/admission (No charge coinsurance coinsurance section facility services after $100 copay/admission after $100 after $100  Private room payable only if medically necessary or through TIHN) copay/admission copay/admission the hospital only has private rooms (payable at semi-private room rate) 15% 20% 40% Requires preauthorization review to avoid services not Home health care coinsurance coinsurance coinsurance being covered. Inpatient: 15% coinsurance Inpatient: 20% Inpatient: 40% after $100 copay/admission coinsurance coinsurance Rehabilitation (No charge after $100 after $100 after $100 Requires preauthorization review to avoid services not services copay/admission through copay/admission copay/admission being covered. TIHN) Outpatient: 20% Outpatient: 40% Outpatient: 15% coinsurance coinsurance coinsurance If you need help  Some services may require preauthorization recovering or review have other Habilitation 15% 20% 40%  Outpatient physical therapy and occupational special health services coinsurance coinsurance coinsurance therapy are limited to maximum allowable charge needs of $90/visit 20% coinsurance 40% coinsurance Skilled nursing 15% coinsurance after $100 Requires preauthorization review to avoid services not after $100 after $100 care copay/admission being covered. copay/admission copay/admission Durable medical 15% 20% 40% Subject to medical necessity review. equipment coinsurance coinsurance coinsurance 15% 20% 40% Requires preauthorization review to avoid a services Hospice services coinsurance coinsurance coinsurance not being covered. Children’s eye Not covered Not covered Not covered If your child exam Vision benefits available through VSP Vision Care. needs dental or Children’s glasses Not covered Not covered Not covered eye care Children’s dental Not covered Not covered Not covered Dental benefits available through Delta Dental. check-up

* For more information about limitations and exceptions, see the plan or policy document at www.pwga.org. 5 of 7 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.)  Cosmetic surgery  Experimental or Investigational procedures  Private duty nursing  Dental care (Adult, child) under a separate  Infertility treatment  Routine eye care (Adult, child) under a dental plan separate vision plan  Long-term care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Acupuncture (for chronic pain up to $60/visit)  Hearing Aids (up to $1,000 maximum/device)  Routine foot care (for vascular impairment due to diabetes)  Breast pump (in-network only, contact the  Non-emergency care when traveling outside Fund if charge exceeds $200) the U.S.  Weight loss Programs  Chiropractic Care (up to $60/visit)

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: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services 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 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: Writers’ Guild-Industry Health Fund at 1-818-846-1015 or 1-800-227-7863. Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. 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 1-800-227-7863 (TTY: 1-818-526-3199). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-227-7863 (TTY: 1-818-526-3199). Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-227-7863 (TTY: 1-818-526-3199). Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-227-7863 (TTY: 1-818-526-3199).

––––––––––––––––––––––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.pwga.org. 6 of 7 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

hospital delivery) controlled condition) up care)

 The plan’s overall deductible $400  The plan’s overall deductible $400  The plan’s overall deductible $400  Specialist coinsurance 15%  Specialist coinsurance 15%  Specialist coinsurance 15%  Hospital (facility) coinsurance 15%  Hospital (facility) coinsurance 15%  Hospital (facility) coinsurance 15%  Other coinsurance 15%  Other coinsurance 15%  Other coinsurance 15%

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

Total Example Cost $12,800 Total Example Cost $4,100 Total Example Cost $9,200

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 $400 Deductibles $400 Deductibles $400 Copayments (hospital admission) $100 Copayments (prescription drugs) $80 Copayments (emergency room) $50 Coinsurance $1,000 Coinsurance $555 Coinsurance $1,000 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $1,500 The total Joe would pay is $1,035 The total Mia would pay is $1,450

The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 7