Coventry Health Care of Virginia, Inc.: Silver $10 Copay POS Plan Coverage Period : 01/01/2014 - 12/31/2014

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: EE, EE/Sp., EE/1Ch., | Plan Type: POS EE/Children, Fam. 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 www.chcva.com or by calling 1-855-449-2889. Important Questions Answers Why This Matters: What is the overall In-network: $3,750 person $7,500 family You must pay all the costs up to the deductible amount before this plan begins to deductible? doesn't apply: PCP, first 5 specialist visits, pay for covered services you use. Check your policy or plan document to see when urgent care, first 3 ER visits, preventive, the deductible starts over (usually, but not always, January 1st). See the chart starting pediatric vision on page 2 for how much you pay for covered services after you meet the deductible. Out-of-network: $6,400 person $12,800 family, applies to all out-of-network services Are there other deductibles Yes $1,000 person, $2,000 family tier 2-5 You must pay all of the costs for these services up to the specific deductible amount for specific services? prescriptions. There are no other specific before this plan begins to pay for these services. deductibles. Is there an out-of-pocket In-network: Yes $6,350 person $12,700 The out-of-pocket limit is the most you could pay during a coverage period (usually limit on my expenses? family one year) for your share of the cost of covered services. This limit helps you plan for Out-of-network: No health care expenses. What is not included in the Premiums, balance-billed charges, health Even though you pay these expenses, they don't count toward the out-of-pocket out-of-pocket limit? care this plan does not cover limit. Is there an overall annual No The chart starting on page 2 describes any limits on what the plan will pay for specific limit on what the plan pays? covered services, such as office visits. Does this plan use a Yes If you use an in-network doctor or other health care provider, this plan will pay some network of providers? For a list of in-network providers, see or all of the costs of covered services. Be aware, your in-network doctor or hospital www.chcva.com or call 1-855-449-2889. may use an out-of-network provider for some services. Plans use the term in- network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a No You can see the specialist you choose without permission from this plan. specialist? Are there services this plan Yes Some of the services this plan doesn’t cover are listed on page 4. See your policy or doesn't cover? plan document for additional information about excluded services.

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 1 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. • Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance 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 co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. • 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 deductibles, copayments and coinsurance amounts.

Your cost if you use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider Primary care visit to treat an $10 co-payment (co- 50% co-insurance (co------none------injury or illness pay)/visit ins) If you visit a health care Specialist visit $75 co-pay/visit 50% co-ins ------none------provider's office or clinic Other practitioner office visit 40% co-ins chiropractor 50% co-ins Limited: 30 visits/year Preventive care/ No Charge 50% co-ins ------none------Screening/Immunization Diagnostic test (x-ray, blood 40% co-ins x-ray 50% co-ins x-ray ------none------work) 40% co-ins lab 50% co-ins lab If you have a test Imaging (CT/PET scans, 40% co-ins 50% co-ins Not covered without preauthorization MRIs) (preauth) Generic drugs $15 co-pay/fill preferred Not Covered Includes select generics for $5 co-pay/fill retail, $20 co-pay/fill preferred retail, $20 co-pay/fill non-preferred If you need drugs to treat non-preferred retail, $30 retail, $10 co-pay/fill mail, Limited: 31 day your illness or condition. co-pay/fill mail supply retail, 90 day supply mail, may require More information about preauth prescription drug coverage is available at Preferred brand drugs $45 co-pay/fill preferred Not Covered Limited: 31 day supply retail, 90 day supply www.chcva.com. retail, $55 co-pay/fill mail, may require preauth non-preferred retail, $112.50 co-pay/fill mail

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 2 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Your cost if you use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider Non-preferred brand drugs $75 co-pay/fill preferred Not Covered Limited: 31 day supply retail, 90 day supply If you need drugs to treat retail, $85 co-pay/fill mail, may require preauth your illness or condition. non-preferred retail, More information about $225 co-pay/fill mail prescription drug coverage is available at Specialty drugs Preferred: 30% co-ins, Not Covered Limited: 31 day supply, not covered without www.chcva.com. Non-preferred: 40% co- preauth ins Facility fee (e.g., ambulatory 40% co-ins 50% co-ins Not covered without preauth If you have outpatient surgery center) surgery Physician/surgeon fees 40% co-ins 50% co-ins Not covered without preauth Emergency room services $500 co-pay/visit $500 co-pay/visit ------none------If you need immediate Emergency medical 40% co-ins 40% co-ins ------none------medical attention transportation Urgent care $75 co-pay/visit 50% co-ins ------none------Facility fee (e.g., hospital 40% co-ins 50% co-ins Not covered without preauth If you have a hospital stay room) Physician/surgeon fee 40% co-ins 50% co-ins Not covered without preauth Mental/Behavioral health $10 co-pay/visit 50% co-ins Some services require preauth for coverage outpatient services Mental/Behavioral health 40% co-ins 50% co-ins Not covered without preauth If you have mental health, inpatient services behavioral health, or substance abuse needs Substance use disorder $10 co-pay/visit 50% co-ins Some services require preauth for coverage outpatient services Substance use disorder 40% co-ins 50% co-ins Not covered without preauth inpatient services Prenatal and postnatal care No Charge 50% co-ins ------none------If you are pregnant Delivery and all inpatient 40% co-ins 50% co-ins ------none------services If you need help Home health care 40% co-ins 50% co-ins Limited: 100 visits/year, not covered without recovering or have other preauth special health needs SNO: 1196153 SBC Name: 002_73209 002_9165 Page 3 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Your cost if you use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider Rehabilitation services Inpatient 40% co-ins Inpatient 50% co-ins Outpatient limited: 30 PT/OT & 30 Speech Outpatient 40% co-ins Outpatient 50% co-ins visits/year, inpatient not covered without preauth Habilitation services 40% co-ins 50% co-ins Outpatient limited: 30 PT/OT & 30 Speech If you need help visits/year, inpatient not covered without recovering or have other preauth special health needs Skilled nursing care 40% co-ins 50% co-ins Limited: 100 days/year, not covered without preauth Durable medical equipment 40% co-ins 50% co-ins Purchase over $500/all rentals require preauth for coverage Hospice Service 40% co-ins 50% co-ins Not covered without preauth Eye exam No Charge Not Covered Limited: members under 19 If your child needs dental Glasses No Charge Not Covered Limited: members under 19, one pair standard or eye care glasses/year Dental check-up Not Covered Not Covered Not Covered 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 • Bariatric Surgery • Child/Dental Check-up • Cosmetic Surgery • Dental Care (Adult) • Hearing Aids • Long-Term Care • Routine Eye Care (Adult) • 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.) • Chiropractic Care • Infertility Treatment • Non-Emergency Care when Traveling Outside the U.S. • Private-Duty Nursing

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions,

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 4 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. however, such as if:

• You commit fraud • The insurer stops offering services in the State • You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at 1-855-449-2889. You may also contact your state insurance department at Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 877-310-6560 (Toll Free) E-Mail: [email protected]. 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: Office of the Managed Care Ombudsman Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 877-310-6560 (Toll Free) E-Mail: [email protected] Additionally, a consumer assistance program can help you file your appeal. Contact Virginia State Corporation Commission Life & Health Division, Bureau of Insurance P.O. Box 1157 Richmond, VA 23218 (877) 310-6560 http://www.scc.virginia.gov/boi [email protected] 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 or policy 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% (actuarial value). This health coverage does meet the minimum value standard for the benefits is provides. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, llame al 1-855-449-2889. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-449-2889. Chinese ĩᷕ㔯ĪĻơġ⤪㝄暨天ᷕ㔯䘬ⷖ≑炻実㊐ㇻ征᷒⎟䞩ġ1-855-449-2889. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-449-2889.

––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 5 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. About these Coverage Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of Examples: a well-controlled condition) These examples show how this plan Amount owed to providers: $7,540 Amount owed to providers: $5,400 might cover medical care in given situations. Use these examples to see, in Plan pays: $2,920 Plan pays: $2,340 You pay: general, how much insurance $4,620 You pay: $3,060 protection you might get from different Sample care costs: plans. Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine Obstetric Care $2,100 Medical equipment and supplies $1,300 This is not a cost Hospital Charges (baby) $900 estimator. Office Visits and Procedures $700 Anesthesia $900 Education $300 Don’t use these examples to estimate your actual costs under Laboratory tests $500 Laboratory tests $100 Vaccine, other preventive $100 this plan. The actual care you Prescriptions $200 receive will be different from these Total $5,400 examples, and the cost of that care Radiology $200 You pay: will also be different. Vaccines, other preventive $40 Deductibles $1,400 See the next page for important Total $7,540 Co-pays $1,600 information about these examples. You pay: Coinsurance $0 Deductibles $3,800 Limits or exclusions $60 Co-pays $20 Total $3,060 Coinsurance $600 Note: These numbers assume the patient is participating in Limits or exclusions $200 our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may Total $4,620 be higher. For more information about the diabetes wellness program, please contact: 1-855-449-2889

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 6 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy. Questions and answers about the Coverage Examples:

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

SNO: 1196153 SBC Name: 002_73209 002_9165 Page 7 of 7 Questions: Call 1-855-449-2889 or visit us at www.chcva.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 1-855-449-2889 to request a copy.