Class Only Model Document

UNIVERSITY OF ARKANSAS SYSTEM: 7670-00-411309 POS Coverage Period:01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type:PPO

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.umr.com or by calling 1-888-438-6105. Important Questions Answers Why this Matters: $1,250 person / $2,500 family In-network $2,000 person / $4,000 family Out-of-network You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan What is the overall Does not apply to copayments and services document to see when the deductible starts over (usually, but not deductible? listed below as "No Charge" unless noted always, January 1st). See the chart starting on page 2 for how much you otherwise in Limitations & Exceptions pay for covered services after you meet the deductible. column. Are there other You don’t have to meet deductibles for specific services, but see the deductibles for specific Yes. TMJ has a separate deductible. chart starting on page 2 for other costs for services this plan covers. services? Yes. Is there an out–of– The out-of-pocket limit is the most you could pay during a coverage $5,250 person / $10,500 family In-network pocket limit on my period (usually one year) for your share of the cost of covered services. $9,000 person / $18,000 family Out-of- expenses? This limit helps you plan for health care expenses. network What is not included in Penalties, premiums, balance-billed charges, Even though you pay these expenses, they don’t count toward the out- the out–of–pocket limit? and health care this plan doesn’t cover. of-pocket limit. Is there an overall The chart starting on page 2 describes any limits on what the plan will annual limit on what the No. pay for specific covered services, such as office visits. plan pays? If you use an in-network doctor or other health care provider, this plan Yes. For a list of preferred providers, see will pay some or all of the costs of covered services. Be aware, your in- Does this plan use a www.umr.com. If you are unsure which network doctor or hospital may use an out-of-network provider for network of providers? network list to select, please call 1-888-438- some services. Plans use the terms in-network, preferred, or 6105. 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 You can see the specialist you choose without permission from this No. see a specialist? plan. Are there services this Yes. Some of the services this plan doesn’t cover are listed on page 6. See

Questions: Call 1-888-438-6105 or visit us at www.umr.com. Page 1 of 9 If you aren’t clear about any of the underscored terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-800-826-9781 to request a copy. UNIVERSITY OF ARKANSAS SYSTEM: 7670-00-411309 POS Coverage Period:01/01/2016 – 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type:PPO

your policy or plan document for additional information about excluded plan doesn’t cover? services.  Copayments are fixed dollar amounts (for example, $15) 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 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.

Common Your cost if you use an Your cost if you use an Medical Services You May Need Out-of-network Limitations & Exceptions In-network Provider Event Provider Primary care visit to treat an $35 Copay per visit 50% Coinsurance Deductible Waived In-network injury or illness

Specialist visit $50 Copay per visit 50% Coinsurance Deductible Waived In-network $35 Copay per office visit; Deductible Waived In-network office 50% Coinsurance If you visit a 30% Coinsurance all other visit; 30 Maximum visits per calendar Other practitioner office visit Chiropractic care; health care services Chiropractic care; year Chiropractic care combined with Not covered Acupuncture provider’s Not covered Acupuncture OT/ST/PT office or clinic 50% Coinsurance to age 3; Not covered Preventive Preventive care/screening/ care; 50% Coinsurance No charge Deductible Waived In-network immunization Immunizations & Preventive screenings from age 3 If you have a Diagnostic test 30% Coinsurance 50% Coinsurance ‍––––––––––––none––––––––––––– test (x-ray, blood work)

Common Your cost if you use an Your cost if you use an Medical Services You May Need Out-of-network Limitations & Exceptions In-network Provider Event Provider $100 Copay per Imaging Deductible applies; occurrence; 50% Coinsurance (CT/PET scans, MRIs) Prior authorization is required 30% Coinsurance

$15 Retail/Mail; one 18.50 Retail/Mail; one ‍Some drugs require Prior Authorization If you need Tier 1drugs Copayment for each 30 day Copayment for each 30 day and others require Step Therapy or drugs to treat have quantity limits. Reference Based your illness or Pricing applies to some drugs. Please condition. $50 Retail/Mail; one $53.50 Retail/Mail; one refer to your "Prescription Drug Tier 2 drugs Copayment for each 30 day Copayment for each 30 day Program Summary of Benefits". Mail More order up to 90 day supply on information maintenance medicines. Specialty about $80 Retail/Mail; one $83.50 Retail/Mail; one Tier 3 drugs drugs applicable Copayment applies. prescription Copayment for each 30 day Copayment for each 30 day drug coverage OOP max does not include costs for is available at excluded or non-covered medications www.medimpa $15 Tier 1 $18.50 Tier 1 or devices. Non covered medications ct.com Specialty drugs $50 Tier 2 $53.50 Tier 2 $80 Tier 3 $83.50 Tier 3 do not go to the Rx Max OOP expense. Facility fee $150 Copay per visit; $150 Copay per visit; Deductible Applies; If you have (e.g., ambulatory surgery 30% Coinsurance 50% Coinsurance Prior authorization is required outpatient center) surgery Physician/surgeon fees 30% Coinsurance 50% Coinsurance ‍––––––––––––none––––––––––––– If you need $150 Copay for 1st ER $150 Copay for 1st ER Deductible Waived; immediate visit; $200 Copay for 2nd visit; $200 Copay for 2nd In-network out-of-pocket applies to medical Emergency room services ER visit; $250 Copay for ER visit; $250 Copay for Out-of-network benefits; attention 3rd + ER visit of the 3rd + ER visit of the Copay may be waived if admitted calendar year calendar year Emergency medical $100 Copay per occurrence $100 Copay per occurrence Deductible Waived; transportation Copay may be waived if admitted

Common Your cost if you use an Your cost if you use an Medical Services You May Need Out-of-network Limitations & Exceptions In-network Provider Event Provider Urgent care $50 Copay per visit $100 Copay per visit Deductible Waived Deductible Applies; Maximum combined Inpatient Copay Facility fee (e.g., hospital $300 Copay per admission; $300 Copay per admission; per calendar year is $1,200 per person, If you have a room) 30% Coinsurance 50% Coinsurance no more than one Copay per 30 hospital stay calendar days; Prior authorization is required Physician/surgeon fee 30% Coinsurance 50% Coinsurance ‍––––––––––––none––––––––––––– $35 Copay per office visit; $150 Copay per day for first 2 days; 30% Deductible Waived In-network office Mental/Behavioral health Coinsurance Intensive Day 50% Coinsurance visit; Deductible Applies Intensive Day outpatient services Treatment; 30% Treatment & other outpatient services Coinsurance other outpatient services Deductible Applies; Maximum combined Inpatient Copay Mental/Behavioral health $300 Copay per admission; per calendar year is $1,200 per person, If you have inpatient services 30% Coinsurance 50% Coinsurance no more than one Copay per 30 mental health, calendar days; Prior authorization is behavioral required health, or $35 Copay per office visit; substance $150 Copay per day for abuse needs first 2 days; 30% Deductible Waived In-network office Substance use disorder Coinsurance Intensive Day 50% Coinsurance visit; Deductible Applies Intensive Day outpatient services Treatment; 30% Treatment & other outpatient services Coinsurance other outpatient services Deductible Applies; Maximum combined Inpatient Copay Substance use disorder $300 Copay per admission; per calendar year is $1,200 per person, inpatient services 30% Coinsurance 50% Coinsurance no more than one Copay per 30 calendar days; Prior authorization is required If you are Prenatal and postnatal care No charge Prenatal; 50% Coinsurance Deductible Waived In-network Prenatal pregnant 30% Coinsurance Postnatal

Common Your cost if you use an Your cost if you use an Medical Services You May Need Out-of-network Limitations & Exceptions In-network Provider Event Provider Deductible Waived In-network Delivery; Deductible Applies other No charge Delivery; inpatient services & Out-of-network; Delivery and all inpatient $300 Copay per admission; Maximum combined Inpatient Copay 50% Coinsurance per calendar year is $1,200 per person, services 30% Coinsurance other no more than one Copay per 30 inpatient services calendar days; Copay waived after completion of Maternity Management Incentive 40 Maximum visits per calendar year; Home health care 30% Coinsurance 50% Coinsurance Prior authorization is required $35 Copay per office visit; Deductible Waived In-network office Rehabilitation services 30% Coinsurance all other 50% Coinsurance visit; 30 Maximum visits per calendar services year combined with Chiropractic care Habilitation services Not covered Not covered ‍––––––––––––none––––––––––––– If you need Deductible Applies; Maximum help combined Inpatient Copay per calendar recovering or year is $1,200 per person, no more than have other $300 Copay per admission; $300 Copay per admission; Skilled nursing care one Copay per 30 calendar days; Copay special health 30% Coinsurance 50% Coinsurance waived if transferred from an Acute needs Care Facility; Prior authorization is required Prior authorization is required for DME Durable medical equipment 30% Coinsurance 50% Coinsurance in excess of $500 for rentals or $1,500 for purchases Hospice service 30% Coinsurance 50% Coinsurance ‍––––––––––––none––––––––––––– Deductible Waived; Eye exam $35 Copay per visit $35 Copay per visit If your child 1 Maximum exam per calendar year needs dental Glasses Not covered Not covered ‍––––––––––––none––––––––––––– or eye care Dental check-up Not covered Not covered ‍––––––––––––none–––––––––––––

Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy for other excluded services.)  Acupuncture  Dental care (adult)  Private-duty nursing  Bariatric surgery  Infertility treatment  Routine foot care  Cosmetic surgery  Long-term care  Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy for other covered services and your costs for these services.)  Chiropractic care  Non-emergency care when traveling outside the U.S.  Routine eye care (adult)  Hearing aids

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 1-800-826-9781. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or http://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. 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: UMR at 1-800-826-9781. Additionally, a consumer assistance program may help you file your appeal. A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http://cciio.cms.gov/programs/consumer/capgrants/index.html.

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 of 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 it provides.

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

Questions: Call 1-888-438-6105 or visit us at www.umr.com. Page 7 of 9 If you aren’t clear about any of the underscored terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-800-826-9781 to request a copy. UNIVERSITY OF ARKANSAS SYSTEM: 7670-00-411309 POS Coverage Period: 01/01/2016 – 12/31/2016 Coverage Examples Coverage for: Individual + Family | Plan Type:PPO

About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might  Amount owed to providers: $7,540  Amount owed to providers: $5,400 cover medical care in given situations. Use  Plan pays $4,340  Plan pays $3,030 these examples to see, in general, how much  Patient pays $3,200  Patient pays $2,370 financial protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 This is Hospital charges (baby) $900 Office Visits and Procedures $700 not a cost Anesthesia $900 Education $300 estimator. Laboratory tests $500 Laboratory tests $100 Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Don’t use these examples to estimate your actual costs Vaccines, other preventive $40 Patient pays: under this plan. The actual Total $7,540 Deductibles $1,250 care you receive will be different from these examples, Patient pays: Copays $720 and the cost of that care also Deductibles $1,250 Coinsurance $320 will be different. Copays $20 Limits or exclusions $80 Coinsurance $1,750 Total $2,370 See the next page for Limits or exclusions $200 important information about Total $3,200 these examples.

Questions: Call 1-888-438-6105 or visit us at www.umr.com. Page 8 of 9 If you aren’t clear about any of the underscored terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-800-826-9781 to request a copy. UNIVERSITY OF ARKANSAS SYSTEM: 7670-00-411309 POS Coverage Period: 01/01/2016 – 12/31/2016 Coverage Examples Coverage for: Individual + Family | Plan Type:PPO

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

Questions: Call 1-888-438-6105 or visit us at www.umr.com. Page 9 of 9 If you aren’t clear about any of the underscored terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or www.cciio.cms.gov or call 1-800-826-9781 to request a copy.