GEISINGER HEALTH PLAN

Coverage you can count on We’ll help you every step of the way.

Call us 800-918-5154 to speak to our dedicated team of trained advisors.

Open Enrollment Period: Nov. 1, 2020, through Jan. 15, 2021 Hours: Monday–Friday, 8 a.m. to 7 p.m.; Saturday, 10 a.m. to 2 p.m. Jan. 16, 2021, through Oct. 31, 2021 Hours: Monday–Friday, 8 a.m. to 5 p.m.

Due to COVID-19 restrictions, Geisinger Community Place will be closed until further notice. Open enrollment begins Nov. 1. Are you ready?

For plan year 2021, Pennsylvania is transitioning from HealthCare.gov to its own state-based health insurance marketplace, Pennie™, where you will enroll in or make changes to your 2021 coverage. The 2021 Open Enrollment Period (OEP) begins Nov. 1, 2020, and lasts until Jan. 15, 2021.

• Nov. 1–Dec. 15, 2020 enrollment: Coverage becomes effective Jan. 1, 2021 Pennie will be live at the • Dec. 16, 2020–Jan. 15, 2021 enrollment: Coverage becomes effective Feb. 1, 2021 beginning of the 2021 OEP. Visit pennie.com or call Are you in our service area? 844-844-8040 to find Geisinger Health Plan's service area includes the following counties: information and assistance • Adams • Cumberland • Luzerne • Somerset on your health insurance. • Berks • Dauphin • Lycoming • Snyder • Blair • Elk • Mifflin • Sullivan • Bradford • Fulton • Monroe • Susquehanna • Cambria • Huntingdon • Montour • Tioga • Cameron • Jefferson • Northumberland • Union • Carbon • Juniata • Northampton • Wayne • Centre • Lackawanna • Perry • Wyoming • Clearfield • Lancaster • Pike • York • Clinton • Lebanon • Potter • Columbia • Lehigh • Schuylkill County restrictions for Premier network plans and Geisinger Extra plans can be found on pages 6 and 7 respectively. 3 Why Geisinger Health Plan? We give you more.

Healthcare reform has changed the way you purchase health insurance. What hasn’t changed is our dedication to helping you find the perfect plan to fit your needs and budget.

In 2021, we are offering Gold, Silver and Bronze plans. care team member can assist with questions regarding Choose from HMO and PPO plans with a variety of ID cards, premiums, billing, benefit/plan information, monthly premiums and out-of-pocket cost options. In application status, removing/adding dependents and addition, you can choose between two dynamic networks, much more. plus Geisinger Extra, a unique plan designed to save you money. We also offer a catastrophic Value plan that Network of providers provides the most basic coverage to people under 30. Plus, Select from our large provider network that includes you'll get plenty of perks to keep you healthy and well. Geisinger hospitals and physicians, as well as thousands of other providers throughout the service area. Our network Local and nationwide discounts includes: You'll have access to our local and nationwide discounts • More than 20,000 primary care and specialty physicians program that gives you a wide variety of discounts on • More than 120 hospitals health- and wellness-related products, such as: • More than 220 urgent and convenient care facilities • Fitness center memberships • Telemedicine services for one-stop virtual care • Eyeglasses • Contact lenses Find a provider online • Chiropractic care Go to GeisingerHealthPlan.com/ProviderSearch and enter • Massage therapy and more your location and plan type. Your plan type will include your network. Select a category to search from our entire Health management programs library of applicable providers, or narrow your search by We offer a number of award-winning health management searching for providers by name, specialty or location. programs to help our members with chronic conditions. Members can enroll at no cost and can work with one Pediatric dental of our health managers to better manage their health coverage through conditions. Programs include: Avesis • Asthma • COPD Dental coverage for children under the age of 19 is • Diabetes • Quitting tobacco embedded in our Geisinger Marketplace plans. All • Heart failure • Weight management pediatric dental benefits are provided by Avesis. Wellness coaching and support Pediatric dental plans from Avesis include coverage for You'll have access to certified wellness coaches who the following services: support your efforts to quit tobacco, manage weight, • Routine oral exams and • Extractions increase physical activity, decrease stress and improve cleanings • Repairs and maintenance their lifestyle. There are also numerous online tools that • X-rays • Anesthesia you can access and complete at your own pace, including • Fillings • Root canal wellness workshops, fitness trackers and • Fluoride treatments • Orthodontia a meal planner.

Customer care Review your Schedule of Benefits for a more detailed list We pride ourselves on our customer care. Our ACA of covered services. Call our customer care team at customer care team, which was assembled to serve 866-379-4489 with questions about your pediatric our individual ACA members, delivers a better service dental benefits. experience through one-call resolution. Each customer

4 Things to know before you shop

Our plans have distinct names and numbers. Here's how to understand them. Geisinger Marketplace All-Access PPO 20 / 40 / 3000

All of our plan names The first number is the The second number is the The third number is the start with Geisinger primary care provider (PCP) specialty care provider deductible amount. Marketplace. The next copay. (SCP) copay. This means each This is the amount you will pay part tells you the network A copay is a fixed amount time you visit a specialty care for healthcare services before name, which will be either you will pay for a covered provider (SCP), you would your insurance pays for its an All-Access or Premier healthcare service, usually pay $40. portion. In the example above, network. The plan type, when you receive the service. you would have to pay $3,000 explained below, is listed In the example above, you for healthcare services before as well. Some All-Access would pay $20 each time you GHP pays for its portion. network plans also visit your PCP. have a Geisinger Extra component.

What are the different plan types?

HMO (health maintenance organization) With an HMO plan, you select a primary care physician (PCP) who will help manage you health and wellness. HMOs generally cost less because you use in-network providers.

POS (point of service) With POS, you select a PCP to help coordinate your care. You can see other healthcare providers — in or out of our network. You will pay more for services received from providers outside our network.

PPO (preferred provider organization) With a PPO, you do not need to select a PCP. You can see other healthcare providers — in or out of our network. You will pay more for services received from providers outside our network.

Geisinger Extra With our Geisinger Extra plans, if you visit a primary care site designated as a “Geisinger Extra” site, you will pay lower office visit copays. Some Geisinger Extra sites are also ProvenHealth Navigator® locations, where extra care is provided because the office is staffed with a Geisinger Health Plan nurse. To find a Geisinger Extra site, visit GeisingerHealthPlan.com/ProviderSearch.

Geisinger Extra plans are only available in select counties and can be found on page 7.

QHDHP A qualified high-deductible health plan (QHDHP) has lower premiums and higher deductibles than a traditional insurance plan. You must have a QHDHP to have a health savings account.

55 Get to know our network options

All-Access network Premier network

What is it? What is it? The All-Access network includes all participating The Premier network is a narrow, selective network providers across the entire service area. network made up of the providers with proven track records of providing great care. What are the benefits? With All-Access, members enjoy access to our What are the benefits? entire provider network all with a single level of Health plans using the Premier network cost-share. generally have a lower cost.

Key consideration? Key consideration? With broader access and one cost-share level, This network is available in 13 counties1. Only premiums may be higher than with other network services obtained through Premier network options. Some All-Access plans come with the providers will be covered. This network's Geisinger Extra component, giving you additional provider options are limited to a small, care for less. exclusive list.

Our All-Access PPO plans give you access to even Visit GeisingerHealthPlan.com/ProviderSearch more providers. to see if your provider is in the Premier network before making your selection.

1The Premier network is only available in the following counties: Carbon, Centre, Columbia, Lackawanna, Luzerne, Mifflin, Monroe, Montour, Northumberland, Schuylkill, Snyder, Union and Wayne.

66 Geisinger Extra: Care you need at a lower cost

You can get the care you need in a truly innovative way through Geisinger Extra, which is available through select plans within the All-Access network. When you select a primary care site designated as an Extra site, you will pay lower office visit copays. Some Geisinger Extra sites are also ProvenHealth Navigator® (PHN) locations. At these offices you’ll receive “extra” care because PHN sites include a Geisinger Health Plan nurse who works closely with physicians and office staff to provide additional services.

Service area & eligibility Geisinger Extra is available to individuals and families as long as their physical location is in our Geisinger Extra service area. Eligible Geisinger Extra counties are listed below. • Carbon • Juniata • Monroe • Snyder • Centre • Lackawanna • Montour • Susquehanna • Clinton • Lehigh • Northampton • Union • Columbia • Luzerne • Northumberland • Wayne • Cumberland • Lycoming • Perry • Wyoming • Dauphin • Mifflin • Schuylkill You must reside in our overall Geisinger service area, which can be found on page 3.

Additional services at PHN sites: • Same-day appointments for urgent care • On-site health coaching • Assistance managing all your care if you have a complex medical condition • Help moving from the hospital to home, if appropriate • Preventive care such as flu shots or other immunizations • Education about better managing diabetes, heart disease and much more Questions? Call 800-918-5154. 7 Financial help: Do I qualify? Depending on your income, you may be eligible for financial help for health insurance. Individuals or families with an income under 400% of the federal poverty level are eligible. If you do not qualify for financial help from Pennie, you may have other options. Pennsylvania’s Medical Assistance program has expanded, which means more financial help is available to more people. Eligibility is based on your 2020 household income and family size. Typically, a person estimated to earn less than $51,000 a year — or a family of four estimated to earn less than $105,000 — would likely qualify for financial assistance through Pennie. Depending on your circumstances, it's possible to qualify for both advance premium tax credits and cost sharing reductions. To see if you qualify, visit pennie.com or call 844-844-8040.

Key terms to know:

Deductible The amount you pay for healthcare services before your insurance starts to pay its portion of costs for covered health expenses.

Copayment or copay A fixed amount you pay for a covered healthcare service, usually paid at the time you receive the service. The amount can vary depending on your plan and the type of service you are receiving.

Coinsurance Coinsurance is your share of the costs of a covered healthcare service, calculated as a percent of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. Your insurance plan pays for the rest of the allowed amount.

Maximum out-of-pocket The maximum out-of-pocket (MOOP) amount includes all member cost sharing, such as deductibles, coinsurance and copays, for all covered services within a policy period. An important note to remember, MOOP does not include your monthly premium. Once your maximum out-of-pocket costs are met, your insurance plan will pay 100% of costs for covered services.

88 Geisinger Marketplace plans: Gold With our Gold plans, you’ll generally have higher monthly premiums and less out-of-pocket costs. For all plan benefit details and to confirm if you're eligible for financial help, visit pennie.com or call 844-844-8040.

Geisinger Marketplace Premier HMO and Geisinger Marketplace Extra plans are only available in certain counties. See page 6 for details on Premier plans and page 7 for details on Extra plans.

Gold Gold Gold Gold

Geisinger Marketplace Geisinger Marketplace Geisinger Marketplace Geisinger Marketplace Extra HMO All-Access All-Access PPO Premier 10/50/5003 HMO 20/40/30003 20/40/3000 HMO 20/40/30003

In-network services $50 PCP copay $20 $20 $20 Extra Site: $101

Specialist copay $50 $40 $40 $40

Deductible: $500/$1,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 Single/Family Max. out-of-pocket: $5,700/$11,400 $8,100/$16,200 $8,100/$16,200 $8,100/$16,200 Single/Family

Coinsurance 20% 20% 20% 20%

$300 per stay after $250 per stay after $250 per stay after $250 per stay after Inpatient services deductible deductible deductible deductible

Outpatient services $400 after deductible $250 after deductible $250 after deductible $250 after deductible

Emergency room $200 $250 $250 $250

Deductible: $500/$1,000 Tier 1: $3 Deductible: $0/$0 Deductible: $0/$0 Deductible: $0/$0 Tier 2: $20 Tier 1: $3 Tier 1: $3 Tier 1: $3 Tier 3: $45 after Tier 2: $15 Tier 2: $15 Tier 2: $15 deductible Tier 3: $35 Tier 3: $35 Tier 3: $35 Prescription drug Tier 4: $80 after Tier 4: $55 Tier 4: $55 Tier 4: $55 deductible Tier 5: 40% Tier 5: 40% Tier 5: 40% Tier 5: 50% coinsurance up to $150 coinsurance up to $150 coinsurance up to $150 coinsurance after Tier 6: $02 Tier 6: $02 Tier 6: $02 deductible up to max. out-of-pocket Tier 6: $02 Out-of-network services Deductible: Single/ $10,000/$20,000 Family No out-of-network No out-of-network No out-of-network Coinsurance 40% benefits available benefits available benefits available Max. out-of-pocket: $15,000/$30,000 Single/Family

1 Notes your PCP copay amount if you use a Geisinger Extra site. 2 Tier 6 prescription drug benefit covers ACA covered preventive medications and other items available at no cost. 3Our HMO plans have been 4-star certified by CMS in the state of Pennsylvania. 9 Geisinger Marketplace Plans: Silver With our Silver plans, you’ll generally pay less in monthly premiums and more out-of-pocket. For all plan benefit details and to confirm if you're eligible for financial help, visit pennie.com or call 844-844-8040.

Geisinger Marketplace Premier HMO and Geisinger Marketplace Extra plans are only available in certain counties. See page 6 for details on Premier plans and page 7 for details on Extra plans.

Silver Silver Silver Silver Geisinger Marketplace Geisinger Marketplace Geisinger Marketplace Geisinger Marketplace All-Access HMO All-Access PPO Extra HMO All-Access HMO 30/60/4600*4 30/50/5000*4 10/50/45003,4 30/60/46503,4 (see below for guidelines) (see below for guidelines) In-network services $50 PCP copay $30 $30 $30 Extra Site: $101 Specialist copay $60 $50 $50 $60 Deductible: $4,600/$9,200 $5,000/$10,000 $4,500/$9,000 $4,650/$9,300 Single/Family Max. out-of-pocket: $7,600/$15,200 $7,350/$14,700 $7,400/$14,800 $7,600/$15,200 Single/Family Coinsurance 20% 30% 30% 20% Inpatient services 20% after deductible 30% after deductible 30% after deductible 20% after deductible Outpatient services 20% after deductible 30% after deductible 30% after deductible 20% after deductible $350 copay after $250 copay after $300 copay after $350 copay after Emergency room deductible deductible deductible deductible Deductible: Deductible: Deductible: Deductible: $500/$1,000 $500/$1,000 $500/$1,000 $500/$1,000 Tier 1: $3 Tier 1: $3 Tier 1: $3 Tier 1: $3 Tier 2: $20 Tier 2: $20 Tier 2: $20 Tier 2: $20 Tier 3: $50 after Tier 3: $45 after Tier 3: $45 after Tier 3: $50 after deductible deductible deductible deductible Prescription drug Tier 4: $85 after Tier 4: $80 after Tier 4: $80 after Tier 4: $85 after deductible deductible deductible deductible Tier 5: 50% Tier 5: 50% Tier 5: 50% Tier 5: 50% coinsurance after coinsurance after coinsurance after coinsurance after deductible up to max. deductible up to max. deductible up to max. deductible up to max. out-of-pocket out-of-pocket out-of-pocket out-of-pocket Tier 6: $02 Tier 6: $02 Tier 6: $02 Tier 6: $02 Out-of-network services Deductible: $10,000/$20,000 Single/Family No out-of-network No out-of-network No out-of-network Coinsurance 40% benefits available benefits available benefits available Max. out-of-pocket: $15,000/$30,000 Single/Family

1 Notes your PCP copay amount if you use a Geisinger Extra site. 2 Tier 6 prescription drug benefit covers ACA covered preventive medications and other items available at no cost. 3 If you are eligible for financial help you may pay less for some of these benefits. You will find additional details on pennie.com. 4 Our HMO plans have been 4-star certified by CMS in the state of Pennsylvania.

*The Geisinger Marketplace HMO and PPO plans highlighted in gray above are not available at pennie.com. 10 Financial help is not available to members with these plans. Geisinger Marketplace Plans: Silver (continued)

Silver Silver

Geisinger Marketplace Geisinger Marketplace All-Access PPO Premier HMO 30/60/46501 30/60/46501,3

In-network services

PCP copay $30 $30

Specialist copay $60 $60

Deductible: $4,650/$9,300 $4,650/$9,300 Single/Family Max. out-of-pocket: $7,600/$15,200 $7,600/$15,200 Single/Family

Coinsurance 20% 20%

Inpatient services 20% after deductible 20% after deductible

Outpatient services 20% after deductible 20% after deductible

$350 copay after $350 copay after Emergency room deductible deductible Deductible: Deductible: $500/$1,000 $500/$1,000 Tier 1: $3 Tier 1: $3 Tier 2: $20 Tier 2: $20 Tier 3: $50 after Tier 3: $50 after deductible deductible Prescription drug Tier 4: $85 after Tier 4: $85 after deductible deductible Tier 5: 50% Tier 5: 50% coinsurance after coinsurance after deductible up to max. deductible up to max. out-of-pocket out-of-pocket Tier 6: $02 Tier 6: $02 Out-of-network services Deductible: Single/ $10,000/$20,000 Family No out-of-network Coinsurance 40% benefits available Max. out-of-pocket: $15,000/$30,000 Single/Family

1 If you are eligible for financial help you may pay less for some of these benefits. You will find additional details at pennie.com. 2 Tier 6 prescription drug benefit covers ACA covered preventive medications and other items available at no cost. 3 Our HMO plans have been 4-star certified by CMS in the state of Pennsylvania.

11 Geisinger Marketplace Plans: Bronze

With Bronze plans, you'll generally pay the least in monthly premiums and the most out-of-pocket for medical care. Our Value plan is only available to people under the age of 30. For all plan benefit details and to confirm if you're eligible for financial help, visit pennie.com or call 844-844-8040. Geisinger Marketplace Premier HMO plans are only available in certain counties. See page 6 for details on the Premier network.

Bronze Bronze Bronze Bronze Value Geisinger Geisinger Geisinger Geisinger Geisinger Marketplace Marketplace Marketplace Marketplace Marketplace All-Access All-Access Value All-Access HMO All-Access PPO Premier HMO QHDHP PPO (for people under 2 2 2 6850 40/80/8400 40/80/8400 40/80/8400 the age of 30) (HSA eligible) In-network services 0% after 0% after deductible PCP copay $40 $40 $40 deductible Note: 3 PCP visits covered before deductible applies 0% after Specialist copay $80 $80 $80 0% after deductible deductible Deductible: $8,400/$16,800 $8,400/$16,800 $8,400/$16,800 $6,850/$13,700 $8,550/$17,100 Single/Family Max. out-of-pocket: $8,550/$17,100 $8,550/$17,100 $8,550/$17,100 $6,850/$13,700 $8,550/$17,100 Single/Family

Coinsurance 0% 0% 0% 0% 0%

Inpatient services 0% after deductible

Outpatient services 0% after deductible

Emergency room 0% after deductible Deductible Deductible Deductible Deductible Deductible is combined is combined is combined is combined is combined with medical with medical with medical with medical with medical Prescription drug deductible. deductible. deductible. deductible. deductible. Tier 1-5: 0% Tier 1-5: 0% Tier 1-5: 0% after Tier 1-5: 0% Tier 1-5: 0% after deductible after deductible deductible after deductible after deductible Tier 6: $01 Tier 6: $01 Tier 6: $01 Tier 6: $01 Tier 6: $01 Out-of-network services Deductible: $10,000/ $15,000/ $10,000/ No out-of- Single/Family $20,000 No out-of- $30,000 $20,000 network Coinsurance 40% network benefits 40% 40% benefits available Max. out-of-pocket: available $15,000/ $15,000/ $15,000/ Single/Family $30,000 $30,000 $30,000

1 Tier 6 prescription drug benefit covers ACA covered preventive medications and other items available at no cost. 2 Our HMO plans have been 4-star certified by CMS in the state of Pennsylvania.

CMS rates qualified health plans (QHPs) offered through the Exchanges using the Quality Rating System (QRS), which is based on third-party validated clinical measure data and QHP Enrollee Survey response data. CMS calculates ratings annually on a 5-star scale, and ratings may change from one year to the next. For more information, see CMS’s Health Insurance Marketplace® Quality Initiatives information here.

12 Geisinger Extra sites

Berks Geisinger Lock Haven St. Luke’s Hamburg Primary Care* Geisinger Lock Haven Pediatrics* Find a location online Susquehanna Health Family Medicine at Visit Bucks Lock Haven GeisingerHealthPlan.com/find Daniel J. Stauffer, MD* Susquehanna Health The Work Center at and select “Find a doctor or Riegelsville Family Practice* Lock Haven location.” In the search area, enter St. Luke’s Internal Medicine* your location and choose your plan. St. Luke’s Quakertown Internal Columbia Click the search button to see a list Medicine Associates* Geisinger Benton of providers based on the location St. Luke’s Quakertown Pediatrics* Geisinger Berwick you entered. St. Luke’s Upper Bucks Family Geisinger Bloomsburg Medical Center* Geisinger Bloomsburg East First St To show only Geisinger Extra Geisinger Bloomsburg Pediatrics* providers, check the “Geisinger Carbon Geisinger Catawissa Extra” or “ProvenHealth Navigator” St. Luke’s Albrightsville Primary Care* Geisinger Millville boxes under the Tiered Networks St. Luke’s Anthracite Primary Care* Susquehanna Valley Medical Specialities filter on the left side of the search St. Luke’s Lehighton Family Practice* results. St. Luke’s Miners Health Center - Cumberland Nesquehoning* Family Practice Center PC - Enola Note: Make sure you know if a St. Luke’s Palmerton Pediatrics* Family Practice Center PC - provider is accepting new patients St. Luke’s Palmerton Primary Care* Mechanicsburg before scheduling an appointment. St. Luke’s Primary Care Nesquehoning* Geisinger Holy Spirit Camp Hill* For ease, you can filter your search Geisinger Holy Spirit Carlisle* results to only show providers that Centre Geisinger Holy Spirit Carlisle - Pediatrics* are accepting new patients. Geisinger Bellefonte Geisinger Holy Spirit Mechanicsburg* Geisinger Gray’s Woods Geisinger Holy Spirit Mechanicsburg - Geisinger Gray’s Woods Pediatrics* Internal Med* Geisinger Philipsburg Geisinger Holy Spirit Mechanicsburg Juniata Geisinger Philipsburg Pediatrics* Pediatrics* Family Practice Center PC - Mifflintown Geisinger Scenery Park Geisinger Holy Spirit Primary Care Enola* Geisinger Mifflin Mount Nittany Physician Group - Geisinger Mifflintown Bellefonte Dauphin Geisinger Richfield Family Practice Mount Nittany Physician Group - Blue Family Practice Center PC - Colonial Rd Course Dr Family Practice Center PC - Commerce Lackawanna Mount Nittany Physician Group - Family Practice Center PC - Elizabethville Anders P. Nelson, MD* Endocrinology Family Practice Center PC - Halifax Blondek Center For Pediatric Health & Mount Nittany Physician Group - Family Practice Center PC - Harrisburg Wellness PC* Greentech Dr Family Practice Center PC - Hershey Carbondale Family Health Center* Mount Nittany Physician Group - Park Family Practice Center PC - Lykens Geisinger Moosic Ave Family Practice Center PC - Geisinger PrimeMed - Clarks Summit Mount Nittany Physician Group - Peds Main St Lykens Geisinger PrimeMed - Dunmore Bellefonte* Family Practice Center PC - Millersburg Geisinger PrimeMed - Jessup Mount Nittany Physician Group - Peds Family Practice Center PC - Geisinger PrimeMed - Moosic Boalsburg* State Route 209 Geisinger PrimeMed - Olyphant Mount Nittany Physician Group - Penns Family Practice Center PC - Steelton Geisinger PrimeMed - Peckville Valley Geisinger Holy Spirit Harrisburg* Geisinger PrimeMed - Scranton Mount Nittany Physician Group - Geisinger Scranton Philipsburg Hunterdon (NJ) Geisinger Scranton Family Practice Oasis Lifecare LLC* St. Luke’s North Hunterdon Physicians* Geisinger Scranton Pediatrics* Main Street Pediatrics* Clinton Huntingdon Paul A. Tomcykoski, DO* Family Practice Center PC - Mill Hall Geisinger Huntingdon Pediatrics of Northeastern Geisinger Avis Pennsylvania*

13 Physicians Health Alliance* Geisinger South Wilkes Barre St. Luke’s Internal Medicine* (pediatric sites only) Geisinger Wilkes Barre Pediatrics* St. Luke’s Internal Medicine Scranton Primary Health Care* Partners in Pediatrics - Dallas* Bartonsville* The Wright Center Medical Group PC* Partners in Pediatrics - Forty Fort* St. Luke’s Kresgeville Family Practice* Pediatric Associates of Kingston LLC* St. Luke’s Medical Associates of Monroe Lancaster Rubina A. Zaman, MD LLC* County* Family Practice Center PC - The Wright Center Medical Group PC* St. Luke’s Monroe Family Practice* Elizabethtown Valley Pediatrics* St. Luke’s Pocono Pediatric Associates* Wyoming Valley Pediatrics* St. Luke’s Stroudsburg Internal Lehigh Medicine* Connelly Family Practice* Lycoming St. Luke’s Zahra Pediatrics* Coopersburg Center Valley Family Family Medicine Residency Center Practice* Family Practice Center PC - Hughesville Montgomery McGorry & Matta Family Medicine* Family Practice Center PC - Pennsburg Family Practice* North Whitehall Family Practice* Montoursville South Mountain Family Practice Family Practice Center PC - Muncy Montour Center* Family Practice Center PC - River Ave Geisinger Woodbine Lane - Family St. Luke’s Allentown Pediatrics* 1st Fl Medicine St. Luke’s Bethlehem Internal Medicine* Family Practice Center PC - River Ave Geisinger Woodbine Lane - General St. Luke’s Coopersburg Pediatrics* 2nd Fl Pediatrics* St. Luke’s Emaus Avenue Family Family Practice Center PC - Southside GMC General Internal Medicine Practice* Geisinger Jersey Shore GMC General Pediatrics* St. Luke’s Fogelsville Primary Care* Geisinger Lycoming St. Luke’s Hospital - SH Allentown SPS Savoy Family Medicine - Klucka Northampton Family Practice* SPS Savoy Family Medicine - Mullarkey Bushkill Family Practice* St. Luke’s Internal Medicine* Susquehanna Health Family Medicine Medical Associates of Bethlehem* St. Luke’s Internal Medicine - at Duboistown Nazareth Family Practice* Allentown* Susquehanna Health Family Medicine Saucon Valley Family Practice* St. Luke’s Internal Medicine Hamilton at Loyalsock St. Luke’s Anderson Pediatrics* Court* Susquehanna Health Family Medicine St. Luke’s Family Medicine 25th Street* St. Luke’s Kids Care* at Montoursville St. Luke’s Family Medicine Easton* St. Luke’s Lehigh Primary Care* Susquehanna Health at Montoursville- St. Luke’s Family Medicine Nazareth* St. Luke’s Macungie Medical Group* Extended Hours St. Luke’s Family Practice - Forks* St. Luke’s Northern Valley Primary Susquehanna Health Internal Medicine St. Luke’s Family Practice - Palmer* Care* Susquehanna Health Pediatrics St. Luke’s Family Practice at Walnutport* St. Luke’s Walbert Avenue Medical Susquehanna Health The Work Center St. Luke’s Family Practice - Wind Gap* Center* Susquehanna Pediatrics at South St. Luke’s Internal Medicine* Total Family Health Care* Williamsport* St. Luke’s Internal Medicine Allentown* Valley Family Practice* The Work Center St. Luke’s Internal Medicine Bath* UPMC Family Medicine at Muncy St. Luke’s Internal Medicine Easton* Luzerne UPMC Susquehanna Health Family St. Luke’s Internal Medicine Wilson* Bassam F. Bittar, MD* Medicine St. Luke’s Kids Care* CommunityCare Hazleton St. Luke’s Lifestyle Medicine Center* CommunityCare Hazleton - Pediatrics* Mifflin St. Luke’s Nazareth Road Internal CommunityCare Kistler Geisinger Big Valley Medicine* CommunityCare Kistler - Pediatrics* Geisinger Lewistown St. Luke’s Northern Valley Primary Care* Geisinger 65Forward Health Center Geisinger Lewistown Pediatrics* St. Luke’s Pediatric Associates* Geisinger Dallas Mount Nittany Physician Group - St. Luke’s Physician Group Family Geisinger Dallas Family Practice Reedsville Medicine* Geisinger Forty Fort Pediatrics* St. Luke’s Primary Care Easton* Geisinger Kingston Monroe St. Luke’s Riverside Internal Medicine* Geisinger Mountain Top Geisinger Mt. Pocono St. Luke’s Southside Medical Center* Geisinger Mountain Top Pediatrics* Geisinger Mt. Pocono Pediatrics* William Penn Family Practice* Geisinger Nanticoke Pocono Pediatric and Adolescent Geisinger Nanticoke Pediatrics* Medicine* Northumberland Geisinger Pittston St. Luke’s Brodheadsville Family Alakananda Chakrabarty, MD PC* Geisinger Pittston Pediatrics* Practice* Family Medicine of Evangelical - Milton

14 Family Medicine of Evangelical - Family Medicine of Evangelical - Centers* Northumberland Selinsgrove Family Practice Center PC - Elysburg Family Practice Center PC - Middleburg Wyoming Family Practice Center PC - Herndon Family Practice Center PC - Mt. Pleasant Geisinger Nicholson Family Practice Center PC - Pagana- Mills Geisinger Tunkhannock DeFazio Family Practice Center PC - Selinsgrove Family Practice Center PC - Sunbury Family Practice Center PC - Shamokin York Family Practice Center PC - Watsontown Dam Family Practice Center PC - Ameigh Geisinger Elysburg Geisinger 65Forward Health Center Family Practice Center PC - Lewisberry Geisinger Kulpmont Geisinger Selinsgrove Geisinger Holy Spirit Dillsburg* Geisinger Milton GMC at Susquehanna University* Geisinger Mt. Carmel Geisinger Sunbury Sullivan Miller Donmoyer Family Health Center* Family Practice Center PC - Laporte Peter E. McNeil, MD* St. Joseph’s Internal Medicine PC* Susquehanna Wardeh-Agha Medical Center LLC* Forest City Family Health Center*

Perry Tioga Family Practice Center PC - Loysville Susquehanna Health Spinal Geisinger Holy Spirit Family Medicine - Rehabilitation & Work Center Duncannon* Geisinger Holy Spirit Marysville* Union Family Medicine of Evangelical - Pike Lewisburg Pinnacle Family Health Center* Family Medicine of Evangelical - Lewisburg POB Schuylkill Family Medicine of Evangelical - Family Practice Center PC - Valley View Mifflinburg Geisinger Frackville Family Practice Center PC - Lewisburg Geisinger Frackville Family Practice Family Practice Center PC - Mifflinburg Geisinger Mahanoy City Geisinger Lewisburg Geisinger Orwigsburg Geisinger Lewisburg Pediatrics* Geisinger Orwigsburg Pediatrics* Ideal Pediatric & Adolescent Care PC* Geisinger Pottsville Internal Medicine of Evangelical Geisinger Pottsville Pediatrics & Specialties* Warren (NJ) Geisinger St. Luke’s Orwigsburg Primary Coventry Family Practice* Care* St. Luke’s Belvidere Family Practice* Integrated Medical Group PC - St. Luke’s Nephrology - Warren* Adukaitis* Village Medical Center* Integrated Medical Group PC - Warren Hills Family Practice* Blue Mtn Peds* St. Luke’s Ashland Family Practice* Wayne St. Luke’s Internal Medicine* Geisinger PrimeMed - Honesdale St. Luke’s Internal Medicine at Tamaqua* Hamlin Family Health Center* St. Luke’s Internal Medicine Miners* Highland Physicians Family Health St. Luke’s Miners Health Center - Center* Hometown* Honesdale Family Health Center* St. Luke’s Miners Health Center - Honesdale Pediatric Center* Ringtown* Northern Wayne Family Health Center* Tamaqua Family Practice* Pike County Medical Center* The Wright Center for Community Snyder Health* Family Medicine of Evangelical - Waymart Pediatric Center* Middleburg Wayne Memorial Community Health

15 Participating hospitals All-Access network

Adams Chester Gettysburg Hospital Paoli Hospital How to find your Allegheny Clearfield Allegheny General Hospital Penn Highlands Clearfield Hospital provider online: 1. Go to Allegheny Valley Hospital Penn Highlands DuBois GeisingerHealthPlan. UPMC Children’s Hospital of Clinton com/ProviderSearch. Pittsburgh Bucktail Medical Center 2. Enter your location. Western Pennsylvania Hospital UPMC Lock Haven 3. Select your plan. Western Pennsylvania Hospital- Columbia 4. Select a category Forbes Regional Campus Berwick Hospital Center to search from our Berks Geisinger Bloomsburg Hospital entire library of St. Joseph Medical Center applicable providers, or Cumberland narrow your search by Surgical Institute of Reading Geisinger Holy Spirit Hospital searching for doctors, Blair UPMC Carlisle specialties, locations or Conemaugh Nason Medical Hospital types of places. Dauphin Tyrone Hospital Penn State Milton S Hershey Medical Center UPMC Altoona Delaware Bradford Riddle Memorial Hospital Lehigh Guthrie Towanda Memorial Hospital Lehigh Valley Health Network - Elk Tilghman** Robert Packer Hospital Penn Highlands Elk Lehigh Valley Hospital - 17th and Troy Community Hospital Fulton Chew** Fulton County Medical Center Bucks Lehigh Valley Hospital - Cedar Jefferson Health Northeast - Bucks Huntingdon Crest** Campus Penn Highlands Huntingdon Memorial Hospital St. Luke's Hospital - Allentown St. Luke’s Hospital Upper Bucks Campus Campus Jefferson Penn Highlands Brookville St. Luke’s Hospital - Sacred Heart St. Luke's Quakertown Hospital Campus Lackawanna Cambria Geisinger Community Medical Center Luzerne Conemaugh Memorial Medical Geisinger Wyoming Valley Medical Center Moses Taylor Hospital Center

Conemaugh Memorial Medical Regional Hospital of Scranton Wilkes-Barre General Hospital Center - Lee Campus Lancaster Lycoming Conemaugh Miners Medical Center Lancaster General Hospital Geisinger Jersey Shore Hospital

Carbon Lancaster General Women & Babies UPMC Muncy St. Luke’s Hospital - Gnaden Huetten Hospital Campus UPMC Williamsport UPMC Lititz St. Luke’s Hospital - Palmerton Mifflin Campus WellSpan Ephrata Community Geisinger Lewistown Hospital Hospital Centre Monroe Mount Nittany Medical Center Lebanon Lehigh Valley Hospital - Pocono Good Samaritan Hospital St. Luke’s Hospital - Monroe Campus *a member of Geisinger **PPO only 16 Montgomery Somerset Washington Abington Lansdale Hospital Chan Soon-Shiong Medical Center Meritus Medical Center at Windber Abington Memorial Hospital New Jersey Bryn Mawr Hospital Conemaugh Meyersdale Medical Atlantic Center AtlantiCare Regional Medical Lankenau Hospital Center - City Campus* Somerset Hospital Montour AtlantiCare Regional Medical Geisinger Medical Center Susquehanna Center - Mainland Campus Barnes-Kasson Hospital Northampton Burlington Lehigh Valley Hospital - Endless Mountains Health Systems Virtua Memorial Hospital of Muhlenberg** Burlington County Tioga St. Luke’s Hospital - Anderson UPMC Wellsboro Virtua West Jersey Hospital Campus Marlton Union St. Luke’s Hospital - Bethlehem Evangelical Community Hospital Camden Virtua West Jersey Hospital Steward Easton Hospital, Inc. Washington Voorhees Canonsburg Hospital Northumberland Warren Geisinger Shamokin Area Wayne St. Luke’s Warren Hospital Community Hospital Wayne Memorial Hospital New York Philadelphia Wyoming Chemung Children’s Hospital of Philadelphia Tyler Memorial Hospital Arnot Ogden Medical Center

Fox Chase Cancer Center York St. Joseph’s Hospital OSS Orthopaedic Hospital LLC Hospital of the University of Orange Pennsylvania UPMC Hanover Bon Secours Community Hospital

Jefferson Health Northeast - UPMC Memorial Orange Regional Medical Center Frankford Campus York Hospital St. Anthony Community Hospital Jefferson Health Northeast - Torresdale Campus Out-of-state Rockland participating hospitals Good Samaritan Hospital Pennsylvania Hospital District of Columbia Steuben Presbyterian Medical Center of the Sibley Memorial Hospital Corning Hospital UPHS Delaware Ira Davenport Memorial Hospital Temple University Hospital - Jeanes New Castle Campus Alfred I duPont Hospital for Sullivan Children Catskill Regional Medical Center Temple University Hospital Maryland Catskill Regional Medical Center - Thomas Jefferson University Baltimore Grover Hermann Hospital Mt. Washington Pediatric Hospital

Thomas Jefferson University UM Rehabilitation & Orthopaedic Hospital - Methodist Campus Institute

Wills Eye Hospital Baltimore City Johns Hopkins Bayview Medical Potter Center Charles Cole Memorial Hospital Johns Hopkins Hospital Schuylkill UMMC Midtown Campus Geisinger St. Luke’s Hospital University of Maryland Medical Center Lehigh Valley Hospital - Schuylkill East Norwegian St. Howard Howard County General Hospital Lehigh Valley Hospital - Schuylkill South Jackson St. Montgomery St. Luke’s Miners Memorial Hospital Suburban Hospital

17 Participating hospitals Premier network

Adams Gettysburg Hospital Luzerne Geisinger Wyoming Valley Medical Berks Center How to find your St. Joseph Medical Center Lycoming provider online: Bradford Geisinger Jersey Shore Hospital 1. Go to Guthrie Towanda Memorial Hospital Mifflin Geisinger Lewistown Hospital GeisingerHealthPlan. Robert Packer Hospital com/ProviderSearch. Monroe Troy Community Hospital St. Luke’s Hospital - Monroe Campus 2. Enter your location. 3. Select your plan. Bucks Montour St. Luke’s Hospital Upper Bucks Geisinger Medical Center 4. Select a category Campus Northampton to search from our St. Luke's Quakertown Hospital St. Luke’s Hospital - Anderson entire library of Campus applicable providers, or Carbon narrow your search by St. Luke’s Hospital - Gnaden Huetten St. Luke’s Hospital - Bethlehem Campus searching for doctors, Northumberland specialties, locations or St. Luke’s Hospital - Palmerton Geisinger Shamokin Area types of places. Campus Community Hospital

Centre Philadelphia Mount Nittany Medical Center Wills Eye Hospital

Columbia Schuylkill Burlington Geisinger Bloomsburg Hospital Geisinger St. Luke’s Hospital Virtua Memorial Hospital of Burlington County Cumberland St. Luke’s Miners Memorial Hospital Geisinger Holy Spirit Hospital Virtua West Jersey Hospital Marlton Somerset Dauphin Somerset Hospital Camden Penn State Milton S Hershey Medical Virtua West Jersey Hospital Center Union Voorhees Evangelical Community Hospital Lackawanna Warren Geisinger Community Medical Wayne St. Luke’s Warren Hospital Center Wayne Memorial Hospital New York Lancaster York Steuben WellSpan Ephrata Community York Hospital Corning Hospital Hospital Out-of-state Lebanon participating hospitals Good Samaritan Hospital New Jersey Lehigh Atlantic St. Luke's Hospital - Allentown AtlantiCare Regional Medical Campus Center - City Campus*

St. Luke’s Hospital - Sacred Heart AtlantiCare Regional Medical Campus Center - Mainland Campus

*a member of Geisinger

18 Discrimination is against the law Geisinger Health Plan, Geisinger Quality Options, If you believe that the Health Plan has failed to Inc., and Geisinger Indemnity Insurance Company provide these services or discriminated in another (the “Health Plan”) comply with applicable federal civil way on the basis of race, color, national origin, age, rights laws and do not discriminate on the basis of disability, sex, gender identity, or sexual orientation, race, color, national origin, age, disability, sex, gender you can file a grievance with: identity, or sexual orientation. The Health Plan does Civil Rights Grievance Coordinator not exclude people or treat them differently because Geisinger Health Plan Appeals Department of race, color, national origin, age, disability, sex, 100 North Academy Avenue gender identity, or sexual orientation. Danville, PA 17822-3220 The Health Plan: Phone: 866-577-7733, TTY: 711 • Provides free aids and services to people with Fax: 570-271-7225 disabilities to communicate effectively with us, [email protected] such as: You can file a grievance in person or by mail, fax, or • Qualified sign language interpreters email. If you need help filing a grievance, the Civil Rights Grievance Coordinator is available to help you. • Written information in other formats (large print, audio, accessible electronic formats, You can also file a civil rights complaint with the U.S. other formats) Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil • Provides free language services to people whose Rights Complaint Portal, available at https://ocrportal. primary language is not English, such as: hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: • Qualified interpreters U.S. Department of Health and Human Services • Information written in other languages 200 Independence Avenue SW., Room 509F If you need these services, call the Health Plan at HHH Building, Washington, DC 20201 800-447-4000 or TTY: 711. Phone: 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 800-447-4000 or TTY: 711.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711).

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ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-447-4000 (TTY: 711).

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ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-447-4000 (TTY: 711).

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ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-447-4000 (ATS : 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-447-4000 (TTY: 711).

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ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚéřǯžŻ ŴƤȓîŷƄ, ȒơƑĐșřȇŻȓŧŚéŴƤȒīŻŶǯřóǯŅĕśȉƉóǽƷĆŹřơșƇŞȥŞșȒƄǶƴŚ éɇĆȄ ƄŏȄƄơȽŬŐ 800-447-4000 (TTY: 711)ɇ

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-447-4000 (TTY: 711).

HPM50 Nondiscrimination 5/2020

19

Geisinger Health Plan may refer collectively to health care coverage sponsors Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted. Geisinger Health Plan is part of Geisinger, an integrated health care delivery and coverage organization.

Geisinger Marketplace plans for individuals are sold through Geisinger Health Plan and Geisinger Quality Options, Inc., which are referred to collectively as “Geisinger Health Plan” or “GHP,” unless otherwise noted.

This brochure is not a contract or policy and is intended as an easy-to-read summary only. Specific benefits, limitations, exclusions and terms are set forth in your benefit documents.

This managed care plan may not cover all your health care expenses. Read your Subscription Certificate/Policy carefully to determine which health care services are covered. For more information, call 800-918-5154.

This benefits guide is intended as an information source and does not constitute a coverage document. TheSubscription Certificate/ Policy is controlling as to any issues of benefits coverage, limitations and exclusions. This managed care plan may not cover all your health care expenses. Read your Subscription Certificate/Policy carefully to determine which health care services are covered. For more information, contact the customer service team at the number on the back of your member ID card.

HPM50 ab Ind All Plans Rev. 10/2020