Health Plan Name: Insurance Company 1

Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs 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.myuhc.com or by calling 1-866-873-3903. For pharmacy call 1-866-461-6343.

Important Questions Answers Why This Matters: Network: $250 Individual / $500 Family You must pay all the costs up to the deductible amount before What is the overall Non-Network: $500 Individual / $1,000 this plan begins to pay for covered services you use. Check your deductible? Family policy or plan document to see when the deductible starts Per Calendar year. over (usually, but not always, January 1st). See the Common Does not apply to copays, prescription Medical Events chart for how much you pay for covered drugs, and services listed below as "No services after you meet the deductible. Charge". Are there other You don’t have to meet deductibles for specific services, but deductibles for specific No. There are no other deductibles. see the Common Medical Events chart for other costs for services? services this plan covers. Network: $1,000 Individual / $2,000 The out-of-pocket limit is the most you could pay during a Is there an out-of-pocket Family coverage period (usually one year) for your share of the cost of limit on my expenses? Non-Network: $1,500 Individual / covered services. This limit helps you plan for health care $3,000 Family expenses. Premium, prescription drugs, balance- What is not included in billed charges, health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit? doesn’t cover, and penalties for failure the out-of-pocket limit. to obtain Pre-Notification for services. Is there an overall The Common Medical Events chart describes any limits on what annual limit on what the No. the plan will pay for specific covered services, such as office plan pays? visits.

Questions: Call 1-866-873-3903 or visit us at www.myuhc.com. If you aren’t clear about any of the terms used in this form, see the Glossary. 1 of 8 You can view the Glossary at www.dol.gov/ebsa/healthreform or call the phone number above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan. Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs If you use a network doctor or other health care provider, this Yes, this plan uses network providers. plan will pay some or all of the costs of covered services. Be If you use a non-network provider your aware, your network doctor or hospital may use a non-network Does this plan use a cost may be more. For a list of network provider for some services. Plans use the term network, network of providers? providers, see www.myuhc.com or preferred, or participating for providers in their network. call 1-866-873-3903 for a list of See the Common Medical Events chart for how this plan pays network providers. different kinds of providers. Do I need a referral to No. You don't need a referral to see a You can see the specialist you choose without permission from see a specialist? specialist. this plan. Are there services this Some of the services this plan doesn’t cover are listed under Yes. Services Your Plan Does NOT Cover. See your policy or plan plan doesn’t cover? document for additional information about excluded services.

Questions: Call 1-866-873-3903 or visit us at www.myuhc.com. If you aren’t clear about any of the terms used in this form, see the Glossary. 2 of 8 You can view the Glossary at www.dol.gov/ebsa/healthreform or call the phone number above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan. Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs

 Co-payments (copays) are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.  Co-insurance (co-ins) 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 a non-network provider charges more than the allowed amount, you may have to pay the difference. For example, if a non-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 network providers by charging you lower deductibles, co-payments and co- insurance amounts.

Common Your cost if you use a Medical Event Services You May Need Network Provider Non-Network Limitations & Exceptions Provider If you visit a health If you receive services in care provider’s Primary care visit to treat an 30% co-ins, after addition to office visit, $25 copay per visit office or clinic injury or illness ded. additional copays, deductibles, or co-ins may apply. If you receive services in 30% co-ins, after addition to office visit, Specialist visit $50 copay per visit ded. additional copays, deductibles, or co-ins may apply. 30% co-ins for 50% co-ins Limited to 15 visits of Other practitioner office visit Manipulative (Spinal) for Manipulative Manipulative (Spinal) services services (Spinal) services per Calendar year. Includes preventive health services specified in the health Preventive care / screening / 30%co-ins*, after No Charge care reform law. immunization ded. *Deductible/co-ins may not apply to certain services. If you have a test Diagnostic test (x-ray, blood $0 copay per service 30% co-ins, after None work) ded.

3 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs Common Your cost if you use a Medical Event Services You May Need Network Provider Non-Network Limitations & Exceptions Provider Imaging (CT / PET scans, 30% co-ins, after 10% co-ins, after ded. None MRIs) ded. If you need drugs to Tier 1 – Your Lowest-Cost Retail: $10 copay treat your illness or Not Covered condition Option Mail-Order: $20 copay

Tier 2 – Your Midrange-Cost Retail: $30 copay Provider means pharmacy for Not Covered Option Mail-Order: $50 copay purposes of this section. Retail: Up to a 31 day supply More information Tier 3 – Your Highest-Cost Retail: $50 copay Mail-Order: Up to a 90 day Not Covered about prescription Option Mail-Order: $80 copay supply drug coverage is available at Tier 4 – Additional High-Cost Not Applicable Not Applicable www.express- Options scripts.com If you have $100 copay per Facility fee (e.g., ambulatory 30% co-ins, after outpatient surgery surgery, then 10% None surgery center) ded. co-ins, after ded. 30% co-ins, after Physician / surgeon fees 10% co-ins, after ded. None ded. If you need Copay is waived if you are immediate medical admitted for Inpatient stay attention directly from the Emergency Emergency room services $150 copay per visit Same as Network Room. Notification is required if confined in a non-Network Hospital. Emergency medical $0 copay per Same as Network None transportation transport Urgent care $25 copay per visit Same as Network If you receive services in addition to urgent care,

4 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs Common Your cost if you use a Medical Event Services You May Need Network Provider Non-Network Limitations & Exceptions Provider additional copays, deductibles, or co-ins may apply. If you have a $100 copay per Facility fee (e.g., hospital 30% co-ins, after Pre-Notification is required hospital stay Inpatient Stay, then room) ded. non-network. 10% co-ins, after ded. 30% co-ins, after Physician / surgeon fees 10% co-ins, after ded. None ded. If you need help Mental / Behavioral health 30% co-ins, after $25 copay per visit None recovering or have outpatient services ded. other special health $100 copay per Mental / Behavioral health 30% co-ins, after needs Inpatient Stay, then None inpatient services ded. 10% co-ins, after ded. Substance use disorder 30% co-ins, after $25 copay per visit None outpatient services ded. $100 copay per Substance use disorder 30% co-ins, after Inpatient Stay, then None inpatient services ded. 10% co-ins, after ded. If you become Additional copays, pregnant deductibles, or co-ins may 30% co-ins, after Prenatal and postnatal care 10% co-ins, after ded. apply. Network routine pre- ded. natal care is covered at No Charge. Additional copays, deductibles $100 copay per 30% co-ins, after Delivery and all inpatient or co-ins may apply. Inpatient Inpatient Stay, then ded. services Pre-Notification may apply 10% co-ins, after ded. non-network. If you have a 30% co-ins, after Pre-Notification is required Home health care 10% co-ins, after ded. recovery or other ded. non-network. special health Rehabilitation services $25 copay per 30% co-ins, after Depending on the type of

5 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs Common Your cost if you use a Medical Event Services You May Need Network Provider Non-Network Limitations & Exceptions Provider needs therapy, there is a limit of 60 outpatient visit ded. visits per Calendar year. $25 copay per 30% co-ins, after Habilitation services None outpatient visit ded. Limited to 90 days per $100 copay per Calendar year. (combined with 30% co-ins, after Skilled nursing care Inpatient Stay, then Inpatient Rehabilitation) Pre- ded. 10% co-ins, after ded. Notification is required non- network. Pre-Notification is required 30% co-ins, after Durable medical equipment 10% co-ins, after ded. non-network for DME over ded. $1,000 or no coverage. Limited to 180 days per 30% co-ins, after Calendar year. Hospice service 10% co-ins, after ded. ded. Inpatient Pre-Notification is required for non-network. If your child needs Limited to 1 exam every 1 dental or eye care year. 30% co-ins, after Eye exam $25 copay per visit Eye Examinations for ded. refractive errors are not covered non-network. Glasses Not Covered Not Covered No coverage for Glasses. 30% co-ins, after Dental check-up No Charge Coverage for children only. ded.

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  Glasses  Non-emergency care when traveling

6 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs

 Cosmetic surgery  Long-term care outside the U.S.  Custodial Care  Private-duty nursing  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 - may be covered with  Hearing aids - may be covered with  Routine eye care (Adult) - may be limitations limitations covered with limitations

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 1-866-747-1019. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or visit http://www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or visit http://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 the Member Service number listed on the back of your ID card or visit www.myuhc.com.

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 standard of benefits of a health plan. The minimum value standard is 60% 7 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Para obtener asistencia en español, llame al número de teléfono en su tarjeta de identificación. 若需要中文协助，请拨打您会员卡上的电话号码 Dine k'ehji shich'i' hadoodzih ninizingo, bee neehozin biniiye nanitinigii number bikaa'igii bich'i' hodiilnih Para sa tulong sa Tagalog, tawagan ang numero sa iyong

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

8 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs About these Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of Coverage a well-controlled condition) Examples:  Amount owed to providers: $7,540  Amount owed to providers: $5,400  Plan Pays $6,740  Plan Pays $4,720 These examples show how this plan  Patient Pays $800  Patient Pays $680 might cover medical care in given situations. Use these examples to Sample care costs: Sample care costs: see, in general, how much financial Hospital charges (mother) $2,700 Prescriptions $2,900 protection a sample patient might Routine obstetric care $2,100 Medical Equipment and $1,300 get if they are covered under Hospital charges (baby) $900 Supplies different plans. Anesthesia $900 Office Visits and Procedures $700 Laboratory tests $500 Education $300 This is Prescriptions $200 Laboratory tests $100 Vaccines, other preventive $100 not a cost Radiology $200 Vaccines, other preventive $40 Total $5,400 estimator. Total $7,54 0 Don’t use these examples Patient pays: to estimate your actual Patient pays: Deductibles $200 costs under this plan. Deductibles $300 Co-pays $400 The actual care you Co-pays $100 Co-insurance $0 receive will be different Co-insurance $200 Limits or exclusions $80 from these examples, and Limits or exclusions $200 Total $680 the cost of that care will Total $800 also be different.

See the next page for important information about these examples.

9 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs Questions and answers about Coverage Examples: What are some of the assumptions What does a Coverage Example Can I use Coverage Examples to behind the Coverage Examples? show? compare plans?

 Costs don’t include premiums. For each treatment situation, the  Yes. When you look at the Summary of  Sample care costs are based on Coverage Example helps you see how Benefits and Coverage for other plans, national averages supplied to the U.S. deductibles, co-payments, and co- you’ll find the same Coverage Examples. Department of Health and Human insurance can add up. It also helps you When you compare plans, check the Services, and aren’t specific to a see what expenses might be left up to “Patient Pays” box in each example. The particular geographic area or health you to pay because the service or smaller that number, the more coverage plan. treatment isn’t covered or payment is the plan provides  The patient’s condition was not an limited. excluded or preexisting condition. Does the Coverage Example predict Are there other costs I should  All services and treatments started my own care needs? consider when comparing plans? and ended in the same coverage

period.  No. Treatments shown are just  Yes. An important cost is the premium examples. The care you would receive you pay. Generally, the lower your  There are no other medical expenses for this condition could be different based premium, the more you’ll pay in out-of- for any member covered under this on your doctor’s advice, your age, how pocket costs, such as co-payments, plan. serious your condition is, and many other deductibles, and co-insurance. You  Out-of-pocket expenses are based factors. should also consider contributions to only on treating the condition in the Does the Coverage Example predict accounts such as health savings accounts example. my future expenses? (HSAs), flexible spending arrangements  The patient received all care from in- (FSAs) or health reimbursement accounts network providers. If the patient had  No. Coverage Examples are not cost (HRAs) that help you pay out-of-pocket received care from out-of-network estimators. You can’t use the examples expenses. providers, costs would have been to estimate costs for an actual condition. higher. They are for comparative purposes only.  If other than individual coverage, the Your own costs will be different Patient Pays amount may be more. depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-866-873-3903 or visit us at www.myuhc.com. If you aren’t clear about any of the terms used in this form, see the

10 of 11 Choice Plus Plan - Madison #705783 Coverage Period: 07/01/2014 – 06/30/2015 Summary of Benefits and Coverage: What This Plan Coverage for: Employee & Family Plan Type: PS1 Covers & What it Costs

Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform or call the phone number above to request a copy. This is only a summary. It in no way modifies your benefits as described in your plan documents. Please refer to your plan documents provided by your employer for complete terms of this plan.

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