Copayments Are Fixed Dollar Amounts (For Example, $15) You Pay for Covered Health Care s1

This is only a summary. If you want more detail about your coverage and costs, you can get the complete document at www.HealthReformPlanSBC.com or by calling 1-888-982-3862. Important Questions Answers Why this Matters: What is the overall For each Calendar Year, In-network: You must pay all the costs up to the Individual $500 / Family $1,000; begins to pay for covered services deductible? Out-of-network: Individual $2,500 / Family document to see when the deductible $5,000. Does not apply to office visits, January 1st). See the chart starting preventive care, and emergency care. covered services after you meet the Are there other deductibles No. You don't have to meet deductibles for specific services? chart starting on page 2 for other costs Is there an Yes, In-network: Individual $2,000 / Family The out-of-pocket limit is the most out-of-pocket limit $4,000. Out-of-network: Individual $5,000 period (usually one year) for your on my expenses? / Family $10,000. This limit helps you plan for health What is not included in Premiums, copays, balance-billed Even though you pay these expenses, the out-of-pocket charges, penalties for failure to obtain out-of-pocket limit. pre-authorization for services and health limit? care this plan doesn't cover. Is there an overall No. The chart starting on page 2 describes annual limit on for what the plan pays? specific covered services, such as Does this plan use a Yes. For a list of in-network providers, If you use an in-network doctor or network of providers? see www.aetna.com or call 1-888-982- pay some or all of the costs of covered 3862. doctor or hospital may use an out-of-network Plans use the term in-network, preferred their network. See Do I need a referral No. You can see the specialist you choose to see a specialist? Are there services Yes. Some of the services this plan doesn't this plan doesn't policy or plan document for additional 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.

Your Cost If You Common Medical Event Your Cost If You Services You May Use an In-Network Use an Limitations & Exceptions Need Provider Out-Of-Network Provider Primary care visit to treat an Custom Network PCP 40% coinsurance ––––––––––– None ––––––––––– injury or illness No Charge; $20 copay per visit for all others Specialist visit $25 copay per visit 40% coinsurance ––––––––––– None ––––––––––– Other practitioner office visit Chiropractic care: $25 40% coinsurance Coverage includes Chiropractic care copay, Acupuncture: and Acupuncture with unlimited visits 20% coinsurance; after per calendar year for Chiropractic If you visit a health care $25 copay care. provider's office or clinic Preventive care /screening No charge, deductible 40% coinsurance, Age and frequency schedules may apply. /immunization waived except No charge: Routine GYN Exam, & Routine Mammogram, Not covered: Routine Physical Exam & Routine Prostate Specific Antigen Diagnostic test (x-ray, blood 10% coinsurance, after 40% coinsurance ––––––––––– None ––––––––––– deductible If you have a test work) Imaging (CT/PET scans, $50 copay per test, $50 copay per test, ––––––––––– None ––––––––––– MRIs) deductible waived deductible waived Your Cost If You Common Medical Event Your Cost If You Services You May Use an In-Network Use an Limitations & Exceptions Need Provider Out-Of-Network Provider Generic drugs $10 copay/ $10 copay/ Covers up to a 90-day supply (retail prescription for a 30 prescription for a 30 prescription); 90 day supply (mail order day supply (retail or day supply (retail or prescription). Includes performance mail order), $15 copay/ mail order), $15 enhancing medication (6 tablets per 30 prescription for a 90 copay/ prescription days for retail or 18 tablets per 90 days for day supply (retail or for a 90 day supply mail order or retail)*Infertility and mail order) (retail or mail order) Erectile Dysfunction drugs: $50.00 copay If you need drugs to treat Preferred brand drugs $30 copay/ $30 copay/ for 30 day supply or $75.00 copay for 90 your illness or condition prescription for a 30 prescription for a 30 day supply, contraceptive drugs and More information about day supply (retail or day supply (retail or devices obtainable from a pharmacy, oral prescription drug coverage mail order), $45 copay/ mail order), $45 and injectable fertility drugs. No charge is available at prescription for a 90 copay/ prescription for formulary generic FDA-approved www.aetna.com/phar macy- day supply (retail or for a 90 day supply women's contraceptives in-network. Precertification required. insurance/indi viduals- mail order) (retail or mail order) families Non-preferred brand drugs $45 copay/ $45 copay/ prescription for a 30 prescription for a 30 day supply (retail or day supply (retail or mail order), $70 copay/ mail order), $70 prescription for a 90 copay/ prescription day supply (retail or for a 90 day supply mail order) (retail or mail order) Specialty drugs Applicable cost as Not covered ––––––––––– None ––––––––––– noted above for generic or brand drugs. Facility fee (e.g., Preferred Network 40% coinsurance ––––––––––– None ––––––––––– ambulatory surgery center) Facility 10% coinsurance, after If you have outpatient deductible. All others surgery 20% coinsurance, after deductible; Non-free standing hospital: 5% coinsurance, after deductible Your Cost If You Common Medical Event Your Cost If You Services You May Use an In-Network Use an Limitations & Exceptions Need Provider Out-Of-Network Provider Physician/surgeon fees Preferred Network 40% coinsurance ––––––––––– None ––––––––––– 10% coinsurance, after deductible. All others 20% coinsurance, after deductible. Emergency room services $150 copay per visit, $150 copay per visit, ––––––––––– None ––––––––––– deductible waived deductible waived If you need immediate medical attention Emergency medical 0% coinsurance, after 0% coinsurance, ––––––––––– None ––––––––––– transportation deductible after in-network Urgent care $25 copay per visit, 40%deductible coinsurance ––––––––––– None ––––––––––– deductible waived Facility fee (e.g., hospital Preferred 10% 40% coinsurance Pre-authorization required for out-of- room) coinsurance, after network care. deductible. All other Facility 20% coinsurance, after If you have a hospital stay deductible Physician/surgeon fee Preferred 10% 40% coinsurance ––––––––––– None ––––––––––– coinsurance, after deductible. All others 20% coinsurance, after deductible Mental/Behavioral health $25 copay per visit, 40% coinsurance ––––––––––– None ––––––––––– outpatient services deductible waived If you have mental health, Mental/Behavioral health 10% coinsurance, after 40% coinsurance Pre-authorization required for out-of- behavioral health, or inpatient services deductible network care. substance abuse needs Substance use disorder $25 copay per visit, 40% coinsurance ––––––––––– None ––––––––––– outpatient services deductible waived Substance use disorder 10% coinsurance, after 40% coinsurance Pre-authorization required for out-of- inpatient services deductible network care. Your Cost If You Common Medical Event Your Cost If You Services You May Use an In-Network Use an Limitations & Exceptions Need Provider Out-Of-Network Provider Prenatal and postnatal care $25 copay per visit, 40% coinsurance If your new plan is subject to health deductible waived care reform law, there will be no charge for If you are pregnant in-network preventive prenatal care. Delivery and all inpatient 0% coinsurance, after 40% coinsurance Pre-authorization required for services deductible out-of-network care. Includes outpatient postnatal care. Home health care 0% coinsurance, after 40% coinsurance Pre-authorization required for out-of- deductible network care. Rehabilitation services $25 copay per visit, 40% coinsurance Coverage includes unlimited visits per deductible waived calendar year for Physical and Occupational therapy. Coverage includes Habilitation services $25 copay per visit, 40% coinsurance BenefitSpeech therapy.limitations may apply. deductible waived If you need help recovering or have other Skilled nursing care 0% coinsurance, after 40% coinsurance Coverage is limited to 100 days per special health needs deductible calendar year. Pre-authorization required for Durable medical equipment 0% coinsurance, after 40% coinsurance Benefitout-of-network limitations care. may apply for Orthotics deductible and Prosthetics. Hospice service Inpatient: 10% 40% coinsurance Pre-authorization required for out-of- coinsurance, after network care. deductible; Outpatient: 0% coinsurance, after deductible Eye exam No charge, deductible 40% coinsurance Coverage is limited to 1 routine eye If your child needs dental waived exam per calendar year. or eye care Glasses Not covered Not covered Not covered Dental check-up Not covered Not covered Not covered Excluded Services & Other Covered Services: (This isn't a complete list. Check your policy or plan document for other excluded services.) Services Your Plan Does NOT Cover Cosmetic surgery Long-term care Private-duty nursing Dental care (Adult & Child) Non-emergency care when traveling outside the Routine foot care U.S. Glasses (Child) Weight loss programs

(This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Other Covered Services Acupuncture Hearing aids - Coverage is limited to a maximum of Routine eye care (Adult) - Coverage is limited to 1 $1,400 per ear during any 36 month period up to routine eye exam per calendar Bariatric surgery year. age 19. Chiropractic care - Coverage includes unlimited 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 1-888-982-3862. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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 assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file an appeal. Contact information is at http://www.aetna.com/individuals-families-health-insurance/member-guidelines/complaints-grievances-appeals.html Language Access Services: Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-982- 1-888-982-3862. 3862. Para obtener asistencia en Español, llame al 1-888-982-3862. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-982-3862. ------To see examples of how this plan might cover costs for a sample medical situation, see the next page.------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: Amount owed to providers: $5,400 cover medical care in given situations. Use $7,540 Plan pays: $4,460 these examples to see, in general, how much Plan pays: $6,850 Patient pays: $940 financial protection a sample patient might get Patient pays: $690 if they are covered under different plans. Sample care costs: Sample care costs:

This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. The Patient pays: actual care you receive Deductibles $500 will be different from Patient Copays $360 these examples, and the pays: Coinsurance $0 cost of that care also will be different. Limits or exclusions $80 Total $940 See the next page for important information Note: Your plan may have both copays and about these examples. coinsurance for covered services; if so, these examples use copays only. Your costs may be higher. 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 Yes. Example helps you see how deductibles, When you look at the Summary Costs don't include premiums. copayments, and coinsurance can add up. of Benefits and Coverage for other Sample care costs are based on national It also helps you see what expenses might plans, you'll find the same Coverage averages supplied by the U.S. be left up to you to pay because the service Examples. Department of Health and Human or treatment isn't covered or payment is When you compare plans, check the "Patient Services, and aren't specific to a limited. Pays" box in each example. The smaller particular geographic area or health that number, the more coverage the plan plan. Does the Coverage Example provides. The patient's condition was not predict my own care needs? an Are there other costs I should excluded or preexisting condition. prices your providers charge, and the All services and treatments started No. Treatments shown are just reimbursement your health plan allows. and ended in the same coverage examples. The care you would receive for period. this condition could be different, based There are no other medical expenses on your doctor's advice, your age, how for any member covered under this serious your condition is, and many other plan. factors. Out-of-pocket expenses are based only on treating the condition in the example. Does the Coverage Example The patient received all care from predict my future expenses? in-network providers. If the patient had received care from out-of-network No. Coverage Examples are not cost providers, costs would have been estimators. You can't use the examples to higher. estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the consider when the lower your premium, the more accounts such as health savings accounts comparing plans? you'll pay in (HSAs), flexible spending arrangements out-of-pocket costs, such as copayments, (FSAs) or health reimbursement accounts Yes. An important cost is the deductibles, and coinsurance. You (HRAs) that help you pay out-of-pocket premium you pay. Generally, should also consider contributions to expenses.