Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2020-12/31/2020 HealthPartners:Peak $3000 Plus Silver - Peak Coverage for: Individual/Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-877-838-4949 or visit us at www.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, , provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary or call 1-877-838-4949 to request a copy. Important Questions Answers Why This Matters: In-network: $3,000 Generally, you must pay all of the costs from providers up to the deductible amount before this What is the overall Individual/$6,000 Family plan begins to pay. If you have other family members on the plan, each family member must meet deductible? Out-of-network: $20,000 their own individual deductible until the total amount of deductible expenses paid by all family Individual/$40,000 Family members meets the overall family deductible. Yes. Coinsurance marked with * This plan covers some items and services even if you haven’t yet met the deductible amount. But Are there services under What You Will Pay and a copayment or coinsurance may apply. For example, this plan covers certain preventive services covered before you meet copays and benefits with no without cost-sharing and before you meet your deductible. See a list of covered preventive your deductible? charge are not subject to services at https://www.healthcare.gov/coverage/preventive-care-benefits/. deductible Are there other for specific No. You don’t have to meet deductibles for specific services. services? In-network medical/pharmacy: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other What is the out-of-pocket $7,900 Individual/$15,800 Family family members in this plan, they have to meet their own out-of-pocket limits until the overall limit for this plan? There is no out-of-network out-of- family out-of-pocket limit has been met. pocket limit. Premium, balance-billed charges What is not included in (unless balanced billing is Even though you pay these expenses, they don’t count toward the out-of-pocket limit. the out-of-pocket limit? prohibited), and health care this plan doesn't cover. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. Yes. See You will pay the most if you use an out-of-network provider, and you might receive a bill from a Will you pay less if you healthpartners.com/peaknetwork provider for the difference between the provider’s charge and what your plan pays (balance use a network provider? or call 1-877-838-4949 for a list of billing). Be aware your network provider might use an out-of-network provider for some services in-network providers. (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist?

1 of 6 PSBC-IE139-200101-01 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) Primary Office Visit: $30 copay for the first three visits and 20% Primary Office Visit: 50% Each family member's first three combined coinsurance thereafter Primary care visit to treat an coinsurance office or urgent care visits are a copay. Other Convenience Care: $15 injury or illness Convenience Care: 50% services like lab, x-rays, MRI/CT scans are copay for the first three coinsurance covered at deductible/coinsurance. visits and 20% If you visit a health coinsurance thereafter care provider’s office virtuwell: No charge or clinic Each family member's first three combined $30 copay for the first office or urgent care visits are a copay. Other Specialist visit three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are coinsurance thereafter covered at deductible/coinsurance. You may have to pay for services that aren’t Preventive care/screening/ preventive. Ask your provider if the services No charge 50% coinsurance immunization you need are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance 50% coinsurance None If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance None Formulary Low Cost: $5 copay at retail, $15 If you need drugs to copay at mail Formulary: 50% treat your illness or Formulary High Cost: coinsurance at retail, mail Generic drugs condition $25 copay at retail, $75 not covered 30 day supply retail / 90 day supply mail order. copay at mail Non-formulary: Not covered Non-formulary drugs are not covered unless More information about Non-formulary: Not an exception is granted. prescription drug covered coverage is available at 50% coinsurance at retail, Formulary brand drugs 20% coinsurance healthpartners.com/gen mail not covered ericsadvantagerx Non-formulary brand drugs Not covered Not covered Specialty drugs are limited to drugs on the Specialty drugs 50% coinsurance Not covered specialty drug list and must be obtained from a 2 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) designated vendor. Facility fee (e.g., ambulatory If you have outpatient 20% coinsurance 50% coinsurance None surgery center) surgery Physician/surgeon fees 20% coinsurance 50% coinsurance None $250 copay before $250 copay before First visit $250 copay, then deductible for the first deductible for the first one Emergency room care deductible/coinsurance. Out-of-network one visit(s) and 20% visit(s) and 20% services apply to the in-network deductible. coinsurance thereafter coinsurance thereafter If you need immediate Emergency medical Out-of-network services apply to the in- 20% coinsurance 20% coinsurance medical attention transportation network deductible. Each family member's first three combined $30 copay for the first office or urgent care visits are a copay. Other Urgent care three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are coinsurance thereafter covered at deductible/coinsurance. If you have a hospital Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance None stay Physician/surgeon fees 20% coinsurance 50% coinsurance None Each family member's first three combined If you need mental $30 copay for the first office or urgent care visits are a copay. Other health, behavioral Outpatient services three visits and 20% 50% coinsurance services like lab, x-rays, MRI/CT scans are health, or substance coinsurance thereafter covered at deductible/coinsurance. use disorder services Inpatient services 20% coinsurance 50% coinsurance None Depending on the type of services, a Office visits No charge 50% coinsurance copayment, coinsurance, or deductible may apply. If you are pregnant Childbirth/delivery professional 20% coinsurance 50% coinsurance None services Childbirth/delivery facility 20% coinsurance 50% coinsurance None services Home health care 20% coinsurance 50% coinsurance 120 visit limit If you need help Rehabilitation services 20% coinsurance 50% coinsurance None recovering or have Habilitation services 20% coinsurance 50% coinsurance None other special health Skilled nursing care 20% coinsurance 50% coinsurance 120 day maximum needs Durable medical equipment 20% coinsurance 50% coinsurance None Hospice services 20% coinsurance 50% coinsurance Respite care is limited to 5 days per episode

3 of 6 Common What You Will Pay Limitations, Exceptions, & Other Important Services You May Need Network Provider Out-of-Network Provider Medical Event Information (You will pay the least) (You will pay the most) and respite care and continuous care combined are limited to 30 days. Children’s eye exam No charge 50% coinsurance None If your child needs Limited to one pair of eyeglasses (lenses and Children’s glasses 20% coinsurance Not covered dental or eye care frames) or one pair of contact lenses per year. Children’s dental check-up 20% coinsurance 50% coinsurance None

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)  Acupuncture  Infertility treatment  Private-duty nursing  Bariatric surgery  Long-term care  Routine eye care (Adult)  Cosmetic surgery with the exception of port wine  Non-emergency care when traveling outside the  Routine foot care stain removal and reconstructive surgery U.S.  Weight loss programs  Dental care (Adult)  Non-formulary drugs without a formulary  Hearing aids(Adult) exception

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)  Chiropractic care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Your plan at 1-800-883-2177, or the MN Dept of Health at 651-201-5100 / 1-800-657-3916, or the Department of Health and Human Services, Center for Consumer Information and Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Marketplace.For more information about the Marketplace, visit www.MNsure.org or call 1-855- 366-7873.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Your plan at 1-800-883-2177 or the MN Dept of Health at 651-201-5100 / 1-800-657-3916.

Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet Minimum Value Standards? Yes. 4 of 6 If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-877-838-4949. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-838-4949. Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-838-4949. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-838-4949. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

5 of 6 About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care)

 The plan’s overall deductible $3,000  The plan’s overall deductible $3,000  The plan’s overall deductible $3,000  Specialist copay $30  Specialist copay $30  Specialist copay $30  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Hospital (facility) coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%  Other coinsurance 20%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $7,300 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $3,000 Deductibles $3,000 Deductibles $1,900 Copayments $20 Copayments $200 Copayments $0 Coinsurance $1,600 Coinsurance $600 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0 The total Peg would pay is $4,680 The total Joe would pay is $3,860 The total Mia would pay is $1,900

6 of 6 Statement of Nondiscrimination for Health Plan Members

Our Responsibilities: If you have questions about our non-discrimination We follow Federal civil rights laws. We do not policy: discriminate on the basis of race, color, national origin, Contact the Civil Rights Coordinator at 1-844-363-8732 age, disability or sex. We do not exclude people or treat or [email protected]. them differently because of their race, color, national To File a Grievance: origin, age, disability or sex, including gender identity. If you believe that we have not provided these services • We help people with disabilities to communicate or have discriminated against you because of your race, with us. This help is free. It includes: color, national origin, age, disability or sex, you can file • Qualified sign language interpreters a grievance by contacting the Civil Rights Coordinator • Written information in other formats, such as at 1-844-363-8732, integrityandcompliance@ large print, audio and accessible electronic healthpartners.com or Civil Rights Coordinator, formats Office of Integrity and Compliance, MS 21103K, • We provide services for people who do not speak 8170 33rd Ave. S., Bloomington, MN 55425. English or who are not comfortable speaking You can also file a civil rights complaint with the U.S. English. These services are free. They include: Department of Health and Human Services, Office for • Qualified interpreters Civil Rights, electronically through the Office for Civil • Information written in other languages Rights Complaint Portal, available at https://ocrportal. For Language or Communication Help: hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Call 1-800-883-2177 if you need language or other U.S. Department of Health and Human Services communication help. (TTY: 711) Room 509F, HHH Building 200 Independence Avenue SW, Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)

Español (Spanish) ƐƞƗƞƕƞƖ (Laotian) ATENCIÓN: si habla español, tiene a su disposición ƫƍƇƅƞƌ: Ɖǚ ƞƖǙ ƞƊǙ ƞƋƩƖǗǚ ƞƐƞƗƞƕƞƖ, servicios gratuitos de asistencia lingüística. Llame al ƀƞƋƌǞ Ǒ ƕƀƞƋƅǙ ƖƆƩƘǔ ǘ ƙƇǚ ƞƋƐƞƗƞƫƇƆƌǞǙ ƩƗǐ ǟƂǙ ƞ 1-800-883-2177. (TTY: 711) ƪƒǙ Ƌƒǒ Ɛǚ ƙƒƬƘǚ ƊǙ ƞƋƫƊƔ 1-800-883-2177. (TTY: 711) Hmoob (Hmong) Deutsch (German) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog ACHTUNG: Wenn Sie Deutsch sprechen, stehen lus, muaj kev pab dawb rau koj. Hu rau 1-800-883-2177. Ihnen kostenlos sprachliche Hilfsdienstleistungen zur (TTY: 711) Verfügung. Rufnummer: 1-800-883-2177. (TTY: 711) Tiếng Việt (Vietnamese) ΔϳΑέόϟ΍ (Arabic) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ήϓ΍ϮΘΗ ΔϳϮϐϠϟ΍ ΓΪϋΎδϤϟ΍ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ΍ ήϛΫ΍ ΙΪΤΘΗ ΖϨϛ ΍Ϋ· :ΔυϮΤϠϣ ngôn ngữ miễn phí dành cho bạn. Gọi số 711 :ϢϜΒϟ΍ϭ Ϣμϟ΍ ϒΗΎϫϢϗέ )1-800-883-2177 ϢϗήΑ ϞμΗ΍ .ϥΎΠϤϟΎΑ Ϛϟ 1-800-883-2177. (TTY: 711) ⦾㧓୰ᩥ (Chinese) Français (French) 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ ⎗ẍ⃵屣䌚 ⼿婆妨㎜≑㚵 ⊁ˤATTENTION: Si vous parlez français, des services d’aide 婳农暣  1-800-883-2177. (TTY: 711) linguistique vous sont proposés gratuitement. Appelez le 1-800-883-2177. (ATS: 711) Русский (Russian) 䞲ῃ㠊(Korean) ВНИМАНИЕ: Если вы говорите на русском языке, то 㨰㢌aG䚐 ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤 SG㛬㛨G㫴㠄G㉐⽸㏘⪰G вам доступны бесплатные услуги перевода. Звоните ⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩ ⏼␘U 1-800-883-2177. (TTY: 711) 1-800-883-2177. (телетайп: 711) Af Soomaali (Somali) Tagalog (Tagalog) OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari Waxaa kuu diyaar ah caawimaad xagga luqadda ah oo kang gumamit ng mga serbisyo ng tulong sa wika nang bilaash ah. Fadlan soo wac 1-800-883-2177. (TTY: 711) walang bayad. Tumawag sa 1-800-883-2177. (TTY: 711)

Page 1 of 2 Additional languages listed on page 2 21849 (7/2017) Oromiffa (Cushite [Oromo]) Italiano (Italian) XIYYEEFFANNAA: Afaan dubbattu Oromiffa, tajaajila ATTENZIONE: In caso la lingua parlata sia l’italiano, gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa sono disponibili servizi di assistenza linguistica gratuiti. 1-800-883-2177. (TTY: 711) Chiamare il numero 1-800-883-2177. (TTY: 711) —0’ (Amharic) £µ¬µÅš¥ (Thai) 8n·>: ÕŠô,p LŒL š0’ Ÿ ‡ Õp0õ œ0ßn á0ñqxŃ Á¦¥œ¸ : ™oµ‡»–¡—£µ¬µÅš¥‡¼ »–­µ¤µ¦™Ä¦o „µ¦· ª¥Á®¨n º°šµŠ£µ¬µÅ—o¢¦ ¸ Ú¦ [‡Ģ Øùʽp kÅ÷ìkºŁ ·Ü Ÿk ¼ DČ0 Úܼ 1-800-883-2177. (TTY: 711) 1-800-883-2177. ( 8p k6Šs¼:711) unD (Karen) ελληνικά (Greek) ymol.ymo;= erh>uwdRAunDAusdmtCdAusdmtw>rRpXRvXA ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας AwvXmbl.vXmphRAeDwrHRb.ohM.vDRIAud; 1-800-883-2177. βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες (TTY: 711) παρέχονται δωρεάν. Καλέστε 1-800-883-2177. (TTY: 711) ȓîŷƄ (Mon-Khmer, Cambodian) Diné Bizaad (Navajo) ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴƅŚéřǯžŻ Ś ŴƤȓîŷƄ,Ś ȒơƑĐřș ȇŻȓŧŚéŴƤŷ Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, ȒīŻŶǯřóǯŅĕś Ɖȉ óǽƷĆŹřơșƇŞȥŞșȒƄƴǶ ŚéɇĆȄƄŏȄƄơŬȽ Ő saad bee áká’ánída’áwo’dęę’,´ ´ t’áá jiik’eh, éí ná hóló,˛ koji’ ˛ 1-800-883-2177. (TTY: 711) hódíílnih 1-800-883-2177. (TTY: 711) Deitsch (Pennsylvanian Dutch) Ikirundi (Bantu – Kirundi) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi ebber gricke, ass dihr helft mit die englisch Schprooch. zo gufasha mu ndimi, ku buntu. Woterefona Ruf selli Nummer uff: Call 1-800-883-2177. (TTY: 711) 1-800-883-2177. (TTY: 711) Polski (Polish) Kiswahili (Swahili) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza z bezpłatnej pomocy językowej. Zadzwoń pod numer kupata, huduma za lugha, bila malipo. Piga simu 1-800-883-2177. (TTY: 711) 1-800-883-2177. (TTY: 711) Lagun age Interp ᪥ᮏㄒ (Japanese) rete r Ser vice s areal so avai ablel in Hi ndi ˜ÝǕ ˜Ʌ ὀព஦㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ —ȡŸȡ ¡ȡ™ȡ ȯȡf Ȳ `”›Þ’ ¡ɇ@ 1-800-883-2177. (TTY: 711) ↓ᩱࡢゝㄒᨭ᥼ࢆࡈ฼⏝࠸ࡓࡔࡅࡲࡍࠋ1-800-883-2177 (TTY: 711) ࡲ࡛ࠊ࠾㟁ヰ࡟࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Shqip (Albanian) lso avairvices ar KUJDES: Nëse flitni shqip, për ju ka në dispozicion lable in Nepali ”ȡ^ɍ›ȯ“ȯ”ȡ›ȣ–Ȫ㓡ۆ—“”ȡ^Ǖ Ǖ ȯ ɍ€ȪǓ“ǔà—ȡŸȡ ¡ȡ™ȡ shërbime të asistencës gjuhësore, pa pagesë. Telefononi ȡ¡ǾǓ“Ȭžã€Ǿ”˜ȡ`”›Þ’ȯ Ǖ †@•Ȫ“ në 1-800-883-2177. (TTY: 711) ‚“Ǖ¡Ȫ[ e a Language InterpreterǑŠǑŠȡ^: Se Srpsko-hrvatski (Serbo-Croatian) Norsk (Norwegian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge MERK: Hvis du snakker norsk, er gratis jezičke pomoći dostupne su vam besplatno. Nazovite språkassistansetjenester tilgjengelige for deg. Ring 1-800-883-2177. (TTY: 711) 1-800-883-2177. (TTY: 711) ȤK^hSjk  (Gujarati) Adamawa (Fulfulde, Sudanic) ɅIWhk Ks S\p ȤK^hSjk Zs_Sh es Ss iW ɃƣDk [hch MAANDO: To a waawi Adamawa, e woodi ballooji-ma to : , : ekkitaaki wolde caahu. Noddu 1-800-883-2177. deh] dpahB S\h^h \hN° ;X_ƞV Jp YsW D^s 1-800-883-2177. (TTY: 711) . (TTY: 711) ϭΩέ˵ ˵΍ (Urdu) Українська (Ukranian) ΗϟϭΑ ϭΩέ΍ ̟΁ έ̳΍ :έ΍ΩέΑΧ УВАГА! Якщо ви розмовляєте українською мовою, виف ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟΁ ϭΗ ˬ؏ϳ٫ ΏΎϳΗγΩ ؏ϳϣ Εϔϣ можете звернутися до безкоштовної служби мовної ϳ٫؏ ل TTY: 711) 1-800-883-2177 ؐϳή̯ ϝΎ̯). підтримки. Телефонуйте за номером 1-800-883-2177. (телетайп: 711)

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