GEISINGER HEALTH PLAN

Coverage you can count on For individuals and families seeking coverage on 's insurance exchange 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. A new election period begins Feb. 15. Are you ready?

Pennsylvania has transitioned from HealthCare.gov to its own state-based health insurance marketplace, Pennie™, where you can enroll in or make changes to your Marketplace coverage. The 2021 Open Enrollment Period (OEP) has ended, but the COVID-19 pandemic has affected millions - and that's why Pennie has initiated a statewide Special Election Period (SEP), available to all.

The COVID-19 SEP runs from Feb. 15, 2021, through Aug. 15, 2021 Your coverage effective date will be the first day of the following month, even if you apply on the last day of the prior month. The Qualifying Life Event (QLE) that you will select for this enrollment period will be the date you enroll on Pennie’s website yourself or with our team’s help. And, with the recently passed American Rescue Plan Act of 2021 (ARPA), you and your family could qualify for unprecedented financial aid. That means that more Pennsylvanians than ever can save on quality, affordable healthcare.

Are you in our service area? Geisinger Health Plan's service area includes the following counties:

• Adams • Cumberland • Luzerne • Somerset • Berks • Dauphin • Lycoming • Snyder • Blair • Elk • Mifflin • Sullivan • Bradford • Fulton • Monroe • Susquehanna Visit pennie.com or call • Cambria • Huntingdon • Montour • Tioga 844-844-8040 to find • Cameron • Jefferson • Northumberland • Union information and assistance • Carbon • Juniata • Northampton • Wayne on your health insurance. • 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. ID cards, premiums, billing, benefit/plan information, Choose from HMO and PPO plans with a variety of application status, removing/adding dependents and monthly premiums and out-of-pocket cost options. In much more. addition, you can choose between two dynamic networks, plus Geisinger Extra, a unique plan designed to save Network of providers you money. We also offer a catastrophic Value plan that Select from our large provider network that includes provides the most basic coverage to people under 30. Plus, Geisinger hospitals and physicians, as well as thousands of you'll get plenty of perks to keep you healthy and well. other providers throughout the service area. Our network includes: Local and nationwide discounts • More than 20,000 primary care and specialty physicians You'll have access to our local and nationwide discounts • More than 120 hospitals program that gives you discounts on health- and • More than 220 urgent and convenient care facilities wellness-related products, such as: • Telemedicine services for one-stop virtual care • Fitness center memberships • Eyeglasses Find a provider online • Contact lenses Go to GeisingerHealthPlan.com/ProviderSearch and enter • Chiropractic care your location and plan type. Your plan type will include • Massage therapy and more your network. Select a category to search from our entire library of applicable providers, or narrow your search by Health management programs searching for providers by name, specialty or location. We offer a number of award-winning health management programs to help our members with chronic conditions. Pediatric dental Members can enroll at no cost and can work with one coverage through of our health managers to better manage their health Avesis conditions. Programs include: Dental coverage for children under the age of 19 is • Asthma • COPD included in our Geisinger Marketplace plans. All pediatric • Diabetes • Quitting tobacco dental benefits are provided by Avesis. • Heart failure • Weight management Pediatric dental plans from Avesis include coverage for Wellness coaching and support the following services: You'll have access to certified wellness coaches who • Routine oral exams and • Extractions support your efforts to quit tobacco, manage weight, cleanings • Repairs and maintenance increase physical activity, decrease stress and improve • X-rays • Anesthesia their lifestyle. There are also numerous online tools that • Fillings • Root canal you can access and complete at your own pace, including • Fluoride treatments • Orthodontia wellness workshops, fitness trackers and a meal planner. After you enroll, you'll receive a Schedule of Benefits. Make sure to review for a more detailed list of covered Customer care services. Call our customer care team at We pride ourselves on our customer care. Our 866-379-4489 with questions about your pediatric Marketplace customer care team delivers a better service dental benefits. experience through one-call resolution. Each customer care team member can assist with questions regarding

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 part tells you the network A copay is a fixed amount time you visit a specialty care pay for healthcare services name, which will be either you will pay for a covered provider (SCP), you would before your insurance coverage an All-Access or Premier healthcare service, usually pay $40. begins. 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 coverage begins. network plans also have a visit your PCP. Geisinger Extra component (see below).

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?

The American Rescue Plan, also known as the COVID-19 relief package, includes provisions specific to the (ACA) resulting in significant impacts, including huge, life-altering savings, for Pennsylvanians seeking individual market coverage and those already enrolled in coverage through Pennie. The plan includes an increase in the eligibility for, and the amount of, premium tax credits for Pennsylvanians at all income levels during the 2021 and 2022 plan years. Those earning more than the current cap of 400% of the federal poverty level -- about $51,000 for an individual and $104,800 for a family of four in 2021 – will be newly eligible for tax credits. Under this law, no one will pay more than 8.5 percent of their income in premiums for the second lowest cost silver plan (SLCSP or benchmark plan) in their county. In some cases, lower-income enrollees could have their premiums eliminated completely. Try out Pennie's savings calculator to see the difference. To see if you qualify, just give us a call at 570-849-7272 or visit GeisingerMarketplace.com to have a member of our team reach out to you. Or, if you’d rather work directly with Pennie, simply visit pennie.com or call 844-844-8040 to get started.

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

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

14 St. Luke’s Northgate Internal Medicine* St. Luke’s Internal Medicine at Tamaqua* Wayne St. Luke’s Pediatric Associates* St. Luke’s Internal Medicine Miners* Geisinger PrimeMed - Honesdale St. Luke’s Physician Group Family St. Luke’s Miners Health Center - Hamlin Family Health Center* Medicine* Hometown* Highland Physicians Family Health St. Luke’s Primary Care Easton* St. Luke’s Miners Health Center - Center* St. Luke’s Riverside Internal Medicine* Ringtown* Honesdale Family Health Center* St. Luke’s Southside Medical Center* Tamaqua Family Practice* Honesdale Pediatric Center* William Penn Family Practice* Northern Wayne Family Health Center* Snyder Pike County Medical Center* Northumberland Family Medicine of Evangelical - The Wright Center for Community Alakananda Chakrabarty, MD PC* Middleburg Health* Family Medicine of Evangelical - Milton Family Medicine of Evangelical - Waymart Pediatric Center* Family Medicine of Evangelical - Selinsgrove Wayne Memorial Community Health Northumberland Family Practice Center PC - Middleburg Centers* Family Practice Center PC - Elysburg Family Practice Center PC - Mt. Pleasant Family Practice Center PC - Herndon Mills Wyoming Family Practice Center PC - Pagana- Family Practice Center PC - Selinsgrove Geisinger Tunkhannock DeFazio Family Practice Center PC - Shamokin Family Practice Center PC - Sunbury Dam York Family Practice Center PC - Watsontown Geisinger 65Forward Health Center Family Practice Center PC - Ameigh Geisinger Elysburg Geisinger Selinsgrove Family Practice Center PC - Lewisberry Geisinger Kulpmont GMC at Susquehanna University* Penn State Health Holy Spirit Dillsburg* Geisinger Milton Geisinger Mt. Carmel Sullivan Geisinger Sunbury Family Practice Center PC - Laporte Miller Donmoyer Family Health Center* Peter E. McNeil, MD* Susquehanna St. Joseph’s Internal Medicine PC* Forest City Family Health Center* Wardeh-Agha Medical Center LLC* Tioga Perry Susquehanna Health Spinal Family Practice Center PC - Loysville Rehabilitation & Work Center Penn State Health Holy Spirit Family Medicine - Duncannon* Union Penn State Health Holy Spirit Marysville* Family Medicine of Evangelical - Lewisburg Pike Family Medicine of Evangelical - Pinnacle Family Health Center* Lewisburg POB Family Medicine of Evangelical - Schuylkill Mifflinburg Family Practice Center PC - Valley View 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 & Mobile Health of Evangelical Specialties* UPMC Primary Care Lewisburg* Geisinger St. Luke’s Orwigsburg Primary Care* Warren (NJ) Integrated Medical Group PC - Coventry Family Practice* Adukaitis* St. Luke’s Belvidere Family Practice* Integrated Medical Group PC - St. Luke’s Nephrology - Warren* Blue Mtn Peds* Village Medical Center* St. Luke’s Ashland Family Practice* Warren Hills Family Practice* St. Luke’s Internal Medicine*

15 * These practices that qualify for the lower copay but do not offer the extra ProvenHealth Navigator® services. Participating hospitals All-Access network

Adams Geisinger Bloomsburg Hospital WellSpan Gettysburg Hospital Allegheny Cumberland How to find your Allegheny General Hospital Penn State Health Holy Spirit Medical provider online: Allegheny Valley Hospital Center UPMC Children’s Hospital of UPMC Carlisle 1. Go to Pittsburgh Western Pennsylvania Hospital GeisingerHealthPlan. Dauphin Western Pennsylvania Hospital- com/ProviderSearch. Penn State Milton S Hershey Medical Forbes Regional Campus Center 2. Enter your location. Berks Delaware 3. Select your plan. St. Joseph Medical Center Riddle Memorial Hospital Surgical Institute of Reading 4. Select a category to search from our Elk Blair Penn Highlands Elk entire library of Conemaugh Nason Medical Hospital Tyrone Hospital applicable providers, or UPMC Altoona Fulton narrow your search by Fulton County Medical Center searching for doctors, Bradford specialties, locations or Robert Packer Hospital Huntingdon types of places. Robert Packer Hospital Towanda Penn Highlands Huntingdon Memorial Campus Hospital Troy Community Hospital Jefferson Bucks Penn Highlands Brookville Lycoming Northeast - Bucks Geisinger Jersey Shore Hospital Campus Lackawanna UPMC Muncy St. Luke’s Hospital Upper Bucks Geisinger Community Medical Center UPMC Williamsport Campus Moses Taylor Hospital St. Luke's Quakertown Hospital Regional Hospital of Scranton Mifflin Geisinger Lewistown Hospital Cambria Lancaster Conemaugh Memorial Medical Lancaster General Hospital Monroe Center Lancaster General Women & Babies - Pocono Conemaugh Memorial Medical Hospital St. Luke’s Hospital - Monroe Campus Center - Lee Campus UPMC Lititz Conemaugh Miners Medical Center WellSpan Ephrata Community Montgomery Hospital Abington Lansdale Hospital Carbon Abington Memorial Hospital St. Luke’s Hospital - Gnaden Huetten Lebanon Bryn Mawr Hospital Campus WellSpan Good Samaritan Hospital Lankenau Hospital

Centre Lehigh Montour Mount Nittany Medical Center Lehigh Valley Health Network - Geisinger Medical Center Tilghman* Chester Lehigh Valley Hospital - 17th and Northampton Chester County Hospital Chew* Lehigh Valley Hospital - Lehigh Valley Hospital - Cedar Muhlenberg** Crest* St. Luke’s Hospital - Anderson St. Luke's Hospital - Allentown Clearfield Campus Campus Penn Highlands Clearfield Hospital St. Luke’s Hospital - Bethlehem St. Luke’s Hospital - Sacred Heart Penn Highlands DuBois St. Luke’s Hospital - Easton Campus Campus Clinton Northumberland Luzerne Bucktail Medical Center Geisinger Shamokin Area Geisinger South Wilkes-Barre Community Hospital Geisinger Wyoming Valley Medical Philadelphia Columbia Center Children’s Hospital of Philadelphia Berwick Hospital Center Wilkes-Barre General Hospital Fox Chase Cancer Center Hospital of the University of Pennsylvania

16 *a member of Geisinger **PPO only Jefferson Health Northeast - Out-of-state Steuben Frankford Campus participating hospitals Corning Hospital Jefferson Health Northeast - Ira Davenport Memorial Hospital Torresdale Campus District of Columbia Pennsylvania Hospital Sibley Memorial Hospital Sullivan Presbyterian Medical Center of the Garnet Health Medical Center - UPHS Catskills - Harris Bushville Rd Temple University Hospital - Jeanes Delaware Garnet Health Medical Center - Campus New Castle Catskills - State Route 97 Temple University Hospital Alfred I duPont Hospital for Thomas Jefferson University Children Hospital Thomas Jefferson University Hospital - Methodist Campus Wills Eye Hospital Baltimore Potter Mt. Pediatric Hospital UPMC Cole UM Rehabilitation & Orthopaedic Institute Schuylkill Geisinger St. Luke’s Hospital Baltimore City Lehigh Valley Hospital - Johns Hopkins Bayview Medical Schuylkill East Norwegian St. Center Lehigh Valley Hospital - Johns Hopkins Hospital Schuylkill South Jackson St. UMMC Midtown Campus St. Luke’s Miners Memorial Hospital University of Maryland Medical Somerset Center Chan Soon-Shiong Medical Center at Windber Howard Conemaugh Meyersdale Medical Howard County General Hospital Center UPMC Somerset Montgomery Suburban Hospital Susquehanna Barnes-Kasson Hospital Washington Endless Mountains Health Systems Meritus Medical Center

Tioga New Jersey UPMC Wellsboro Burlington Virtua Memorial Hospital of Union Burlington County Evangelical Community Hospital Virtua West Jersey Hospital Washington Marlton Canonsburg Hospital Virtua Willingboro Hospital

Wayne Camden Wayne Memorial Hospital Virtua Our Lady of Lourdes Hospital Virtua West Jersey Hospital Wyoming Voorhees Tyler Memorial Hospital Warren York St. Luke’s Warren Hospital OSS Orthopaedic Hospital LLC UPMC Hanover UPMC Memorial Chemung WellSpan York Hospital Arnot Ogden Medical Center St. Joseph’s Hospital

Cortland Guthrie Cortland Medical Center

Orange Bon Secours Community Hospital Garnet Health Medical Center St. Anthony Community Hospital

Rockland Good Samaritan Hospital

*Lehigh Valley Health Network does not accept our small group ACA HMO product. 17 Participating hospitals Premier network

Adams WellSpan Gettysburg Hospital Monroe Berks St. Luke’s Hospital - Monroe Campus St. Joseph Medical Center How to find your Montour provider online: Bradford Geisinger Medical Center Robert Packer Hospital 1. Go to Robert Packer Hospital Towanda Northampton GeisingerHealthPlan. Campus Troy Community Hospital St. Luke’s Hospital - Anderson com/ProviderSearch. Campus St. Luke’s Hospital - Bethlehem 2. Enter your location. Bucks St. Luke’s Hospital - Easton Campus St. Luke’s Hospital Upper Bucks 3. Select your plan. Campus Northumberland St. Luke's Quakertown Hospital 4. Select a category Geisinger Shamokin Area to search from our Community Hospital Carbon entire library of St. Luke’s Hospital - Gnaden Huetten Philadelphia applicable providers, or Campus Wills Eye Hospital narrow your search by Centre searching for doctors, Schuylkill Mount Nittany Medical Center specialties, locations or Geisinger St. Luke’s Hospital St. Luke’s Miners Memorial Hospital types of places. Columbia Geisinger Bloomsburg Hospital Somerset UPMC Somerset Cumberland New York Penn State Health Holy Spirit Union Cortland Medical Center Evangelical Community Hospital Guthrie Cortland Medical Center Dauphin Wayne Steuben Penn State Milton S Hershey Medical Corning Hospital Center Wayne Memorial Hospital

Lackawanna York Geisinger Community Medical WellSpan York Hospital Center Out-of-state participating hospitals Lancaster WellSpan Ephrata Community District of Columbia Hospital Sibley Memorial Hospital Lebanon Maryland WellSpan Good Samaritan Hospital Baltimore City Lehigh Johns Hopkins Bayview Medical St. Luke's Hospital - Allentown Center Campus Johns Hopkins Hospital St. Luke’s Hospital - Sacred Heart Campus Howard Howard County General Hospital Luzerne Geisinger South Wilkes-Barre Montgomery Geisinger Wyoming Valley Medical Suburban Hospital Center New Jersey Lycoming Warren Geisinger Jersey Shore Hospital St. Luke’s Warren Hospital

Mifflin Geisinger Lewistown Hospital 18 *a member of Geisinger 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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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. 4 /2021