Coventry Health and Life Insurance Company: Silver $10 Co-pay PPO Coverage Period : 01/01/2014 - 12/31/2014 Exchange Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: PPO

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.chckansas.com or by calling 855-449-2889. Important Questions Answers Why This Matters: What is the overall In-network: Individual (Ind): $3,750. You must pay all the costs up to the deductible amount before this plan begins to deductible? Family: $7,500. Doesn't apply to: pay for covered services you use. Check your policy or plan document to see when preventive care, PCP office visits, the deductible starts over (usually, but not always, January 1st). See the chart starting convenience care, urgent care, on page 2 for how much you pay for covered services after you meet the deductible. pre/postnatal visits, pediatric vision. Out-of-network: Ind: $6,400. Family: $12,800. Are there other deductibles Yes. $1,000 deductible on prescription You must pay all of the costs for these services up to the specific deductible amount for specific services? drugs. before this plan begins to pay for these services. Is there an out-of-pocket In-network: Yes. Ind: $6,350. Family: The out-of-pocket limit is the most you could pay during a coverage period (usually limit on my expenses? $12,700. one year) for your share of the cost of covered services. This limit helps you plan for Out-of-network: Yes. Ind: $16,500. health care expenses. Family: $33,000. What is not included in the Premiums, balance-billing and health care Even though you pay these expenses, they don't count toward the out-of-pocket out-of-pocket limit? this plan does not cover. limit. Is there an overall annual No The chart starting on page 2 describes any limits on what the plan will pay for specific limit on what the plan pays? covered services, such as office visits. Does this plan use a Yes If you use an in-network doctor or other health care provider, this plan will pay some network of providers? For a list of In-network providers, visit or all of the costs of covered services. Be aware, your in-network doctor or hospital www.chckansas.com or call 855-449-2889. may use an out-of-network provider for some services. Plans use the term in- network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see a No You can see the specialist you choose without permission from this plan. specialist? Are there services this plan Yes Some of the services this plan doesn’t cover are listed on page 5. See your policy or doesn't cover? plan document for additional information about excluded services.

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 1 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. • Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance 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 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 use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider Primary care visit to treat an $10 Co-payment (Co- 50% Co-insurance (Co- None injury or illness pay) ins) Specialist visit First Visit: $75 Co-pay 50% Co-ins 2+ visits will be Co-pay plus deductible If you visit a health care Other practitioner office visit 30% Co-ins spinal 50% Co-ins spinal None provider's office or clinic manipulation manipulation (chiropractic care) (chiropractic care) Preventive care/ $0 Co-pay 50% Co-ins None Screening/Immunization Diagnostic test (x-ray, blood 30% Co-ins x-ray 50% Co-ins x-ray None work) 30% Co-ins lab 50% Co-ins lab If you have a test Imaging (CT/PET scans, $250 Co-pay 50% Co-ins May require prior authorization (prior auth). MRIs) Failure to prior auth may result in non-covered services. Generic drugs Preferred Pharmacy: $15 Non Preferred Includes $5 Co-pay for select generic drugs. Co-pay / 31 day supply Pharmacy: $20 Co-pay / Prior Auth is required for some drugs. Failure If you need drugs to treat 31 day supply to prior auth may result in non-covered your illness or condition. services. Mail order is available for 2x the retail More information about Copay / 90 day supply. prescription drug coverage is available at Preferred brand drugs Preferred Pharmacy: Non Preferred Prior Auth is required for some drugs. Failure www.chckansas.com. Deductible + $45 Co-pay Pharmacy: Deductible + to prior auth may result in non-covered / 31 day supply $55 Co-pay / 31 day services. Mail order is available for 2.5x the supply retail Copay / 90 day supply.

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 2 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. Your cost if you use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider Non-preferred brand drugs Preferred Pharmacy: Non Preferred Prior Auth is required for some drugs. Failure Deductible + $75 Co-pay Pharmacy: Deductible + to prior auth may result in non-covered If you need drugs to treat / 31 day supply $85 Co-pay / 31 day services. Mail order is available for 3x the retail your illness or condition. supply Copay / 90 day supply. More information about prescription drug coverage Specialty drugs Preferred Drugs: Not Applicable Prior Auth is required for some drugs. Failure is available at Deductible + 30% Co- to prior-auth may result in non-covered www.chckansas.com. ins; Non-Preferred services. Drugs: Deductible + 40% / 31 day supply Facility fee (e.g., ambulatory $250 Co-pay plus 30% $250 Co-pay plus 50% May require prior auth. Failure to prior auth If you have outpatient surgery center) Co-ins Co-ins may result in non-covered services. surgery Physician/surgeon fees 30% Co-ins 50% Co-ins May require prior auth. Failure to prior auth may result in non-covered services. Emergency room services First Visit: $500 Co-pay First Visit: $500 Co-pay 2+ Visits: $500 Co-pay plus deductible. Must meet emergency criteria. If you need immediate Emergency medical 30% Co-ins 30% Co-ins Must meet emergency criteria. medical attention transportation Urgent care $75 Co-pay 50% Co-ins None Facility fee (e.g., hospital $500 Co-pay / admission $1,000 Co-pay / Prior auth required. Failure to prior auth may room) plus 30% Co-ins admission plus 50% Co- result in non-covered services. If you have a hospital stay ins Physician/surgeon fee 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may result in non-covered services. Mental/Behavioral health First Visit: $75 Co-pay 50% Co-ins 2+ visits will be Co-pay plus deductible outpatient services If you have mental health, Mental/Behavioral health $500 Co-pay / admission $1,000 Co-pay / Prior auth required. Failure to prior auth may behavioral health, or inpatient services plus 30% Co-ins admission plus 50% Co- result in non-covered services. Call MHNet at substance abuse needs ins 1-866-607-5970. Substance use disorder First Visit: $75 Co-pay 50% Co-ins 2+ visits will be Co-pay plus deductible outpatient services

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 3 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. Your cost if you use a Common Medical Event Services You May Need In-network Out-of-network Limitations & Exceptions Provider Provider If you have mental health, Substance use disorder $500 Co-pay / admission $1,000 Co-pay / Prior auth required. Failure to prior auth may behavioral health, or inpatient services plus 30% Co-ins admission plus 50% Co- result in non-covered services. Call MHNet at substance abuse needs ins 1-866-607-5970. Prenatal and postnatal care $250 Co-pay 50% Co-ins One time copayment for physician charges, prenatal, postnatal, ultrasound and delivery If you are pregnant Delivery and all inpatient $500 Co-pay / admission $1,000 Co-pay / Stays beyond 48/96 hours for vaginal services plus 30% Co-ins admission plus 50% Co- delivery/cesarean section require prior auth. ins Failure to prior auth may result in non-covered services. Home health care 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may result in non-covered services. Rehabilitation services Inpatient $500 Co-pay / Inpatient $1,000 Co-pay Prior auth required. Failure to prior auth may admission plus 30% Co- / admission plus 50% result in non-covered services. Limited to 20 ins Co-ins visits per therapy per calendar year. Outpatient 30% Co-ins Outpatient 50% Co-ins Habilitation services 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may If you need help result in non-covered services. Limited to 20 recovering or have other visits per therapy per calendar year. special health needs Skilled nursing care 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may result in non-covered services. Limited to 60 days per Calendar Year. Durable medical equipment 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may result in non-covered services. Hospice Service 30% Co-ins 50% Co-ins Prior auth required. Failure to prior auth may result in non-covered services. Inpatient limited to 15 days per Calendar Year. Eye exam $0 Co-pay 40% Co-ins One exam per calendar year. Glasses $0 Co-pay 40% Co-ins Lenses or Contact Lenses – Once each If your child needs dental Calendar Year; Frame – Once each Calendar or eye care year Dental check-up Not Covered Not Covered Excluded Service

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 4 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. 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 • Bariatric Surgery • Child/Dental Check-up • Cosmetic Surgery • Dental Care (Adult) • Hearing Aids • Infertility Treatment • Long-Term Care • 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 • Non-Emergency Care when Traveling Outside • Private-Duty Nursing the U.S. • Routine Eye Care (Adult)

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

• You commit fraud • The insurer stops offering services in the State • You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at 855-449-2889. You may also contact your state insurance department at Missouri Department of Insurance; P.O. Box 690 Jefferson City, MO 76102-0690 (Toll Free) 800-726-7390 E-mail: [email protected]. 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: Missouri Department of Insurance; P.O. Box 690 Jefferson City, MO 76102-0690 (Toll Free) 800-726-7390 E-mail: [email protected] Missouri Department of Insurance 301 W. High Street, Room 830 Harry S. Truman State Office Building Jefferson City, MO 65101 (Toll Free) 800-726-7390 or online at www.insurance.mo.gov or [email protected] 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. SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 5 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. 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% (actuarial value). This health coverage does meet the minimum value standard for the benefits is provides. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, llame al 855-449-2889. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 855-449-2889. Chinese ĩᷕ㔯ĪĻơġ⤪㝄暨天ᷕ㔯䘬ⷖ≑炻実㊐ㇻ征᷒⎟䞩ġ855-449-2889. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 855-449-2889.

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

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 6 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. About these Coverage Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of Examples: a well-controlled condition) These examples show how this plan Amount owed to providers: $7,540 Amount owed to providers: $5,400 might cover medical care in given situations. Use these examples to see, in Plan pays: $3,840 Plan pays: $2,440 You pay: general, how much insurance $3,700 You pay: $2,960 protection you might get from different Sample care costs: plans. Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine Obstetric Care $2,100 Medical equipment and supplies $1,300 This is not a cost Hospital Charges (baby) $900 estimator. Office Visits and Procedures $700 Anesthesia $900 Education $300 Don’t use these examples to estimate your actual costs under Laboratory tests $500 Laboratory tests $100 Vaccine, other preventive $100 this plan. The actual care you Prescriptions $200 receive will be different from these Total $5,400 examples, and the cost of that care Radiology $200 You pay: will also be different. Vaccines, other preventive $40 Deductibles $1,100 See the next page for important Total $7,540 Co-pays $1,800 information about these examples. You pay: Coinsurance $0 Deductibles $2,700 Limits or exclusions $60 Co-pays $800 Total $2,960 Coinsurance $0 Note: These numbers assume the patient is participating in Limits or exclusions $200 our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may Total $3,700 be higher. For more information about the diabetes wellness program, please contact: 855-449-2889

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 7 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy. 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 Example helps you see how deductibles, Yes. When you look at the Summary Costs don’t include premiums. copayments, and coinsurance can add up. It of Benefits and Coverage for other plans, also helps you see what expenses might be left Sample care costs are based on national you’ll find the same Coverage Examples. up to you to pay because the service or treatment averages supplied by the U.S. Department When you compare plans, check the isn’t covered or payment is limited. of Health and Human Services, and aren’t “Patient Pays” box in each example. The specific to a particular geographic area or smaller that number, the more coverage health plan. Does the Coverage Example predict the plan provides. my own care needs? The patient’s condition was not an excluded or preexisting condition. No. Treatments shown are just examples. The care you would receive for this condition Are there other costs I should All services and treatments started and could be different based on your doctor’s advice, consider when comparing ended in the same coverage period. your age, how serious your condition is, and many other factors. plans? There are no other medical expenses for Yes. An important cost is the any member covered under this plan. premium you pay. Generally, the lower Does the Coverage Example predict your premium , the more you’ll pay in Out-of-pocket expenses are based only on my future expenses? out-of-pocket costs, such as treating the condition in the example. copayments, deductibles, and No. Coverage Examples are not cost coinsurance . You should also consider estimators. You can’t use the examples to contributions to accounts such as health The patient received all care from in- estimate costs for an actual condition. They are savings accounts (HSAs), flexible network providers. If the patient had for comparative purposes only. Your own costs spending arrangements (FSAs) or health received care from out-of-network will be different depending on the care you reimbursement accounts (HRAs) that providers, costs would have been higher. receive, the prices your providers charge, and help you pay out-of-pocket expenses. the reimbursement your health plan allows.

SNO: 1234422 SBC Name: 020_72414 CVTY PPO SBC 9/12 Page 8 of 8 Questions: Call 855-449-2889 or visit us at www.chckansas.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.cms.gov/CCIIO/resources/files/downloads/uniform-glossary-final.pdf or call 855-449-2889 to request a copy.