Group Health : Compass Group-Gold Plus Coverage Period: 1/1/2017 to 1/1/2018 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Group | Plan Type: HMO

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.ghc.org or by calling 1-888-901-4636.

Important Questions Answers Why this Matters: You must pay all the costs up to the amount before this plan begins to $500 individual/$1,000 family pay for covered services you use. Check your policy or plan document to see when What is the overall Does not apply to preventive care, the deductible starts over (usually, but not always, January 1st). See the chart deductible? prescription drugs, ambulance, durable starting on page 2 for how much you pay for covered services after you meet the medical equipment. deductible. Are there other You don’t have to meet for specific services, but see the chart starting deductibles for specific No. on page 2 for other costs for services this plan covers. services? Is there an out–of– The out-of-pocket limit is the most you could pay during a coverage period pocket limit on my Yes, $4,000 individual/$8,000 family (usually one year) for your share of the cost of covered services. This limit helps expenses? you plan for expenses. What is not included in Premiums, balance-billed charges and Even though you pay these expenses, they don’t count toward the out-of-pocket the out–of–pocket health care this plan doesn’t cover. limit. limit? If you use an in-network doctor or other health care provider, this plan will pay Yes. See www.ghc.org or call 1-888- some or all of the costs of covered services. Be aware, your in-network doctor or Does this plan use a 901-4636 for a list of in-network hospital may use an out-of-network provider for some services. Plans use the term network of providers? providers. 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. Yes. See www.ghc.org or call 1-888- Do I need a referral to This plan will pay some or all of the costs to see a specialist for covered services 901-4636 for a list of specialist see a specialist? but only if you have the plan’s permission before you see the specialist. providers. Are there services this Some of the services this plan doesn’t cover are listed on page 5. See your policy or Yes. plan doesn’t cover? plan document for additional information about excluded services.

Questions: Call 1-888-901-4636 or visit us at www.ghc.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 8 at www.ghc.org or call 1-888-901-4636 to request a copy. RQ-105742-3

 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 network providers by charging you lower deductibles, copayments and coinsurance amounts.

Your Cost If Your Cost If Common You Use a You Use a Services You May Need Limitations & Exceptions Medical Event Network Non-network Provider Provider Primary care visit to treat an injury or Deductible does not apply for network provider $25 copayment Not covered illness office visits Deductible does not apply for network provider Specialist visit $50 copayment Not covered office visits Deductible does not apply for network provider office visits If you visit a $25 copayment for Manipulative therapy limited to 10 visits per health care manipulative calendar year, and naturopathy limited to 3 visits provider’s office Other practitioner office visit therapy, Not covered per medical diagnosis per calendar year, or clinic acupuncture and additional visits are covered with naturopathy Preauthorization or will not be covered. Acupuncture is limited to 12 visits per calendar year. Deductible does not apply for network provider Preventive No charge Not covered Services must be in accordance with the Group care/screening/immunization Health well-care schedule. Diagnostic test (x-ray, blood work) 20% coinsurance Not covered ______none______

If you have a test High end radiology imaging services such as CT, Imaging (CT/PET scans, MRIs) 20% coinsurance Not covered MRI and PET require preauthorization or will not be covered.

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Your Cost If Your Cost If Common You Use a You Use a Services You May Need Limitations & Exceptions Medical Event Network Non-network Provider Provider Deductible does not apply for network provider. Preferred generic drugs $10 copayment Not covered If you need drugs Covers up to a 30-day supply to treat your Deductible does not apply for network provider. Preferred brand drugs $30 copayment Not covered illness or Covers up to a 30-day supply condition Non-preferred generic/brand drugs Not covered Not covered ______none______More information Available when about prescription Member pays two dispensed drug coverage is times the through the Deductible does not apply for network provider. Mail-order drugs available at prescription drug Group Health Covers up to a 90-day supply www.ghc.org. cost share designated mail order service. Facility fee (e.g., ambulatory surgery ______none______20% coinsurance Not covered If you have center) outpatient surgery $50 copayment + ______none______Physician/surgeon fees Not covered 20% coinsurance $50 copayment Notify Group Health within 24 hours of $50 copayment + Emergency room services + 20% admission, or as soon thereafter as medically 20% coinsurance coinsurance possible. Copay is waived if admitted. If you need 20% benefit 20% benefit Deductible does not apply. immediate Emergency medical transportation specific specific medical attention coinsurance coinsurance $50 copayment Deductible does not apply for network provider Urgent care $25 copayment + 20% office visits coinsurance Non-emergency inpatient services require Facility fee (e.g., hospital room) 20% coinsurance Not covered If you have a preauthorization or will not be covered. hospital stay Non-emergency inpatient services require Physician/surgeon fee 20% coinsurance Not covered preauthorization or will not be covered.

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Your Cost If Your Cost If Common You Use a You Use a Services You May Need Limitations & Exceptions Medical Event Network Non-network Provider Provider Mental/Behavioral health outpatient Deductible does not apply for network provider $25 copayment Not covered services office visits If you have Mental/Behavioral health inpatient Non-emergency inpatient services require mental health, 20% coinsurance Not covered services preauthorization or will not be covered. behavioral health, Substance use disorder outpatient Deductible does not apply for network provider or substance $25 copayment Not covered services office visits abuse needs Substance use disorder inpatient Non-emergency inpatient services require 20% coinsurance Not covered services preauthorization or will not be covered. Deductible does not apply for network provider office visits Preventive services related to prenatal and Prenatal and postnatal care $25 copayment Not covered preconception care are covered as preventive care. If you are Routine prenatal and postnatal care is not subject pregnant to the co-pay. Notify Group Health within 24 hours of admission, or as soon thereafter as medically Delivery and all inpatient services 20% coinsurance Not covered possible. Newborn services cost shares are separate from that of the mother.

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Your Cost If Your Cost If Common You Use a You Use a Services You May Need Limitations & Exceptions Medical Event Network Non-network Provider Provider Deductible does not apply for network provider. Home health care No charge Not covered Requires preauthorization or will not be covered. Deductible does not apply for network provider/outpatient office visits $50 copayment / Limited to 45 visits per calendar year/outpatient. outpatient Limited to 30 days per calendar year/inpatient Rehabilitation services Not covered 20% coinsurance/ (combined limit with Habilitation services). inpatient Services with mental health diagnoses are covered with no limit. Requires preauthorization or will not be covered. Deductible does not apply for network If you need help provider/outpatient office visits recovering or have $50 copayment / Limited to 45 visits per calendar year/outpatient. other special outpatient Limited to 30 days per calendar year/inpatient health needs Habilitation services Not covered 20% coinsurance/ (combined limit with Rehabilitation services). inpatient Services with mental health diagnoses are covered with no limit. Requires preauthorization or will not be covered. Limited to 60 days per calendar year. Requires Skilled nursing care 20% coinsurance Not covered preauthorization or will not be covered. 20% benefit- Deductible does not apply for network provider. Durable medical equipment specific Not covered Requires preauthorization or will not be covered. coinsurance Deductible does not apply for network provider. Hospice service No charge Not covered Requires preauthorization or will not be covered. Deductible does not apply for network provider. Eye exam $25 copayment Not covered If your child Limited to one exam every 12 months needs dental or Glasses Not covered Not covered ______none______eye care Dental check-up Not covered Not covered ______none______

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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.)  Bariatric surgery  Hearing Aids  Non-emergency care when traveling outside  Cosmetic surgery  Infertility treatment the U.S.  Dental care (Adult)  Long-term care  Private-duty nursing  Glasses  Most coverage provided outside the United  Routine foot care States. See www.ghc.org  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.)  Acupuncture  Chiropractic care (if prescribed for  Routine eye care (Adult) rehabilitation purposes)

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 1-888-901-4636. You may also contact your state 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 questions about your rights, this notice, or assistance, you can contact: The Washington Office of Insurance Commissioner at : http://www.insurance.wa.gov/your-insurance/health-insurance/appeal/. The Insurance Consumer Hotline at 1-800-562-6900 or access to a page to email the same office: http://www.insurance.wa.gov/your-insurance/email-us/. Or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-888-901-4636. Does this Coverage Provide Minimum Essential Coverage? The requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

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Having a baby Managing type 2 diabetes

About these Coverage (normal delivery) (routine maintenance of

Examples: a well-controlled condition)

These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $5,400 medical care in given situations. Use these  Plan pays $5,020  Plan pays $4,020 examples to see, in general, how much financial  Patient pays $2,520  Patient pays $1,380 protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 Hospital charges (baby) $900 Office Visits and Procedures $700 This is Anesthesia $900 Education $300 not a cost Laboratory tests $500 Laboratory tests $100

estimator. Prescriptions $200 Vaccines, other preventive $100

Radiology $200 Total $5,400 Don’t use these examples to estimate your actual costs Vaccines, other preventive $40 under this plan. The actual Total $7,540 Patient pays: care you receive will be Deductibles $500 different from these Patient pays: Copays $700 examples, and the cost of Deductibles $1,000 Coinsurance $100 that care will also be Copays $20 Limits or exclusions $80 different. Coinsurance $1,300 Total $1,380 See the next page for Limits or exclusions $200 important information about Total $2,520 these examples.

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Questions and answers about the Coverage Examples:

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

Questions: Call 1-888-901-4636 or visit us at www.ghc.org. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8 at www.ghc.org or call 1-888-901-4636 to request a copy.