Summary Plan Description Avnet, Inc. HSA 70, HSA 80, Classic 70, and Out-of-Area Medical Plan Effective: January 1, 2017 Group Number: 905940 IMPORTANT INFORMATION This is not an insured benefit plan. The benefits described in this booklet are self-insured by Avnet, Inc. which is responsible for their payment. UnitedHealthcare and OptumRx provide claim administration services to the plan, but UnitedHealthcare and OptumRx do not insure the benefits described. This booklet serves as both the Plan document and Summary Plan Description for the Avnet, Inc. HSA 70, HSA 80, Classic 70, and Out-of-Area Medical Plan (the “Plan”) , which is offered as a group medical option under the Avnet Group Benefits Plan. Nothing contained in this document shall be construed as a contract of employment between Avnet (the “Company”) or any of its subsidiaries, and any Employee or other individual, nor as any limitation of the Company’s right (and the right of any employing subsidiary or other entity) to discipline, discharge, or take action with respect to any Employee or other service provider, with or without cause, at any time, or otherwise limit the employment-at-will relationship between the Company (or employing subsidiary or other entity) and an Employee or other service provider. Avnet, Inc. intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. AVNET, INC. HSA 70, HSA 80, CLASSIC 70, AND OUT-OF-AREA MEDICAL PLAN TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3 Cost of Coverage ......................................................................................................................... 4 How to Enroll .............................................................................................................................. 4 When Coverage Begins ............................................................................................................... 4 Changing Your Coverage ............................................................................................................ 5 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7 Accessing Benefits ....................................................................................................................... 7 Eligible Expenses ....................................................................................................................... 10 Annual Deductible ..................................................................................................................... 11 Coinsurance ................................................................................................................................ 11 Copayment .................................................................................................................................. 12 Out-of-Pocket Maximum ......................................................................................................... 12 SECTION 4 - PERSONAL HEALTH SUPPORT and PRIOR AUTHORIZATION .......................... 14 Care Management ...................................................................................................................... 14 Prior Authorization.................................................................................................................... 15 Covered Health Services which Require Prior Authorization ............................................. 15 Special Note Regarding Medicare ............................................................................................ 17 SECTION 5 - PLAN BENEFITS ...................................................................................................... 18 Covered Health Services ........................................................................................................... 18 Plan Benefits – Details .............................................................................................................. 19 Acupuncture Services ................................................................................................................ 19 Ambulance Services ................................................................................................................... 20 Clinical Trials .............................................................................................................................. 21 Congenital Heart Disease (CHD) Surgeries ........................................................................... 23 Dental Services - Accident Only .............................................................................................. 24 Diabetes Services ....................................................................................................................... 25 Durable Medical Equipment (DME) ...................................................................................... 26 Emergency Health Services - Outpatient ............................................................................... 27 Gender Dysphoria (Gender Identity Disorder) .................................................................... 27 I TABLE OF CONTENTS AVNET, INC. HSA 70, HSA 80, CLASSIC 70, AND OUT-OF-AREA MEDICAL PLAN Hearing Aids ............................................................................................................................... 28 Home Health Care ..................................................................................................................... 29 Hospice Care .............................................................................................................................. 29 Hospital - Inpatient Stay ........................................................................................................... 30 Infertility Services ...................................................................................................................... 30 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 31 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 32 Men’s Family Planning Services ............................................................................................... 32 Mental Health Services .............................................................................................................. 32 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 33 Nutritional Counseling .............................................................................................................. 35 Obesity Surgery .......................................................................................................................... 36 Ostomy Supplies ........................................................................................................................ 36 Pharmaceutical Products - Outpatient .................................................................................... 36 Physician Fees for Surgical and Medical Services ................................................................. 37 Physician's Office Services - Sickness and Injury .................................................................. 37 Pregnancy - Maternity Services ................................................................................................ 38 Preventive Care Services ........................................................................................................... 38 Private Duty Nursing - Outpatient.......................................................................................... 39 Prosthetic Devices ..................................................................................................................... 39 Reconstructive Procedures ....................................................................................................... 40 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 41 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 43 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 43 Substance-Related and Addictive Disorders Services........................................................... 45 Surgery - Outpatient .................................................................................................................. 46 Temporomandibular Joint (TMJ) Services ............................................................................. 46 Therapeutic Treatments - Outpatient ..................................................................................... 47 Transplantation Services ........................................................................................................... 47 Travel