Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: 0411/01/ /31/2018

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1 Summary of Benefits and Coverage: What this Plan Covers & What You For Covered Services Insert Issuer name here : 2-Tier SBC Sample Template - Alliance Select PCP CopayWashington County HDHP PPO Plan 3 (HSA) Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? In-Network: $52,000 person/$1,54,000 family per calendar year. Out-of-Network: $1,000 person/$3,000 family per calendar year. Yes. Well-child care, in-network preventive care, in-network independent routine vision exams and transplant serviceslabs, in-network prosthetic limbs and services subject to copayments are covered before you meet your deductible. No.Yes. $00 person/$00 family per calendar year for drug card, which does not apply to Tier 1 Rx. There are no other specific deductibles. Health In-Network: $12,000 person/ $34,000 family per calendar year. Health Out-Of-Network: $23,000 person/$56,000 family per calendar year. Drug Card: $0,000 person/$0,000 family per calendar year. The In-Network Coverage Period: 0411/01/ /31/2018 Coverage for: Single & Family Plan Type: PPO HDHP Generally, you must pay all the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible must be met before the plan begins to pay. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. If no Rx deductible then use: You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. ;0411/01/2017;T-2017 AS PCPIY6;

2 Important Questions Answers Why this Matters: health and drug card out-ofpocket maximum amounts accumulate together. What is not included in the out-of-pocket limit? Premiums, pre-service review penalties, your drug card coststransplant services, balance-billed charges, and health care this plan doesn t cover. Even though you pay these expenses, they don t count toward the out-ofpocket limit. Green highlight is for GF, take out for NGF then remove this note. For more information about limitations and exceptions, see your plan document or call Wellmark at To find your Coverage Manual visit click on Large Group Plans and enter the following number, including dashes, into the search field

3 Important Questions Answers Why this Matters: Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. See or call for a list of health network providers. No. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an outof-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your You provider can see before the you specialist get services. you choose without a referral. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit In-Network (IN) Provider (You will pay the least) coinsurance$25 copay per date of service coinsurance$50 copay per date of service Out-of- Network (OON) Provider (You will pay the most) 2 coinsurance 2 coinsurance Limitations, Exceptions, & Other Important Information Doctor on Demand contracted telehealth services are covered. If covered by Medicare Part A, benefits will be coordinated with benefits available under Medicare Part A and Part B, even if not enrolled in Part B. ment will be calculated by reducing allowed charges by 8 for benefits attributable to Part B eligibility.primary Care Practitioners (PCP) are defined as General and Family Practice, Internal Medicine, OB/GYN, Pediatricians, Nurse Practitioners, and PAs None------Applies to Non-PCP providers. Preventive One preventive exam and one gynecological care/screening/ No charge 2 coinsurance exam per calendar year. One mammogram per immunization calendar year. Well- child care is covered to age 7. You may have to pay for services that For more information about limitations and exceptions, see your plan document or call Wellmark at

4 Common Medical Event If you have a test Services You May Need Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) In-Network (IN) Provider (You will pay the least) 1 coinsurance Out-of- Network (OON) Provider (You will pay the most) 2 coinsurance 1 coinsurance 2 coinsurance Limitations, Exceptions, & Other Important Information aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.one preventive exam and one gynecological exam per calendar year. One mammogram per calendar year. Well- child care is covered to age 7. You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for None------For a test in a provider's office or clinic, your cost is included in the cost-share listed above. Waive cost-share on in-network independent lab services for mental health/ substance abuse None------For a test in a provider's office or clinic, your cost is included in the cost-share listed above. If you need drugs to treat your Tier 1 coinsurance coinsurance Drugs listed on Wellmark's Blue Rx Complete Drug List are covered. Drugs not on this Drug illness or Tier 2 coinsurance coinsurance List are not covered. You pay the discounted condition cost of your drugs until your deductible is met. More information Tier 3 coinsurance coinsurance For out-of-network prescription drugs, you may be balance billed. about prescription Tier 4 coinsurance coinsurance 34-day supply for prescription drugs. drug coverage is 90-day supply prescription maximum available at (Mail order maintenance) day supply for prescription drugs ellmark.com. Specialty drugs coinsurance Not covered (Specialty drugs). Specialty drugs are covered only when obtained through the Specialty Pharmacy Program.Address drug card benefits here. For more information about limitations and exceptions, see your plan document or call Wellmark at

5 Common Medical Event If you have outpatient surgery If you need immediate medical attention Services You May Need In-Network (IN) Provider (You will pay the least) Out-of- Network (OON) Provider (You will pay the most) Facility fee (e.g., 1 coinsurance 2 coinsurance ambulatory surgery None center) Physician/surgeon fees 1 coinsurance 2 coinsurance None coinsurance$15 coinsurance$15 Emergency room care 0 copay per date of service for 0 copay per date of service for facility and physician(s) facility and physician(s) combined combined Emergency medical transportation Urgent care 1 coinsurance 2 coinsurance None coinsurance$25 copay per date of service 2 oinsurance None Limitations, Exceptions, & Other Important Information For emergency medical conditions treated outof-network, you may be balance billed. Dental treatment for accidental injury is limited to care completed within 12 months of the injury. For more information about limitations and exceptions, see your plan document or call Wellmark at

6 Common Medical Event If you have a hospital stay Services You May Need Facility fee (e.g., hospital room) In-Network (IN) Provider (You will pay the least) Out-of- Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information 1 coinsurance 2 coinsurance Reduction for failure to precertify out-of-network services is 5 and will not exceed $500 per admission. If you need mental health, behavioral health, or substance abuse services Physician/surgeon fees 1 coinsurance 2 coinsurance None Office: $25 PCP/$50 Non- Outpatient services PCP copay per date of service 2 coinsurance None Facility: 1 coinsurance Reduction for failure to precertify out-ofnetwork services is 5 and will not exceed Inpatient services 1 coinsurance 2 coinsurance $500 per admission. For more information about limitations and exceptions, see your plan document or call Wellmark at

7 Common Medical Event If you are pregnant Services You May Need Office visits Childbirth/delivery professional services Childbirth/delivery facility services In-Network (IN) Provider (You will pay the least) Out-of- Network (OON) Provider (You will pay the most) Limitations, Exceptions, & Other Important Information 1 coinsurance 2 coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Cost sharing does not apply to certain preventive services. For any in- network services that fall outside of routine obstetric care, the office visit benefits shown above may apply. 1 coinsurance 2 coinsurance 1 coinsurance 2 coinsurance None Benefits shown reflect OB/GYN practitioner services which are typically globally billed at time of delivery for pre-natal, post-natal and delivery services. For more information about limitations and exceptions, see your plan document or call Wellmark at

8 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need In-Network (IN) Provider (You will pay the least) Out-of- Network (OON) Provider (You will pay the most) Home health care 1 coinsurance 2 coinsurance Rehabilitation services Habilitation services Office: $25 PCP/$50 Non- PCP copay per date of service Facility: 1 coinsurance Office: $25 PCP/$50 Non- PCP copay per date of service Facility: 1 coinsurance 2 coinsurance 2 coinsurance Skilled nursing care 1 coinsurance 2 coinsurance Durable medical equipment 1 coinsurance 2 coinsurance None Hospice services 1 coinsurance 2 coinsurance Children s eye exam Not chargeovered 2 coinsurancenot covered Children s glasses Not covered Not covered None Children s dental checkup Not covered Not covered None Limitations, Exceptions, & Other Important Information Reduction for failure to precertify is 5 per covered service None------$25 copay per provider per date of service applies to in- network Physical and Occupational Therapists and Speech Language Pathologists None------$25 copay per provider per date of service applies to in- network Physical and Occupational Therapists and Speech Language Pathologists. Limit of 90 days per calendar year. Reduction for failure to precertify out-of-network services is 5 and will not exceed $500 per admission. Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime. One routine vision exam per calendar year None For more information about limitations and exceptions, see your plan document or call Wellmark at

9 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 Glasses Bariatric surgery Hearing aids Cosmetic surgery Long-term care Custodial care - in home or facility Routine foot care Dental care - Adult Weight loss programs Dental check-up Extended home skilled nursingacupuncture Glasses Cosmetic surgery Hearing aids Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care Infertility treatment (excludes some services) Most coverage provided outside the U.S. Private-duty nursing - short term intermittent home skilled nursing Routine eye care - Adult (one vision exam per calendar year)bariatric surgery 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: the U.S. Department of Labor, Employee Benefits Security Administration at EBSA (3272) or 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, you can contact: Washington County at (319) , Iowa Insurance Division at , or Employee Benefits Security Administration at EBSA (3272) or Does this plan provide Minimum Essential Coverage? 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. This plan or policy does provide minimum essential coverage. Does this plan meet the Minimum Value Standards? 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. This health coverage does meet the minimum 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. This contains only a partial description of the benefits, limitations, exclusions and other provisions of the health care plan. It is not a contract or policy. It is a general overview only. It does not provide all the details of coverage, including benefits, exclusions, and policy limitations. In the event there are discrepancies between this

10 document and the Coverage Manual, Certificate, or Policy, the terms and conditions of the Coverage Manual, Certificate, or Policy will govern.

11 About These Coverage Examples: Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan's overall deductible 0500 PCP copaymentinsurance $2, $2 5 Hospital(facility) coinsurance 1 Tier 1 Rx copaymentother coinsurance $ This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Managing Joe's type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) The plan's overall deductible,000 PCP & SSpecialist copaymentinsurance $25 & $5 Tiers 1 & 2 Rx copayments Hospital(facility) coinsurance $ & $00 Durable medical equip. coinsurance 1 $52 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Mia's Simple Fracture (in-network emergency room visit and follow up care) The plan's overall deductible $52,00 0 Specialist copaymentinsurance $5 Hospital(facility) coinsurance Emergency room copayment $150 Durable medical equip. coinsurance 1 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:

12 Cost Sharing Deductibles $52,0 Copayments Coinsurance $ What isn t covered 40 Limits or exclusions $60 The total Peg would pay is $12,0 Cost Sharing Deductibles $12,0 Copayments Coinsurance $0 What isn t covered Limits or exclusions $200 The total Joe would pay is $12,2 Cost Sharing Deductibles $51,9 Copayments Coinsurance $30 What isn t covered Limits or exclusions $0 The total Mia would pay is RX Admin Note: Excluded charges include all pharmacy drugs. Immunizations in office are covered under medical as preventive. All amounts rounded to nearest $10. Remove these notes prior to distributing to members.