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.

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1 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 by contacting Human Resources. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? $350 person / $1,050 family in network $1,000 person / $3,000 family non-network Yes. $100 for prescription drug coverage.. There are no other specific deductibles. Yes. For participating providers $25,000 per person up to $250,000 then person pays 90% of remaining amount. Premiums, balance-billed charges, health care this plan doesn t cover, out-of-network charges, deductible and copay requirements, and penalties for failure to obtain preauthorization for services No. Yes. See You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. 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. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The out-of-pocket limit applies from $25,000 to $250,000 of eligible expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital 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. 1 of 8

2 Important Questions Answers Why this Matters: Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. You don t need a referral to see a specialist. Yes. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. 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 participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Non- Limitations & Exceptions Primary care visit to treat an injury or illness $25 copay/visit 70% coinsurance none Specialist visit $25 copay/visit 70% coinsurance none $10 copay for 70% coinsurance chiropractor and Other practitioner office visit for chiropractor none 20% coinsurance and acupuncture for all other Preventive care/screening 20% coinsurance 70% coinsurance If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 70% coinsurancelab; 85% coinsurance x-ray Covers mammograms, pap smears and infant immunization up to 12 months. X-ray done at Reno Diagnostic Center 20% coinsurance; all other 85% coinsurance 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Human Resources. If you have outpatient surgery If you need immediate medical attention Services You May Need Imaging (CT/PET scans, MRIs) 20% coinsurance Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs $10 copay/ prescription retail; $20 copay/ prescription mail order $25 copay/ prescription retail; $50 copay/ prescription mail order $50 copay coinsurance retail; $100 copay mail order Same as preferred brand Non- 70% coinsurancelab; 85% coinsurance x-ray Limitations & Exceptions X-ray done at Reno Diagnostic Center 20% coinsurance; all other 85% coinsurance Covers up to a 30-day supply (retail prescription); day supply (mail order prescription) Covers up to a 30-day supply (retail prescription); day supply (mail order prescription) none Covers up to a 30-day supply (retail prescription); day supply (mail order prescription) $300 copay then Facility fee (e.g., ambulatory surgery center) none 20% coinsurance Physician/surgeon fees 20% coinsurance 70% coinsurance none $300 copay then Emergency room services 70% coinsurance none 20% coinsurance 50% coinsurance if not admitted to a Emergency medical transportation 20% coinsurance 70% coinsurance hospital. Urgent care $25 copay. 70% coinsurance none 3 of 8

4 Common Medical Event If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Non- Limitations & Exceptions Facility fee (e.g., hospital room) $300 copay then 20% coinsurance. 70% coinsurance none Physician/surgeon fee 20% coinsurance 70% coinsurance none Mental/Behavioral health outpatient services none Mental/Behavioral health inpatient services none Substance use disorder outpatient services none Substance use disorder inpatient services none Prenatal and postnatal care 20% coinsurance 70% coinsurance none Delivery and all inpatient services 20% coinsurance 70% coinsurance none Home health care 20% coinsurance 70% coinsurance none Rehabilitation services 20% coinsurance 70% coinsurance none Habilitation services 20% coinsurance 70% coinsurance none Skilled nursing care 20% coinsurance 70% coinsurance none Durable medical equipment 20% coinsurance 70% coinsurance none Hospice service 20% coinsurance 70% coinsurance none Eye exam none Glasses none Dental check-up none 4 of 8

5 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 Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment Long-term care Routine foot care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult) 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 5 of 8

6 Your Rights to Continue Coverage: ** Individual health insurance sample 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 [contact number]. You may also contact your state insurance department at [insert applicable State Department of Insurance contact information]. OR ** Group health coverage sample 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 [contact number]. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or 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: [insert applicable contact information from instructions]. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8