Summary of Benefits and Coverage: What this Plan Covers ...

1 HRS8682 Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2022-12/31/2022 Wells Fargo & Company: Copay Plan with HRA Coverage for: All coverage levels | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

2 This is only a Summary . For more information about your coverage, or to get a copy of the complete terms of coverage, employees visit Benefits on Teamworks or access ; or call 1-877-479-3557. COBRA participants visit or call 1-877-292-6272. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at or request a copy by calling 1-877-479-3557 (employees) or 1-877-292-6272 (COBRA).

3 Important QuestionsAnswersWhy This Matters:What is the overall deductible?CoverageIn-network(or Out of Area * coverage)Out-of-networkYou$1,000$4,000 You + spouse/partner$1,600$6,400 You + children$1,350$5,400 You + spouse/partner+ children $1,900$ 7, 6 0 0If you have HRA dollars available, they can help cover the cost of the deductible.* Out of Area coverage only available if you do not live in network areaGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay.

4 If you have other family members on the policy, the overall family deductible must be met before the plan begins to there services coveredbefore you meet your deductible? Yes. Eligible preventive care, in-network (or Out of Area coverage): PCP and outpatient mental health office visit charge, specialist office visit charge, urgent care visit charge, telemedicine/virtual visit charge at certain in-network providers, and retail convenience care visit charge; and prescription drug costs are not subject to the deductible and don t count toward the plan Covers some items and services even if you haven t yet met the deductible amount.

5 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 there other deductiblesfor specific services? don t have to meet deductibles for specific is the out-of-pocket limit for this plan?CoverageIn-network(or Out of Area * coverage)Out-of-networkYou$3,500$10,000 You + spouse/partner$5,600$16,800 You + children$4,550$14,400 You + spouse/partner+ children $6,650$19,200*Out of Area coverage only available if you do not live in network out-of-pocket limit is the most you could pay in a year for covered services.

6 If you have other family members in this plan, the overall family out-of-pocket limit is the most you could pay in a year for covered 2 of 8 What is not included in the out-of-pocket limit?Penalties for failure to obtain pre-service authorization, premiums, balance-billing charges, and health care this plan doesn t though you pay these expenses, they don t count toward the out-of-pocket you pay less if you use a network provider?Generally, yes. Contact your claims administrator for a list of network providers.

7 For Aetna visit, or call 1-877-320-4577 For Anthem BCBS, visit or call 1-866-418-7749 For UnitedHealthcare, visit or call 1-800-842-9722 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 out-of-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 that your network provider might use an out-of-network provider for some services (such as lab work).

8 Check with your provider before you get you need a referral to see a specialist? can see the specialist you choose without a copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important Information*In-network Provider or Out of Area coverage (You will pay the least)Out-of-network Provider (You will pay the most)If you visit a health care provider s office or clinicPrimary care visit to treat an injury or illness $25 office visit copay 20% coinsurance all other charges (even if related to office visit)50% coinsuranceDeductible doesn t apply to copay for office visit charge only.

9 Copay doesn t count toward deductible. Deductible and coinsurance apply to all other in-network charges and all out-of-network visit $45 office visit copay 20% coinsurance all other charges (even if related to office visit)50% coinsurance Deductible doesn t apply to copay for office visit charge only. Copay doesn t count toward deductible. Deductible and coinsurance apply to all other in-network charges and all out-of-network charges. Infertility/fertility: pre-service authorization required, $25,000 lifetime max for medical services and $10,000 lifetime max for related prescriptions Chiropractic: 26-visit limit annually * Acupuncture: 26-visit limit annually * Therapies(all physical, occupational, and speech combined): 90-visit limit annually* * $25 office visit copay applies* For more information about limitations and exceptions, see the Summary plan description at.

10 Or for COBRA at * For more information about limitations and exceptions, see the Summary plan description at ; or for COBRA at Page 3 of 8 Common Medical EventServices You May NeedWhat You Will PayLimitations, Exceptions, & Other Important Information*In-network Provider or Out of Area coverage (You will pay the least)Out-of-network Provider (You will pay the most)Preventive care/screening/immunizationNo charge50% coinsuranceDeductible doesn t apply. Category also includes women s preventive health care services.