BENEFIT PLAN What Your Plan Covers and How …

1 1 BENEFIT PLAN Prepared Exclusively for The McClatchy Company aetna Classic Care Plan What Your Plan Covers and How Benefits are Paid 2 Table of Contents Schedule of 1 Preface ..21 Coverage for You and Your Dependents ..21 Health Expense Coverage ..21 When Your Coverage Begins .. 22 Who Can Be Covered ..22 Employees Determining if You Are in an Eligible Class Obtaining Coverage for Dependents How and When to Enroll ..23 Initial Enrollment in the Plan Late Enrollment Annual Enrollment Special Enrollment Periods When Your Coverage Begins.

2 25 Your Effective Date of Coverage Your Dependent s Effective Date of Coverage How Your Medical Plan Works .. 27 Common Terms ..27 About Your aetna Classic Care Medical Plan ..27 Availability of Providers How Your aetna Classic Care Medical Plan Works ..28 Understanding Precertification Services and Supplies Which Require Precertification Emergency and Urgent Care ..34 Coverage for Emergency Medical Conditions In Case of an Urgent Condition Coverage for an Urgent Condition Requirements For Coverage .. 36 What The Plan Covers .. 37 aetna Classic Care Medical Plan.

3 37 Preventive Care ..37 Routine Physical Exams Preventive Care Immunizations Well Woman Preventive Visits Routine Cancer Screenings Screening and Counseling Services Prenatal Care Comprehensive Lactation Support and Counseling Services Family Planning Services - Female Contraceptives Family Planning - Other Hearing Exam Physician Services ..43 Physician Visits Surgery Anesthetics Alternatives to Physician Office Visits Hospital Expenses .. 44 Room and Board Other Hospital Services and Supplies Outpatient Hospital Expenses Coverage for Emergency Medical Conditions Coverage for Urgent Conditions Alternatives to Hospital Stays.

4 46 Outpatient Surgery and Physician Surgical Services Birthing Center Home Health Care Private Duty Nursing Skilled Nursing Facility Hospice Care Other Covered Health Care Expenses .. 51 Acupuncture Ambulance Service Ground Ambulance Air or Water Ambulance Diagnostic and Preoperative Testing .. 52 Diagnostic Complex Imaging Expenses Outpatient Diagnostic Lab Work and Radiological Services Outpatient Preoperative Testing Durable Medical and Surgical Equipment (DME) 53 Experimental or Investigational Treatment .. 54 Pregnancy Related Expenses .. 55 Prosthetic 55 Hearing Aids Benefits After Termination of Coverage Short-Term Rehabilitation Therapy Services.

5 56 Cardiac and Pulmonary Rehabilitation Benefits. Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and Speech Therapy and Neurodevelopmental Therapy Rehabilitation Benefits. Reconstructive or Cosmetic Surgery and Supplies 58 Reconstructive Breast Surgery Specialized Care .. 58 Chemotherapy Radiation Therapy Benefits Outpatient Infusion Therapy Benefits Treatment of 59 Basic Infertility Expenses Spinal Manipulation 60 Jaw Joint Disorder Treatment .. 60 Transplant Services .. 60 Network of Transplant Specialist Facilities 3 Obesity Treatment.

6 62 Treatment of Mental Disorders and Substance Abuse ..64 Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth) ..66 Medical Plan Exclusions ..66 When Coverage Ends ..74 When Coverage Ends For Employees Your Proof of Prior Medical Coverage When Coverage Ends for Dependents Continuation of Coverage ..75 Continuing Health Care Benefits Handicapped Dependent Children COBRA Continuation of Coverage ..76 Continuing Coverage through COBRA Who Qualifies for COBRA Disability May Increase Maximum Continuation to 29 Months Determining Your Contributions For Continuation Coverage When You Acquire a Dependent During a Continuation Period When Your COBRA Continuation Coverage Ends Coordination of Benefits - What Happens When There is More Than One Health Plan.

7 78 Other Plans Not Including Medicare .. 78 When You Have Medicare Coverage .. 80 Effect of Medicare .. 80 General Provisions .. 81 Type of Coverage .. 81 Physical Examinations .. 81 Legal Action .. 81 Additional Provisions .. 81 Assignments .. 81 Misstatements .. 81 Subrogation and Right of Recovery Provision .. 82 Workers 84 Recovery of Overpayments .. 84 Health Coverage Reporting of Claims .. 84 Payment of Benefits .. 85 Records of Expenses .. 85 Contacting aetna .. 85 Claims, Appeals and External Review .. 85 Glossary * .. 92 Pharmacy Coverage 115 *Defines the Terms Shown in Bold Type in the Text of This Document.

8 1 Schedule of Benefits Employer: The McClatchy Company ASA: 620229 Issue Date: January 1, 2017 Effective Date: January 1, 2017 Schedule: 19A Booklet Base: 19 The aetna Classic Care Plan uses the Choice POS II Network. This is an ERISA plan, and you have certain rights under this plan. Please contact your Employer for additional information. aetna Classic Care Medical Plan PLAN FEATURES NETWORK OUT-OF-NETWORK Calendar Year Deductible* Individual Deductible* $400 $1,000 Family Deductible* $1,200 $3,000 Per Admission Copayment $400 per admission Not Applicable Per Admission Deductible* Not Applicable $1,000 per admission The Per Admission Copayment/Deductible will not exceed $1,200 for Network or $3,000 for Out-Of-Network per member per Calendar Year.

9 The Per Admission Copayment/Deductible does not apply to a confinement of a well newborn child that starts on the day of birth. *Unless otherwise indicated, any applicable deductible must be met before benefits are paid. Plan Maximum Out of Pocket Limit includes plan deductible and copayments. Plan Maximum Out of Pocket Limit excludes precertification penalties. Individual Maximum Out of Pocket Limit: For network expenses: $5,500. For out-of-network expenses: $10,000. Family Maximum Out of Pocket Limit: For network expenses: $11,000. For out-of-network expenses: $20,000.

10 2 Lifetime Maximum BENEFIT per person Unlimited Unlimited Payment Percentage listed in the Schedule below reflects the Plan Payment Percentage. This is the amount the Plan pays. You are responsible to pay any deductibles and the remaining payment percentage. You are responsible for full payment of any non-covered expenses you incur. All Covered Expenses are subject to the Calendar Year Deductible unless otherwise noted in the schedule below. Maximums for specific covered expenses, including visit, day and dollar maximums are combined maximums between network and out-of-network, unless specifically stated otherwise.