CGHC Solutions Bronze $0 Deductible

1 PA = Prior AuthorizationIn Network Benefits Only7(You Pay)Calendar Year Deductible (Runs Jan 1 Dec 31)$0 single/$0 familyCoinsurance (applies only to certain services)50%$8,700 single/$17,400 familyOffice VisitsPrimary Care Provider Visit (to treat an illness or injury)1$15 CopayAurora Quick Care or Bellin/ThedaCare Fast Care$20 CopayObstetrics/Gynecology Visit$15 CopaySpecialist Visit $200 CopayChiropractic Visit $15 CopayHearing Exam$15 CopayDiagnostic ServicesDiagnostic Laboratory Tests$50 CopayDiagnostic X-rays $50 CopayImaging (MRI, MRA, PET and CT Services only) PA$1,000 CopayMental/Behavioral Health & Substance AbuseOutpatient - Office / Physician Visit$15 CopayOutpatient - Facility Fee$200 CopayOutpatient - All Other Services Deductible /CoinsuranceTransitional Deductible /CoinsuranceInpatient Including ResidentialPA$1,500 Copay Per DayEmergency ServicesEmergency Room2 (copay waived if admitted)$1,800 CopayPhysician ServicesDeductible/CoinsuranceUrgent Care$200 CopayAmbulance (ground and air) Deductible /CoinsuranceHospital ServicesOutpatient Surgical Facility/Ambulatory Surgical Care CentersPA$200 CopayOutpatient Surgical ServicesPA$200 CopayInpatient Hospital ServicesPA$1,500 Copay Per DayInpatient Physician and Surgical ServicesPADeductible/CoinsuranceInpatien t Rehabilitation (limited to 60 days/year)

2 PA$1,500 Copay Per DayMaternity ServicesPrenatal Care Deductible /CoinsuranceDelivery and Inpatient ServicesPA* Deductible /CoinsurancePrevent ive ServicesPreventive Services3 - ACA RequiredCovered in FullPreventive Services - Not ACA RequiredDeductible/CoinsuranceVision ServicesChildren's Vision Exam (1 exam per year)Covered in FullChildren s Eye Glasses or Contacts (1 pair per year) Deductible /CoinsuranceRoutine Vision Exam for Adults8 (1 exam/year)Not CoveredOther ServicesTransplants4 PADeductible/Coinsurance$200 Copay$200 CopayCardiac/Pulmonary Rehabilitation (up to 36 visits/year) Deductible /CoinsurancePost-Cochlear Implant Aural Therapy (up to 30 visits/year) Deductible /CoinsuranceCognitive Rehabilitation Therapy (up to 20 visits/year) $200 CopayHabilitative Services (Physical, Speech, Occupational Therapy - 20 visits per therapy type per year)Rehabilitative Services (Physical, Speech, Occupational Therapy - 20 visits per therapy type per year)Maximum Out-of-Pocket (includes Deductible , coinsurance, copays)CGHC Solutions Bronze $0 Deductible2022 Schedule of Solutions Bronze 0 Ded87416WI0030003 Autism Spectrum Disorders Deductible /CoinsuranceSkilled Nursing Facility (up to 30 days per stay)PA$1,500 Copay Per DayOutpatient Chemotherapy Deductible /CoinsuranceOutpatient Radiation Therapy Deductible /CoinsuranceHospice Services/End of Life ServicesDeductible/CoinsuranceHome Health Services (up to 60 visits/year) Deductible /CoinsuranceNon-Surgical Treatment for Temporomandibular Joint (TMJ)

3 PADeductible/CoinsuranceSpecified Oral Surgical Procedures5 PADeductible/CoinsuranceNot CoveredAccidental Dental Services Deductible /CoinsurancePreventive Dental Services for Adults9 Not CoveredPreventive Dental Services for Children9 Not CoveredAllergy TestingNot CoveredPrescription DrugsSeparate Rx Deductible $3,000 single/$6,000 familyPreventative Drugs (30-day supply)$0 (See formulary for details)Tier CM - Oral Chemotherapy Drugs Deductible Then Covered in FullTier 1 - Generic Drugs$25 CopayTier 2 - Preferred Brand Drugs$125 CopayTier 3 - Non-Preferred Brand DrugsDeductible/50% CoinsuranceTier 4 - Specialty DrugsPADeductible/50% CoinsuranceSupplies & EquipmentDurable Medical EquipmentPADeductible/CoinsuranceProsthe tic DevicesPADeductible/CoinsuranceDiabetic EquipmentPADeductible/CoinsuranceHearing Aids and Cochlear Implants (One aid per ear every 36 months)

4 Deductible /Coinsurance7 No payment will be made for out-of-network care except for emergency care, urgent care outside of our service area or when there is no in-network provider that can perform covered services and written approval is obtained as outlined in our certificate of Refraction and dilation are not included in the adult eye Preventive dental services include: 2 exams per year, 2 cleanings per year, x-rays (one full mouth, one bite wing), fluoride with cleanings (up to age 14, limit 2 per year), sealants (up to age 14 on permanent molars only)This Schedule of Benefits does not replace the legal contract or certificate which identifies all covered services, additional details, limitations and exclusions of the coverage. For a complete description of covered services, please see your Certificate of Coverage and any amendments to your Benefit Plan.

5 If you have questions regarding Common Ground Healthcare Cooperative Benefits, please call us at 1-877-514-CGHC (2442).PA indicates Prior Authorization is required for these services. Call 1-877-825-9293 for Prior Authorization. Failure to obtain Prior Authorization when required will result in the Member receiving a lesser Benefit. (*PA required when inpatient stay extends beyond the standard 48 hours (vaginal) to 96 hours (cesarean)). When working with a health insurance broker, the broker is compensated $20 per member per Care Provider may include general pediatrics, internal medicine, obstetrics/gynecology, family practice, general medicine and will only apply to facility charge. All other charges related to ER visit are subject to Deductible /coinsurance. 3 The Affordable Care Act (ACA) provides for coverage of certain preventive services based on age, gender and other health factors at no cost to the member.

6 Visit for a complete listing. 4 Examples of transplants for which benefits are available include bone marrow, heart, heart/lung, lung, kidney, kidney/pancreas, liver, liver/small bowel, pancreas, small bowel and cornea when medically necessary and not experimental. 5 Please refer to the Certificate of Coverage to determine what oral surgeries procedures are Only certain Prescription Drug products are available through mail order. Routine Dental Care (Pediatric dental coverage or a stand-alone dental services product can be purchased separately in Wisconsin) See formulary to determine tier and if medication is preventative. Diabetic test strips are are available in Retail setting (30-day supply) at coinsurance or 1 copayor using Mail Order6 (90-day supply) at coinsurance or 2 copays2022 Schedule of Solutions Bronze 0 Ded87416WI0030003