Department of Defense Non-Appropriated Funds …

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2018-12/31/2018. Department OF Defense Non-Appropriated Funds . HEALTH BENEFITS PROGRAM: Traditional Choice Coverage for: Employee + Family | Plan Type: Indemnity The 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. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, or by calling 1- 800-370-4526.

2 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 call 1-800-370-4526 to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount What is the overall Individual $500 / Family of 2 $1,000 / Family of before this plan begins to pay. If you have other family members on the plan, each deductible? 3 or more $1,500. 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.

3 This plan covers some items and services even if you haven't yet met the deductible Are there services covered amount. But a copayment or coinsurance may apply. For example, this plan covers Yes. Preventive care & prescription drugs are before you meet your certain preventive services without cost sharing and before you meet your deductible. covered before you meet your deductible. deductible? See a list of covered preventive services at Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? The out of pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket Individual $4,000 / Family of 2 $8,000 / Family have other family members in this plan, they have to meet their own out of pocket limit for this plan?

4 Of 3 or more $12,000. limits until the overall family out of pocket limit has been met. Premiums, balance-billing charges, health care What is not included in the this plan doesn't cover & penalties for failure to Even though you pay these expenses, they don't count toward the out of pocket limit. out-of-pocket limit? obtain pre-authorization for services. Will you pay less if you use a This plan does not use a provider network. You can receive covered services from any Not applicable. network provider? provider. Do you need a referral to see No. You can see the specialist you choose without a referral. a specialist? 178506-276464-354001 1 of 6. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

5 Common Medical Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information Event Primary care visit to treat an injury or illness 20% coinsurance None If you visit a health Specialist visit 20% coinsurance None care provider's You may have to pay for services that aren't preventive. Ask office or clinic Preventive care /screening /immunization No charge your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) 20% coinsurance None If you have a test Imaging (CT/PET scans, MRIs) 20% coinsurance None Copay/prescription, deductible doesn't Generic drugs apply: $10 (retail &.)

6 Mail order) Covers 30 day supply (retail), 31-90 day supply (mail order). Includes contraceptive drugs & devices obtainable from a If you need drugs Copay/prescription, pharmacy, oral & injectable fertility drugs. No charge for to treat your deductible doesn't Preferred brand drugs preferred generic FDA-approved women's contraceptives in- illness or apply: $35 (retail &. network. Your cost will be higher for choosing Brand over condition mail order). Generics. Covers a 180 day supply of certain smoking 35% coinsurance Cessation drugs. Includes weight loss drugs at applicable More information with minimum & copay. No charge for generic drugs & 20% coinsurance for about prescription maximum/prescripti brand drugs purchased overseas.

7 Maintenance drugs - after drug coverage is on, deductible two retail fills, members are required to fill a 90-day supply at available at Non-preferred brand drugs doesn't apply: $60 Aetna RX Home Delivery or CVS Pharmacy. minimum & $125. maximum (retail &. mail order). Premier Plus 40% coinsurance Formulary with $60 minimum First prescription fill at a retail pharmacy or specialty & $125 maximum/. Specialty drugs pharmacy. Subsequent fills must be through the Aetna prescription, Specialty Performance Pharmacy Network. deductible doesn't apply If you have Facility fee ( , ambulatory surgery center) 20% coinsurance None outpatient surgery Physician/surgeon fees 20% coinsurance None If you need Emergency room care 20% coinsurance 50% coinsurance for non-emergency use.

8 178506-276464-354001 2 of 6. Common Medical Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information Event immediate medical Emergency medical transportation 20% coinsurance None attention Urgent care 20% coinsurance No coverage for non-urgent use. If you have a Facility fee ( , hospital room) 20% coinsurance Penalty of $500 for failure to obtain pre-authorization hospital stay Physician/surgeon fees 20% coinsurance None If you need mental Office & other health, behavioral Outpatient services outpatient services: None health, or 20% coinsurance substance abuse services Inpatient services 20% coinsurance Penalty of $500 for failure to obtain pre-authorization Office visits No charge Cost sharing does not apply for preventive services.

9 Maternity care may include tests and services described If you are pregnant Childbirth/delivery professional services 20% coinsurance elsewhere in the SBC ( ultrasound.) Penalty of $500 for Childbirth/delivery facility services 20% coinsurance failure to obtain pre-authorization may apply. 90 visits/calendar year. Penalty of $500 for failure to obtain Home health care 20% coinsurance pre-authorization 60 visits/calendar year for Physical, Occupational & Speech Rehabilitation services 20% coinsurance If you need help Therapy combined. recovering or have Habilitation services Not covered Not covered. other special 90 days/calendar year. Penalty of $500 for failure to obtain health needs Skilled nursing care 20% coinsurance pre-authorization Limited to 1 durable medical equipment for same/similar Durable medical equipment 20% coinsurance purpose.

10 Excludes repairs for misuse/abuse. Hospice services No charge Penalty of $500 for failure to obtain pre-authorization Children's eye exam No charge 1 routine eye exam/calendar year. If your child needs Children's glasses No charge Not covered. dental or eye care Children's dental check-up Not covered Not covered. 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 Habilitation services Non-emergency care when traveling outside the Cosmetic surgery Long-term care Routine foot care Dental care (Adult & Child) Weight loss programs - Except for required preventive serivces.