INDIVIDUAL PAYMENT SUMMARY

1 IN-NETWORKOUT-OF-NETWORKSELECTHEALTH NETWORK DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM4,5IN-NETWORKOUT-OF-NETWORK$8,550 $17,100 $8,550 $85,500 $8,550/$17,100$17,100/$34,200$8,550/$17, 100$85,500/$171,000 INPATIENT SERVICES3IN-NETWORKOUT-OF-NETWORK Medical, Surgical, Hospice, Emergency AdmissionsCovered 100% after Deductible50% after Deductible Skilled Nursing FacilityCovered 100% after Deductible50% after DeductibleUp to 30 days/calendar Year Rehab/Habilitative Therapy: Physical, Speech, OccupationalCovered 100% after Deductible50% after Deductible PROFESSIONAL SERVICES3IN-NETWORKOUT-OF-NETWORK Office Visits and Office Surgeries Primary Care Provider (PCP)1 Secondary Care Provider (SCP)1$90 50% after Deductible Allergy Tests See office visitsSee office visits Allergy Treatment and SerumCovered 100%50% after Deductible Physician's Fees - Medical, Surgical, Maternity, AnesthesiaCovered 100% after Deductible50% after Deductible preventive CARE AS OUTLINED BY THE ACA2IN-NETWORKOUT-OF-NETWORK Office Visits (PCP/SCP)1 Covered 100%50% after Deductible Adult and Pediatric ImmunizationsCovered 100%50% after Deductible Diagnostic Tests.

2 Minor Covered 100%50% after Deductible Other preventive ServicesCovered 100%50% after Deductible VISION SERVICESIN-NETWORKOUT-OF-NETWORK Pediatric preventive Eye Exams - Through Age 18 Years, Only2 Covered 100%50% after Deductible Adult preventive Eye Exams - Age 19 and Over2 Not CoveredNot Covered All Other Eye Exams - Adult/Pediatric$90 50% after Deductible Contacts, Corrective Lenses, Frames - Through Age 18 Years, OnlyCovered 100% after Deductible50% after Deductible OUTPATIENT SERVICESIN-NETWORKOUT-OF-NETWORK Outpatient Facility and Ambulatory Surgical Covered 100% after Deductible50% after Deductible Ambulance (Air or Ground) - emergencies onlyCovered 100% after DeductibleSee In-Network Benefit Emergency Room In-Network FacilityCovered 100% after DeductibleSee In-Network Benefit Emergency Room Out-of-Network FacilityCovered 100% after DeductibleSee In-Network Benefit Urgent Care Facilities $90 50% after Deductible Intermountain Connect Care Chemotherapy, Radiation, DialysisCovered 100% after Deductible50% after Deductible Diagnostic Tests: MinorCovered 100% after Deductible50% after Deductible Diagnostic Tests: MajorCovered 100% after Deductible50% after Deductible Home Health3 Covered 100% after Deductible50% after Deductible Hospice3 Covered 100% after Deductible50% after Deductible Outpatient Private NurseNot CoveredNot Covered Outpatient Rehab Therapy: Physical, Speech, OccupationalCovered 100% after Deductible50% after DeductibleUp to 20 visits/calendar Year for all therapy types combined Outpatient Habilitative Therapy.

3 Physical, Speech, OccupationalCovered 100% after Deductible50% after DeductibleUp to 20 visits/calendar Year for all therapy types combined26002ID0010033-01 01-01-2021 See next page for additional benefits and 100%See Professional, Inpatient, Outpatient, or Miscellaneous Services$45 50% after DeductibleLimit one pair of eyeglass lenses or contact lenses and one pair of eyeglass frames per Year This amount is your Deductible + your Coinsurance and Copay (medical and Rx) Self Only Coverage, 1 person enrolled - per calendar YearDeductibleOut-of-Pocket Maximum Family Coverage, 2 or more enrolled - per calendar YearDeductible - per person/familyOut-of-Pocket Maximum - per person/familyINDIVIDUAL PAYMENT SUMMARY 1/1/2021 I70C0874 This is a Expanded Bronze plan as defined by the Affordable Care Act When using In-Network Providers, you are responsible to pay the amounts in this using Out-of-Network Providers, you are responsible to pay the amounts in this column.

4 MISCELLANEOUS SERVICESOUT-OF-NETWORK Maternity3 Includes all related maternity services. Enroll in SelectHealth Healthy Beginnings Program : 866-442-5052 Chiropractic CareCovered 100% after Deductible50% after DeductibleUp to 18 visits/calendar Year combined for In-Network/Out-of-Network Miscellaneous Medical Supplies (MMS)2 Covered 100% after Deductible50% after Deductible Autism Spectrum Disorder Durable Medical Equipment (DME)3 Covered 100% after Deductible50% after Deductible Prosthetic Devices3 Covered 100% after Deductible50% after Deductible Injectable Drugs and Specialty Medications3 Covered 100% after Deductible50% after Deductible Infertility (select services only)xxCovered 100% after Deductible50% after Deductible Mental Health and Chemical Dependency3 Covered 100% after Deductible50% after DeductibleCovered 100% after Deductible50% after DeductibleCovered 100% after Deductible50% after Deductible Cochlear Implants, Hearing Aids, or Auditory Osseointegrated Devices3 One device every 36 months per ear.

5 Up to 45 language/speech therapy visits during the 12 months after the delivery of the covered device. Donor Fees for Organ Transplants3 TMJ (Temporomandibular Joint) Services PRESCRIPTION DRUGS3 Prescription Drug List (formulary) Prescription Drug Deductible - Per Person Out-of-Pocket Maximum Prescription Drugs Up to 30-day supply for covered medications Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Maintenance Drugs 90-day supply Tier 1 - Mail-Order, Retail90 Tier 2 - Mail-Order, Retail90 Tier 3 - Mail-Order Tier 4 - Mail-Order Generic Substitution Required FOOTNOTES26002ID0010033-01 01-01-2021 Benefits are administered and underwritten by SelectHealth, (domiciled in Utah) Covered Services obtained outside the United States, except for routine, Urgent, or Emergency conditions require more information, refer to your Certificate of Coverage or Contract or call Member Services at 800-538-5038 weekdays, from 7:00 to 8:00 , and Saturdays, from 9:00 to 2.

6 00 TTY users should call Visit to find out whether a Provider is a Primary Care or Secondary Care Frequency and/or quantity limitations apply to some preventive and MMS Preauthorization is required for certain services. Benefits may be reduced or denied if you do not preauthorize certain services with Out-of-Network Providers. Please refer to Section 11--" Healthcare Management", in your Certificate of Coverage, for All Deductible/Copay/Coinsurance amounts are based on the allowed amounts and not on the Providers billed charges. Out-of-Network Providers or Facilities have not agreed to accept the allowed amount for Covered Services. When this occurs, you are responsible to pay for any charges that exceed the amount that SelectHealth pays for Covered Services, sometimes referred to as balance billing. These fees are called Excess Charges, and they do not apply to your Out-of-Pocket Certain Services as noted on this document and in your Certificate of Coverage are not subject to the 100% after DeductibleCovered 100% after DeductibleGeneric required or must pay Copay plus costdifference between name brand and generic$20 $30 $20 $30 Covered 100% after DeductibleCovered 100% after DeductibleCovered 100% after DeductibleRxCore Combined with medicalCombined with medicalNot CoveredNot CoveredSee Professional, Inpatient, or Outpatient ServicesSee Professional, Inpatient, or Outpatient ServicesSee Professional, Inpatient, or Outpatient ServicesSee Professional, Inpatient, or Outpatient Services Inpatient Outpatient Residential Treatment Center Office Visits$45 50% after DeductibleSee Professional, Inpatient, or Outpatient ServicesSee Professional, Inpatient, or Outpatient ServicesSee Professional, Inpatient, Outpatient.

7 Or Mental Health and Chemical Dependency ServicesSee Professional, Inpatient, Outpatient, or Mental Health and Chemical Dependency ServicesIN-NETWORK