Memorial Hermann Health Plan: Elect Bronze 5000 …

1 Memorial Hermann Health Plan: Elect Bronze 5000 HSA Coverage Period: 01/01/2016 12/31/2016. Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: HMO. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling 1-888-594-0671. Important Questions Answers Why this Matters: You must pay all the costs up to the deductible amount before this plan Participating Provider- $5,000 Individual / begins to pay for covered services you use.

2 Check your policy or plan What is the overall $10,000 Family; Does not apply to document to see when the deductible starts over (usually, but not always, deductible? penalties or preventive. Non Participating January 1st). See the chart starting on page 2 for how much you pay for Provider-None covered services after you meet the deductible. Are there other You must pay all of the costs for these services up to the specific deductible deductibles for specific No. amount before this plan begins to pay for these services. services?

3 Yes. Participating Provider-$6,250 The out-of-pocket limit is the most you could pay during a coverage period Is there an out of pocket Individual / $12,500 Family; Non (usually one year) for your share of the cost of covered services. This limit limit on my expenses? Participating Provider-None helps you plan for Health care expenses. Premiums, balance-billed charges, What is not included in Even though you pay these expenses, they don't count toward the out-of- utilization review penalties and Health care the out of pocket limit?

4 Pocket limit. this plan doesn't cover. Is there an overall annual The chart starting on page 2 describes any limits on what the plan will pay limit on what the plan No. for specific covered services, such as office visits. pays? If you use an in-network doctor or other Health care provider, this plan will Yes. See pay some or all of the costs of covered services. Be aware, your in-network Does this plan use a doctor or hospital may use an out-of-network provider for some services. network of providers? or call 1-888-594-0671 for a list of Plans use the term in-network, preferred, or participating for providers in participating providers.

5 Their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see No. You don't need a referral to see a You can see the specialist you choose without permission from this plan. a specialist? specialist. Some of the services this plan doesn't cover are listed on page 6. See your Are there services this plan policy or plan document for additional information about excluded Yes. doesn't cover? services. Questions: Call 1-888-594-0671 or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary.

6 You can view the Glossary 1 of 9. at or call 1- 888-594-0671 to request a copy. Memorial Hermann Health Plan: Elect Bronze 5000 HSA Coverage Period: 01/01/2016 12/31/2016. Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: HMO. Copayments are fixed dollar amounts (for example, $15) you pay for covered Health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service.

7 For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

8 This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Your Cost If You Use a Common Services You May Your Cost If You Use a Non Limitations & Exceptions Medical Event Need Participating Provider Participating Provider Primary care visit to treat 20% coinsurance, after Not covered none . an injury or illness deductible 20% coinsurance, after Not covered Specialist visit none . deductible If you visit a Health Physical/Occupational Therapy & Chiropractic care provider's Other practitioner office 20% coinsurance, after Not covered limited to 35 visits combined per year office or clinic visit deductible Preventive care/.

9 No charge Not covered Participating Provider deductible waived screening/immunizations Lab 20% coinsurance, after Diagnostic test (x-ray, Prior Authorization required for Genetic Testing deductible X-ray 20%. blood work) Not covered 50% Reduction in Benefits Penalty; No charge, coinsurance, after deductible after deductible with office visit. If you have a test Imaging (CT/PET scans 20% coinsurance, after Prior Authorization required MRIs) Not covered deductible 50% Reduction in Benefits Penalty Questions: Call 1-888-594-0671 or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary.

10 You can view the Glossary 2 of 9. at or call 1- 888-594-0671 to request a copy. Memorial Hermann Health Plan: Elect Bronze 5000 HSA Coverage Period: 01/01/2016 12/31/2016. Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Family | Plan Type: HMO. Your Cost If You Use a Common Services You May Your Cost If You Use a Non Limitations & Exceptions Medical Event Need Participating Provider Participating Provider 20% coinsurance/prescription Not covered Generic drugs (30 day Retail) & (90 day Retail & Mail Order).