Prime Care Advantage - Human Resources at Ohio State

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2022 - 12/31/2022. The Ohio State University: Prime care Advantage Coverage for: Employee Only, Employee + Children, Employee + Spouse, Family | Plan Type: EPO. 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, visit or call 614- 292-1050 or 1-800-678-6010.

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 glossary/ or call 614-292-1050 or 1-800-678-6010 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 before this plan begins to pay. If you have other family members on What is the overall $450/individual or $900/family the plan, each family member must meet their own individual deductible until deductible? the total amount of deductible expenses paid by all family members meets the overall family deductible.

3 Yes. Network preventive care and outpatient This plan covers some items and services even if you haven't yet met the Are there services behavioral health visits are covered before you meet deductible amount. But a copayment or coinsurance may apply. For covered before you meet your deductible. Premier network primary care and example, this plan covers certain preventive services without cost-sharing your deductible? specialist office visits are covered before you meet and before you meet your deductible. See a list of covered preventive your deductible. services at Are there other Yes. $1,000 for infertility treatment and $50/individual You must pay all of the costs for these services up to the specific deductible deductibles for specific or $100/family for prescription drugs.

4 Amount before this plan begins to pay for these services. services? The out-of-pocket limit is the most you could pay in a year for covered What is the out-of-pocket $2,600 individual / $5,200 family For prescription services. If you have other family members in this plan, they have to meet limit for this plan? drugs: $2,500 individual / $5,000 family their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Infertility services, weight management programs, non-essential specialty drugs, penalties for failure to What is not included in Even though you pay these expenses, they don't count toward the out-of- obtain preauthorization for services, premiums, the out-of-pocket limit?

5 Pocket limit. balance-billing charges and health care this plan doesn't cover. Page 1 of 7. Important Questions Answers Why This Matters: You pay the least if you use a provider in the Premier network. You pay more if you use a provider in the Standard network. You will pay the most if you use Yes. See or call 614- an out-of-network provider, and you might receive a bill from a provider for the Will you pay less if you use 292-4700 or 1-800- 678-6269 for a list of network difference between the provider's charge and what your plan pays (balance a network provider? providers. billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

6 Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Premier Network Standard Network Out-of-Network Limitations, Exceptions, & Other Common Services You May Provider Provider Provider Important Medical Event Need (You will pay the (You will pay (You will pay the Information least) more) most). Primary care visit to treat an injury or No charge 30% coinsurance Not covered illness None If you visit a 20% coinsurance health care Specialist visit Deductible does 30% coinsurance Not covered provider's not apply office or clinic You may have to pay for services that aren't Preventive preventive.

7 Ask your provider if the services care /screening/ No charge No charge Not covered needed are preventive. Then check what your plan immunization will pay for. Diagnostic test (x- 20% coinsurance 30% coinsurance Not covered If you have a ray, blood work). None test Imaging (CT/PET. 20% coinsurance 30% coinsurance Not covered scans, MRIs). If you need Preferred Pharmacy: $10. Covers up to a 30-day supply (retail), up to a 90- drugs to treat Generic drugs copay/prescription for retail; $25 Not covered day supply (home delivery or Retail90). your illness or copay/prescription for home delivery or * For more information about limitations and exceptions, see the plan or policy document at Page 2 of 7. What You Will Pay Premier Network Standard Network Out-of-Network Limitations, Exceptions, & Other Common Services You May Provider Provider Provider Important Medical Event Need (You will pay the (You will pay (You will pay the Information least) more) most).

8 Condition Retail90; no charge for value-based program; deductible does not apply. Non- Preferred Pharmacy: $20. copay/prescription for retail; value-based program not covered; deductible does not apply. More information Covers up to a 30-day supply (retail), up to a 90- about day supply (home delivery or Retail90). Certain prescription prescription drugs require preauthorization. Preferred Pharmacy: 30% coinsurance for drug coverage Preferred Pharmacy: $100 maximum (formulary retail, home delivery and Retail90; 15%. is available at Formulary brand brand name, retail), $50 maximum (formulary coinsurance for value- based program. drugs (Preferred Not covered brand name, value-based retail) Non-Preferred Non-Preferred Pharmacy: 35%.)

9 Its/prescription brand drugs) Pharmacy: $110 maximum (formulary brand coinsurance for retail; value-based name, retail) Home Delivery/Retail90: $250. program not covered. maximum (formulary brand name, home delivery/Retail90), $125 maximum (formulary brand name, value-based home delivery). Non-formulary brand Preferred Pharmacy: 50% coinsurance for Covers up to a 30-day supply (retail), up to a 90- drugs (Non- retail, home delivery and Retail90. Non- Not covered day supply (home delivery or Retail90). Certain preferred brand Preferred Pharmacy: 55% coinsurance prescription drugs require preauthorization. drugs Covers up to 30-day supply. Must use Ohio State 20% coinsurance for generic and University Outpatient Pharmacy, Nationwide formulary brand name; 50% coinsurance Children's Hospital Outpatient Pharmacy, or for non-formulary brand name; deductible Accredo Pharmacy.

10 $50 maximum (generic), $100. Specialty drugs does not apply to generics. If enrolled in Not covered maximum (formulary brand name). Certain the SaveonSP program, certain specialty prescription drugs require preauthorization. Copay drugs available at no charge. To enroll, for non-essential health benefit specialty drugs contact SaveonSP at 1-800-683-1074. under the SaveonSP program do not accumulate to the prescription drug out-of-pocket limit. * For more information about limitations and exceptions, see the plan or policy document at Page 3 of 7. What You Will Pay Premier Network Standard Network Out-of-Network Limitations, Exceptions, & Other Common Services You May Provider Provider Provider Important Medical Event Need (You will pay the (You will pay (You will pay the Information least) more) most).