Summary of Benefits and Coverage: Coverage Period: 01/01 ...

1 Page 1 of 8 Summary of Benefits and Coverage : What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01 /2022 12/31/2022 Ambetter from Sunshine Health: Coverage for: Individual/Family| Plan Type: EPO Ambetter Essential care : $0 Medical Deductible SBC-21663FL0130106-01 Underwritten by Celtic Insurance Company 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.

2 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 1-877-687-1169 (Relay Florida 1-800-955-8770). 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 1-877-687-1169 (Relay Florida 1-800-955-8770) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible?

3 $0 individual / $0 family. See the Common Medical Events chart below for your cost for services this plan covers. Are there services covered before you meet your deductible? Yes, except for Non-Preferred Brand (Tier 3) and Specialty drugs (Tier 4). This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services?

4 Yes, $3,800 individual / $7,600 family for prescription drug Coverage . There are no other specific deductibles. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. What is the out-of-pocket limit for this plan? For network providers: $8,700 individual / $17,400 family. Not applicable for out-of-network providers. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

5 What is not included in the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn t cover. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See or call 1-877-687-1169 (Relay Florida 1-800-955-8770) for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing).

6 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. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. Page 2 of 8 *For more information about limitations and exceptions, see plan or policy document at All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness $45 Copay / visit Not covered Unlimited Virtual care Visits received from Ambetter Telehealth covered at No Charge, providers covered in full.

7 Specialist visit $115 Copay / visit Not covered Covered No Limit. Preventive care /screening/ immunization No charge Not covered You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) $60 Copay / test for laboratory & professional services 50% Coinsurance for x-ray & diagnostic imaging 50% Coinsurance for laboratory & professional services and x-ray & diagnostic imaging at other places of service Not covered Prior authorization may be required.

8 Covered No Limit. Other places of service may include Hospital, Emergency Room, or Outpatient Facility. Failure to obtain prior authorization for any service that requires prior authorization will result in a denial of Benefits . See your policy for more details. Imaging (CT/PET scans, MRIs) 50% Coinsurance Not covered Prior authorization may be required. Covered No Limit. Page 3 of 8 *For more information about limitations and exceptions, see plan or policy document at Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug Coverage is available at Generic drugs (Tier 1) Preferred Generic Retail: $5 Copay / prescription Generic Retail.

9 $35 Copay / prescription Not covered Prior authorization may be required. Prescription drugs are provided up to 30 days retail and up to 90 days through mail order. Mail orders are subject to retail cost-sharing amount. Preferred brand drugs (Tier 2) Retail: $195 Copay / prescription Not covered Prior authorization may be required. Prescription drugs are provided up to 30 days retail and up to 90 days through mail order. Mail orders are subject to retail cost-sharing amount. Non-preferred brand drugs (Tier 3) Retail: $250 Copay / prescription; subject to Rx drug deductible Not covered Prior authorization may be required.

10 Prescription drugs are provided up to 30 days retail and up to 90 days through mail order. Mail orders are subject to retail cost-sharing amount. $3,800 individual / $7,600 family Rx drug deductible for non-preferred brand and specialty drugs. Specialty drugs (Tier 4) Retail: 50% Coinsurance; subject to Rx drug deductible Not covered Prior authorization may be required. Prescription drugs are provided up to 30 days retail and up to 30 days through mail order. $3,800 individual / $7,600 family Rx drug deductible for non-preferred brand and specialty drugs. If you have outpatient surgery Facility fee ( , ambulatory surgery center) 50% Coinsurance Not covered Prior authorization may be required.