Summary of Benefits and Coverage: What this Plan …

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018 - 12/31/2018. IHC Silver EPO HSA Local Value $50/$75 Coverage for: 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 by calling 1-888-YOUR-AH1 (TTY:711). 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 1-888-YOUR-AH1 (TTY:711) 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 What is the overall For participating providers $1,800.

2 To pay. If you have other family members on the policy, the overall family deductible must be met before the deductible? person / $3,600 family. plan begins to pay. This plan covers some items and services even if you haven't yet met the deductible amount. But a Are there services Yes. Preventive care are covered copayment or coinsurance may apply. For example, this plan covers certain preventive services without covered before you meet before you meet your deductible. cost sharing and before you meet your deductible. See a list of covered preventive services at https://. your deductible? 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 have other family What is the out-of-pocket For participating providers $5,000. members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit for this plan?

3 Person / $10,000 family. limit has been met. Premiums, out-of-network balance- billed charges, health care this plan What is not included in the doesn't cover, and penalties for Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? failure to obtain precertification for services. This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay Yes. See the most if you use an out-of-network provider, and you might receive a bill from a provider for the Will you pay less if you provider_finder or call 1-888-YOUR- difference between the provider's charge and what your plan pays (balance billing). Be aware your network use a network provider? AH1 (TTY:711) for a list of network provider might use an out-of-network provider for some services (such as lab work). Check with your providers. provider before you get services. Do you need a referral to No.

4 You can see the specialist you choose without a referral. see a specialist? 1 of 6. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Provider Out of Network Provider Limitations, Exceptions, & Other Important (You will pay the least) (You will pay the most) Information Telemedicine is a covered benefit only when Primary care visit to treat an $50/Visit (PCP). No charge provided through (MDLive ). Visit https://. Not covered. injury or illness (Telemedicine). to activate your If you visit a health account. care provider's office Specialist visit $75/Visit. Not covered. None or clinic Age and frequency schedules may apply. You may have to pay for services that aren't Preventive care/screening/ No charge. Deductible does Not covered. preventive. Ask your provider if the services immunization not apply.

5 Needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood X-Ray $50/Visit. Not covered. None If you have a test work) Blood Work No charge. Prior authorization is required. *See section Imaging (CT/PET scans, MRIs) $100/Scan. Not covered. "using services that require preapproval". Retail/Mail Order (1-30 days Prior authorization may be required on some Generic Drugs supply) $7/Fill. Mail Order Not covered. drugs. Covers up to a 90 day supply. If you need drugs to (31-90 days supply) $14/Fill. treat your illness or Retail/Mail Order (1-30 days condition supply) 50% coinsurance Prior authorization may be required on some More information about Preferred Drugs ($125 max/fill). Mail Order Not covered. drugs. Covers up to a 90 day supply. prescription drug (31-90 days supply) 50%. coverage is available at coinsurance ($250 max/fill). Retail/Mail Order (1-30 days formulary. supply) 50% coinsurance Prior authorization may be required on some Non Preferred Drugs ($125 max/fill).

6 Mail Order Not covered. drugs. Covers up to a 90 day supply. (31-90 days supply) 50%. coinsurance ($250 max/fill). *For more information about limitations and exceptions, see plan or policy document at 2 of 6. What You Will Pay Common Medical Event Services You May Need In-Network Provider Out of Network Provider Limitations, Exceptions, & Other Important (You will pay the least) (You will pay the most) Information This applies to oral or injectable self- administered Specialty Drugs which are covered under the Prescription Drug Plan. Covers up to a 90 day supply. Prior Retail/Mail Order (1-30 days authorization and/or dispensing limits may supply) 50% coinsurance apply. Other Specialty Drugs and infusion Specialty Drugs ($125 max/fill). Mail Order Not covered. therapy drugs may be covered under your (31-90 days supply) 50%. medical Benefits plan as stated within your coinsurance ($250 max/fill). Policy and/or Drug Rider information.

7 A. complete list of drugs requiring Prior authorization is available, *see section "Using services that require preapproval". If you have outpatient Facility fee ( , ambulatory 30% coinsurance. Not covered. Prior authorization is required for certain surgery surgery center) services. *See section using services that Physician/surgeon fees 30% coinsurance. Not covered. require preapproval.". Emergency room care $100/Visit. Covered at in-network level. Emergency medical None 50% coinsurance. Covered at in-network level. If you need immediate transportation medical attention Your costs for urgent care are based on care received at a designated urgent care center or Urgent care $75/Visit. Covered at in-network level. facility, not your physician's office. Costs may vary depending on where you receive care. If you have a hospital $500/Day. 5 Copayment(s)/. Facility fee ( , hospital room) Not covered. Prior authorization is required. *See section stay Admission.

8 "using services that require preapproval". Physician/surgeon fees No charge. Not covered. If you need mental Outpatient services $60/Visit. Not covered. None health, behavioral Prior authorization may be required. *See health, or substance $500/Day. 5 Copayment(s)/. Inpatient services Not covered. section "using services that require abuse services Admission. preapproval". *For more information about limitations and exceptions, see plan or policy document at 3 of 6. What You Will Pay Common Medical Event Services You May Need In-Network Provider Out of Network Provider Limitations, Exceptions, & Other Important (You will pay the least) (You will pay the most) Information No charge. Deductible does Cost sharing does not apply for preventive Office visits Not covered. not apply. services. Depending on the type of services a copayment and coinsurance may apply. If you are pregnant Childbirth/delivery professional Maternity care may include tests and services No charge.

9 Not covered. services described elsewhere in the SBC ( ultrasound.). $500/Day. 5 Copayment(s)/. Childbirth/delivery facility services Not covered. Prior notification requested. Admission. Prior authorization is required. *See section Home health care 50% coinsurance. Not covered. using services that require preapproval . Physical, Occupational Speech, and Cognitive Rehabilitation services $50/Visit. Not covered. therapies: 30 visits each/Calendar Year. Physical, Occupational Speech, and Cognitive If you need help Habilitation services $50/Visit. Not covered. therapies: 30 visits each/Calendar Year. Visit recovering or have limits do not apply for Treatment of Autism. other special health $500/Day. 5 Copayment(s)/ Prior authorization is required. *See section needs Skilled nursing care Not covered. Admission. using services that require preapproval . Prior authorization is required for selected Durable medical equipment 50% coinsurance.

10 Not covered. items. *See section "using services that require preapproval". Prior authorization is required. *See section Hospice services 50% coinsurance. Not covered. "using services that require preapproval". No charge. Deductible does If your child needs Children's eye exam Not covered. not apply. Pediatric Vision; Once every Calendar Year. dental or eye care Children's glasses No charge. Not covered. Children's dental check-up Not covered. Not covered. None 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 Cosmetic surgery Dental care (Adult). Long-term care Non-emergency care when Routine eye care (Adult). traveling outside the Routine foot care Weight loss programs *For more information about limitations and exceptions, see plan or policy document at 4 of 6. Other Covered Services (Limitations may apply to these services.)