$0 See the Common Medical Events chart below for your costs for services this plan covers.

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1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/ /31/2018 Wal-Mart Stores, Inc.: Sleep Apnea Program Coverage for: Part-time and full-time truck drivers Plan Type: Supplemental Benefit 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, see the Safety Manager at any distribution center or call 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 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? $0 See the Common Medical Events chart below for your costs for services this plan covers. This plan has no deductible. No. Not Applicable. Not Applicable. Yes. Only counselors affiliated with the Sleep Apnea Program for Truck Drivers will be available to you at no cost. Counselors are available anytime by calling Yes. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. You don t have to meet deductibles for specific services. This plan does not have an out-of-pocket limit on your expenses. This plan does not have an out-of-pocket limit on your expenses. 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). 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. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. 1 of 5

2 Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Services You May Need Network Provider (You will pay the least) What You Will Pay Primary care visit to treat an injury or illness No charge Specialist visit No charge Preventive care/screening/ immunization Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Limited to sleep apnea screening and tests; sleep apnea coaching; comprehensive sleep management; a SleepSafe counselor to monitor and assist with treatment on a periodic basis. 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. Diagnostic test (x-ray, blood No charge work) Limited to sleep apnea screening and tests, including Home Sleep Tests and in-lab studies Imaging (CT/PET scans, MRIs) No charge Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory If you have outpatient surgery center) surgery Physician/surgeon fees Emergency room care If you need immediate Emergency medical medical attention transportation Urgent care If you have a hospital Facility fee (e.g., hospital room) stay Physician/surgeon fees If you need mental health, behavioral Outpatient services health, or substance abuse services Inpatient services If you are pregnant Office visits 2 of 7

3 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Network Provider (You will pay the least) What You Will Pay Non-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information Childbirth/delivery professional services Childbirth/delivery facility services Home health care No charge Limited to sleep apnea treatments, coaching and sleep management. Rehabilitation services No charge Limited to sleep apnea treatments, coaching and sleep management. Habilitation services Limited to sleep apnea treatments, coaching and sleep management. Skilled nursing care Durable medical equipment No charge Limited to CPAP/APAP DME and related supplies. Hospice services Children s eye exam Children s glasses Children s dental check-up 3 of 7

4 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 Hearing Aids Primary care visit to treat an injury or illness Bariatric Surgery Home health care (except for sleep apnea (except for sleep apnea screening and tests; Chiropractic Care treatments, coaching and sleep management) sleep apnea coaching; comprehensive sleep Cosmetic Surgery Hospice services management; a SleepSafe counselor to monitor Childbirth/delivery professional services Imaging (except for sleep apnea screening and and assist with treatment on a periodic basis) Childbirth/delivery facility services tests) Private-Duty Nursing Dental Care (Adult or child) Infertility Treatment Rehabilitation services (except for sleep apnea Diagnostic tests (except for sleep apnea Long Term Care treatment) screening and tests) Mental/behavioral health or substance use Routine Eye Care (Adult or child) Durable medical equipment (except for disorder outpatient services Routine Foot Care CPAP/APAP equipment and related supplies) Mental/behavioral health or substance use Skilled nursing care Emergency medical transportation disorder inpatient services Specialty drugs Emergency room care Non-Emergency Care when Traveling Outside The Specialist visit (except for sleep apnea screening Eye exam (adult or child) U.S. and tests; sleep apnea coaching; comprehensive Facility fee (e.g., ambulatory surgery center) Non-preferred brand drugs sleep management; a SleepSafe counselor to Facility fee (e.g., hospital room) Physician/surgeon s fee monitor and assist with treatment on a periodic Generic drugs Preferred brand drugs basis) Glasses (adult or child) Pregnancy-related office visits Urgent care Habilitation services (except for sleep apnea Prescription drugs Weight Loss Programs treatment) Preventive care/screening/immunizations Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Walmart People Services, Attn: Internal Appeals, 508 SW 8th Street, Bentonville, AR You may also contact the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Additionally, a consumer assistance program can help you file your appeal. A list of states with Consumer Assistance Programs is available at: and 4 of 7

5 Does this plan provide Minimum Essential Coverage? No, not on its own. If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? No, not on its own. If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next section. 5 of 7

6 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) n The plan s overall deductible n Specialist copayment/coinsurance n Hospital (facility) copayment/coinsurance n Other copayment/ coinsurance This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: This condition is not covered so patient would pay 100 percent. Cost Sharing Deductibles Copayments Coinsurance What isn t covered Limits or exclusions The total Peg would pay is $12,800 n The plan s overall deductible n Specialist copayment/coinsurance n Hospital (facility) copayment/coinsurance n Other copayment/coinsurance This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: This condition is not covered so patient would pay 100 percent. Cost Sharing Deductibles* Copayments Coinsurance What isn t covered Limits or exclusions The total Joe would pay is $7,400 n The plan s overall deductible n Specialist copayment/coinsurance n Hospital (facility) copayment/coinsurance n Other copayment/coinsurance This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: This condition is not covered so patient would pay 100 percent. Cost Sharing Deductibles* Copayments Coinsurance What isn t covered Limits or exclusions The total Mia would pay is $1,900 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 7

7 Valued Plan Participant The Associates Health and Welfare Plan (AHWP) respects the dignity of each individual who participates in the Plan. The AHWP does not discriminate on the basis of race, color, national origin, sex, age, or disability and strictly prohibits retaliation against any person making a complaint of discrimination. Additionally, we gladly provide our participants with language assistance, auxiliary aids and services at no cost. We value you as our participant and your satisfaction is important to us. If you need such assistance or have concerns with your Plan services, please call the number on the back of your plan ID card. If you have any questions or concerns, please use one of the methods below so that we can better serve you. For assistance, call the number on the back of your plan ID card. To learn about or use our grievance process, contact the Associate Support Team at: To file a complaint of discrimination, contact the U.S. Department of Health and Human Services, Office of Civil Rights: Phone: or (TDD) Website: OCRCompliant@hhs.gov Interpreter Services are available at no cost Arabic Burmese Chinese Farsi French

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