& BAS Health Bronze Plan page 1/5 Coverage Period: 2015 Coverage for Employee & Family

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1 & BAS Health Bronze Plan page 1/5 Coverage Period: 2015 Coverage for Employee & Family This is only a summary Important Questions Answers Why this is important What is the overall Deductible In-Network Individual $3,000 Family $6,000 No Out-of-Network benefits for this You must pay all the costs up to the deductible amount before this health insurance begins to pay for covered services you use. Check your policy to see when the Deductible starts over. See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific benefits No You must pay for all of the costs for these services up to the specific deductible amount before this begins to pay for these services. What is the co-insurance on this 50% your share of the costs of a covered services, generally a percentage of the allowable amount Is there an out-of-pocket limit on my expenses, Yes In-Network Individual $6,350 Family $12,700 What is not included in the out-ofpocket limit? Is there an overall annual limit on the Does this use a network of providers Premium payments, balance bill charges, and health care expenses for services not covered in this. It does not cover penalties for failure to obtain pre-authorization for services if required. No, this has no overall annual limit on the amount it will pay each year Yes, this uses network providers, if you use a non-network provider, you will not have coverage. The out-of-pocket limit is the most you could pay during a policy period for your share of the cost of covered services. This limit helps you for health care expenses. Even though you pay these expenses, they don t count toward the outof-pocket limit. So, a longer list of expenses means you have less coverage. The chart starting on page 2 describes any limits on what will be paid thru BAS Health for specific covered services, such as office visits. If you use an in-network doctor or other healthcare provider, this will pay some or all of the costs of covered services. Plans use the term in-network, or preferred, or participating to refer to providers in their network. Do I need a referral to see a specialist No If the is non-gated, you can see the specialist without permission from the. For a gated, a referral is required. Are there services this does not cover Yes Some of the services not covered by this are listed on page 5 See your policy or document for additional information about excluded services.

2 & BAS Health Bronze Plan page 2/5 Summary of Benefits and Coverage: What this covers & What it Costs Co-payments are fixed dollar amounts (ie $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered services, calculated as a percent of the allowed amount for the service. For example if the s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you have not yet met the deductible amount. The amount the 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 difference. This is called Balance Billing The may encourage you to use participating providersby charging you lower deductibles, copayments, and coinsurance amounts. CCommon If you visit a health care s office Or clinic If you have a test Primary care visit to treat an injury or illness Specialist Visit Other practitioner office visit Preventive Care/Screening/ Immunization Diagnostic test (x-ray, bloodwork) Imaging (CT/PET scans, MRI) If you receive services in addition to office visits, additional co-pays, deductibles or co-insurance may apply. If you receive services in addition to office visits, additional co-pays, deductibles or co-insurance may apply. Pre-Certification required for specialized office procedures such as sugery No Charge Includes preventive health services specified in the healthcare reform law Pre-Authorization required for sleep studies Pre-Authorization required

3 CCommon If you need drugs $100 deductible To treat your Illness or condition For Out-Patient Surgery & BAS Health Bronze Plan page 3/5 Tier 1- Your lowest cost option Tier 2- Your midrange option deductible applies Tier 3- Your highest cost option deductible applies 50% up to $125 means pharmacy for purposes of this section; deductible applies toward the Maximum Out of Pocket 50% up to $125 Retail: up to a 31 day supply, Mail Order 90 day supply 50% up to $125 You may need to obtain certain drugs from a pharmacy designated by the. Certain drugs may require pre-authorization or result in a higher charge Tier 4- You may be required to use a lower-cost drug prior to benefits under your being available for certain prescribed drugs. Facility Fee (eg ambulatory surgical center) Out-Patient physician/surgeon fees No Non-Network Benefits No Charge None If you need Emergency Room Services $250 waived if admit $250 waived if Immediate Emergency Room Transportation Medical attention Urgent Care $75 co-pay If you have a Facility Fee (e.g. hospital room) admit For the ER, the in-network and out-of network benefit is the same For ER Transportation, the in-network and out-of network benefit is the same If you receive services in addition to urgent care, additional co-pays, deductibles, or coins may apply Pre-Authorization required Hospital stay Physician/surgeon fee No Charge No Non-Network Benefits

4 CCommon If you have mental Health or Substance abuse Needs & BAS Health Bronze Plan page 4/5 Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services limit 30 visits per year, Out-of-Network charges are not covered by this 30 visits per year, Out-of-Network charges are not covered by this If you are Pre-Natal & Post Natal Care No Charge Routine pre-natal services are covered at No Pregnant Delivery & all inpatient services If you need Home Health Care after deductible, 40 visits/cal yr Charge Help recovering Rehabilitation Services after deductible, limit 60 visits/calendar year Or have other Habilitative Services Share with Rehab See Rehabilitative, this a combined benefit Special health Skilled Nursing after ded, Depending on the type of therapy there is a limit of 30 visits per calendar year, combined with Habilitative. Limit 30 calendar days/year, out-of-network charges are not covered by this needs Durable Medical Equipment 50% co-ins after ded Pre-Auth required for items over $500 Hospice Service Limited to 210 days (combined in-patient & home hospice) per calendar year. In-Patient Authorization required

5 & BAS Health Extended Services & Other Covered Services page 5/5 Services Your Plan Does Not Cover (This isn t a complete list) Check your policy or summary document for other excluded services Acupuncture Long-Term Care Routine Eye Care (Child/Adult) Cosmetic Surgery Non-Emergency Travel when traveling Routine Foot Care outside the USA Dental Check-Up (Child/Adult) Private Duty Nursing Weight Loss Programs Glasses (Child/Adult) Hearing Aids Bariatric Surgery Infertility Treatment This or policy does provide minimum essential coverage This does meet the minimum value standard for the benefits it provides ( greater than a 60% actuarial value)