Important Questions Answers Why this Matters: Is there an overall annual limit on what the plan pays?

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy from the Open Enrollment Self Service site. Important Questions Answers Why this Matters: Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist. Yes. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. The Plan will pay the amount shown on the Schedule of Benefits whether a participating or nonparticipating provider is used. See the chart starting on page 2 for your benefit amounts. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed at the end of page 3. See your policy or plan document for additional information about excluded services. Questions: Visit the Open Enrollment Self Service Site. 1

2 Common Medical Event Services You May Need Your Benefit Amount Limitations & Exceptions If you visit a health care provider s office or clinic (includes outpatient office visits and inpatient visits) Primary care visit to treat an injury or illness Preventive care/screening Immunizations covered for children birth through age 5. Maximum of 9 visits per Plan Year; 1 visit may be used for a Wellness Visit 1 Doctor visit may be used towards Wellness 2 Outpatient Lab Test & X-Ray visits may be used towards Wellness If you have a test Diagnostic test (x-ray, laboratory tests) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have surgery If you need immediate medical attention If you have a hospital stay* 1 If you are critically ill Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Inpatient $1,000 Maximum of 8 visits per Plan Year; 2 visits may be used for Wellness Visits. s on prescription drugs are accessed through an independent pharmacy benefit management company. For 1 surgery performed while Hospital Confined per Plan Year. Outpatient $500 For 1 surgery per Plan Year. Emergency room Urgent care Daily Hospital Confinement Intensive Care Unit (payable in addition to the Daily Hospital Confinement Benefit) $400 per visit for Injury or Sickness $200 per visit $250 per day $500 per day Limited to two Emergency Room visits per insured person per Plan Year. Limited to four Urgent Care Center visits per insured person per Plan Year. Maximum of 100 days per Hospital Confinement per Plan Year. *The Plan will not pay more than a combined maximum of 100 days per Hospital Confinement for all of these benefits in total per Plan Year. Questions: Visit the Open Enrollment Self Service Site. 2

3 If you have mental health, behavioral health, or substance abuse needs* Mental/Behavioral health inpatient services (payable in lieu of the Daily Hospital Confinement Benefit) Substance use disorder inpatient services (payable in lieu of the Daily Hospital Confinement Benefit) If you give birth Routine Newborn Nursery Care Benefit $250 per day If you need help recovering or have other special health needs If you need eye care If you want to protect those who depend on your income in case of your death If you need time off work due to a disability that occurs during your employment If you are involved in a sudden, unforeseeable external event Physical Therapy Skilled nursing care facility* $100 per visit Maximum of 3 days for routine nursery care of a newborn child born to a Covered Associate. Maximum of 10 outpatient visits per Plan Year. Physical Therapy must be ordered by a Doctor. Maximum of 60 days per Hospital Confinement Skilled Nursing Care Facility confinement must begin within 3 days of a Hospital confinement of at least 3 days. Routine eye exam $25 Limited to one exam per plan year. Glasses or Contact Lenses $50 Limited to every two Plan Years. Life Insurance $5,000 Disability Benefit (for Covered Associates only) $40 per week Accidental Death & Dismemberment Insurance $15,000 Fully insured by The Standard Insurance Company (policy:649250). Maximum benefit period of 13 weeks, and 7 consecutive days benefit waiting period. Fully insured by ACE American Insurance Company (policy: ADD N ). Excluded Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Dental care Infertility treatment Weight loss programs Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Acupuncture (except an office visit) Routine foot care Bariatric surgery Hearing aids Chiropractic care (except an office visit) Questions: Visit the Open Enrollment Self Service Site. 3

4 Other Covered Services: Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Emergency services outside the United States. Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does NOT provide minimum essential coverage unless combined with Preventive Care coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Questions: Visit the Open Enrollment Self Service Site. 4

5 Questions: Visit the Open Enrollment Self Service Site. 5