EZ Empower HSA Embedded 6350-100 - Achieve

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesHealthPartners:EZ Empower HSA Embedded 6350-100 - AchieveCoverage Period: 01/01/2018 - 12/31/2018Coverage for: Single/Family Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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, call 1-800-883-2177 or visit us atwww.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-883-2177 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible?In-network: 6,350Individual/ 12,700 FamilyOut-of-network: 19,050Individual/ 38,100 FamilyGenerally, you must pay all of the costs from providers up to the deductible amount before thisplan begins to pay. If you have other family members on the plan, each family member must meettheir own individual deductible until the total amount of deductible expenses paid by all familymembers meets the overall family deductible.Are there servicescovered before you meetyour deductible?Yes. Coinsurance marked with * inCommon Medical Events andbenefits with no charge are notsubject to deductibleThis plan covers some items and services even if you haven’t yet met the deductible amount. Buta copayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at e-benefits/.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services.What is the out-of-pocketlimit for this plan?In-network medical/pharmacy: 6,350 Individual/ 12,700 Family The out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, they have to meet their own out-of-pocket limits until the overallOut-of-network medical/pharmacy: family out-of-pocket limit has been met. 38,100 Individual/ 76,200 FamilyWhat is not included inthe out-of-pocket limit?Premium, balance-billed charges(unless balanced billing isprohibited), and health care thisplan doesn't cover.Will you pay less if youuse a network provider?Yes. Seewww.healthpartners.com/achieveor call 1-800-883-2177 for a list ofin-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 aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). 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 tosee a specialist?No.You can see the specialist you choose without a referral.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.1 of 5P-EZ-MNHSA6350E-100A-18-E

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventServices You May NeedPrimary care visit to treat aninjury or illnessIf you visit a healthcare provider’s officeor clinicSpecialist visitPreventive care/screening/immunizationIf you have a testIf you need drugs totreat your illness orconditionDiagnostic test (x-ray, bloodwork)Imaging (CT/PET scans, MRIs)Generic drugsWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Primary Office Visit: 0%coinsurancePrimary Office Visit: 50%Convenience Care: 0% coinsurancecoinsuranceConvenience Care: 50%coinsurancevirtuwell: 0%coinsurance0% coinsurance50% coinsurance0% coinsurance50% coinsuranceNone0% coinsuranceFormulary: 0%coinsuranceNon-formulary: Notcovered50% coinsuranceFormulary: 50%coinsurance at retail, mailnot coveredNon-formulary: Not covered50% coinsurance at retail,mail not coveredNot covered50% coinsurance at retail,mail not coveredNone0% coinsurance50% coinsuranceNone0% coinsurance50% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsurance50% coinsurance50% coinsurance50% coinsuranceNoneOut-of-network services apply to the innetwork deductible.Out-of-network services apply to the innetwork deductible.NoneNoneNone0% coinsuranceNon-formulary brand drugsNot pecialty drugs0% coinsuranceIf you have outpatientsurgeryFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesIf you have a hospitalstayEmergency medicaltransportationUrgent careFacility fee (e.g., hospital room)Physician/surgeon feesNoneYou may have to pay for services that aren’tpreventive. Ask your provider if the servicesyou need are preventive. Then check whatyour plan will pay for.50% coinsuranceFormulary brand drugsIf you need immediatemedical attentionNoneNo chargeMore information aboutprescription drugcoverage is available atEmergency room careLimitations, Exceptions, & Other ImportantInformation31 day supply retail/ 93 day supply mail orderNone2 of 5

CommonMedical EventIf you need mentalhealth, behavioralhealth, or substanceuse disorder servicesWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Limitations, Exceptions, & Other ImportantInformationOutpatient services0% coinsurance50% coinsuranceNoneInpatient services0% coinsurance50% coinsuranceNoneNo charge50% coinsuranceDepending on the type of services, acopayment, coinsurance, or deductible mayapply.0% coinsurance50% coinsuranceNone0% coinsurance50% coinsuranceNone0% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsurance0% coinsuranceNo chargeNot coveredNot covered50% coinsurance50% coinsurance50% coinsurance50% coinsurance50% coinsurance50% coinsurance50% coinsuranceNot coveredNot covered120 visit limitNoneNone120 days per confinementNoneNoneNoneNoneNoneServices You May NeedOffice visitsIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careChildbirth/delivery professionalservicesChildbirth/delivery facilityservicesHome health careRehabilitation servicesHabilitation servicesSkilled nursing careDurable medical equipmentHospice servicesChildren’s eye examChildren’s glassesChildren’s dental check-upExcluded 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 Private-duty nursing Bariatric surgery Infertility treatment Routine foot care Cosmetic surgery Long-term care Weight loss programs Dental care (Adult)Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care Non-emergency care when traveling outside the Routine eye care (Adult)U.S.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 thoseagencies is: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916 or the MN Dept of Commerce at 651-539-1600 / 1-800-657-3602. Other3 of 5

coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information aboutthe Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.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 agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide 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: Your plan at 1-800-883-2177, the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform or MN Dept of Health at 651-201-5100 / 1-800-657-3916 or the MN Dept of Commerce at 651-539-1600 / 1-800-657-3602.Does this plan provide Minimum Essential Coverage? Yes.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 therequirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? Yes.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 1-866-398-9119.Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-883-2177.Chinese (中文): �1-800-883-2177.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 ––––––––4 of 5

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 bedifferent depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharingamounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion ofcosts you might pay under different health plans. Please note these coverage examples are based on self-only coverage.Peg is Having a BabyManaging Joe’s type 2 DiabetesMia’s Simple Fracture(9 months of in-network pre-natal care and ahospital delivery)(a year of routine in-network care of a wellcontrolled condition)(in-network emergency room visit and follow upcare) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance 6,3500%0%0% The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance 6,3500%0%0% The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance 6,3500%0%0%This EXAMPLE event includes services like:Specialist office visits (prenatal care)Childbirth/Delivery Professional ServicesChildbirth/Delivery Facility ServicesDiagnostic tests (ultrasounds and blood work)Specialist visit (anesthesia)This EXAMPLE event includes services like:Primary care physician office visits (includingdisease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)This EXAMPLE event includes services like:Emergency room care (including medicalsupplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)Total Example CostTotal Example CostTotal Example CostIn this example, Peg would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Peg would pay is 12,700 6,350 0 0 60 6,410In this example, Joe would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Joe would pay is 7,300 6,350 0 0 60 6,410In this example, Mia would pay:Cost SharingDeductiblesCopaymentsCoinsuranceWhat isn’t coveredLimits or exclusionsThe total Mia would pay is 1,900 1,900 0 0 0 1,9005 of 5

Statement of Nondiscrimination for Health Plan MembersOur Responsibilities:We follow Federal civil rights laws. We do not discriminate on the basis of race, color, national origin, age, disabilityor sex. We do not exclude people or treat them differently because of their race, color, national origin, age, disabilityor sex, including gender identity. We help people with disabilities to communicate with us. This help is free. It includes: Qualified sign language interpreters Written information in other formats, such as large print, audio and accessible electronic formats We provide services for people who do not speak English or who are not comfortable speaking English.These services are free. They include: Qualified interpreters Information written in other languagesFor Language or Communication Help:Call 1-800-883-2177 if you need language or other communication help. (TTY: 711)If you have questions about our non-discrimination policy:Contact the Civil Rights Coordinator at 1-844-363-8732 or integrityandcompliance@healthpartners.com.To File a Grievance:If you believe that we have not provided these services or have discriminated against you because of your race,color, national origin, age, disability or sex, you can file a grievance by contacting the Civil Rights Coordinator at1-844-363-8732, integrityandcompliance@healthpartners.com or Civil Rights Coordinator, Office of Integrity andCompliance, MS 21103K, 8170 33rd Ave S., Bloomington, MN 55425.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for CivilRights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:U.S. Department of Health and Human ServicesRoom 509F, HHH Building200 Independence Avenue SWWashington, DC 202011-800-368-1019, 800-537-7697 (TDD)Español(Spanish)ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencialingüística. Llame al 1-800-883-2177. (TTY: 711)Hmoob(Hmong)LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb raukoj. Hu rau 1-800-883-2177. (TTY: 711)Tiếng Việt(Vietnamese)CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.Gọi số 1-800-883-2177. (TTY: 711) 㧓 ᩥ 㲐シ烉 㝄ぐἧ䓐 橼ᷕ㔯炻ぐ ẍ 屣䌚 婆妨 㚵 ˤ婳农暣 1-800-883-2177.(Chinese)(TTY: 711)Русский(Russian)ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатныеуслуги перевода. Звоните 1-800-883-2177. (телетайп: 711)Af Soomaali(Somali)OGAYSIIS: Haddii aad ku hadasho afka soomaaliga, Waxaa kuu diyaar ah caawimaadxagga luqadda ah oo bilaash ah. Fadlan soo wac 1-800-883-2177. (TTY: 711)Additional languages listed on page 2Page 1 of 221849 (9/2016)

ƐƞƗƞƕƞƖ (Laotian)Deutsch(German)ƫƍƇƅƞƌ: ƉƞƖƞ ƊƞƋƩƖƞƐƞƗƞ ƕƞƖ,ƀƞƋƌǚ ǙǙǞ Ǒ ƕƀƞƋƅƖƆƩƘǙǚǞǙ ƩƗǟƂƞ ǔ ǘ ƙƇƞƋƐƞƗƞ ƫƇƆƌǐ ǙǗǚƪƒǙ Ƌƒǚ ƙƒƬƘǚ ƊǙ ƞƋ ƫƊƔ 1-800-883-2177. (TTY: 711)ǒ ƐACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachlicheHilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-883-2177. (TTY: 711)ΔϳΑέόϟ (Arabic)ϢϗήΑ ϞμΗ .ϥΎΠϤϟΎΑ Ϛϟ ήϓ ϮΘΗ ΔϳϮϐϠϟ ΓΪϋΎδϤϟ ΕΎϣΪΧ ϥΈϓ ˬΔϐϠϟ ήϛΫ ΙΪΤΘΗ ΖϨϛ Ϋ· :ΔυϮΤϠϣ711 :ϢϜΒϟ ϭ Ϣμϟ ϒΗΎϫ Ϣϗέ)1-800-883-2177Français(French)ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposésgratuitement. Appelez le 1-800-883-2177. (ATS: 711)䞲ῃ㠊 㨰㢌aG䚐ạ㛨 G 㟝䚌㐐 Gᷱ㟤SG㛬㛨G㫴㠄G Gⱨ ⦐G㢨㟝䚌㐘G G㢼 U (Korean)1-800-883-2177. (TTY: 711)Tagalog(Tagalog)PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ngtulong sa wika nang walang bayad. Tumawag sa 1-800-883-2177. (TTY: 711)Oroomiffa(Cushite [Oromo])XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaanala, ni argama. Bilbilaa 1-800-883-2177. (TTY: 711) 0 (Amharic)8n· : Õ ô,p L L 0 Õp0õ 0ßn á0ñqxŃ [ Ģ Øùʽp kÅ ìkº Ł ·Ü k ¼ DČ0 Úܼ 1-800-883-2177. ( 8 p k6 s¼: 711)unD(Karen)ymol.ymo; erh uwdRAunDAusdmtCd AerRM Ausdmtw rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM.vDRIAȓîƄ ŷ(Mon-Khmer, Cambodian)ȋ ǯŚǯŴƤȓîƄ,ŷ ȒơƑĐșřȇ ŻȓŧŚ éŴƤ ȒīŻŶřóŅĕƉ ǯǯś ȉƅŞŻŅŚȽ ɉ ȒŞơřēƴéřžŻȄ Ȅ ȽŬŐ 1-800-883-2177. (TTY: 711)óƷĆŹřơƇŞŞȒƄǽșȥ ș ǶƴŚ éɇ ĆƄ ŏƄơDeitsch(Pennsylvanian Dutch)Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helftmit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-883-2177. (TTY: 711)Polski(Polish)UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.Zadzwoń pod numer 1-800-883-2177. (TTY: 711)Ǒ¡ ȣ Ȳ(Hindi)Ú ȡ Ʌ : Ǒ ] Ǒ¡ ȣȲ Ȫ ȯ ¡ɇ Ȫ ] ȯ ͧ f Ý Ʌ ȡ ȡǕ1-800-883-2177. (TTY: 711)Shqip(Albanian)KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore,pa pagesë. Telefononi në 1-800-883-2177. (TTY: 711)Srpsko-hrvatski(Serbo-Croatian)OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vambesplatno. Nazovite 1-800-883-2177. (TTY: 711)kȤK hSj (Gujarati)kkk [hch deh] dpahB S\h h \hN ɅIWh:Ks S\p ȤK hSjZs Sh es, Ss iW:ɃƣD;X ƞV Jp . YsW D s 1-800-883-2177. (TTY: 711)ϭΩέ (Urdu)ud; 1-800-883-2177. (TTY: 711)¡ȡ ȡ ȯ ȡfȲ Þ ¡ɇ@ϝΎ̯ ل ϳ٫ ΏΎϳΗγΩ ϳϣ Εϔϣ ΕΎϣΩΧ ̶̯ ΩΩϣ ̶̯ ϥΎΑί ϭ̯ ̟ ϭΗ ˬ ϳ٫ ف ΗϟϭΑ ϭΩέ ̟ έ̳ :έ ΩέΑΧ.(TTY: 711) 1-800-883-2177 ؐϳή̯ Italiano(Italian)ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenzalinguistica gratuiti. Chiamare il numero 1-800-883-2177. (TTY: 711) µ µÅ (Thai)Á : oµ » ¡¼ µ µÅ » µ µ Ä o · µ nª Á º µ µ µÅ o à 1-800-883-2177.(TTY: 711)ελληνικά(Greek)ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικήςυποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-883-2177. (TTY: 711)Diné Bizaad(Navajo)Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dęę’, t’áá jiik’eh, éí ná hóló, koji’ hódíílnih 1-800-883-2177. (TTY: 711)Page 2 of 221849 (9/2016)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 01/01/2018 - 12/31/2018 HealthPartners:EZ Empower HSA Embedded 6350-100 - AchieveCoverage for: Single/Family Plan Type: PPO 1 of 5 P-EZ-MNHSA6350E-100A-18-E The Summary of Benefits and Co

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