EZ Empower HSA Embedded 6350-100 - Achieve

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