State Employees Group Insurance Program

HMO BenefitsHealth Maintenance Organization (HMO) members are required to stay within the health plan provider network.No out-of-network services are available, other than listed below. Members will need to select a primary carephysician (PCP) from a network of participating providers. The PCP will direct all healthcare services and makereferrals to specialists and hospitalization. Benefits are outlined in each plan’s Summary Plan Document (SPD).It is the member’s responsibility to know and follow the specific requirements of the HMO plan selected. For acopy of the SPD, contact the plan administrator (see page 11).HMO Plan DesignPlan Year Out-of-Pocket Maximum 3,000 Individual 6,000 FamilyHospital ServicesIn-NetworkOut-of-NetworkEmergency Room Services 275 copayment per visit 275 copayment per visitInpatient Hospitalization 425 copayment per admissionNot coveredInpatient Alcohol and Substance Abuse 425 copayment per admissionNot coveredInpatient Psychiatric Admission 425 copayment per admissionNot coveredOutpatient Surgery 300 copayment per visitNot coveredSkilled Nursing Facility100% coveredNot coveredDiagnostic Lab and X-ray100% coveredNot coveredComplex Imaging (CT/Pet Scans/MRIs) 30 copaymentNot coveredTransplant Services 375 copay limited to network transplant facilities as determined by the medical plan administrator.To assure coverage, the transplant candidate must contact your plan provider prior to beginningevaluation services.Organ and TissueTransplantsProfessional and Other ServicesIn-NetworkOut-of-NetworkPreventive Care/Well-Baby/Immunizations100% coveredNot coveredPhysician Office Visit 30 copayment per visitNot coveredSpecialist Office Visit 35 copayment per visitNot coveredTelemedicine 10 copaymentNot coveredOutpatient Psychiatric and SubstanceAbuse 30 or 35 copayment per visitNot coveredDurable Medical Equipment80% coveredNot coveredHome Health Care 35 copayment per visitNot coveredComplex Imaging (CT/Pet Scans/MRIs) 30 copaymentNot coveredPrescription DrugsPlan Year Pharmacy Deductible – 150 per enrolleePreventive Prescription Drugs – 0Reduced Tier I *Tier ITier IITier IIICopayments (30-day supply) 4.00 16.00 33.00 57.00Copayments (90-day supply) 10.00 40.00 82.50 142.50* Applies to specific medications as defined by plan.Some HMOs may have benefit limitations based on a calendar year.4FY2023 Benefit Choice Options

Open Access Plan (OAP) BenefitsOpen Access Plan (OAP) members will have three tiers of providers from which to choose to obtain services. Tier I offers a managed care network which provides enhanced benefits and operates similar to an HMO. Tier II offers an expanded network of providers and is a hybrid plan operating like an HMO and PPO. Tier III covers all providers which are not in the managed care networks of Tiers I or II (out-of-networkproviders). It is the member’s responsibility to know and follow the specific requirements of the OAP.Benefits are outlined in each plan's Summary Plan Document (SPD), contact the plan administrator(see page 11).BenefitTier IPlan Year Out-of-Pocket Maximum Per Individual Per FamilyTier II 3,000 (includes eligible charges from Tier I and Tier II combined) 6,000 (includes eligible charges from Tier I and Tier II combined)Plan Year Deductible (must besatisfied for all services) 300 per enrollee* 0Tier III (Out-of-Network)**Not Applicable 400 per enrollee*Hospital Services (Percentages listed represent how much is covered by the plan)Emergency Room ServicesInpatient Hospitalization 275 copayment per visit 275 copayment per visitof network charges after 425 copayment per admission 90% 475 copayment per admission*of network charges after 425 copayment per admission 90% 475 copayment per admission* 275 copayment per visit60% of allowable charges after 575 copayment per admission*60% of allowable charges after 575 copayment per admission*Outpatient Surgeryof network charges after 425 copayment per admission 90% 475 copayment per admission*90% of network charges after 300 copayment per visit 300 copayment*60% of allowable charges after 575 copayment per admission*60% of allowable charges after 300 copayment*Skilled Nursing Facility100% covered90% of network charges*Not coveredDiagnostic Lab and X-ray100% covered90% of network charges*60% of allowable charges*Complex Imaging (CT/Pet Scans/MRIs) 30 copayment90% of network charges*60% of allowable charges*Inpatient Alcohol andSubstance AbuseInpatient Psychiatric AdmissionTransplant ServicesTier I: 100% covered. Tier II: 90% of network charges. Tier III: Not covered. To assure coverage, thetransplant candidate must contact your plan provider prior to beginning evaluation services.Organ and TissueTransplantsPreventive Care/Well-Baby/ImmunizationsPhysician Office VisitsSpecialist Office VisitsTelemedicineOutpatient Psychiatric andSubstance AbuseDurable Medical EquipmentHome Health CareProfessional and Other Services100% covered100% coveredNot covered 30 copayment 35 copayment 10 copayment90% of network charges*90% of network charges*Not covered60% of allowable charges*60% of allowable charges*Not covered 30 or 35 copayment90% of network charges*60% of allowable charges*80% of network charges 35 copayment80% of network charges*90% of network charges*60% of allowable charges*Not coveredPrescription DrugsPlan Year Pharmacy Deductible – 150 per enrolleeCopayments (30-day supply)Copayments (90-day supply)***Maintenance Choice (90-day supply)****Tier I 16.00 40.00 20.00Preventive Prescription Drugs – 0Tier II 33.00 82.50 41.25Tier III 57.00 142.50 71.25* A plan year deductible must be met before Tier II and Tier III plan benefits apply. Benefit limits are measured on a plan year basis.** Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges do not counttoward your plan year out-of-pocket maximum; this varies by plan and geographic region.*** If a member or dependent elects a higher Tier drug where a lower Tier drug is available, the member or dependent is responsible for the highercopayment plus the difference in cost between the drugs.**** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.MyBenefits.illinois.govSEGIP5

Quality Care Health Plan (QCHP) BenefitsQuality Care Health Plan (QCHP) members may choose any physician or hospital for medical services; however,members receive enhanced benefits, resulting in lower out-of-pocket costs, when receiving services from aQCHP in-network provider. QCHP has a nationwide network of providers through Aetna PPO. Benefits areoutlined in the plan’s Summary Plan Document (SPD). It is the member’s responsibility to know and follow thespecific requirements of the QCHP. For a copy of the SPD, contact the plan administrator (see page 11).Plan Year Maximums and DeductiblesEmployee’s Annual Salary (based on eachemployee’s annual salary as of March 1st) 60,700 or less 60,701 - 75,900 75,901 and moreRetiree/Annuitant/SurvivorDependentsIndividual PlanYear Deductible 425 525 575 425 425Family Plan YearDeductible Cap 1,000 1,250 1,375 1,000N/AOut-of-Pocket Maximum LimitsIn-Network Individual 1,750In-Network Family 4,375Out-of-Network Individual 7,000Out-of-Network Family 13,500Hospital Services (Percentages listed represent how much is covered by the plan)In-NetworkEmergency Room Services 450 per visit; Deductible applies85% of network charges; Deductible appliesInpatient Hospitalizationafter 200 per admissionof network charges; Deductible appliesInpatient Alcohol and Substance Abuse 85%after 200 per admission85% of network charges; Deductible appliesInpatient Psychiatric Admissionafter 200 per admissionOutpatient Surgery85% of network charges; Deductible appliesSkilled Nursing Facility85% of network charges; Deductible appliesDiagnostic Lab and X-ray85% of network charges; Deductible appliesOut-of-Network* 450 per visit; Deductible applies60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible appliesafter 800 per admission60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)60% of allowable charges; Deductible applies85% of network charges; Deductible appliesTransplant ServicesOrgan and TissueTransplants85% after 200 transplant deductible, limited to network transplant facilities as determined bythe medical plan administrator. Benefits are not available unless approved by the NotificationAdministrator. To assure coverage, contact Aetna prior to beginning evaluation services.Professional and Other ServicesIn-NetworkPreventive Care/Well-Baby/Immunizations 100% coveredPhysician Office Visit85% of network charges; Deductible appliesSpecialist Office Visit85% of network charges; Deductible appliesTelemedicine85% of network charges; Deductible appliesOutpatient Psychiatric and Substance Abuse 85% of network charges; Deductible appliesDurable Medical Equipment85% of network charges; Deductible appliesHome Health Care85% of network charges; Deductible appliesOut-of-Network*60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesDoes Not Apply60% of allowable charges; Deductible applies60% of allowable charges; Deductible applies60% of allowable charges; Deductible appliesPrescription DrugsPlan Year Pharmacy Deductible – 175 per enrolleeCopayments (30-day supply)Copayments (90-day supply)Maintenance Choice (90-day supply)**Tier I 18.00 45.00 22.50Preventive Prescription Drugs – 0Tier II 38.00 95.00 47.50Tier III 60.00 150.00 75.00* Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges donot count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.6FY2023 Benefit Choice Options

Consumer Driven Health Plan (CDHP) BenefitsThis is a high-deductible health plan as defined by the IRS. Consumer Driven Health Plan (CDHP) members maychoose any physician or hospital for medical services; however, members receive enhanced benefits, resultingin lower out-of-pocket costs, when receiving services from a CDHP in-network provider. CDHP has a nationwidenetwork of providers through Aetna PPO. CDHP is available for active employees only, under the StateEmployees’ Group Insurance Program. This plan is not available to retirees. Benefits are outlined in the plan’sSummary Plan Document (SPD). It is the member’s responsibility to know and follow the specific requirementsof the CDHP. For a copy of the SPD, contact the plan administrator (see page 11).Plan Year Medical DeductiblesIn-Network Individual 1,500In-Network Family 3,000Out-of-Network Individual 1,500Out-of-Network Family 3,000Out-of-Pocket Maximum LimitsIn-Network Individual 3,000In-Network Family 6,000Out-of-Network Individual 3,000Out-of-Network Family 6,000Hospital Services (Percentages listed represent how much is covered by the plan)In-NetworkEmergency Room ServicesOut-of-Network*90% of coinsurance; Deductible applies90% of coinsurance; Deductible appliesInpatient Hospitalization90% of network charges; Deductible applies65% of allowable charges; Deductible appliesInpatient Alcohol and Substance Abuse90% of network charges; Deductible applies65% of allowable charges; Deductible appliesInpatient Psychiatric Admission90% of network charges; Deductible applies65% of allowable charges; Deductible appliesOutpatient Surgery90% of network charges; Deductible applies65% of allowable charges; Deductible appliesSkilled Nursing Facility90% of network charges; Deductible applies65% of allowable charges; Deductible appliesDiagnostic Lab and X-ray90% of network charges; Deductible applies65% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)90% of network charges; Deductible applies65% of allowable charges; Deductible appliesTransplant ServicesOrgan and TissueTransplants90% after plan year deductible, limited to network transplant facilities as determined by the medicalplan administrator. Not covered out-of-network. Benefits are not available unless approved by theNotification Administrator. To assure coverage, contact Aetna prior to beginning evaluation services.Professional and Other ServicesIn-NetworkOut-of-Network*Preventive Care/Well-Baby/Immunizations100% covered65% of allowable charges; Deductible appliesPreventive Services (IRS-allowed)**90% of network charges; No Deductible65% of allowable charges; Deductible appliesPhysician Office Visit90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesSpecialist Office Visit90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesTelemedicine90% of network charges; Deductible applies Does Not ApplyOutpatient Psychiatric and Substance Abuse 90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesDurable Medical Equipment90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesComplex Imaging (CT/Pet Scans/MRIs)90% of network charges; Deductible applies 65% of allowable charges; Deductible appliesPrescription DrugsPreventive Prescription Drugs – 0 Preventive Prescription Drugs (IRS-allowed) ** - 90% covered; No DeductibleCopayments (30-day supply)Copayments (90-day supply)Maintenance Choice (90-day supply)***Tier I90%; Deductible Applies90%; Deductible Applies95%; Deductible AppliesTier II90%; Deductible Applies90%; Deductible Applies95%; Deductible AppliesTier III90%; Deductible Applies90%; Deductible Applies95%; Deductible Applies* Using out-of-network services may significantly increase your out-of-pocket expense. Amounts over the plan’s allowable charges donot count toward your plan year out-of-pocket maximum; this varies by plan and geographic region.** Contact Aetna for IRS-allowed services and prescriptions.*** Medications received at CVS Caremark Retail Pharmacy or through CVS Caremark Mail Service Pharmacy.MyBenefits.illinois.govSEGIP7

Medical Care Assistance Program (MCAP) - Companion to yourHMO, OAP, QCHP, or CDHP (if not enrolled in an HSA)EMPLOYEES MUST RE-ENROLL EACH YEARThe MCAP maximum contribution limit is 2,850 for the FY23 plan year period. The rollover of unused FY23funds will be capped at 570.00. Participants who do not re‐enroll for the new plan year will forfeit anyamount eligible for rollover.Dependent Care (Day Care) Assistance Program (DCAP)DCAP is an account that allows you to set aside pre‐tax contributions per pay period to pay for dependent care(Day Care) expenses, for children age 12 and under, or care for a physically or mentally disabled dependent.DCAP cannot be used for dependent medical expenses or for children for which you are not considered theprimary or custodial parent. The DCAP maximum contribution limit is 5,000 for the FY23 plan year period.Any unused DCAP funds at the end of the plan year will be forfeited.Health Savings Accounts (HSA) for Active State Employees Companion to CDHP Enrollment ONLYEMPLOYEES MUST RE-ENROLL EACH YEARAn HSA is like a 401(k) for healthcare, yet the HSA tax benefits are far greater. It is a tax‐favored, interest-bearingaccount that active State employees can use to pay for qualified medical expenses now, or in the future. ActiveState employees who qualify (see Qualifying for an HSA below), can save or invest the account funds. Paired withthe Consumer Driven Health Plan (CDHP), an HSA is a powerful financial tool that gives you more control of yourhealthcare decisions.The State will contribute a third of the deductible to an active State employee's HSA. Maximum HSAcontributions (Employer Employee) for FY23 will be:Under Age 55Age 55 and olderIndividualFamilyEmployer Contribution 500 1,000Employee Contribution 3,150Max IRS Allowed Contribution 3,650IndividualFamilyEmployer Contribution 500 1,000 6,300Employee Contribution 4,150 7,300 7,300Max IRS Allowed Contribution 4,650 8,300Contributions to your HSA can be made through pre-tax payroll deductions or post-tax direct payment. ActiveState employees can make tax‐free withdrawals to pay for qualified medical expenses, for you and your eligibledependents. HSAs are portable and all contributions rollover to the next plan year. If the employee investsHSA funds, those funds remain in the investment account. HSAs may be used for future healthcare expensesincluding out‐of‐pocket expenses after retirement, Medicare, and long‐term care (LTC) premiums, up to IRS limitsand certain LTC expenses. There are no income limitations.Qualifying for an HSATo be an eligible individual and qualify for an HSA, you must: Be covered under a high-deductible health plan Have no other health coverage (except what ispermitted under Other health S 2019 publink1000204039) Not be enrolled in Medicare. This includes Part A Not be claimed as a dependent on someoneelse’s tax returnYou cannot be enrolled in both an HSA and MCAP Flexible Spending Account.8FY2023 Benefit Choice Options

VisionVision coverage is provided at no cost to all members enrolled in a State health plan and is administered by EyeMed.All enrolled members and dependents receive the same vision coverage regardless of the health plan selected.ServiceIn-NetworkOut-of-Network**Benefit FrequencyEye Exam 30 copayment 30 allowanceOnce every 12 monthsStandard Frames 30 copayment (up to 175 retailframe cost; member responsiblefor balance over 175) 70 allowanceOnce every 24 monthsVision Lenses* (single, bifocaland trifocal) 30 copayment 50 allowance for singlevision lenses. 80 allowancefor bifocal and trifocal lensesOnce every 12 monthsContact Lenses (All contactlenses are in lieu of vision lenses) 120 allowance 120 allowanceOnce every 12 months* Vision Lenses: Member pays all optional lens enhancement charges. In-network providers may offer additional discounts on lens enhancementsand multiple pair purchases.** Out-of-network claims must be filed within one year from the date of service.DentalEmployees have the option to enroll in Dental Only coverage. However, if you enroll in health coverage andchoose dental coverage, dependents must mirror the coverage of the member.The State’s Quality Care Dental Plan (QCDP) offers a comprehensive range of benefits and is available to all membersand is administered by Delta Dental of Illinois. Visit MyBenefits.illinois.gov for a Dental Schedule of Benefits.Deductible and Plan Year MaximumPlan year deductible for preventive servicesN/APlan year deductible for all other covered services 175Plan Year Maximum Benefit (Orthodontics All Other Covered Expenses Maximum Benefit)In-network plan year maximum benefit 2,500Out-of-network plan year maximum benefit 2,000It is strongly recommended that plan members obtain a pretreatment estimate through Delta Dental for any service more than 200. Failure to obtain apretreatment estimate may result in unanticipated out-of-pocket costs.Child Orthodontia BenefitLength of Orthodontia Treatment*Maximum BenefitIn-NetworkOut-of-Network0 - 36 Months 2,000 1,5000 - 18 Months 1,820 1,3640 - 12 Months 1,040 780Member Monthly Quality Care Dental Plan (QCDP) Contributions**Member OnlyMember 1 DependentMember 2 or More Dependents 14.00 23.00 25.50* Orthodontia Treatments must start prior to age 19.** Part-time employees are required to pay a percentage of the

Quality Care Health Plan (QCHP) Aetna HMO. Health Alliance HMO. Aetna OAP Blue Cross Blue Shield OAP Tiers I, II & III HealthLink OAP Tiers I, II & III (Except Ford County) Consumer Driven Health Plan (CDHP) Quality Care Health Plan (QCHP) Aetna HMO. Health Alliance HMO. Aetna OAP (Gallatin County has Tiers II & III Only) Blue Cross Blue Shield .