Summary Of Benefits And Coverage: KANSAS STATE EMPLOYEES HEALTH CARE .

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesKANSAS STATE EMPLOYEES HEALTH CARE COMMISSION (DBA STATEOF KANSAS) : Aetna Choice POS II - Plan ACoverage Period: 01/01/2022-12/31/2022Coverage for: Individual Family Plan Type: POSThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would sharethe cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is onlya summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1866-851-0754. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-866-851-0754 to request a copy.Important QuestionsAnswersWhat is the overalldeductible?In-Network: 900 individual / 1,800 family.Out-of-Network: 900 individual / 1,800 family.Are there services coveredbefore you meet yourdeductible?Yes. Prescription drugs, plus in-network officevisits & preventive care are covered before youmeet your deductible.Are there other deductiblesfor specific services?No. There are no other specific deductibles.What is the out-of-pocketlimit for this plan?What is not included in theout-of-pocket limit?Medical and Pharmacy combined Out ofPocket: In-Network: Individual 5,250 / Family 10,500. Out-of-Network: Individual 5,250 /Family 10,500.Premiums, balance-billing charges & healthcare this plan doesn't cover.Why This Matters:Generally, you must pay all of the costs from providers up to the deductible amountbefore this plan begins to pay. If you have other family members on the plan, eachfamily member must meet their own individual deductible until the total amount ofdeductible expenses paid by all family members meets the overall family deductible.This plan covers some items and services even if you haven't yet met the deductibleamount. But a copayment or coinsurance may apply. For example, this plan coverscertain preventive services without cost sharing and before you meet your deductible.See a list of covered preventive services are-benefits/You don’t have to meet deductibles for specific services.The out–of–pocket limit is the most you could pay in a year for covered services. If youhave other family members in this plan, they have to meet their own out–of–pocketlimits until the overall family out–of–pocket limit has been met.Even though you pay these expenses, they don’t count toward the out–of–pocket limit.Will you pay less if you use anetwork provider?Yes. For a list of in-network providers, seewww.aetnastateofkansas.com or call 1-866851-0754.This plan uses a provider network. You will pay less if you use a provider in the plan’snetwork. You will pay the most if you use an out-of-network provider, and you mightreceive a bill from a provider for the difference between the provider's charge and whatyour plan pays (balance billing). Be aware, your network provider might use an out-ofnetwork provider for some services (such as lab work). Check with your providerbefore you get services.Do you need a referral to seea specialist?No.You can see the specialist you choose without a referral.500024-926723-843021Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.Common MedicalEventServices You May NeedPrimary care visit to treat an injury or illnessSpecialist visitWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)Deductible plus 30 copay/visit50% coinsuranceDeductible plus 60 copay/visit50% coinsuranceIf you visit a healthcare provider’soffice or clinicPreventive care /screening /immunizationDiagnostic test (x-ray, blood work)If you have a testImaging (CT/PET scans, MRIs)If you need drugsto treat yourillness orcondition 0 copaymentDeductible plus20% coinsuranceDeductible plus20% coinsuranceGeneric drugs20% coinsurance(retail or mail order)Preferred brand drugs35% coinsurance(retail or mail order)Non-preferred brand drugs60% coinsurance(retail or mail order)Prescription drugcoverage isadministered byCVS CaremarkDeductible plus50% coinsurance;no charge for childimmunizations toage 6Deductible plus50% coinsuranceDeductible plus50% coinsurance20% coinsurance onthe plans allowedcharge35% coinsurance onthe plans allowedchargeLimitations, Exceptions, & Other ImportantInformationNoneNoneYou may have to pay for services that aren'tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for. Colonoscopies, Mammogramsand Pap Smears - Not limited to once per year /in network 100% regardless of diagnosis.Immunizations with Non Network providerscovered in full up to age 6 only.Lab services paid at 100% when using preferredlabs (Quest, Stormont Vail or University of KS).NoneFirst fill is a 30 day supply at retail and mail. A 90day supply is allowed at retail and mail forsubsequent refills.Diabetics and Asthma medications that areconsidered generic or preferred brand with thefollowing copays:Generic: 10% coinsurance with a 20 maximumper 30 day supply.Preferred brand: 20% coinsurance with a 4060% coinsurance on maximum per 30 day supply.the plans allowedNon Preferred Contraceptives: Covered subjectchargeto 65% coinsurance.Compound Medications covered only at aNetwork Pharmacy.500024-926723-843021Page 2 of 7

Common MedicalEventMore informationabout prescriptiondrug coverage isavailable atwww.caremark.comIf you haveoutpatient surgeryServices You May NeedSpecialty drugsFacility fee (e.g., ambulatory surgery center)Physician/surgeon feesEmergency room careIf you needimmediate medicalEmergency medical transportationattentionUrgent careIf you have ahospital stayIf you need mentalhealth, behavioralhealth, orsubstance abuseservicesFacility fee (e.g., hospital room)Physician/surgeon feesOutpatient servicesInpatient servicesOffice visitsIf you are pregnant Childbirth/delivery professional servicesChildbirth/delivery facility servicesWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)40% coinsurance(with a 100maximum) per 30day supplyDeductible plus20% coinsuranceDeductible plus20% coinsurance 100 copaymentplus deductible and20% coinsuranceDeductible plus20% coinsurance 50 copay/visitDeductible plus20% coinsuranceDeductible plus20% coinsuranceOffice & otheroutpatient services: 30 copay/visit,deductible doesn'tapplyDeductible plus20% coinsurance 0 copaymentDeductible plus20% coinsuranceDeductible plus20% coinsuranceNoneDeductible plus50% coinsuranceDeductible plus50% coinsurance 100 copaymentplus deductible and20% coinsuranceDeductible plus20% coinsuranceDeductible plus50% coinsuranceDeductible plus50% coinsuranceDeductible plus50% coinsuranceOffice & otheroutpatient services:Deductible plus50% coinsuranceDeductible plus50% coinsuranceDeductible plus50% coinsuranceDeductible plus50% coinsuranceDeductible plus50% coinsuranceLimitations, Exceptions, & Other ImportantInformationAll fills must be filled through CVS CaremarkSpecialty (1-800-237-2767)Prior Authorization is required.Prior Authorization is required.Must meet emergency criteria. Copay waived ifadmitted within 24 hours.Must meet emergency criteria.NonePrior Authorization is required.Prior Authorization is required. 20 copayment for group therapy sessions.Prior authorization is required for inpatientservices.Cost sharing does not apply for preventiveservices. Maternity care may include tests andservices described elsewhere in the SBC (i.e.ultrasound.) Prior authorization required for stayslonger than 48/96 hours.500024-926723-843021Page 3 of 7

Common MedicalEventServices You May NeedHome health careRehabilitation servicesIf you need helpHabilitation servicesrecovering or haveother specialSkilled nursing carehealth needsDurable medical equipmentHospice servicesIf your child needsdental or eye careChildren's eye examChildren's glassesChildren's dental check-upWhat You Will PayIn-NetworkOut-of-NetworkProviderProvider(You will pay the(You will pay theleast)most)Deductible plusDeductible plus20% coinsurance50% coinsuranceDeductible plusDeductible plus20% coinsurance50% coinsuranceDeductible plusDeductible plus20% coinsurance50% coinsuranceNot coveredNot coveredDeductible plusDeductible plus20% coinsurance50% coinsuranceDeductible plus20% coinsurance 0 copayment forfirst annual visit,then 60 copaymentper visitNot coveredNot coveredLimitations, Exceptions, & Other ImportantInformationPrior authorization may be required.Prior authorization required.Limited to treatment of Autism.Not covered.Prior authorization required.Deductible plus50% coinsurancePrior authorization may be required. InpatientHospice care limited to 180 daysmaximum/lifetime.Deductible plus50% coinsurance1 routine eye exam/calendar year.Not coveredNot coveredNot covered.Not covered.500024-926723-843021Page 4 of 7

Excluded 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.) AcupunctureCosmetic surgery - (to improve appearance ofnormal body structure)Dental care (Adult & Child)Glasses (Child) Hearing aidsLong-term carePrivate-duty nursing Routine foot careSkilled nursingWeight loss programs - Except for required preventiveservices.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgery - Limited to in-networkproviders. (for qualified patients)Chiropractic care - 30 visits/calendar year.Hearing exam Infertility treatment - For more information &exceptions, see policy document provided byyour employer or call the number on your IDcard.Non-emergency care when traveling outsidethe U.S. - Most coverage provided outside ofUnited States. Seewww.aetnainternational.com Nutritional Evaluation and Diabetes ManagementRoutine eye care (Adult) - 1 routine eye exam/calendaryear.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 those agencies is: For more information on your rights to continue coverage, contact the plan at 1-866-851-0754. If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272)or http://www.dol/gov/ebsa/healthreform For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and InsuranceOversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals shouldcontact their State insurance regulator regarding their possible rights to continuation coverage under State law.Other 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 a grievance or appeal. For more informationabout your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:500024-926723-843021Page 5 of 7