7/1/2021 - 6/30/2022 Coverage Period: Summary Of Benefits And Coverage .

Coverage Period: 7/1/2021 - 6/30/2022Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage for: Individual/FamilyEmblemHealth : PPOPlan 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 1-800-624-2414. For general definitionsof common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can viewthe Glossary at www.emblemhealth.com or call 1-800-624-2414 to request a copy.Important Questions AnswersWhy this Matters:Generally, you must pay all of the costs from providers up to the deductible amount before this 0, in network providers,plan begins to pay. If you have other family members on the plan, each family member must meetWhat is the overall 200 Individual / 500 Family out oftheir own individual deductible until the total amount of deductible expenses paid by all familydeductible?network providers.members meets the overall family deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. ButAre there services coveredIn network services are not subject a copayment or coinsurance may apply. For example, this plan covers certain preventivebefore you meet yourto a deductible.services without cost-sharing and before you meet your deductible. See a list of covereddeductible?preventive services at e-benefits/.You must pay all of the costs for these services up to the specific deductible amount before thisAre there other deductibles Yes, 100 for durable medicalequipment.plan begins to pay for these services.for specific services?The out-of-pocket limit is the most you could pay in a year for covered services. If you have otherWhat is the out-of-pocket For in network providers 4,550family members in this plan, they have to meet their own out-of-pocket limits until the overallIndividual / 9,100 Family.limit for this plan?family out-of-pocket limit has been met.Premiums, penalties, balanced-billWhat is not included in thecharges, and health care this plan Even though you pay these expenses, they don’t count toward the out–of–pocket limit.out-of-pocket limit?doesn't cover.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 aYes. See www.EmblemHealth.comprovider for the difference between the provider’s charge and what your plan pays (balanceWill you pay less if you useor call 1-877-842-3625 for a list ofbilling). Be aware, your network provider might use an out-of-network provider for somea network provider?participating providers.services (such as lab work). Check with your provider before you get services.You can see thespecialist you choose without a referral.Do you need a referral toNosee a specialist?OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Released on April 6, 20162521 of 10

7/1/2021 - 6/30/2022All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atwww.EmblemHealth.com.If you have outpatientsurgeryWhat You Will PayServices You May NeedNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Primary care visit to treat Preferred: 0 co-pay per visitAfter Plan deductible is met,an injury or illnessParticipating: 15 co-pay per visit No chargePreferred: 0 co-pay per visitAfter Plan deductible is met,Specialist visitParticipating: 30 co-pay per visit No chargePreventiveAfter Plan deductible is met,care/screening/No chargeNo chargeimmunizationDiagnostic test (x-ray,After Plan deductible is met, 20 co-pay per visitblood work)No chargeImaging (CT/PET scans,After Plan deductible is met, 50 co-pay per visitMRIs)No chargeRetail-30 day supply-2 fills; 20%Generic drugs (Tier 1)coinsurance with min charge of 5 Not coveredor actual cost if less*Limitations, Exceptions, & OtherImportant Information-----None----Lower co-pay applies when a PreferredProvider refers-----None---------None----Pre-certification requiredRetail-90 day supply; 12.50 co-pay.Prescriptions will not be filled at retail after 2fills.Retail-90 day supply; 50 co-pay.Prescriptions will not be filled at retail after 2fills. Prior-authorization is required for certainbrand name medications.Retail-90 day supply; 75 co-pay.Prescriptions will not be filled at retail after 2fills.Must be dispensed by the SpecialtyPharmacy Program Provider. Precertificationrequired contact NYC Healthline at 1-800521-9574.Preferred brand drugs(Tier 2)Retail-30 day supply-2 fills; 40%coinsurance with min charge of 25 or actual cost if lessNot coveredNon-preferred branddrugs (Tier 3)Retail-30 day supply-2 fills; 50%coinsurance with min charge of 40 or actual cost if lessNot coveredSpecialty drugsCoveredNot coveredFacility fee (e.g.,ambulatory surgerycenter)Not coveredNot coveredPlease check with your employer.Physician/surgeon feesCoveredAfter Plan deductible is met,No charge-----None-----* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com/sbc.2522 of 10

7/1/2021 - 6/30/2022CommonMedical EventIf you need immediatemedical attentionIf you have a hospitalstayServices You May Need*Limitations, Exceptions, & OtherImportant InformationEmergency room careEmergency medicaltransportationNot coveredNot covered-----None-----Not covered20% coinsuranceNo air ambulance or ambulette serviceUrgent care 50 co-pay per visitAfter Plan deductible is met,No charge-----None-----Not coveredPlease check with your employer.Facility fee (e.g., hospitalNot coveredroom)Physician/surgeon feeOutpatient servicesIf you need mentalhealth, behavioralhealth, or substanceabuse servicesWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Inpatient servicesOffice visitsChildbirth/deliveryprofessional servicesAfter Plan deductible is met,No chargePreferred: 0 co-pay per visitAfter Plan deductible is met,Participating: 15 co-pay per visit No charge 500 co-pay peradmission/ 1,250 maximum 300 co-pay per admission/ 750per calendar year. 20% tomaximum per calendar yearmax of 2,000 per person percalendar year.After Plan deductible is met,No chargeNo chargeAfter Plan deductible is met,No chargeNo chargeCoveredIf you are pregnantChildbirth/delivery facilityNo chargeservicesAfter Plan deductible is met,No charge-----None----No prior approval requiredPre-certification required-----None---------None----Enhanced schedule increases thereimbursement of the basic program's nonparticipating provider fee schedule, onaverage, by 75%. Pre-certification requiredcontact NYC Healthline at 1-800-521-9574.* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com/sbc.2523 of 10

7/1/2021 - 6/30/2022CommonMedical EventServices You May NeedHome health careRehabilitation servicesIf you need helprecovering or haveother special healthneedsHabilitation servicesSkilled nursing careDurable medicalequipmentIf your child needsdental or eye careHospice servicesChildren’s eye examChildren’s glassesChildren’s dental checkupWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most) 50 deductible per episode;20% coinsurance insurancePreferred: 0 co-pay per visitAfter Plan deductible is met,Participating: 30 co-pay per visit No chargePreferred: 0 co-pay per visitAfter Plan deductible is met,Participating: 30 co-pay per visit No chargeNot coveredNot coveredNo charge*Limitations, Exceptions, & OtherImportant Information200 visits per member per plan year.Preauthorization required.Coverage limited to 16 visits per calendaryear. Pre-certification required for additionalvisitsNot coveredNot coveredNot covered-----None----Pre-certification required on greater than 100 deductible; 50% of usual 2,000 call NYC Healthline at 1-800-521and customary charge9574.Not covered-----None----Not covered-----None----Not covered-----None-----Not coveredNot covered 100 deductible-----None-----* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com/sbc.2524 of 10

7/1/2021 - 6/30/2022Excluded 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.) Hearing aids Acupuncture Long-term care Routine foot care Cosmetic surgery Most coverage provided outside the United States Weight loss programs Dental care Non-emergency care when traveling outside the U.S.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Bariatric surgery (Prior Approval required) Private-duty nursing Infertility treatment (Prior Approval required) Chiropractic care Routine eye careYour 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: New York State Department of Financial Services at 1-800-342-3736 or www.dfs.ny.gov/, U.S. Department of Health and Human Services at 1-877-2672323 x1565 or www.cciio.cms.gov, U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 html or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buyingindividual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call1-800-318-2596.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 right, 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:EmblemHealthBy Phone:Please call the number on your ID card.In writing:EmblemHealthGrievance and Appeals DepartmentP.O. Box 2801New York, NY 10116-2807Website: www.emblemhealth.comFor All Coverage TypesNew York State Department of Financial ServicesBy Phone: 1-800-342-3736In writing:New York State Department of Financial ServicesConsumer Assistance UnitOne Commerce PlazaAlbany, NY 12257Website: www.dfs.ny.gov* For more information about limitations and exceptions, see the plan or policy document at www.emblemhealth.com/sbc.2525 of 10