Summary Of Benefits And Coverage: 01/01/20 21- /3 /20 Coverage For .

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 - 12/31/2021 Horizon BCBSNJ: St. Joseph’s Health Coverage for: All Coverage Types Plan Type: EPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share 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. Benefits may change upon renewal. For more information about your coverage, or to get a copy of the complete terms of coverage, visit Member Online Services at www.HorizonBlue.com/SJH or by calling 1-800-355-BLUE(2583). If you do not currently have coverage with Horizon BCBSNJ you can view a sample policy here, HorizonBlue.com/sample-benefit-booklets. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.cciio.cms.gov or call 1-800-355-BLUE(2583) to request a copy. Important Questions What is the overall deductible? Are there services covered before you meet your deductible? Why This Matters: 0 See the Common Medical Events chart below for your costs for services this plan covers. Yes. Preventive care is covered before This plan covers some items and services even if you haven’t yet met the deductible you meet your deductible. amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at e-benefits/. Are there other deductibles No. You don’t have to meet deductibles for specific services. for specific services? What is the out-of-pocket For Health/Pharmacy Inner Circle The out-of-pocket limit is the most you could pay in a year for covered services. If limit for this plan? providers 2,000.00 Individual/ you have other family members in this plan, they have to meet their own out-of 4,000.00 Family. Aggregate family. pocket limits until the overall family out-of-pocket limit has been met. What is not included in the Premiums, balance-billing charges and Even though you pay these expenses, they don’t count toward the out-of-pocket out-of-pocket limit? health care this plan doesn’t cover. limit. Will you pay less if you use Yes. See www.HorizonBlue.com/SJH You pay the least if you use a provider in Inner Circle. You pay more if you use a a network provider? or call 1-800-355-BLUE(2583) for a Participating Provider. You will pay the most if you use an out-of-network provider, list of network provider. and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). 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 to No. You can see the specialist you choose without a referral. see a specialist? (0076322:0003:0004:0005; pkg 001) M/CP Answers (Prescription/Advantage EPO Inner Circle 1 of 8

Services You May Need Common Inner Circle(You Medical Event will pay the least) If you visit a health care provider’s office or clinic What You Will Pay In-Network Provider Primary care visit to treat an 5.00 Copayment per Not Covered. injury or illness visit. 10.00 Copayment per visit applies only to Horizon CareOnline. Specialist visit 10.00 Copayment per Not Covered. visit. Preventive No Charge. Not Covered. care/screening/immunization If you have a test Diagnostic test (x-ray, blood No Charge for Office, Not Covered. work) Independent Laboratory, Outpatient Hospital. Imaging (CT/PET scans, No Charge for Not Covered. MRIs) Outpatient Hospital. Preferred Generic drugs No Charge for In 20.00 Copayment/ If you need drugs House Pharmacy. Retail; 50.00 to Copayment/Mail treat your illness Order. or condition Non-Preferred Generic drugs No Charge for In 20.00 Copayment/ More information House Pharmacy. Retail; 50.00 about prescription Copayment/Mail drug coverage is Order. available at * For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/SJH. Limitations, Exceptions, & Out-of-Network Other Important Information Provider (You will pay the most) Not Covered. Horizon CareOnline Telemedicine services is an additional telemedicine feature provided through Horizon BCBSNJ's telemedicine vendor. Not Covered. Not Covered. One per calendar year. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Not Covered. Not Covered. Requires pre-approval. Not Covered. Prior authorization may be required. Covers up to a 30 day supply (retail) and a 90 day supply (mail order/Walgreens). St Joseph’s Pharmacy (Inner Circle) covers up to 30 day supply (retail) and a 31 to 90 day supply (mail order). Not Covered. none 2 of 8

Services You May Need Common Inner Circle(You Medical Event will pay the least) Prime Therapeutics Preferred brand drugs LLC (Prime) Service Center www.MyPrime.com or 1-800-370-5088. Non-preferred brand drugs 15.00 Copayment/ Retail; 35.00 Copayment/ Mail Order. No Charge for In House Pharmacy. 30.00 Copayment/ Retail; 75.00 Copayment/Mail Order. No Charge for In House Pharmacy. Not Covered. What You Will Pay In-Network Provider 50.00 Copayment/ Retail; 100.00 Copayment/Mail Order. 75.00 Copayment/ Retail; 200.00 Copayment/Mail Order. Specialty drugs 20.00 Preferred/Non-Preferred Copayment/Retail. Generic Specialty drugs Not Covered. 10% Coinsurance up Preferred/Non-Preferred to 250.00 maximum/ Brand Retail. If you have Facility fee (e.g., ambulatory No Charge for Not Covered. outpatient surgery surgery center) Outpatient Hospital, Ambulatory Surgical Center. Physician/surgeon fees No Charge for Not Covered. Outpatient Hospital, Ambulatory Surgical Center. If you need Emergency room care 30.00 Copayment per 30.00 Copayment per immediate visit for Outpatient visit for Outpatient medical Hospital. Hospital. attention Emergency medical transportation No Charge. Not Covered. * For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/SJH. Limitations, Exceptions, & Out-of-Network Other Important Information Provider (You will pay the most) Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. none Not Covered. none 30.00 Copayment per Copayment waived if admitted visit for Outpatient within 24 hours. Out-of-network Hospital. payment at the Inner Circle level of benefits applies only to true medical emergencies and accidental injuries. none Not Covered. 3 of 8

Services You May Need Common Inner Circle(You Medical Event will pay the least) Urgent care If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fees If you need mental Outpatient services health, behavioral health, or Inpatient services substance abuse services If you are Office visits pregnant Childbirth/delivery professional services Childbirth/delivery facility services If you need help Home health care recovering or have other special health Rehabilitation services needs Habilitation services Skilled nursing care What You Will Pay In-Network Provider 10.00 Copayment per Not Covered. visit for Specialist. No Charge for Not Covered. Inpatient Hospital. No Charge for Inpatient Hospital. No Charge for Outpatient Hospital. No Charge for Inpatient Hospital. Limitations, Exceptions, & Out-of-Network Other Important Information Provider (You will pay the most) none Not Covered. Not Covered. Requires pre-approval. In-network inpatient separation period is limited to 90 days. none Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. 5.00 Copayment per Not Covered. visit for Office. 10.00 Copayment per visit for Specialist. Not Covered. No Charge for Inpatient Hospital. No Charge for Inpatient Hospital. Not Covered. Not Covered. Requires pre-approval. In-network inpatient separation period is limited to 90 days. Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. Ultrasound). none Not Covered. Not Covered. In-network inpatient separation period is limited to 90 days. No Charge. Not Covered. Not Covered. No Charge for Inpatient Hospital. No Charge for Inpatient Hospital. No Charge for Inpatient Facility. Not Covered. Not Covered. Not Covered. Not Covered. Requires pre-approval. Home healthcare is limited to 60 visits combined across all tiers. Requires pre-approval. In-network inpatient separation period is limited to 90 days. Not Covered. Not Covered. * For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/SJH. none Requires pre-approval. In-network inpatient skilled nursing facility days are limited to 120 days. 4 of 8

Services You May Need Common Inner Circle(You Medical Event will pay the least) What You Will Pay In-Network Provider Durable medical equipment 5.00 Copayment. Not Covered. Hospice services No Charge for Inpatient Facility. Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. Not Covered. If your child needs Children’s eye exam dental or eye care Children’s glasses Children’s dental check-up Limitations, Exceptions, & Out-of-Network Other Important Information Provider (You will pay the most) Not Covered. Prior authorization required for outof-network DME purchases over 500.00. Not Covered. Requires pre-approval. Hospice days are limited to 180 days combined across all tiers. none Not Covered. none Not Covered. none Not Covered. 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.) Cosmetic Surgery Dental care (Adult) Long Term Care Most coverage provided outside the United States Routine foot care Weight Loss Programs Non-emergency care when traveling outside the U.S. Routine eye care (Adult) * For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/SJH. 5 of 8