Select Plus AKSA /405 Coverage Period: Based on group plan year

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee/Family | Plan Type: POS
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or
plan document at www.welcometouhc.com or by calling 1-800-782-3740.
Important Answers Why this Matters:
Questions
What is the overall Network: $2,000 Indiv / $4,000 Family You must pay all the costs up to the deductible amount before this plan begins to
deductible? Non-Network: $4,000 Indiv / $8,000 Family pay for covered services you use. Check your policy or plan document to see when
Per calendar year. Does not apply to prescription the deductible starts over (usually, but not always, January 1st). See the chart
drugs, services listed below as "No Charge" and starting on page 2 for how much you pay for covered services after you meet the
copays except as noted below. deductible.
Are there other Yes, prescription drugs - $200 Indiv, $400 You must pay all of the costs for these services up to the specific deductible
deductibles for Family amount before this plan begins to pay for these services.
specific services? There are no other specific deductibles.
Is there an Yes, Network: $6,750 Indiv / $13,500 Family The out-of-pocket limit is the most you could pay during a coverage period
out-of-pocket limit Non-Network: $13,500 Indiv / $27,000 (usually one year) for your share of the cost of covered services. This limit helps
on my expenses? Family you plan for health care expenses.
What is not included Premiums, balance-billed charges, health care this Even though you pay these expenses, they dont count toward the out-of-pocket
in the out-of-pocket plan doesnt cover and penalties for failure to limit.
limit? obtain pre-authorization for services.
Is there an overall No. The chart starting on page 2 describes any limits on what the plan will pay for specific
annual limit on what covered services, such as office visits.
the plan pays?
Does this plan use a Yes. For a list of network providers, see If you use an in-network doctor or other health care provider, this plan will pay
network of www.welcometouhc.com or call some or all of the costs of covered services. Be aware, your in-network doctor or
providers? 1-800-782-3740. hospital may use an out-of-network provider for some services. Plans use the term
in-network, preferred, or participating for providers in their network. See the
chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral No. You can see the specialist you choose without permission from this plan.
to see a specialist?
Are there services Yes. Some of the services this plan doesnt cover are listed on page 5. See your policy or
this plan doesnt plan document for additional information about excluded services.
cover?

Questions: Call 1-800-782-3740 or visit us at www.welcometouhc.com. If you arent clear about any of the
underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or
www.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.
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 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance isyour share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plans allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
havent met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Services Your Cost If You Use Your Cost If You Use
Medical You May a Network Provider a Non-Network Limitations & Exceptions
Event Need Provider
If you visit a Primary care $30 copay per visit 50% co-ins, after ded If you receive services in addition to office visit, additional
health care visit to treat an copays, deductibles, or co-ins may apply.
providers injury or illness
office or clinic
Specialist visit $60 copay per visit 50% co-ins, after ded If you receive services in addition to office visit, additional
copays, deductibles, or co-ins may apply.
Other $30 copay per visit 50% co-ins, after ded Includes Acupuncture and Manipulative (Chiropractic) Services.
practitioner Manipulative (Chiropractic) Services are limited to 24 visits per
office visit year.
Pre-Authorization required for non-network or benefit reduces
by $1,000 per visit.
Preventive No Charge Not Covered No coverage non-Network.
care/screening- Includes preventive health services specified in the health care
/immunization reform law.
If you have a Diagnostic test Free Standing Provider: 50% co-ins, after ded Pre-Authorization required for non-network for sleep studies or
test (x-ray, blood 30% co-ins, after ded benefit reduces by $1,000 per visit.
work) Hospital-Based: 30% $250 Hospital-Based per occurrence Copayment applies prior to
co-ins, after ded the Annual Deductible.
Imaging Free Standing Provider: 50% co-ins, after ded $250 Hospital-Based per occurrence Copayment applies prior to
(CT/PET 30% co-ins, after ded the Annual Deductible.
scans, MRIs) Hospital-Based: 30% Pre-Authorization required for non-network or benefit reduces
co-ins, after ded by $1,000 per visit.

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 Your Cost If Your Cost If
Common Services You May Need You Use a You Use a Limitations & Exceptions
Medical Event Network Non-Network
Provider Provider
If you need drugs Tier 1 - Your Lowest-Cost Retail: $20 copay Retail: $20 copay Pharmacy Deductible does not apply to Tier 1.
to treat your Option Mail-Order: $50 Provider means pharmacy for purposes of this section.
illness or copay Retail: Up to a 31 day supply.
condition Tier 2 - Your Midrange-Cost Retail: $50 copay Retail: $50 copay Mail-Order: Up to a 90 day supply.
Option Mail-Order: $125 Copay is per prescription order up to the day supply limit listed
More information copay above.
about prescription You may need to obtain certain drugs, including certain specialty
drug coverage is Tier 3 - Your Highest-Cost Retail: $100 copay Retail: $100 copay drugs, from a pharmacy designated by us.
available at www. Option Mail-Order: $250 Certain drugs may not be covered until prior authorization is
welcometouhc.com. copay obtained.
Tier 4 (if applicable) - Retail: 25% co-ins Retail: 25% co-ins You may be required to use a lower-cost drug(s) prior to
Additional High-Cost with a $250 copay with a $250 copay benefits under your policy being available for certain prescribed
Options max. max. drugs.
Mail-Order: 25% See the website listed for information on drugs covered by your
co-ins plan. Not all drugs are covered unless medically necessary.
If a dispensed drug has a chemically equivalent drug at a lower
tier, the cost difference between drugs in addition to any
applicable Copay and/or Co-ins may be applied.
Tier 1 contraceptives are covered at No Charge.
If you have Facility fee (e.g., ambulatory Ambulatory Surg 50% co-ins, after Pre-Authorization required for certain services for non-network
outpatient surgery surgery center) Center / ded or benefit reduces $1,000 per surgery.
Office: 30% $250 Hospital-Based per occurrence Copayment applies prior to
co-ins, after ded the Annual Deductible.
Hospital-Based:
30% co-ins, after
ded
Physician/surgeon fees 30% co-ins, after 50% co-ins, after None
ded ded
If you need Emergency room services $250 copay per $250 copay per Copayment waived if admitted directly to hospital.
immediate visit visit
medical attention
Emergency medical 30% co-ins, after 30% co-ins, after Network Deductible applies.
transportation ded ded

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 Your Cost If Your Cost If
Common Services You May Need You Use a You Use a Limitations & Exceptions
Medical Event Network Non-Network
Provider Provider
Urgent care $75 copay per 50% co-ins, after If you receive services in addition to urgent care, additional
visit ded copays, deductibles, or co-ins may apply.
If you have a Facility fee (e.g., hospital 30% co-ins, after 50% co-ins, after Pre-Authorization required for non-network or benefit reduces
hospital stay room) ded ded by $1,000 per admission.
$250 Inpatient Stay per occurrence Copayment applies prior to
the Annual Deductible.
Physician/surgeon fee 30% co-ins, after 50% co-ins, after None
ded ded
If you have mental Mental/Behavioral health Outpatient Office 50% co-ins, after Pre-Authorization required for certain services for non-network
health, behavioral outpatient services Visits: $30 copay ded or benefit reduces by $1,000 per visit.
health, or per visit . All
substance abuse other outpatient
needs Treatment: 30%
co-ins, after ded
Mental/Behavioral health 30% co-ins, after 50% co-ins, after Pre-Authorization required for non-network or benefit reduces
inpatient services ded ded by $1,000 per admission.
Substance use disorder Outpatient Office 50% co-ins, after Pre-Authorization required for certain services for non-network
outpatient services Visits: $30 copay ded or benefit reduces by $1,000 per visit.
per visit . All
other outpatient
Treatment: 30%
co-ins, after ded
Substance use disorder 30% co-ins, after 50% co-ins, after Pre-Authorization required for non-network or benefit reduces
inpatient services ded ded by $1,000 per admission.
If you are Prenatal and postnatal care No Charge 50% co-ins, after Additional copays, deductibles, or co-ins may apply depending
pregnant ded on services rendered.
Applies to routine prenatal care and office visits. One post-natal
office visit is covered.
Delivery and all inpatient 30% co-ins, after 50% co-ins, after Inpatient Authorization may apply.
services ded ded $250 Inpatient Stay per occurrence Copayment applies prior to
the Annual Deductible.
If you need help Home health care 30% co-ins, after 50% co-ins, after Limited to 100 visits per policy year.
recovering or have ded ded Pre-Authorization required for non-network or benefit reduces
other special by $1,000 per visit.
health needs

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 Your Cost If Your Cost If
Common Services You May Need You Use a You Use a Limitations & Exceptions
Medical Event Network Non-Network
Provider Provider
Rehabilitation services $30 copay per 50% co-ins, after Pre-Authorization required for certain services for non-network
outpatient visit ded or benefit reduces by $1,000 per visit.
Habilitative services $30 copay per 50% co-ins, after Pre-Authorization required for certain services for non-network
outpatient visit ded or benefit reduces by $1,000 per visit.
Skilled nursing care 30% co-ins, after 50% co-ins, after Limited to 100 days per benefit period (combined with Inpatient
ded ded Rehabilitation) .
Pre-Authorization required for non-network or benefit reduces
by $1,000 per admission.
Durable medical equipment 30% co-ins, after 50% co-ins, after Pre-Authorization required for non-network DME over $1,000
ded ded or benefit reduces by $1,000 per item.
Hospice service 30% co-ins, after 50% co-ins, after Inpatient Pre-Authorization required for non-network or
ded ded benefit reduces by $1,000 per admission
If your child needs Eye exam No Charge 50% co-ins One exam per year.
dental or eye care
Glasses 30% co-ins 50% co-ins One pair per year.
Dental check-up No Charge 20% co-ins Cleanings covered 2 times per 12 months. Additional limitations
may apply.

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isnt a complete list. Check your policy or plan document for other excluded services.)
Cosmetic surgery Dental care (Adult) Long-term care Non-emergency care when Private-duty nursing
traveling outside the U.S.
Routine foot care Weight loss programs

Other Covered Services (This isnt a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Acupuncture Bariatric surgery Chiropractic care - 24 visits Hearing aids - 1 every 3 Infertility treatment -
per year years; $2500 per year $2000 lifetime
Routine eye care (Adult) - 1
exam every year

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Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact us at 1-800-782-3740 ; or the Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or www.dol.gov/ebsa/healthreform.

You may also contact the California Department of Insurance, Consumer Communications Bureau Health Unit, 300 South Spring Street, South Tower, Los
Angeles, CA 90013 or at 1-800-927-HELP (4357), 1-800-482-4833 TDD or at www.insurance.ca.gov. Additionally, a consumer assistance program can help
you file your appeal. Contact the California Department of Insurance at the contact information provided above.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does
provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-800-782-3740 .

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3740 .

Chinese 1-800-782-3740 .

Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3740 .

To see examples of how this plan might cover costs for a sample medical situation, see the next page.

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 Select Plus AKSA /405 Coverage Period: Based on group plan year
Coverage Examples Coverage for: Employee/Family | Plan Type: POS

About these Coverage Having a baby Managing type 2 diabetes

Examples: (normal delivery) (routine maintenance of
a well-controlled condition)
These examples show how this plan might Amount owed to providers: $7,540 Amount owed to providers: $5,400
cover medical care in given situations. Use these Plan pays $3,920 Plan pays $3,060
examples to see, in general, how much financial
protection a sample patient might get if they are Patient pays $3,620 Patient pays $2,340
covered under different plans.
Sample care costs: Sample care costs:

This is Hospital charges (mother) $2,700 Prescriptions $2,900

not a cost Routine obstetric care $2,100 Medical Equipment and $1,300
estimator. Hospital charges (baby) $900 Supplies
Anesthesia $900 Office Visits and Procedures $700
Dont use these examples to Education $300
estimate your actual costs Laboratory tests $500
under this plan. The actual Prescriptions $200 Laboratory tests $100
care you receive will be Radiology $200 Vaccines, other preventive $100
different from these Total $5,400
examples, and the cost of Vaccines, other preventive $40
that care will also be Total $7,540
different. Patient pays:
Patient pays: Deductibles $500
See the next page for
important information Deductibles $2,200 Copays $1,800
about these examples. Coinsurance $0
Copays $20
Coinsurance $1,200 Limits or exclusions $40
Limits or exclusions $200 Total $2,340
Total $3,620

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 Select Plus AKSA /405 Coverage Period: Based on group plan year
Coverage Examples Coverage for: Employee/Family | Plan Type: POS

Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example Can I use Coverage Examples to
assumptions behind the show? compare plans?
Coverage Examples?
For each treatment situation, the Coverage
Example helps you see how deductibles, Yes . When you look at the Summary of
Costs dont include premiums. Benefits and Coverage for other plans, youll
copayments, and coinsurance can add up. It
Sample care costs are based on national find the same Coverage Examples. When
also helps you see what expenses might be left
averages supplied by the U.S. Department you compare plans, check the "Patient Pays"
up to you to pay because the service or
of Health and Human Services, and arent box in each example. The smaller that
treatment isnt covered or payment is limited.
specific to a particular geographic area or number, the more coverage the plan
health plan. provides.
The patients condition was not an Does the Coverage Example
excluded or preexisting condition. predict my own care needs? Are there other costs I should
All services and treatments started and consider when comparing plans?
ended in the same coverage period. No . Treatments shown are just examples.
There are no other medical expenses for The care you would receive for this
any member covered under this plan. condition could be different based on your Yes . An important cost is the premium
Out-of-pocket expenses are based only on doctors advice, your age, how serious your you pay. Generally, the lower your
treating the condition in the example. condition is, and many other factors. premium, the more youll pay in
out-of-pocket costs, such as copayments,
The patient received all care from deductibles, and coinsurance. You should
in-network providers. If the patient had Does the Coverage Example also consider contributions to accounts such
received care from out-of-network predict my future expenses? as health savings accounts (HSAs), flexible
providers, costs would have been higher. spending arrangements (FSAs) or health
If other than individual coverage, the reimbursement accounts (HRAs) that help
Patient Pays amount may be more. No . Coverage Examples are not cost you pay out-of-pocket expenses.
estimators. You cant use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on the
care you receive, the prices your providers
charge, and the reimbursement your health
plan allows.

Questions: Call 1-800-782-3740 or visit us at www.welcometouhc.com. If you arent clear about any of the
underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or
www.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.
SBCCA14AKSA 8 of 8