ESBD_525520_1782850757610_RFP 2606-001 Addendum 5 Question Number 4 Document.pdf

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services TRAVIS COUNTY HEALTHCARE DISTRICT - CENTRAL HEALTH : Aetna

Open Access® Aetna SelectSM - HDHP

Coverage Period: 01/01/2026-12/31/2026

Coverage for: Individual + Family | 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. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1- 888-982-3862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible? In-Network: Individual $3,300 / Family $6,600.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network preventive care is covered before you meet your deductible.

This plan covers some items and services even if you haven't yet met the 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 https://www.healthcare.gov/coverage/preventive-care-benefits/

Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan? In-Network: Individual $4,000 / Family $8,000.

The out–of–pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out–of–pocket limits until the overall family out–of–pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges & health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See www.aetna.com/docfind or call 1-888- 982-3862 for a list of in-network providers.

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 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 see a specialist? No. You can see the specialist you choose without a referral.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network

Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 20% coinsurance Not covered None Specialist visit 20% coinsurance Not covered None

Preventive care /screening /immunization No charge Not covered 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.

If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance Not covered None Imaging (CT/PET scans, MRIs) 20% coinsurance Not covered None

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.aetnapharmac y.com/standard

Generic drugs 20% coinsurance (retail & mail order) Not covered Covers 30 day supply (retail), 31-90 day supply

(retail & mail order). Includes contraceptive drugs & devices obtainable from a pharmacy. No charge for preferred generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring precertification for coverage. Your cost will be higher for choosing Brand over Generics.

Preferred brand drugs 20% coinsurance (retail & mail order) Not covered

Non-preferred brand drugs 20% coinsurance (retail & mail order) Not covered

Specialty drugs Applicable cost as noted above for generic or brand drugs

Not covered All prescriptions must be filled through the Aetna Specialty Pharmacy Network.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

If you need immediate medical attention

Emergency room care 20% coinsurance 20% coinsurance Out-of-network emergency use paid the same as in-network. No coverage for non-emergency use.

Emergency medical transportation 20% coinsurance 20% coinsurance Out-of-network emergency use paid the same as in-network. Non-emergency transport: not covered, except if pre-authorized.

Urgent care 20% coinsurance Not covered No coverage for non-urgent use.

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Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network

Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

CVS Minute Clinic No charge

Teladoc $15 copay;

deductible doesn’t apply

Specialist visit $30 copay; deductible doesn’t apply

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

If you need mental health, behavioral health, or substance abuse services

Outpatient services Office & other outpatient services:

20% coinsurance

Not covered None

Inpatient services 20% coinsurance Not covered None

If you are pregnant Office visits No charge Not covered Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Childbirth/delivery professional services 20% coinsurance Not covered Childbirth/delivery facility services 20% coinsurance Not covered

If you need help recovering or have other special health needs

Home health care 20% coinsurance Not covered 60 visits/calendar year.

Rehabilitation services 20% coinsurance Not covered Limited to 20 visits per benefit, per year.

Includes physical, occupational, and speech therapies and spinal manipulation.

Habilitation services 20% coinsurance Not covered None Skilled nursing care 20% coinsurance Not covered 60 days/calendar year.

Durable medical equipment 20% coinsurance Not covered Limited to 1 durable medical equipment for same/similar purpose. Excludes repairs for misuse/abuse.

Hospice services 20% coinsurance Not covered None

If your child needs dental or eye care

Children's eye exam No charge Not covered 1 routine eye exam/24 months Children's glasses Not covered Not covered Not covered.

Children's dental check-up Not covered Not covered Not covered.

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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.)

• Bariatric surgery

• Cosmetic surgery

Dental care (Adult & Child) Glasses (Child) Long-term care

Non-emergency care when traveling outside the U.S.

Routine foot care Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Chiropractic care - 20 visits/calenar year.

Hearing aids - 1 hearing aid per ear/3 years.

Acupuncture – In lieu of anesthesia only

Infertility treatment - Limited to the diagnosis & treatment of underlying medical condition including artificial insemination.

Private-duty nursing - 70- 8 hour shifts/calendar year.

Routine eye care (Adult) - 1 routine eye exam/24 months.

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 1-888-982-3862.

• 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 Insurance

Oversight, 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 should contact 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 about the 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 information about 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 a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

• If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number at 1-888-982-3862. 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 Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.

• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:

http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.

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Does this plan provide Minimum Essential Coverage? Yes.

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet Minimum Value Standards? No.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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

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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

The plan's overall deductible $3,300 Specialist coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700 In this example, Peg would pay:

Cost Sharing Deductibles $3,300 Copayments $0 Coinsurance $700 What isn't covered Limits or exclusions $60 The total Peg would pay is $4,060

Primary care provider office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Diabetic supplies (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Cost Sharing

Deductibles $3,300

Copayments $0

Coinsurance $400

What isn't covered

Limits or exclusions $20

The total Joe would pay is $3,720

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800 In this example, Mia would pay:

Cost Sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn't covered Limits or exclusions $0 The total Mia would pay is $2,800

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Mia’s Simple Fracture (in-network emergency room visit and follow up care)

The plan would be responsible for the other costs of these EXAMPLE covered services.

Assistive Technology Persons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-982-3862.

Smartphone or Tablet To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.

Non-Discrimination Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, disability, gender identity or sexual orientation.

We provide free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

TTY: 711

Language Assistance:

To access language services at no cost to you, call 1-888-982-3862.

Albanian - Për shërbime përkthimi falas për ju, telefononi 1-888-982-3862.

Amharic - 1-888-982-3862

Arabic - 1-888-982-3862

Armenian - 1-888-982-3862 :

Bahasa Indonesia - Untuk bantuan dalam bahasa Indonesia, silakan hubungi 1-888-982-3862 tanpa dikenakan biaya.

Bantu-Kirundi - Kugira uronke serivisi z’indimi atakiguzi, hamagara 1-888-982-3862.

Bengali-Bangala - : 1-888-982-3862

Bisayan-Visayan - Ngadto maakses ang mga serbisyo sa pinulongan alang libre, tawagan sa 1-888-982-3862.

Burmese - 1-888-982-3862

Catalan - Per accedir a serveis lingüístics sense cap cost per vostè, telefoni al 1-888-982-3862.

Chamorro - Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang 1-888-982-3862.

Cherokee - , 1-888-982-3862.

Chinese -

Choctaw - Anumpa tohsholi I toksvli ya peh pilla ho ish I paya hinla, I paya 1-888-982-3862.

Cushite - Tajaajiiloota afaanii garuu bilisaa ati argaachuuf,bilbili 1-888-982-3862.

Dutch - Voor gratis toegang tot taaldiensten, bell 1-888-982-3862.

French - Afin d'accéder aux services langagiers sans frais, composez le 1-888-982-3862.

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Hawaiian - No ka wala au ana me ka lawelawe lelo e kahea aku i k ia helu kelepona 1-888-982-3862. K ki ole

Hindi - ,1-888-982- 8 2

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Indonesian - Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi 1-888-982-3862.

Italian - Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero 1-888-982-3862.

Japanese -

Karen - 1-888-982-3862 Korean -

Kru-Bassa - M dyi wu u-dù kà kò ò dyi m ú n P dyi n , n , á n à n à k : 1-888-982-3862 Kurdish - 1-888-982-3862

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Mon-Khmer, 1-888-982-3862 Cambodian - Navajo - 1-888-982-3862.

Nepali - 1-888-982-3862

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Pennsylvania Dutch - Um Schprooch Services zu griege mitaus Koscht, ruff 1-888-982-3862.

Persian - . 1-888-982-3862 Polish - -888-982-3862.

Portuguese - Para acessar os serviços de idiomas sem custo para você, ligue para 1-888-982-3862.

Punjabi - , 1-888-982-3862 ‘

Romanian - -888-982-3862.

Russian - , 1-888-982-3862.

Samoan - Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala’au le 1-888-982-3862.

Serbo-Croatian - -888-982-3862.

Spanish - Para acceder a los servicios de idiomas sin costo, llame al 1-888-982-3862.

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TRAVIS COUNTY HEALTHCARE DISTRICT - CENTRAL HEALTH : Aetna

Open Access® Aetna SelectSM - Texas Med Neighborhood

Coverage Period: 01/01/2026-12/31/2026

Coverage for: Individual + Family | 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. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1- 888-982-3862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible? In-Network: Individual $1,500 / Family $2,500.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network office visits, prescription drugs & preventive care are covered before you meet your deductible.

This plan covers some items and services even if you haven't yet met the 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 https://www.healthcare.gov/coverage/preventive-care-benefits/

Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan? In-Network: Individual $4,000 / Family $8,000.

The out–of–pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out–of–pocket limits until the overall family out–of–pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges & health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See www.aetna.com/docfind or call 1-888- 982-3862 for a list of in-network providers.

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 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.

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network

Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $25 copay/visit, deductible doesn't apply

Not covered None

Specialist visit

Deductible doesn't apply: $40 copay/visit for Tier 1; $50 copay/visit for Tier 2

Not covered None

Preventive care /screening /immunization No charge Not covered 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.

If you have a test Diagnostic test (x-ray, blood work) No charge Not covered None Imaging (CT/PET scans, MRIs) 20% coinsurance Not covered None

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.aetnapharmac y.com/standard

Generic drugs

Copay/prescription, deductible doesn't apply: $15 for 31 day supply (retail), $37.50 for 32-90 day supply (retail & mail order)

Not covered

Covers 31 day supply (retail), 32-90 day supply (retail at Extended Day Supply Network Pharmacy & mail order). Includes contraceptive drugs & devices obtainable from a pharmacy. No charge for preferred generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring step therapy for coverage. Your cost will be higher for choosing Brand over Generics; cost difference penalty doesn't apply to out-of-pocket limit.

Review your Aetna Extended Day Supply Network provider directory for a list of network providers.

Preferred brand drugs

Copay/prescription, deductible doesn't apply: $40 for 31 day supply (retail), $100 for 32-90 day supply (retail & mail order)

Not covered

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Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network

Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

Non-preferred brand drugs

Copay/prescription, deductible doesn't apply: $75 for 31 day supply (retail), $187.50 for 32-90 day supply (retail & mail order)

Not covered

Specialty drugs Applicable cost as noted above for generic or brand drugs

Not covered All prescriptions must be filled through the Aetna Specialty Performance Pharmacy Network.

Precertification required for coverage.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

If you need immediate medical attention

Emergency room care 20% coinsurance after $500 copay/visit

20% coinsurance after $500 copay/visit

Out-of-network emergency use paid the same as in-network. No coverage for non-emergency use.

Emergency medical transportation 20% coinsurance 20% coinsurance Out-of-network emergency use paid the same as in-network. Non-emergency transport: not covered, except if pre-authorized.

Urgent care $50 copay/visit, deductible doesn't apply

Not covered No coverage for non-urgent use.

CVS Minute Clinic No charge

Teladoc $25 copay;

deductible doesn’t apply

Specialist Teladoc visit $40 copay; deductible doesn’t apply

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

564558-184953-750008 Page 4 of 7

Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information In-Network

Provider (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you need mental health, behavioral health, or substance abuse services

Outpatient services

Office: $40 copay/visit, deductible doesn't apply; other outpatient services:

no charge

Not covered None

Inpatient services 20% coinsurance Not covered None

If you are pregnant Office visits No charge Not covered Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Childbirth/delivery professional services 20% coinsurance Not covered Childbirth/delivery facility services 20% coinsurance Not covered

If you need help recovering or have other special health needs

Home health care 20% coinsurance Not covered 60 visits/calendar year.

Rehabilitation services $40 copay/visit, deductible doesn't apply

Not covered Limited to 20 visits per benefit, per year.

Includes physical, occupational, and speech therapies and spinal manipulation.

Habilitation services No charge Not covered None Skilled nursing care 20% coinsurance Not covered 60 days/calendar year.

Durable medical equipment 20% coinsurance Not covered Limited to 1 durable medical equipment for same/similar purpose. Excludes repairs for misuse/abuse.

Hospice services 20% coinsurance Not covered None

If your child needs dental or eye care

Children's eye exam No charge Not covered 1 routine eye exam/24 months.

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

564558-184953-750008 Page 5 of 7

Bariatric surgery Cosmetic surgery

Dental care (Adult & Child) Glasses (Child) Long-term 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.)

Chiropractic care - 20 visits/calendar year.

Hearing aids - 1 hearing aid per ear/3 years.

Acupuncture – In lieu of anesthesia only

Infertility treatment - Limited to the diagnosis & treatment of underlying medical condition, including artificial insemination.

Private-duty nursing - 70- 8 hour

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:

• 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 Insurance

Oversight, 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 should contact 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 about

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 information about 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 a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

• If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number at 1-888-982-3862. 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 Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.

• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:

http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

564558-184953-750008 Page 6 of 7

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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

564558-184953-750008 Page 7 of 7

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 1-888-982-3862.

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

The plan's overall deductible $1,000 Specialist copayment $40

Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services

Cost Sharing Deductibles $1,000 Copayments $10 Coinsurance $1,800 What isn't covered

The total Peg would pay is $2,870 disease education) Diagnostic tests (blood work) Prescription drugs

Deductibles $0

Copayments $1,300

Coinsurance $0

The total Joe would pay is $1,320 supplies) Diagnostic test (x-ray)

Cost Sharing Deductibles $1,000 Copayments $200 Coinsurance $200 What isn't covered

The total Mia would pay is $1,400 hospital delivery)

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

Mia’s Simple Fracture (in-network emergency room visit and follow up

Persons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-982-3862.

To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.

Non-Discrimination Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, disability, gender identity or sexual orientation.

We provide free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates

Arabic - 1-888-982-3862

Armenian - 1-888-982-3862 :

Bahasa Indonesia - Untuk bantuan dalam bahasa Indonesia, silakan hubungi 1-888-982-3862 tanpa dikenakan biaya.

Bantu-Kirundi - Kugira uronke serivisi z’indimi atakiguzi, hamagara 1-888-982-3862.

Bengali-Bangala - : 1-888-982-3862

Bisayan-Visayan - Ngadto maakses ang mga serbisyo sa pinulongan alang libre, tawagan sa 1-888-982-3862.

Burmese - 1-888-982-3862

Catalan - Per accedir a serveis lingüístics sense cap cost per vostè, telefoni al 1-888-982-3862.

Chamorro - Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang 1-888-982-3862.

Cherokee - , 1-888-982-3862.

Chinese -

Choctaw - Anumpa tohsholi I toksvli ya peh pilla ho ish I paya hinla, I paya 1-888-982-3862.

Cushite - Tajaajiiloota afaanii garuu bilisaa ati argaachuuf,bilbili 1-888-982-3862.

Dutch - Voor gratis toegang tot taaldiensten, bell 1-888-982-3862.

French - Afin d'accéder aux services langagiers sans frais, composez le 1-888-982-3862.

French Creole - Pou jwenn sèvis lang gratis, rele 1-888-982-3862.

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Greek -

Hawaiian - No ka wala au ana me ka lawelawe lelo e kahea aku i k ia helu kelepona 1-888-982-3862. K ki ole

Hmong - Xav tau kev pab txhais lus tsis muaj nqi them rau koj, hu 1-888-982-3862.

Igbo - Iji nwetaòhèrè na r gas as s n'efu, kp 1-888-982-3862

Ilocano - Tapno maaksesyo dagiti serbisio maipapan iti pagsasao nga awan ti bayadanyo, tawagan ti 1-888-982-3862.

Indonesian - Untuk mengakses layanan bahasa tanpa dikenakan biaya, hubungi 1-888-982-3862.

Italian - Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero 1-888-982-3862.

Japanese -

Karen - 1-888-982-3862 Korean -

Kru-Bassa - M dyi wu u-dù kà kò ò dyi m ú n P dyi n , n , á n à n à k : 1-888-982-3862 Kurdish - 1-888-982-3862

Laotian - , 1-888-982-3862 Marathi - ,, 1-888-982- 8 2 .

Marshallese - Nan etal nan jikin jiban ikijen Kajin ilo an ejelok onen nan kwe, kirlok 1-888-982-3862.

Micronesian- Pohnpeyan - Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih 1-888-982-3862.

Mon-Khmer, 1-888-982-3862 Cambodian - Navajo - 1-888-982-3862.

Nepali - 1-888-982-3862

Nilotic-Dinka - Të k r yïn w de thokic ke cïn wëu k r keek tën Ke c l k c ye k c ku ny ne n mba 1-888-982-3862.

Polish - 1-888-982-3862.

Romanian - Pentru a accesa gratuit -888-982-3862.

Russian - , 1-888-982-3862.

Samoan - Mo le mauaina o auaunaga tau gagana e aunoa ma se totogi, vala’au le 1-888-982-3862.

Serbo-Croatian - -888-982-3862.

Spanish - Para acceder a los servicios de idiomas sin costo, llame al 1-888-982-3862.

Sudanic-Fulfude - Heeba a nasta jangirde djey wolde wola chede bo apelou lamba 1-888-982-3862.

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Telugu - o , 1-888-982-3862

Thai - 1-888-982-3862.

Tongan - Kapau ‘oku ke fiema’u -888-982-3862.

Trukese - -888-982-3862.

Turkish - -888-982-

Ukrainian - -888-982-3862.

Urdu - . 1-888-982-3862

Vietnamese - N u quý v mu n s d ng mi n ph các d ch v ngôn ng , hãy g i t i s 1-888-982-3862.

564558-184953-750009 Page 1 of 7

TRAVIS COUNTY HEALTHCARE DISTRICT - CENTRAL HEALTH : Seton

Open Access® Aetna SelectSM - ACO

Coverage Period: 01/01/2026-12/31/2026

Coverage for: Individual + Family | 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. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1- 888-982-3862. 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 https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

Seton Health In-Network: Individual $1,000 / Family $2,000.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. In-network office visits, prescription drugs & preventive care are covered before you meet your deductible.

This plan covers some items and services even if you haven't yet met the 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 https://www.healthcare.gov/coverage/preventive-care-benefits/

Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Seton Health In-Network: Individual $4,000 / Family $8,000.

The out–of–pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out–of–pocket limits until the overall family out–of–pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges & health care this plan doesn't cover. Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See www.aetna.com/docfind or call 1-888- 982-3862 for a list of Seton Health In-Network providers.

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 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.

564558-184953-750009 Page 2 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Seton Health In-

Network (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $15 copay/visit, deductible doesn't apply

Not covered None

Specialist visit $30 copay/visit, deductible doesn't apply

Not covered None

Preventive care /screening /immunization No charge Not covered 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.

If you have a test Diagnostic test (x-ray, blood work) No charge Not covered None Imaging (CT/PET scans, MRIs) 20% coinsurance Not covered None

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.aetnapharmac y.com/standard

Generic drugs

Copay/prescription, deductible doesn't apply: $15 for 31 day supply (retail), $37.50 for 32-90 day supply (retail & mail order)

Not covered

Covers 31 day supply (retail), 32-90 day supply (retail at Extended Day Supply Network Pharmacy & mail order). Includes contraceptive drugs & devices obtainable from a pharmacy. No charge for preferred generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring step therapy for coverage. Your cost will be higher for choosing Brand over Generics; cost difference penalty doesn't apply to out-of-pocket limit.

Review your Aetna Extended Day Supply Network provider directory for a list of network providers.

Preferred brand drugs

Copay/prescription, deductible doesn't apply: $40 for 31 day supply (retail), $100 for 32-90 day supply (retail & mail order)

Not covered

564558-184953-750009 Page 3 of 7

Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Seton Health In-

Network (You will pay the least)

Out-of-Network Provider

(You will pay the most)

Non-preferred brand drugs

Copay/prescription, deductible doesn't apply: $75 for 31 day supply (retail), $187.50 for 32-90 day supply (retail & mail order)

Not covered

Specialty drugs Applicable cost as noted above for generic or brand drugs

Not covered All prescriptions must be filled through the Aetna Specialty Performance Pharmacy Network.

Precertification required for coverage.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

If you need immediate medical attention

Emergency room care 20% coinsurance after $500 copay/ visit

20% coinsurance after $500 copay/ visit

Out-of-network emergency use paid the same as in-network. No coverage for non-emergency use.

Emergency medical transportation 20% coinsurance 20% coinsurance Out-of-network emergency use paid the same as in-network. Non-emergency transport: not covered, except if pre-authorized.

Urgent care $50 copay/visit, deductible doesn't apply

Not covered No coverage for non-urgent use.

CVS Minute Clinic No charge

Teladoc $15 copay;

deductible doesn’t apply

Specialist visit $30 copay; deductible doesn’t apply

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance Not covered None Physician/surgeon fees 20% coinsurance Not covered None

564558-184953-750009 Page 4 of 7

Event Services You May Need

What You Will Pay Limitations, Exceptions, & Other Important

Information Seton Health In-

Network (You will pay the least)

Out-of-Network Provider

(You will pay the most)

If you need mental health, behavioral health, or substance abuse services

Outpatient services

Office: $30 copay/visit, deductible doesn't apply; other outpatient services:

no charge

Not covered None

Inpatient services 20% coinsurance Not covered None

If you are pregnant Office visits No charge Not covered Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Childbirth/delivery professional services 20% coinsurance Not covered Childbirth/delivery facility services 20% coinsurance Not covered

If you need help recovering or have other special health needs

Home health care 20% coinsurance Not covered 60 visits/calendar year.

Rehabilitation services $30 copay/visit, deductible doesn't apply

Not covered Limited to 20 visits per benefit, per year.

Includes physical, occupational, and speech therapies and spinal manipulation.

Habilitation services No charge Not covered None Skilled nursing care 20% coinsurance Not covered 60 days/calendar year.

Durable medical equipment 20% coinsurance Not covered Limited to 1 durable medical equipment for same/similar purpose. Excludes repairs for misuse/abuse.

Hospice services 20% coinsurance Not covered None

If your child needs dental or eye care

Children's eye exam No charge Not covered 1 routine eye exam/24 months.

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

564558-184953-750009 Page 5 of 7

Bariatric surgery Cosmetic surgery

Dental care (Adult & Child) Glasses (Child) Long-term 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.)

Chiropractic care - 20 visits/calenar year.

Hearing aids - 1 hearing aid per ear/3 years.

Acupuncture – In lieu of anesthesia only

Infertility treatment - Limited to the diagnosis & treatment of underlying medical condition including artificial insemination.

Private-duty nursing - 70- 8 hour

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:

• 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 Insurance

Oversight, 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 should contact 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 about

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 information about 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 a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

• If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number at 1-888-982-3862. 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 Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.

• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:

http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

564558-184953-750009 Page 6 of 7

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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

564558-184953-750009 Page 7 of 7

Note: These numbers assume the patient does not participate in the plan’s wellness…