Exhibit_B_-_City_of_Tampa_Simple_Wellness_Plans_2026_SPD_(2).pdf

City of Tampa Simple Wellness Medical Plans ($0, $250, $500, $750, $1000

Effective: January 1, 2026 Group Number: 730334

Summary Plan Description

CITY OF TAMPA SIMPLE WELLNESS MEDICAL PLANS

i TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 - WELCOME

SECTION 2 - INTRODUCTION

Eligibility

How to Enroll

When Coverage Begins

Changing Your Coverage

SECTION 3 - HOW THE PLAN WORKS

Accessing Benefits

Eligible Expenses

Dollar First Benefit Allowance

Annual Deductible

Copayment

Coinsurance

Out-of-Pocket Maximum

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

Care Management

Prior Authorization

Special Note Regarding Medicare

SECTION 5 - PLAN HIGHLIGHTS

Simple Wellness $0 Plan

Payment Terms and Features

Schedule of Benefits

Simple Wellness $250, $500, $750 and $1,000 Plans

Payment Terms and Features

Schedule of Benefits

SECTION 6 - ADDITIONAL COVERAGE DETAILS

Ambulance Services

Bones or Joints of the Jaw and Facial Region

Cellular and Gene Therapy ii TABLE OF CONTENTS

Cleft Lip/Cleft Palate Treatment

Clinical Trials

Congenital Heart Disease (CHD) Surgeries

Dental Services - Accident Only

Dental Services – Anesthesia and Hospitalization

Diabetes Services

Durable Medical Equipment (DME)

Emergency Health Services - Outpatient

Enteral Formulas

Home Health Care

Hospice Care

Hospital - Inpatient Stay

Lab, X-Ray and Diagnostics - Outpatient

Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine

- Outpatient

Mental Health Services

Neurobiological Disorders - Autism Spectrum Disorder Services

Additional Autism Spectrum Disorder Benefits

Obesity Surgery

Osteoporosis Treatment

Ostomy Supplies

Pharmaceutical Products - Outpatient

Physician Fees for Surgical and Medical Services

Physician's Office Services - Sickness and Injury

Pregnancy - Maternity Services

Preventive Care Services

Prosthetic Devices

Reconstructive Procedures

Rehabilitation Services - Outpatient Therapy and Manipulative Treatment

Scopic Procedures - Outpatient Diagnostic and Therapeutic

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Substance-Related and Addictive Disorders Services

Surgery - Outpatient iii TABLE OF CONTENTS

Therapeutic Treatments - Outpatient

Transplantation Services

Urgent Care Center Services

Urinary Catheters

Vision Examinations

Wigs

SECTION 7 - CLINICAL PROGRAMS AND RESOURCES

Consumer Solutions and Self-Service Tools

Disease Management Services

Complex Medical Conditions Programs and Services

Women's Health/Reproductive

SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER

Alternative Treatments

Dental

Devices, Appliances and Prosthetics

Drugs

Experimental or Investigational or Unproven Services

Gender Dysphoria

Foot Care

Medical Supplies and Equipment

Nutrition

Personal Care, Comfort or Convenience

Physical Appearance

Procedures and Treatments

Providers

Services Provided under Another Plan

Transplants

Travel

Types of Care, Supportive Services, and Housing

Vision and Hearing

All Other Exclusions

SECTION 9 - CLAIMS PROCEDURES

iv TABLE OF CONTENTS

Network Benefits

Non-Network Benefits

Prescription Drug Benefit Claims

How To File Your Claim

Health Statements

Explanation of Benefits (EOB)

Claim Denials and Appeals

External Review Program

Standard External Review

Limitation of Action

SECTION 10 - COORDINATION OF BENEFITS (COB)

SECTION 11 - SUBROGATION AND REIMBURSEMENT

SECTION 12 - WHEN COVERAGE ENDS

Coverage for a Disabled Child

Extended Coverage for Students

Extended Coverage for Total Disability

Continuing Coverage Through COBRA

When COBRA Ends

Uniformed Services Employment and Reemployment Rights Act

SECTION 13 - OTHER IMPORTANT INFORMATION

Qualified Medical Child Support Orders (QMCSOs)

Your Relationship with UnitedHealthcare and City of Tampa

Your Relationship with Providers

Interpretation of Benefits

Information and Records

Incentives to Providers

Incentives to You

Rebates and Other Payments

Workers' Compensation Not Affected

Future of the Plan

Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement Policies v TABLE OF CONTENTS

SECTION 14 - GLOSSARY

SECTION 15 - PRESCRIPTION DRUGS

Benefits for Prescription Drug Products

What You Must Pay

Payment Terms and Features - Outpatient Prescription Drugs

Identification Card (ID Card) – Network Pharmacy

Benefit Levels

Retail

Mail Order

Designated Pharmacies

Assigning Prescription Drug Products to the PDL

Prescription Drug Benefit Claims

Limitation on Selection of Pharmacies

Supply Limits

If a Brand-name Drug Becomes Available as a Generic

Special Programs

Prescription Drug Products Prescribed by a Specialist Physician

Step Therapy

Rebates and Other Discounts

Coupons, Incentives and Other Communications

Exclusions - What the Prescription Drug Plan Will Not Cover

Glossary - Prescription Drugs

SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION

ATTACHMENT I - HEALTH CARE REFORM NOTICES

Patient Protection and Affordable Care Act ("PPACA")

ATTACHMENT II - NOTICES

Women's Health and Cancer Rights Act of 1998

Statement of Rights under the Newborns’ and Mothers’ Health Protection Act

ATTACHMENT III – Nondiscrimination

ATTACHMENT IV – NOTICE OF AVAILABILITY OF LANGUAGE ASSISTANCE AND

AUXILIARY AIDS AND SERVICES

vi TABLE OF CONTENTS

1 SECTION 1 - WELCOME

SECTION 1 - WELCOME

Quick Reference Box

■ Member services, claim inquiries, Personal Health Support and Mental Health/Substance-Related and Addictive Disorders Administrator: (800) 918-8667;

■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 740800, Atlanta, GA 30374-0800; and

■ Online assistance: www.myuhc.com.

City of Tampa is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members. It includes summaries of:

■ who is eligible;

■ services that are covered, called Covered Health Services;

■ services that are not covered, called Exclusions;

■ how Benefits are paid; and

■ your rights and responsibilities under the Plan.

This SPD is designed to meet your information needs. It supersedes any previous printed or electronic SPD for this Plan.

City of Tampa intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice subject to any collective bargaining agreements between the Employer and various unions, if applicable. This SPD is not to be construed as a contract of or for employment.

UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. City of Tampa is solely responsible for paying Benefits described in this SPD.

Please read this SPD thoroughly to learn how the Plan works. If you have questions contact City of Tampa at (813) 274-8041 or call the number on your ID card.

2 SECTION 1 - WELCOME

How To Use This SPD

■ Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.

■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.

■ You can find copies of your SPD and any future amendments at www.tampagov.net or request printed copies by contacting City of Tampa at (813)-274-8041.

■ Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.

■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.

■ City of Tampa is also referred to as Group.

■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.

http://www.tampagov.net/

3 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes:

■ Who's eligible for coverage under the Plan;

■ The factors that impact your cost for coverage;

■ Instructions and timeframes for enrolling yourself and your eligible Dependents;

■ When coverage begins; and

■ When you can make coverage changes under the Plan.

Eligibility

You are eligible to enroll in the Plan if you are a regular full-time Employee, a person that retires from the City of Tampa, a part-time employee who has a full-time status for the purposes of health insurance coverage who is scheduled to work at least 30 hours per week, and any other part-time Employee who is eligible by other guidelines as determined by the City of Tampa.

Effective January 1, 2018 retirees not enrolled in the City’s group health coverage as of this date will no longer be allowed to enroll in group health coverage in the future. Should current or future retirees/surviving spouses elect to waive enrollement or if dropped from coverage due to non-payment, they will not be permitted to enroll in group health coverage at a later date.

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

■ your Spouse (includes Domestic Partner), as defined in Section 14, Glossary;

■ your or your Spouse's child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption, a child placed for foster care, or a child for whom you or your Spouse are the legal guardian;

■ a child placed for foster care;

■ a newborn child of an Enrolled Dependent. The newborn child may be covered from birth to 18 months of age;

■ an unmarried child age 26 or over who is or becomes disabled and dependent upon you.

To be eligible for coverage under the Plan, a Dependent must reside within the United States.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. In addition, if you and your Spouse are both covered under the Plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Plan, only one parent may enroll your child as a Dependent.

4 SECTION 2 - INTRODUCTION

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

In the event that your Dependent meets the following requirements, extended coverage is available for that Dependent up to the age of 30. Contact City of Tampa at (813)-274-8041 for details. To be eligible for extended coverage, a Dependent must satisfy the following:

■ is unmarried and does not have a dependent of his or her own;

■ is a resident of Florida or a Full-Time pr Part-Time Student, and

■ is not provided coverage as a named subscriber, insured, enrollee or covered person under any other group, blanket, or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Title XVIII of the Social Security Act.

If such a Dependent's coverage is terminated after the end of the calendar year in which the Dependent reached age 26, the child is not eligible to be covered under the Plan unless the Dependent was continuously covered by Creditable Coverage without a gap in coverage of more than 63 days.

A child who is covered under extended coverage provisions set forth above ceases to be eligible as a Dependent on the last day of the calendar year following the child's attainment of the limiting age or when the child no longer meets the requirements.

Cost of Coverage

You and City of Tampa may share in the cost of the Plan. Your contribution amount depends on your classification, the Plan you select and the family members you choose to enroll.

Your contributions are deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld -and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

Note: The Internal Revenue Service generally does not consider Domestic Partners and their children eligible Dependents. Therefore, the value of City of Tampa's cost in covering a Domestic Partner may be imputed to the Employee as income. In addition, the share of the Employee's contribution that covers a Domestic Partner and their children may be paid using after-tax payroll deductions. This may also apply to your dependent children age 26 and over.

Your contributions are subject to review and City of Tampa reserves the right to change your contribution amount from time to time.

You can obtain current contribution rates by calling City of Tampa at (813)-274-8041 or logging onto www.tampagov.net

5 SECTION 2 - INTRODUCTION

How to Enroll

To enroll, call City of Tampa at (813)-274-8041 or log onto www.tampagov.net within 31 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 31 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Open Enrollment will become effective the following January 1.

Important If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child, placement for foster care, or other family status change, you must contact City of Tampa at (813)-274-8041 within 31 days of the event.

Otherwise, you will need to wait until the next annual Open Enrollment to change your elections.

When Coverage Begins

Once City of Tampa receives your properly completed enrollment, coverage will begin after completion of one full pay period of employment. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the first of the month following the date City of Tampa receives notice of your marriage, provided you notify City of Tampa within 31 days of your marriage. Coverage for Dependent children, except for newborns, acquired through, adoption, or placement for adoption, placement for foster care is effective the date of the family status change, provided you notify City of Tampa within 31 days of the birth, adoption, or placement.

For newborns, coverage begins at the moment of birth if the newborn is enrolled by you as described below. For newborns who are placed for adoption or foster care, coverage begins from the moment of birth if there is an agreement to place or adopt the newborn and the newborn is ultimately placed in the your home. For newborns, adopted children and children placed for foster care, no Premium will be charged for the first 31 days if written notice to enroll the new dependent is given within 31 days of the event. If you fail to enroll the new dependent within 31 days but do so within 63 days of the event, you will be required to pay an additional Premium from the date of birth or placement. If written notice is not given within 63 days of birth or placement, the newborn, foster child or adopted child may be enrolled during any Open Enrollment Period.

If You Are Hospitalized When Your Coverage Begins

If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

6 SECTION 2 - INTRODUCTION

You should notify UnitedHealthcare within 48 hours of the day your coverage begins, or as soon as is reasonably possible. Network Benefits are available only if you receive Covered Health Services from Network providers.

Use Your Prior Health Care Coverage

If you have prior coverage that extends benefits for a particular condition or a disability, the Plan will not pay Benefits for health care services for that condition or disability until the prior coverage ends. Benefits for that particular condition or disability are subject to your prior coverage.

Changing Your Coverage

You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

■ your marriage, divorce, legal separation or annulment;

■ registering a Domestic Partner;

■ the birth, adoption, placement for adoption, or legal guardianship of a child;

■ a change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan;

■ loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis;

■ the death of a Dependent;

■ your Dependent child no longer qualifying as an eligible Dependent;

■ a change in your or your Spouse's position or work schedule that impacts eligibility for health coverage;

■ contributions were no longer paid by the employer (This is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer);

■ you or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent;

■ benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent;

■ termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact City of Tampa within 60 days of termination);

■ you or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact City of Tampa within 60 days of determination of subsidy eligibility);

■ a strike or lockout involving you or your Spouse; or

■ a court or administrative order.

7 SECTION 2 - INTRODUCTION

Unless otherwise noted above, if you wish to change your elections, you must contact City of Tampa within 31 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.

Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

Change in Family Status - Example Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in City of Tampa's medical plan, because her husband, Tom, has family coverage under his employer's medical plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical coverage. Due to this family status change, Jane can elect family medical coverage under City of Tampa's medical plan outside of annual Open Enrollment.

8 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes:

■ Network and Non-Network Benefits;

■ Eligible Expenses;

■ Dollar First Benefit Allowance;

■ Annual Deductible;

■ Copayment;

■ Coinsurance; and

■ Out-of-Pocket Maximum.

Accessing Benefits

As a participant in this Plan, you have the freedom to choose the Physician or health care professional you prefer each time you need to receive Covered Health Services. The choices you make affect the amounts you pay, as well as the level of Benefits you receive and any benefit limitations that may apply.

You are eligible for the Network level of Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare to provide those services.

You can choose to receive Designated Network Benefits, Network Benefits or non-Network Benefits.

Depending on the geographic area and the service you receive, you may have access through UnitedHealthcare's Shared Savings Program to non-Network providers who have agreed to discounts negotiated from their charges on certain claims for Covered Health Services. Refer to the definition of Shared Savings Program in Section 14, Glossary, of the SPD for details about how the Shared Savings Program applies.

Designated Network Benefits and Network Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider. You are not required to select a Primary Physician in order to obtain Network Benefits. In general health care terminology, a Primary Physician may also be referred to as a Primary Care Physician or PCP.

Non-Network Benefits apply to Covered Health Services that are provided by a non- Network Physician or other non-Network provider, or Covered Health Services that are provided at a non-Network facility.

You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive.

9 SECTION 3 - HOW THE PLAN WORKS

Generally, when you receive Covered Health Services from a Network provider, you pay less than you would if you receive the same care from a non-Network provider. Therefore, in most instances, your out-of-pocket expenses will be less if you use a Network provider.

If you choose to seek care outside the Network, the Plan generally pays Benefits at a lower level. You are required to pay the amount that exceeds the Eligible Expense. The amount in excess of the Eligible Expense could be significant, and this amount does not apply to the Out-of-Pocket Maximum. You may want to ask the non-Network provider about their billed charges before you receive care.

Emergency Health Services provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Covered Health Services provided at certain Network facilities by a non-Network Physician, when not Emergency Health Services, will be reimbursed as set forth under Eligible Expenses as described at the end of this section. For these Covered Health Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Air Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Ground Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Health Services from Non-Network Providers Paid as Network Benefits

If specific Covered Health Services are not available from a Network provider, you may be eligible to receive Network Benefits when Covered Health Services are received from a non- Network provider. In this situation, your Network Physician will notify UnitedHealthcare, and if UnitedHealthcare confirms that care is not available from a Network provider, UnitedHealthcare will work with you and your Network Physician to coordinate care through a non-Network provider.

Looking for a Network Provider?

In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

Network Providers

UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of Network providers

10 SECTION 3 - HOW THE PLAN WORKS

free of charge. Keep in mind, a provider's Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the toll-free number on your ID card or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of City of Tampa or UnitedHealthcare.

UnitedHealthcare’s credentialing process confirms public information about the providers’ licenses and other credentials, but does not assure the quality of the services provided.

Before obtaining services you should always verify the Network status of a provider. A provider's status may change. You can verify the provider's status by calling UnitedHealthcare. A directory of providers is available online at www.myuhc.com or by calling the number on your ID card to request a copy. If you receive a Covered Health Service from a non-Network provider and were informed incorrectly prior to receipt of the Covered Health Service that the provider was a Network provider, either through a database, provider directory, or in a response to your request for such information (via telephone, electronic, web-based or internet-based means), you may be eligible for Network Benefits.

It is possible that you might not be able to obtain services from a particular Network provider. The network of providers is subject to change. Or you might find that a particular Network provider may not be accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must choose another Network provider to get Network Benefits. However, if you are currently receiving treatment for Covered Health Services from a provider whose network status changes from Network to non-Network during such treatment due to expiration or nonrenewal of the provider's contract, you may be eligible to request continued care from your current provider at the Network Benefit level for specified conditions and timeframes. This provision does not apply to provider contract terminations for failure to meet applicable quality standards or for fraud. If you would like help to find out if you are eligible for continuity of care Benefits, please call the telephone number on your ID card.

If you are currently undergoing a course of treatment utilizing a non-Network Physician or health care facility, you may be eligible to receive transition of care Benefits. This transition period is available for specific medical services and for limited periods of time. If you have questions regarding this transition of care reimbursement policy or would like help determining whether you are eligible for transition of care Benefits, please contact UnitedHealthcare at the number on your ID card.

Do not assume that a Network provider's agreement includes all Covered Health Services.

Some Network providers contract with UnitedHealthcare to provide only certain Covered Health Services, but not all Covered Health Services. Some Network providers choose to be a Network provider for only some of our products. Refer to your provider directory or contact us for assistance.

11 SECTION 3 - HOW THE PLAN WORKS

Designated Providers

If you have a medical condition that UnitedHealthcare believes needs special services, UnitedHealthcare may direct you to a Designated Provider chosen by UnitedHealthcare. If you require certain complex Covered Health Services for which expertise is limited, UnitedHealthcare may direct you to a Network provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Services from a Designated Provider, UnitedHealthcare may reimburse certain travel expenses at UnitedHealthcare's discretion.

In both cases, Network Benefits will only be paid if your Covered Health Services for that condition are provided by or arranged by the Designated Provider or other provider chosen by UnitedHealthcare.

You or your Network Physician must notify UnitedHealthcare of special service needs (such as transplants or cancer treatment) that might warrant referral to a Designated Provider. If you do not notify UnitedHealthcare in advance, and if you receive services from a non- Network provider (regardless of whether it is a Designated Provider) or other non-Network provider, Network Benefits will not be paid. Non-Network Benefits may be available if the special needs services you receive are Covered Health Services for which Benefits are provided under the Plan.

Limitations on Selection of Providers

If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to provide and coordinate all of your future Covered Health Services. If you don't make a selection within 31 days of the date you are notified, UnitedHealthcare will select a single Network Physician for you. In the event that you do not use the selected Network Physician Covered Health Services will be paid as Non-Network Benefits.

Eligible Expenses

City of Tampa has delegated to the Claims Administrator the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Eligible Expenses are the amount the Claims Administrator determines that the Plan will pay for Benefits.

■ For Designated Network Benefits and Network Benefits for Covered Health Services provided by a Network provider, except for your cost sharing obligations, you are not responsible for any difference between Eligible Expenses and the amount the provider bills.

■ For Non-Network Benefits, except as described below, you are responsible for paying, directly to the non-Network provider, any difference between the amount the provider bills you and the amount the Claims Administrator will pay for Eligible Expenses.

- For Covered Health Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians, you are not responsible, and the non-Network provider may not bill

12 SECTION 3 - HOW THE PLAN WORKS

you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are non-Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-Ancillary Service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

- For Covered Health Services that are Emergency Health Services provided by a non-Network provider, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are Air Ambulance services provided by a non-Network provider, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider which is based on the Recognized Amount as defined in the SPD.

Eligible Expenses are determined in accordance with the Claims Administrator's reimbursement policy guidelines or as required by law, as described in the SPD.

Designated Network Benefits and Network Benefits

Eligible Expenses are based on the following:

■ When Covered Health Services are received from a Designated Network and Network provider, Eligible Expenses are our contracted fee(s) with that provider.

■ When Covered Health Services are received from a non-Network provider as arranged by the Claims Administrator, including when there is no Network provider who is reasonably accessible or available to provide Covered Health Services, Eligible Expenses are an amount negotiated by the Claims Administrator or an amount permitted by law. Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible.

The Plan will not pay excessive charges or amounts you are not legally obligated to pay.

Non-Network Benefits

When Covered Health Services are received from a non-Network provider as described below, Eligible Expenses are determined as follows:

■ For non-Emergency Covered Health Services received at certain Network facilities from non-Network Physicians when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of

13 SECTION 3 - HOW THE PLAN WORKS

section 2799B-2(d) of the Public Health Service Act with respect to a visit as defined by the Secretary, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a service is provided for which notice and consent has been satisfied, you are not responsible, and a non-Network Physician may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

■ For Emergency Health Services provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

■ For Emergency ground ambulance transportation provided by a non-Network provider, the Eligible Expense, which includes mileage, is a rate agreed upon by the non-Network provider or, unless a different amount is required by applicable law, determined based upon the median amount negotiated with Network providers for the same or similar service.

IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider’s billed charges and the Eligible Expense described here.

■ For Air Ambulance transportation provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

14 SECTION 3 - HOW THE PLAN WORKS

- The amount determined by Independent Dispute Resolution (IDR).

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider which is based on the Recognized Amount as defined in the

SPD.

■ When Covered Health Services are received from a non-Network provider, except as described above, Eligible Expenses are determined, based on one of the following:

- Negotiated rates agreed to by the non-Network provider and either the Claims Administrator or one of the Claims Administrator's vendors, affiliates or subcontractors, at the Claims Administrator's discretion.

Eligible Expenses are determined based on 110% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market, with the exception of the following:

- 50% of CMS for the same or similar freestanding laboratory service.

- 45% of CMS for the same or similar Durable Medical Equipment from a freestanding supplier, or CMS competitive bid rates.

- 70% of CMS for the same or similar physical therapy service from a freestanding provider.

When a rate is not published by CMS for the service, the Claims Administrator uses an available gap methodology to determine a rate for the service as follows:

- For services other than Pharmaceutical Products, the Claims Administrator uses a gap methodology established by OptumInsight and/or a third party vendor that uses a relative value scale or the amount typically accepted by a provider for the same or similar service. The relative value scale may be based on the difficulty, time, work, risk, location and resources of the service.

If the relative value scale(s) currently in use become no longer available, the Claims Administrator will use a comparable scale(s). UnitedHealthcare and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to UnitedHealthcare's website at www.myuhc.com for information regarding the vendor that provides the applicable gap fill relative value scale information.

- For Pharmaceutical Products, the Claims Administrator uses gap methodologies that are similar to the pricing methodology used by CMS, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or UnitedHealthcare based on an internally developed pharmaceutical pricing resource.

- When a rate for a laboratory service is not published by CMS for the service and gap methodology does not apply to the service, the rate is based on the

15 SECTION 3 - HOW THE PLAN WORKS

average amount negotiated with similar Network providers for the same or similar service.

- When a rate for all other services is not published by CMS for the service and a gap methodology does not apply to the service, the Eligible Expense is based on 50% of the provider’s billed charge.

The Claims Administrator updates the CMS published rate data on a regular basis when updated data from CMS becomes available. These updates are typically implemented within 30 to 90 days after CMS updates its data.

IMPORTANT NOTICE: non-Network providers may bill you for any difference between the provider's billed charges and the Eligible Expense described here. This includes non-Ancillary Services when notice and consent is satisfied as described under section 2799B-2(d) of the Public Health Service Act.

Don't Forget Your ID Card Remember to show your UnitedHealthcare ID card every time you receive health care services from a provider. If you do not show your ID card, a provider has no way of knowing that you are enrolled under the Plan.

Dollar First Benefit Allowance

Dollar First Benefit Allowance is the amount of Eligible Expenses that will be paid per Covered Person in a single calendar year for certain Covered Health Services before you are responsible for meeting the Annual Deductible described below and shown in Section 5, Plan Highlights. Covered Health Services may be received from a Network provider.

Copays paid under Dollar First Benefit Allowance will not apply towards the Annual Deductible but will, however, be applied to the Out-of-Pocket Maximum. Coinsurance paid under Dollar First Benefit Allowance will also not apply towards the Annual Deductible but will, however, be applied to the Out-of-Pocket Maximum.

Benefits for Covered Health Services that are subject to day or visit limits are reduced by any days or visits paid as Dollar First Benefit Allowance. Benefits for Covered Health Services that are subject to dollar limits are not reduced by any dollars paid as Dollar First Benefit Allowance.

Dollar First Benefit Allowance – Example Let's assume that your Plan provides you with $1,000 comprehensive coverage for the Dollar First Benefit Allowance and you have not gone to the doctor yet. If the Eligible Expenses the first time you went to the Physician came to $100, you would be responsible for your Copay (for example $30) and the remaining $70 would be deducted from your Dollar First Benefit Allowance amount. The next time you visit the Physician you will have $930 remaining which can be used towards Dollar First Benefit Allowance Eligible Expenses before you are subject to meeting the Annual Deductible.

16 SECTION 3 - HOW THE PLAN WORKS

Dollar First Benefit Allowance Health Incentives

UnitedHealthcare offers a health incentive and consumer engagement program that seeks to increase consumer awareness. Health Incentives are earned when the Employee (but not a spouse or partner) completes any of the following activities as described by the Employer:

Health Action Incentive

Rally Health Survey $100

Annual Exam, Prenatal Exam, Cancer Screening, Mammogram

$200

Biometric Screening $200

Maternity Support Program $200

Complete Real Appeal (9 sessions) $200

Tobacco-Free Attestation $200

Engage with UHC Wellness Coach (3 sessions)

$200

Virtual Visit $100

Complete (3) Rally Missions $100

Attend UHC approved Wellness Class (repeatable quarterly)

$100

Complete a City of Tampa Walking Challenge (repeatable quarterly)

$100

Receive your Flu Shot/COVID Booster (each)

$50

Annual Dental Exam Attestation $100

Annual Vision Exam Attestation $100

Incentive Earning Max $1000

Below is the incentive structure for the Simple Wellness Plan. Incentives can be earned through various activities as listed in the above incentive activities and rewards chart.

17 SECTION 3 - HOW THE PLAN WORKS

Depending on how much wellness incentive you earn, that will determine your First Dollar Benefit amount. In order to receive any First Dollar Benefit, you must earn at least $250 in incentives. For example, if you earn $600 in wellness incentives, you will be placed into the $500 Simple Wellness Plan, If you earn $50 in wellness incentives, you will be placed in the $0 Simple Wellness Plan.

$0 - $249 = $0 incentive Simple Wellness Plan

$250 - $499 = $250 incentive Simple Wellness Plan

$500 - $749 = $500 incentive Simple Wellness Plan

$750 – $999 = $750 incentive Simple Wellness Plan

$1,000 or more = $1,000 incentive Simple Wellness Plan

Employees and Spouses register to complete the health survey, certify tobacco use status and complete other incentive activities by visiting www.myuhc.com and selecting Rally.

Participation is completely voluntary and without extra charge. Qualifying activities and incentive amounts are fully described on www.myuhc.com/health & wellness/Rally.

Annual Deductible

The Annual Deductible is the amount of Eligible Expenses, or the Recognized Amount when applicable, you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits. There are separate Network and non-Network Annual Deductibles for this Plan. The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

Copayment

A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services. The Copay is a flat dollar amount and is paid at the time of service or when billed by the provider. Copays count toward the Out-of-Pocket-Maximum. Copays do not count toward the Annual Deductible. If the Eligible Expense is less than the Copay, you are only responsible for paying the Eligible Expense and not the Copay.

http://www.myuhc.com/health

18 SECTION 3 - HOW THE PLAN WORKS

Coinsurance

Coinsurance is the percentage of Eligible Expenses that you are responsible for paying.

Coinsurance is a fixed percentage that applies to certain Covered Health Services both while you receive Covered Health Services under the Dollar First Benefit Allowance and after you meet the Annual Deductible.

Out-of-Pocket Maximum

The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. There are separate Network and non-Network Out-of-Pocket Maximums for this Plan. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.

The Out-of-Pocket Maximum applies to all Covered Health Services under the Plan, including Covered Health Services provided in Section 15, Prescription Drugs.

The following table identifies what does and does not apply toward your Network and non- Network Out-of-Pocket Maximums:

Plan Features Applies to the

Network Out-of- Pocket Maximum?

Applies to the Non-Network Out-of-Pocket

Maximum?

Copays, even those for Covered Health Services available in Section 15, Prescription Drugs

Yes Yes

Payments toward the Annual Deductible Yes Yes

Coinsurance Payments Yes Yes

Charges for non-Covered Health Services No No

The amounts of any reductions in Benefits you incur by not obtaining prior authorization as required

No No

Charges that exceed Eligible Expenses, or the Recognized Amount when applicable.

No No

19 SECTION 4 - PERSONAL HEALTH SUPPORT

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

What this section includes:

■ An overview of the Personal Health Support program; and

■ Covered Health Services for which you need to contact Personal Health Support.

■ Covered Health Services which Require Prior Authorization.

Care Management

When you seek prior authorization as required, the Claims Administrator will work with you to implement the care management process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy.

UnitedHealthcare provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse, to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. When the Claims Administrator is called as required, they will work with you to implement the Personal Health Support process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy. As of the publication of this SPD, the Personal Health Support program includes:

■ Admission counseling - Personal Health Support Nurses are available to help you prepare for a successful surgical admission and recovery. Call the number on your ID card for support.

■ Inpatient care management - If you are hospitalized, a nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

■ Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call

20 SECTION 4 - PERSONAL HEALTH SUPPORT

from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

■…