SMCO-TPA-RFP-APP-B-SBC.pdf

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 – 12/31/2025 Summit County Government 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 see www.lucenthealth.com/cypress or call 1-877-236-0844. 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 1-877-236-0844 to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible?

Peak Health Alliance/Common Spirit providers:

$0 individual / $0 family Aetna Network providers:

$2,500 individual / $5,000 family Out-of-network providers:

Not Covered

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. Preventive care and services with a copay may be 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?

Peak Health Alliance/Common Spirit providers:

$4,000 individual / $8,000 family Aetna Network providers:

$5,000 individual / $10,000 family Out-of-network providers:

Not Covered

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, and 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. For Peak Health Alliance/Common Spirit, see lucentco.connect.payercompass.com for a list of participating providers.

See www.aetna.com/asa for a list of Aetna participating 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.

https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#premium http://www.lucenthealth.com/cypress https://www.healthcare.gov/sbc-glossary/#allowed-amount https://www.healthcare.gov/sbc-glossary/#balance-billing https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#provider https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.healthcare.gov%2Fsbc-glossary%2F&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859387316%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=JzBR7XHhwqP%2BV6TdgnD9ZmCSJY1gTjZB5OKrxyA32gw%3D&reserved=0 https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#out-of-network-provider https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#copayment http://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/coverage/preventive-care-benefits/ https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#out-of-network-provider https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#premium https://www.healthcare.gov/sbc-glossary/#balance-billing https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#out-of-pocket-limit https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#network-provider http://www.aetna.com/asa https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#network https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#network https://www.healthcare.gov/sbc-glossary/#out-of-network-provider https://www.healthcare.gov/sbc-glossary/#out-of-network-provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#balance-billing https://www.healthcare.gov/sbc-glossary/#network-provider https://www.healthcare.gov/sbc-glossary/#out-of-network-provider https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#referral https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#referral

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress 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 Peak Health Alliance

/Common Spirit Provider

Aetna Network Provider

Out-of-Network Provider

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

Primary care visit to treat an injury or illness

$10 copay; deductible does not apply 30% coinsurance Not Covered None

Specialist visit $20 copay; deductible does not apply 30% coinsurance Not Covered None

Preventive care/screening/ immunization

No charge; deductible does not apply

No charge;

deductible does not apply 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;

deductible does not apply 30% coinsurance Not Covered None

Imaging (CT/PET scans, MRIs)

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered Preauthorization may be required.

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.primetherapeutics.

com

Generic drugs Retail 30-day supply: $0 copay/prescription

Retail 90-day supply: $30 copay/prescription Mail Order: $0 copay/prescription

Not Covered

Deductible does not apply.

Covers up to a 90-day supply (retail and mail order prescription).

Prescription Drugs recommended by the HRSA or USPSTF will be covered at 100% as required by

ACA.

Specialty drugs are limited to a

Preferred brand drugs Retail 30-day supply: $20 copay/prescription Retail 90-day supply: $60 copay/prescription

Mail Order: $40 copay/prescription

Non-preferred brand drugs

Retail 30-day supply: $40 copay/prescription Retail 90-day supply: $120 copay/prescription

Mail Order: $80 copay/prescription https://www.healthcare.gov/sbc-glossary/#plan http://www.lucenthealth.com/cypress https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#screening https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.primetherapeutics.com%2F&data=05%7C02%7Camber.gilliland%40lucenthealth.com%7Cef2fd7cb0e3b406a90d908dd1ecfdf4b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C638700600357293710%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=6OsgtsnFzB00bRi6VvNIdbf4nYsbMrlTF%2F5B8b7GohA%3D&reserved=0 https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.primetherapeutics.com%2F&data=05%7C02%7Camber.gilliland%40lucenthealth.com%7Cef2fd7cb0e3b406a90d908dd1ecfdf4b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C638700600357293710%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=6OsgtsnFzB00bRi6VvNIdbf4nYsbMrlTF%2F5B8b7GohA%3D&reserved=0 https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#prescription-drugs https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#copayment

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress Page 3 of 7

Need

What You Will Pay Limitations, Exceptions, &

Other Important Information Peak Health Alliance

/Common Spirit Provider

Aetna Network Provider

Out-of-Network Provider

Specialty drugs Retail and Mail Order:

20% coinsurance/prescription up to $250 max

30-day supply.

This Plan uses the Payer Matrix non-formulary Specialty Drug list.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered

Preauthorization is required.

Physician/surgeon fees 20% coinsurance;

deductible does not apply

30% coinsurance Not Covered

If you need immediate medical attention

Emergency room care 20% coinsurance up to $500 max; deductible does not apply

True Emergency:

20% coinsurance up to $500 max;

deductible does not apply Non-True

Emergency:

30% coinsurance

True Emergency:

20% coinsurance up to $500 max;

deductible does not apply Non-True

Emergency:

Not covered

None

Emergency medical transportation

20% coinsurance up to $500 max; deductible does not apply

True Emergency:

20% coinsurance up to $500 max;

deductible does not apply Non-True

Emergency:

30% coinsurance

True Emergency:

20% coinsurance up to $500 max;

deductible does not apply Non-True

Emergency:

Not covered

None

Urgent care $75 copay; deductible does not apply 30% coinsurance Not Covered None

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered Preauthorization is required.

https://www.healthcare.gov/sbc-glossary/#plan http://www.lucenthealth.com/cypress https://www.healthcare.gov/sbc-glossary/#specialty-drug https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#emergency-medical-transportation https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#urgent-care https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress Page 4 of 7

Need

What You Will Pay Limitations, Exceptions, &

Other Important Information Peak Health Alliance

/Common Spirit Provider

Aetna Network Provider

Out-of-Network Provider

Physician/surgeon fees 20% coinsurance;

deductible does not apply

30% coinsurance Not Covered

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

Outpatient services No charge; deductible does not apply

No charge;

deductible does not apply Not Covered None

Inpatient services 20% coinsurance, deductible does not apply

30% coinsurance Not Covered Preauthorization is required.

If you are pregnant

Office visits $10 copay; deductible does not apply 30% coinsurance Not Covered

Cost sharing does not apply to certain preventive services.

Depending on the type of services, coinsurance may apply.

Maternity care may include tests and services described elsewhere in the SBC (i.e.

ultrasound). Preauthorization is required for vaginal deliveries requiring more than a 48 hour stay and for cesarean section deliveries requiring more than a 96 hour stay.

Childbirth/delivery professional services

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered

Childbirth/delivery facility services

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered

If you need help recovering or have other special health needs

Home health care 20% coinsurance;

deductible does not apply

30% coinsurance Not Covered Preauthorization is required.

Rehabilitation services

Cognitive, Occupational, Physical, and Speech Therapy: $20 copay;

deductible does not apply All others: 20% coinsurance; deductible does not apply

30% coinsurance Not Covered

Occupational, Physical, and Speech Therapy is limited to 20 visits each per Calendar Year.

Benefits for Autism are based upon the services rendered and limits do not apply. Habilitation services https://www.healthcare.gov/sbc-glossary/#plan http://www.lucenthealth.com/cypress https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#preventive-care https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#home-health-care https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#habilitation-services

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress Page 5 of 7

Need

What You Will Pay Limitations, Exceptions, &

Other Important Information Peak Health Alliance

/Common Spirit Provider

Aetna Network Provider

Out-of-Network Provider

Skilled nursing care 20% coinsurance;

deductible does not apply

30% coinsurance Not Covered Preauthorization is required.

Durable medical equipment

20% coinsurance;

deductible does not apply 30% coinsurance Not Covered None

Hospice services 20% coinsurance;

deductible does not apply

30% coinsurance Not Covered Coverage begins when life expectancy is six months or less.

If your child needs dental or eye care

Children’s eye exam Not Covered Not Covered Not Covered Routine screenings covered as defined under the Patient Protection and Affordable Care Act of 2010.

Children’s glasses Not Covered Not Covered Not Covered Not Covered

Children’s dental check-up Not Covered Not Covered Not Covered

Routine screenings covered as defined under the Patient Protection and Affordable Care Act of 2010.

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.)

• Abortion (except in cases of rape, incest, or when the life of the mother is endangered)

• Bariatric Surgery (except for Morbid Obesity)

• Cosmetic Surgery

• Dental Care (adult)

• Long Term Care

• Routine Eye Care (adult)

• 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.)

• Acupuncture

• Chiropractic Care (limited to 30 visits per

Calendar Year)

• Hearing Aids (only when due to a congenital hearing defect or an accident/injury)

• Infertility Treatment

• Private Duty Nursing (see SPD for full benefit and limitations) https://www.healthcare.gov/sbc-glossary/#plan http://www.lucenthealth.com/cypress https://www.healthcare.gov/sbc-glossary/#skilled-nursing-care https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#preauthorization https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#hospice-services https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#plan

* For more information about limitations and exceptions, see the plan or policy document at www.lucenthealth.com/cypress Page 6 of 7

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: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. 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: the plan at Summit County Government Health Plan c/o Lucent Health Solutions, LLC at PO Box 7020 Appleton, WI 54912-7020 or call 1-877- 236-0844. You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, Additionally, a consumer assistance program can help you file your appeal. A list of states with Consumer Assistance Programs is available at: www.dol.gov/ebsa/healthreform and http://www.cms.gov/CCIO/Resources/Consumer-Assistance-Grants.

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 the 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.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-877-236-0844 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-236-0844 Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-877-236-0844 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-236-0844

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850.

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

http://www.lucenthealth.com/cypress https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.dol.gov%2Febsa%2Fhealthreform&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859147463%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=N7uZTXIsqG%2Fv9Xh%2B4F%2FXg3iNfD7Ds7Q%2BRcbstJ9Fhk4%3D&reserved=0 https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.cciio.cms.gov%2F&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859147463%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=pELK2eG7pxguXNPa6m7uExJbzD8gco3TCsrb2RIv8xg%3D&reserved=0 https://www.healthcare.gov/sbc-glossary/#health-insurance https://www.healthcare.gov/sbc-glossary/#marketplace https://www.healthcare.gov/sbc-glossary/#marketplace http://www.healthcare.gov/ https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#claim https://www.healthcare.gov/sbc-glossary/#grievance https://www.healthcare.gov/sbc-glossary/#appeal https://www.healthcare.gov/sbc-glossary/#claim https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#claim https://www.healthcare.gov/sbc-glossary/#appeal https://www.healthcare.gov/sbc-glossary/#grievance https://www.healthcare.gov/sbc-glossary/#plan https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.dol.gov%2Febsa&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859237400%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=xA9XqMB9knCBQU7ym%2BSA3xQAG6tKu%2FQakfs1AXhiEUY%3D&reserved=0 https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.dol.gov%2Febsa%2Fhealthreform&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859237400%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=h3Ct9BR7brFQNT1jQJm2bt%2BqBrdWEEaIH4MZuiXEHYs%3D&reserved=0 https://nam11.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.cms.gov%2FCCIO%2FResources%2FConsumer-Assistance-Grants&data=04%7C01%7CJoanna.Jones%40lucenthealth.com%7C562b605dbbeb4d41635908d8ac3e092b%7Cb3d92c987171466982cafa81cec4590d%7C0%7C0%7C637448729859247393%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=RwpbeJZdfwoyQbw3Iuwun8JcH0fhImm%2BmK4u6Mudn7s%3D&reserved=0 https://www.healthcare.gov/sbc-glossary/#minimum-essential-coverage https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#health-insurance https://www.healthcare.gov/sbc-glossary/#marketplace https://www.healthcare.gov/sbc-glossary/#minimum-essential-coverage https://www.healthcare.gov/sbc-glossary/#premium-tax-credits https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#minimum-value-standard https://www.healthcare.gov/sbc-glossary/#premium-tax-credits https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#marketplace

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 $2,500 Specialist coinsurance 30% Hospital (facility) coinsurance 30% Other coinsurance 30%

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 $2,500 Copayments $0 Coinsurance $2,500

What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060

Hospital (facility) coinsurance 30% Other coinsurance 30%

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Cost Sharing

Deductibles $1,900 Copayments $300 Coinsurance $0

What isn’t covered Limits or exclusions $20 The total Joe would pay is $2,220

Hospital (facility) coinsurance 30% Other coinsurance 30%

This EXAMPLE event includes services like:

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 $1,100 Copayments $0 Coinsurance $400

What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,500

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

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) https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#provider https://www.healthcare.gov/sbc-glossary/#cost-sharing https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#excluded-services https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#primary-care-physician https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#prescription-drugs https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#plan https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#specialist https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#coinsurance https://www.healthcare.gov/sbc-glossary/#emergency-room-care-emergency-services https://www.healthcare.gov/sbc-glossary/#diagnostic-test https://www.healthcare.gov/sbc-glossary/#durable-medical-equipment https://www.healthcare.gov/sbc-glossary/#rehabilitation-services https://www.healthcare.gov/sbc-glossary/#deductible https://www.healthcare.gov/sbc-glossary/#copayment