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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesAmbetter from Home State Health:Ambetter Balanced Care 11 (2021) Vision Adult DentalCoverage Period: 01/01/2021 – 12/31/2021Coverage for: Individual/Family Plan Type: EPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare 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, chures.html, or call 1-855-650-3789 (TTY/TDD 1-877-250-6113). For general definitions of common terms, such asallowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary athttps://www.healthcare.gov/sbc-glossary or call 1-855-650-3789 (TTY/TDD 1-877-250-6113) to request a copy.Important QuestionsWhat is the overalldeductible?Are there servicescovered before you meetyour deductible?Are there otherdeductibles for specificservices?What is the out-of-pocketlimit for this plan?What is not included inthe out-of-pocket limit?AnswersWhy This Matters: 0See the Common Medical Events chart below for your cost for services this plan covers.There is no deductible.There is no deductible. See a list of covered preventive services are-benefits/.No.You don’t have to meet deductibles for specific services.For network providers: 1,150individual / 2,300 family. Notapplicable for out-of-networkproviders.Premiums, balance-billingcharges, and health care this plandoesn’t cover.The out-of-pocket limit is the most you could pay in a year for covered services. If you have otherfamily members in this plan, they have to meet their own out-of-pocket limits until the overallfamily out-of-pocket limit has been met.Even though you pay these expenses, they don’t count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See Find a Provider or call 1855-650-3789 (TTY/TDD 1-877250-6113) for a list of networkproviders.Do you need a referral tosee a specialist?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 aprovider for the difference between the provider’s charge and what your plan pays (balancebilling). 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.No.You can see the specialist you choose without a referral.SBC-99723MO0110013-06Underwritten by Home State Health Plan, Inc.Page 1 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.CommonMedical EventIf you visit a healthcare provider’s officeor clinicIf you have a testIf you need drugs totreat your illness orconditionMore information aboutprescription drugcoverage is available atPreferred Drug List.If you have outpatientsurgeryIf you need immediatemedical attentionServices You May NeedPrimary care visit to treat aninjury or illnessSpecialist visitWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)No chargeNot covered 5 Copay / visitNot coveredPreventive care/screening/immunizationNo chargeNot coveredDiagnostic test (x-ray, bloodwork)No charge for laboratoryoutpatient & professionalservices; 25%Not coveredCoinsurance for x-ray anddiagnostic imagingImaging (CT/PET scans, MRIs)25% CoinsuranceNot coveredGeneric drugs (Tier 1)Retail: No chargeNot coveredPreferred brand drugs (Tier 2)Retail: 25 Copay /prescriptionNot coveredNon-preferred brand drugs(Tier 3)Retail: 35% CoinsuranceNot coveredSpecialty drugs (Tier 4)Retail: 35% CoinsuranceNot coveredFacility fee (e.g., ambulatorysurgery center)25% CoinsuranceNot coveredPhysician/surgeon fees25% CoinsuranceNot coveredEmergency room care25% Coinsurance25% Coinsurance;deductible does not applyLimitations, Exceptions, & Other ImportantInformationVirtual Visits from Ambetter Health covered at 0, providers covered in full.----None---You may have to pay for services that aren’tpreventive. Ask your provider if the servicesneeded are preventive. Then check what yourplan will pay for.Prior authorization may be required. CoveredNo Limit. Failure to obtain prior authorizationfor any service that requires prior authorizationmay result in reduction of benefits. See yourpolicy for more details.Prior authorization may be required. CoveredNo Limit.Prescription drugs are provided up to 30 daysretail and up to 90 days through mail order.Mail orders are subject to 2.5x retail costsharing amount.Prior authorization may be required.Prescription drugs are provided up to 30 daysretail and up to 90 days through mail order.Mail orders are subject to 2.5x retail costsharing amount.Prior authorization may be required.Prescription drugs are provided up to 30 daysretail and up to 30 days through mail order.Prior authorization may be required. CoveredNo Limit.Prior authorization may be required. CoveredNo Limit.-----None-----*For more information about limitations and exceptions, see plan or policy document at ge 2 of 7

CommonMedical EventIf you have a hospitalstayIf you need mentalhealth, behavioralhealth, or substanceabuse servicesWhat You Will PayLimitations, Exceptions, & Other ImportantServices You May NeedNetwork ProviderOut-of-Network ProviderInformation(You will pay the least)(You will pay the most)Emergency medical25% Coinsurance;25% Coinsurance-----None----transportationdeductible does not applyUrgent care 10 Copay / visitNot covered-----None----Prior authorization may be required. CoveredFacility fee (e.g., hospital room) 25% CoinsuranceNot coveredNo Limit.Prior authorization may be required. CoveredPhysician/surgeon fees25% CoinsuranceNot coveredNo Limit.Prior authorization may be required. Note:Services (excluding emergency services)rendered by an out-of-network provider are notNo charge / Office Visits;covered under this plan, with the exception ofOutpatient services25% Coinsurance for allNot coveredtwo (2) sessions per year forother outpatient servicesdiagnosis/assessment by a licensed mentalhealth provider. (PCP and other practitionervisits do not require prior authorization).Prior authorization may be required. CoveredInpatient services25% CoinsuranceNot coveredNo Limit.Office visitsNo chargeNot coveredChildbirth/delivery professionalservices25% CoinsuranceNot coveredChildbirth/delivery facilityservices25% CoinsuranceNot coveredIf you are pregnantPrior authorization not required for deliverieswithin the standard timeframe per federalregulation, but may be required for otherservices. Cost-sharing does not apply forpreventive services, such as routine pre-nataland post-natal screenings. Depending on thetype of services, coinsurance, deductible orcopayment may apply. Maternity care mayinclude tests and services describedelsewhere in the SBC (i.e. ultrasound).Prior authorization may be required. Costsharing does not apply for preventive services.Depending on the type of services, copayment,coinsurance or deductible may apply.Maternity care may include tests and servicesdescribed elsewhere in the SBC (i.e.ultrasound).*For more information about limitations and exceptions, see plan or policy document at ge 3 of 7

CommonMedical EventWhat You Will PayNetwork ProviderOut-of-Network Provider(You will pay the least)(You will pay the most)Services You May NeedHome health care25% CoinsuranceNo charge / office visit forphysical and occupationaltherapy; 25%Not coveredCoinsurance for all otherservicesNo charge / office visit forphysical and occupationaltherapy; 25%Not coveredCoinsurance for otherservicesRehabilitation servicesIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye careNot coveredHabilitation servicesSkilled nursing care25% CoinsuranceNot coveredDurable medical equipment25% CoinsuranceNot coveredHospice services25% CoinsuranceNot coveredChildren’s eye examChildren’s glassesChildren’s dental check-upNo chargeNo chargeNot coveredNot coveredNot coveredNot coveredLimitations, Exceptions, & Other ImportantInformationPrior authorization may be required. Limited to100 visits per year.Prior authorization may be required. Limited to20 visits per year per therapy (occupationaland physical therapy); no limit applies forspeech therapy or pulmonary therapy; limitedto 36 visits per year for cardiac therapy.Prior authorization may be required. Limited to20 visits per year per therapy (occupationaland physical therapy); no limit applies forspeech therapy or pulmonary therapy; limitedto 36 visits per year for cardiac therapy.Prior authorization may be required. Limited to150 days per year.Prior authorization may be required. CoveredNo Limit.Prior authorization may be required. CoveredNo Limit.Limited to 1 visit per year.Limited to 1 item per year.-----None-----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, orwhen the life of the mother is endangered) Acupuncture Bariatric surgery Cosmetic surgery Long-term care Non-emergency care when traveling outside theU.S. Weight loss programs*For more information about limitations and exceptions, see plan or policy document at ge 4 of 7

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Chiropractic care (Limited to 26 visits per year.Visits in excess of 26 require prior authorization.) Dental care (Adult-visit & item limits apply peryear. 1,000 annual dollar limit per year.) Hearing aids (Limited to 1 item per ear per year.) Infertility treatment (Covered Services includediagnostic tests to find the cause of infertility andservices to treat the underlying medicalconditions that cause infertility.)Private-duty nursing (Limited to 82 visits peryear.) Routine eye care (Adult-visit & one item per year.Dollar limits apply.) Routine foot care (Coverage is limited to diabetescare only.)Page 5 of 7