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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: Beginning on or after 01/01/2022Sutter Health Plus: (2022) Gold MI02 HMOCoverage for: Individual and Family Plan Plan Type: HMOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the planwould share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be providedseparately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact SutterHealth Plus at 1-855-315-5800 or visit sutterhealthplus.org. For general definitions of common terms, such as allowed amount, balance billing, coinsurance,copayment (copay), deductible, provider, or other underlined terms, see the Glossary of Health Coverage and Medical Terms. You can view the Glossary atwww.healthcare.gov/sbc-glossary or call 1-855-315-5800 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible? 0 individual / 0 individual familymember / 0 family per calendaryear.See the Common Medical Events chart below for your costs for services this plan covers.Are there servicescovered before you meetyour deductible?Yes. There is no deductible forcovered services.You don’t have to meet deductibles for covered items and services. But a copayment (copay) orcoinsurance may apply. This plan covers certain preventive services without cost sharing. See alist of covered preventive services at ts/.Are there otherdeductibles for specificservices?No.You don’t have to meet deductibles for specific services. 8,200 individual / 8,200What is the out-of-pocketindividual family member /limit for this plan? 16,400 family per calendar year.The out-of-pocket limit is the most you could pay in a year for covered services. If you haveother family members in this plan, they have to meet their own out-of-pocket limits until theoverall family out-of-pocket limit has been met.What is not included inthe out-of-pocket limit?Even though you pay these expenses, they don’t count toward the out-of-pocket limit.Premiums and health care thisplan doesn’t cover.MI02 2022 v2.01 of 8

Will you pay less if youuse a network provider?Yes. Seewww.sutterhealthplus.org/provider-search or call 1-855-315-5800 fora list of network providers.This plan uses a provider network. You will pay less if you use a provider in the plan’s network.You will pay the most if you use an out-of-network provider, and you might receive a bill from 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.Do you need a referral tosee a specialist?Yes.This plan will pay some or all of the costs to see a specialist for covered services but only if youhave a referral before you see the specialist.What You Will PayCommon Medical EventServices You May NeedPrimary Care Physician(PCP) Visit to treat an injuryor illnessIf you visit a health careprovider’s office or clinicSpecialist VisitPreventive Care / Screening /ImmunizationIf you have a testParticipating Provider 35 copay per visit 65 copay per visitNo chargeNon-ParticipatingProviderNot coveredIncludes Other Health Professional andSutter Walk-in Care visits. *SeeDefinitions section in EOC for list ofOther Health Professionals.Not coveredPrior authorization for some referrals tospecialists is required. If it is notreceived, you may be responsible forpaying all charges.Not coveredYou may have to pay for services thataren’t preventive. Ask your provider ifthe services needed are preventive.Then check what your plan will pay for.Diagnostic Test (X-ray, blood Lab: 40 copay per visitwork)X-ray: 75 copay per procedureNot coveredImaging (CT/PET scans,MRIs)Not covered20% coinsuranceLimitations, Exceptions & OtherImportant InformationPrior authorization for some diagnosticservices is required. If it is not received,you may be responsible for paying allcharges.* For more information about limitations and exceptions, see plan Evidence of Coverage (EOC) at www.sutterhealthplus.org/about/plans-benefits or call 1-855-315-5800.2 of 8

What You Will PayCommon Medical EventServices You May NeedParticipating ProviderTier 1 (Most generic drugsand low-cost preferred brandname drugs)Retail: 15 copay per prescriptionIf you need drugs to treat Tier 2 (Preferred brand nameyour illness or condition drugs and non-preferredgeneric drugs)For information aboutprescription drug coverage,including the Sutter HealthPlus (SHP) Formulary, visitwww.sutterhealthplus.org/pTier 3 (Non-preferred brandharmacy or call CVSname drugs)Caremark at 1-844-7400635.Retail: 55 copay per prescriptionIf you have outpatientsurgeryMail Order: 30 copay perprescriptionMail Order: 110 copay perprescriptionNon-ParticipatingProviderNot coveredRetail: covers up to a 30-day supplythrough a CVS Health NationalNetwork pharmacy and covers up to a100-day supply of maintenance drugs, attwo times the retail cost sharing, througha CVS retail pharmacy that participatesin the Retail-90 Network.Not coveredMail Order/home delivery service:covers up to a 100-day supply ofmaintenance drugs, at two times theretail cost sharing, through the CVSCaremark Mail Service Pharmacy.Retail: 80 copay per prescriptionMail Order: 160 copay perprescriptionLimitations, Exceptions & OtherImportant InformationNot coveredSpecialty Pharmacy: covers up to a 30day supply of specialty drugs throughthe CVS Specialty pharmacy.FDA-approved, self-administeredhormonal contraceptives are availablefor up to a 12-month supply.Tier 4 (Specialty drugs)Specialty Pharmacy: 20%coinsurance up to 250 perprescriptionNot coveredFacility Fee (e.g., ambulatorysurgery center)20% coinsuranceNot coveredPhysician / Surgeon Fee20% coinsuranceNot covered*See SHP Formulary or the OutpatientPrescription Drugs, Supplies, Equipmentand Supplement section in EOC for anySHP policy requirements such as priorauthorization and step therapy, orcoverage limitations and exceptions.Prior authorization is required. If it is notreceived, you may be responsible forpaying all charges.* For more information about limitations and exceptions, see plan Evidence of Coverage (EOC) at www.sutterhealthplus.org/about/plans-benefits or call 1-855-315-5800.3 of 8

Emergency Room CareIf you need immediatemedical attentionIf you have a hospitalstayProfessional: No chargeIf admitted to the hospital, EmergencyRoom Care cost sharing will not apply.See hospital stay information below forapplicable cost sharing.Emergency MedicalTransportation 250 copay per tripTransportation by car, taxi, bus, gurneyvan, wheelchair van, and any other typeof transportation (other than a licensedambulance or psychiatric transport van)is not covered.Urgent Care 35 copay per visitNoneFacility Fee (e.g., hospitalroom)20% coinsuranceNot coveredPhysician / Surgeon Fees20% coinsuranceNot coveredIf you need mentalhealth, behavioral health,or substance usedisorder (MH/SUD)Outpatient ServicesservicesFor information, call U.S.Behavioral Health Plan,California (USBHPC) at 1855-202-0984 or visitwww.liveandworkwell.com(access code: “Sutter”).Facility: 350 copay per visitInpatient ServicesIndividual Office Visit: 35 copayper visitGroup Office Visit: 17.50 copayper visitYou may self-refer to a USBHPCprovider for Office Visits.Not coveredOther Outpatient Services: 20%coinsurance (maximum 35 copayper visit)Facility: 20% coinsuranceProfessional: 20% coinsurancePrior authorization is required. If it is notreceived, you may be responsible forpaying all charges.Not coveredPrior authorization is required for OtherOutpatient Services and all InpatientServices by USBHPC. If it is notobtained when required, you may beliable for the payment of services orsupplies.* For more information about limitations and exceptions, see plan Evidence of Coverage (EOC) at www.sutterhealthplus.org/about/plans-benefits or call 1-855-315-5800.4 of 8

Office VisitsPrenatal and Postnatal Care: NochargeNot coveredMaternity care may include tests andservices described elsewhere in theSBC (e.g., Diagnostic Tests such asultrasounds and blood work).If you are pregnantIf you need helprecovering or have otherspecial health needsPrenatal and Postnatal Care includes allprenatal office visits and the firstpostnatal office visit. Refer to the PCPVisit cost sharing for all subsequentpostnatal office visits.Childbirth / DeliveryProfessional Services20% coinsuranceChildbirth / Delivery FacilityServices20% coinsuranceNot coveredHome Health Care20% coinsuranceNot coveredRehabilitation Services 35 copay per visitNot coveredHabilitation Services 35 copay per visitNot coveredSkilled Nursing Care20% coinsuranceNot coveredDurable Medical Equipment20% coinsuranceNot coveredHospice ServicesNo chargeNot coveredNot coveredNonePrior authorization is required. If it is notreceived, you may be responsible forpaying all charges.Quantitative limits exist for the followingservices:Home Health Care – 100 visits percalendar year.Skilled Nursing Care – 100 days perbenefit period. *See Skilled NursingFacility Care section in EOC foradditional information.Hospice Services – respite care isoccasional short-term inpatient carelimited to no more than five consecutivedays at a time.* For more information about limitations and exceptions, see plan Evidence of Coverage (EOC) at www.sutterhealthplus.org/about/plans-benefits or call 1-855-315-5800.5 of 8

Children’s Eye ExamNo chargeNot coveredIf your child needs dentalor eye careFor more information,contact Vision ServicesPlan (VSP) at 1-800-8777195 or Delta Dental at 1800-422-4234.Children’s GlassesNo chargeNot coveredChildren’s Dental Check-upNo chargeNot coveredQuantitative limits exist for the followingchildren’s services:Eye Exam – 1 preventive exam peryear.Glasses – 1 pair of glasses (or contactlenses in lieu of glasses) per year.Dental Check-up – preventiveprophylaxis and diagnostic oralevaluation limited to 1 per 6 months.These are embedded pediatric vision anddental benefits that are provided throughthe end of the month in which you turn 19years of age.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.) Chiropractic care Hearing aids Private-duty nursing Commercial weight loss programs Infertility treatment Routine eye care (Adult) Cosmetic surgery Long-term care Routine foot care Dental care (Adult) Non-emergency care when traveling outside theU.S.Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Abortion Acupuncture typically provided only for thetreatment of nausea or chronic pain; embeddedin medical plan. PCP referral and priorauthorization are required. Bariatric surgery* For more information about limitations and exceptions, see plan Evidence of Coverage (EOC) at www.sutterhealthplus.org/about/plans-benefits or call 1-855-315-5800.6 of 8