WIXLIB

8/01/2018Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesSutter Health Plus: Platinum MS38 HMOCoverage Period:Coverage for: Small Group 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 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, visit sutterhealthplus.org or call 1-855-315-5800. For generaldefinitions of common terms, such as allowed amount, balance billing, coinsurance, copayment (copay), deductible, provider, or other underlined terms see theGlossary of Health Coverage and Medical Terms. You can view the Glossary at sutterhealthplus.org or call 1-855-315-5800 to request a copy.Important QuestionsAnswersWhy This Matters:What is the overalldeductible? 0 individual/ 0 individualfamily member/ 0 family for See the Common Medical Events chart below for your costs for services thiscertain medical services per plan covers.calendar year.Are there servicescovered before youmeet yourdeductible?Yes. There is no deductiblefor covered services.This plan covers some items and services even if you haven’t yet met thedeductible amount. But a copayment (copay) or coinsurance may apply. Forexample, this plan covers certain preventive services without cost-sharing andbefore you meet your deductible. See a list of covered preventive services /.Are there otherdeductibles forspecific services?No.You don’t have to meet deductibles for specific services.What is the out-ofpocket limit for thisplan? 3,500 individual/ 3,500individual family member/ 7,000 family per calendaryear.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 outof-pocket limits until the overall family out-of-pocket limit has been met.What is not includedin the out-of-pocketlimit?Premiums, health care thisplan doesn’t cover and costsharing for optional benefitriders if elected by youremployer group.Even though you pay these expenses, they don’t count toward the out-of-pocketlimit.MS38 2018 v2.01 of 8

Will you pay less ifyou use a networkprovider?Do you need areferral to see aspecialist?8/01/2018This plan uses a provider network. You will pay less if you use a provider in theYes. For a list ofplan’s network. You will pay the most if you use an out-of-network provider, andparticipating providers, go to you might receive a bill from a provider for the difference between the provider’ssutterhealthplus.org or callcharge and what your plan pays (balance billing). Be aware, your network1-855-315-5800.provider might use an out-of-network provider for some services (such as labwork). Check with your provider before you get services.Yes.This plan will pay some or all of the costs to see a specialist for covered servicesbut only if you have a referral before you see the specialist.What You Will PayCommonMedical EventServices You MayNeedPrimary care visit to treatan injury or illnessIf you visit ahealth careprovider’s officeor clinicIf you have a testParticipating Provider 25 copay per visitNonparticipatingProviderLimitations, Exceptions, &Other ImportantInformationNot coveredSpecialist visit 25 copay per visitNot coveredPreventivecare/screening/immunizationNo chargeNot coveredDiagnostic test (X-ray,blood work)Lab: 25 copay per visitX-ray: 25 copay perprocedureNot coveredImaging (CT/PET scans,MRIs) 150 copay per procedureNot coveredNonePrior authorization for somereferrals to specialists is required.If it is not received, you may beresponsible for paying all charges.You may have to pay for servicesthat aren’t preventive. Ask yourprovider if the services you needare preventive. Then check whatyour plan will pay for.Prior authorization for somediagnostic services is required. Ifit is not received, you may beresponsible for paying all charges.* For more information about limitations and exceptions, see the plan or policy document at sutterhealthplus.org or call 1-855-315-5800.2 of 8

8/01/2018What You Will PayCommonMedical EventIf you need drugsto treat yourillness orconditionMore information aboutprescription drugcoverage, including theSutter Health Plus(SHP) Formulary, isavailable atmp.medimpact.com/STH or call 1-844-2825330.If you haveoutpatient surgeryServices You MayNeedParticipating ProviderNonparticipatingProviderLimitations, Exceptions, &Other ImportantInformationTier 1 (most generic drugsand low-cost preferred brandname drugs)Retail: 5 copay perprescriptionMail-Order: 10 copay perprescriptionNot coveredTier 2 (preferred brand namedrugs, non-preferred genericdrugs and drugs recommendedby Sutter Health Plus’s (SHP)pharmacy and therapeuticscommittee based on drugsafety, efficacy and cost)Retail: 15 copay perprescriptionMail-Order: 30 copay perprescriptionRetail: up to a 30-day supply.Mail-Order: up to a 100-daysupply.Specialty Pharmacy: up to a 30day supply.Not coveredFDA-approved, self-administeredhormonal contraceptives areavailable for up to a 12-monthsupply.Tier 3 (non-preferred brandname drugs or drugs that arerecommended by SHP’spharmacy and therapeuticscommittee based on drugsafety, efficacy and cost)Retail: 25 copay perprescriptionMail-Order: 50 copay perprescriptionTier 4 (specialty drugs, selfadministered drugs that requiretraining or clinical monitoring,drugs that cost SHP more than 600 net of rebates for a onemonth supply or bioengineereddrugs)Specialty Pharmacy: 10%coinsurance up to 250 perprescriptionNot coveredFacility fee (e.g., ambulatorysurgery center)10% coinsuranceNot coveredPhysician/surgeon fee10% coinsuranceNot coveredNot coveredSexual dysfunction drugs have50% cost sharing and some arelimited to 8 doses per 30-daysupply.Some drugs have processrequirements, such as priorauthorization, or limitations forcoverage, such as a quantity limit.Please refer to the SHPFormulary for details.Prior authorization is required. If itis not received, you may beresponsible for paying all charges.* For more information about limitations and exceptions, see the plan or policy document at sutterhealthplus.org or call 1-855-315-5800.3 of 8

8/01/2018What You Will PayCommonMedical EventServices You MayNeedParticipating ProviderFacility: 100 copay per visitEmergency room careIf you needimmediatemedical attentionIf you have ahospital stayIf you need mentalhealth, behavioralhealth, orsubstance usedisorder services(MH/SUD)More information aboutUS Behavioral HealthPlan, California isavailable atliveandworkwell.com orcall l: No chargeLimitations, Exceptions, &Other ImportantInformationDoes not apply if admitted forhospitalization for coveredservices.Emergency medicaltransportation 100 copay per tripTransportation by car, taxi, bus,gurney van, wheelchair van, andany other type of transportation(other than a licensed ambulanceor psychiatric transport van) is notcovered.Urgent care 25 copay per visitNoneFacility fee (e.g., hospitalroom) 250 copay per day up to amaximum of 5 days peradmissionNot coveredPhysician/surgeon feesNo chargeNot coveredPrior authorization is required. If itis not received, you may beresponsible for paying all charges.Individual office visit: 25copay per visitOutpatient servicesGroup office visit: 12.50copay per visitNot coveredOther outpatient services:10% coinsuranceInpatient servicesFacility: 250 copay per dayup to a maximum of 5 daysper admissionNot coveredPrior authorization is required forOther outpatient services and allInpatient services by USBehavioral Health Plan,California. If it is not obtainedwhen required, you may be liablefor the payment of services orsupplies.Professional: No charge* For more information about limitations and exceptions, see the plan or policy document at sutterhealthplus.org or call 1-855-315-5800.4 of 8

8/01/2018What You Will PayCommonMedical EventIf you arepregnantIf you need helprecovering orhave other specialhealth needsServices You MayNeedParticipating ProviderNonparticipatingProviderOffice visitsPrenatal and postnatal care:No chargeNot coveredChildbirth/deliveryprofessional servicesNo chargeNot coveredChildbirth/delivery facilityservices 250 copay per day up to amaximum of 5 days peradmissionNot coveredHome health care 25 copay per visitNot coveredRehabilitation services 25 copay per visitNot coveredHabilitation services 25 copay per visitNot coveredSkilled nursing care10% coinsuranceNot coveredDurable medicalequipment10% coinsuranceNot coveredHospice servicesNo chargeNot coveredLimitations, Exceptions, &Other ImportantInformationPrenatal and postnatal careincludes all prenatal office visitsand the first postnatal office visit.Refer to the primary care visit costsharing for all subsequentpostnatal office visits.NonePrior authorization is required. If itis not received, you may beresponsible for paying all charges.Quantitative limits exist for thefollowing services:Home health care – 100 visits percalendar year.Skilled nursing care – 100 daysper benefit period.Hospice services – respite care isoccasional short-term inpatientcare limited to no more than fiveconsecutive days at a time.* For more information about limitations and exceptions, see the plan or policy document at sutterhealthplus.org or call 1-855-315-5800.5 of 8

8/01/2018What You Will PayCommonMedical EventServices You MayNeedParticipating ProviderChildren’s eye examIf your child needsdental or eye careChildren’s glassesProvided through theend of the month inwhich the member turns19 years of age.Children’s dental checkupNonparticipatingProviderNo chargeNot coveredNo chargeNot coveredNo chargeNot coveredLimitations, Exceptions, &Other ImportantInformation1 preventive exam per year.Offered through Vision ServicePlan (VSP).1 pair of glasses (or contactlenses in lieu of glasses) per year.Offered through (VSP).Preventive prophylaxis anddiagnostic oral evaluation limitedto 1 per 6 months. Offeredthrough Delta Dental.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 travelingoutside the U.S.Other Covered Services(Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Acupuncture services typically provided only for the treatment of nausea or chronic pain; embeddedin medical plan. A primary care physician referraland prior authorization are required.Bariatric surgery* For more information about limitations and exceptions, see the plan or policy document at sutterhealthplus.org or call 1-855-315-5800.6 of 8